Professional Ceiling Clouds

Finally getting around to publishing this post from the summer…enjoy 🙂

For the year and a half, we’ve been extremely lucky to be able to provide bi-annual professional development for our dental technicians and clinic assistants.  It has quickly become one of my favorite parts of our project.  Jevaia dental clinics deliver the Basic Package of Oral Care, a collection of dental procedures that was designed in collaboration with the World Health Organization for limited-resources settings.  The BPOC was developed by Europeans, and it has mostly been used in developing world settings as aid or transient care.

Since we train local dental technicians to provide the BPOC in Health Posts instead of temporary camps or outreach programs, we’ve had the chance think about applying it as a sustained primary health care strategy–especially since we started working with Berkeley, Dr. Bethy and Dr. Keri and other collaborators in 2016.  I suppose that kind of thinking is one difference between aid, or any kind of temporary relief, and human rights, which entitles people to a consistent standard of health care.

Our past three professional development workshops have focused on the use of Silver Diamine Fluoride; infection control tailored to rural Health Posts; and treatment planning (one thing about a stable primary care provider is: they can actually plan!).  This summer, Dr. Bethy is teaching our professional development on school-based treatment planning, so we can shift to a more systematic school-based oral health care model with local dental technicians.

Dental technicians in JOHC already conduct monthly school seminars to do school-based screening and treatment for children and parents.  We call these “seminars” rather than “camps” because they are run by a local provider and they help connect people with the Health Post dental clinic. Unlike most “camps,” seminars don’t aim to treat as many teeth as possible in the shortest time, but to build relationships with the technician and raise public support for a government dental clinic and community outreach programs.

Our 2018 summer professional development was seven days long for veteran technicians and ten days for new technicians. It kicked of with technicians and assistants examining photos of real ART fillings (like the kind they do) organizing them in to acceptable and unacceptable outcomes. Then the clinicians had to use the photos to diagnose why the unacceptable treatments had partly or fully failed, which lead to a review of practice technique. It was really gratifying to see how this impacted everyone’s thinking a few days later, when we were back in a school placing fillings.

Since the BPOC was originally conceptualized as crisis management, a challenge of our project establishing a quality of care standard in a stable primary care setting. At this year’s workshop Bethy helped introduce a competency framework.  During the three days of classroom work, our new technicians supervised old technicians in a “simulation seminar” where they had to demonstrate each technique using the competency checklist.  When we moved to the three-day school setting with live patients, new technicians were supervised through ten of each procedure and had to pass the competency checklist ten times.  Veteran technicians performed one of each technique under a doctor’s supervision and we used the completed checklists to award “competency certifications” that are valid for 18 months.  We even created a framework for technicians to review their competency certification every 1-2 years.

 

 

 

 

 

 

 

Overall, the workshop was meant to guide our clinical teams toward a more rigorously informed, holistic approach to school-based health care, where JOHC technicians work as members of the primary care system rather than visitors. The training emphasized taking time to slow down and connect with patients rather than blowing through a line at the door.  Dentistry can be scary and rather than jumping straight at a kid’s teeth, the intake leaves time to comfort frightened children and to learn about their lifestyle habits and disease risk factors. In turn that information is used to provide more complete and well-informed care, instead of just treating as many teeth as possible. It seems obvious, especially for primary care practice, but in reality that’s not usually how dentistry is done in our setting (or often, in general, if we’re being honest). As part of this, the clinical teams spent a good amount of time reviewing cariology (the biology of oral disease) which unlike the practicalities of how to mix cement and apply it properly, informs which techniques should be used when.  In other words, without adding in more high-technology interventions, we are focusing on more effective deployment of the conventional BPOC.

For me as a non-clinician, it’s super interesting to see how these minimally-invasive techniques can be used not only for emergency management of foregone problems, but for early intervention and prevention of disease in the whole child.  In all children, actually.  This same package of care can be used in service to population level public health needs where resources are a practical limitation, and yet there has been little focus on applying it that way. My dream is that one day it will be rural technicians and assistants presenting to academics at conferences on how they’ve adapted and improved these innovations to benefit their communities in the real world.

An incredible thing happened on the third day of our practice seminar in Kaskikot.  The school we chose is next door to the Health Post.  The third day was reserved for parents so that technicians could apply the training concepts to adult patients.  I was waiting out in the stairwell when suddenly I saw a face I could never forget: Nisha, one of the students I taught for a year at Sada Shiva Primary when she was in fourth grade, a million years ago.  It was with Nisha and her classmates that Govinda dai and I ran our first ever school oral health program back in 2004.  At the end of that day, we took a photo of all of us in front of the Kaskikot Health Post, which at that time was just one simple building that today is fully dedicated to our Dental Clinic.  Nisha had come to our seminar because her daughter is a student at the school where we were running the training in 2018–with five dental technicians, seven assistants, and an international expert in public health dentistry as trainer.



 

 

 

 

 

 

Finally, the icing on our professional development cake was a world-class makeover for the Kaskikot Clinic.  My friend Maelle who lives in Pokhara started an organization called We Art One that paints murals and does art programs in schools.  We asked We Art One to turn our Kaskikot Dental Clinic in to something bright and welcoming.  They took it next level, putting this exuberant mural on the outside and literally building a ceiling mobile inside for patients to gaze at while lying in the chair. It’s made from hand-cut wooden clouds that Maelle painted.

I know not every rural Health Post in the world can have clouds and rainbows hanging from the ceiling.  But I think they all should and I think we should try. The only reason we need is that every patient in the world is a person.  Those of us with choices would never choose health care in an unfriendly, cold or unwelcoming environment, especially for medical treatment that can be scary like dentistry. I don’t know why we seem to believe in some kind of false economy that suggests it’s not realistic to afford that dignity to everyone.  This beautiful artwork was not expensive or difficult; it was just a decision.  It mattered more than doing something else for some other purpose.

So that was our summer.  Two new clinics and nine veterans are open for business, if anyone out there needs an appointment!  Come visit us soon!

2004:

2018:

 

 

 

 

 

 

 

Farmer vs. Medic: Mountain Carry

 

I consider myself something of a carrying specialist.  I have carried water, I have carried wood, I have carried grass, I have carried stinky buffalo-poop fertilizer in a basket and I have carried straw.  I have dropped sacks of rice and recovered and soldiered on with other sacks of rice.  I know carrying, and I know the hills of Nepal.

Relatedly, Bethy is here doing summer-session professional development with our clinical staff, and it just so happens that she spent 10 years as a medic in the New Zealand army.  Recently, we got to talking about the topic of carrying.  It turns out a core skill of army medics is the “fireman’s carry,” and also that this skill may be used either in an emergency with an unconscious or wounded individual or in situations such as on a dance floor, at a bar with friends, or in the middle of the road in Pokhara.

Now Bethy and I are both what you might call competitive individuals–in an entirely healthy and reasonable way, of course.  Out of pure scientific curiosity and in pursuit of expanding human knowledge generally, we got to discussing who could carry whom from the house to the water tap in Kaski.  As Bethy is a scientist and published researcher, and I am a self-made live-in-Nepal-and-start-dental-projects-and-write-stories-er, it became imperative to deploy a proper study on the matter.

Our publication follows herewith.  It is my deep hope that this work will contribute to a deeper understanding of the world and serve as a basis for future investigation.

Phase 1

Phase 2

 

 

 

Afternoons

 

First Saturday of Summer  

our hands sweat in the grass until

plateaus and peaks draw in their woolen covers.

Fried fresh corn kernels from the fire

salt.  

Each drop on tin, a world

An hour, or so

maybe more or less

to talk about, so

We gaze out the door

where slick leaves are dripping

lick our salty fingers

and pass the minutes

…or so they pass us

listening to the rain.

*

At the Base of a Tree

 

The cicadas came when I was five
behind the school yard.
I put my finger on one
and then I picked it up
it was like a fig, dark and rough.

At five cicadas were interesting, like figs.

Now I am much bigger
friendly, the little goat nuzzles my shoulder with his warm snout
soft, we are alive, together easily.
And then I press my eyes shut
as I capture the insect that has invaded this carpet, which is mine
because I own it.

Sometimes I wonder how I can find my way back
from the pliant kid to the figs to the cicadas, captivated
with all their legs, their slick ribbed shells, all their songs enchanting
the school yard
all chirping and chirping tickling my ears until my ears overflowed with music
amid the crunching leaves and delicate wings
a symphony, a society, a universe blossom
after seventeen years of silence.

Sometimes I wonder
what we are afraid of
why we crush things, bugs and leaves and oceans and people
when I was five, I used
just one tiny finger
to say hello.

*

 

Keys and Threes

 

Thirteen days ago, Butu bouju’s father died. Out of all the possible things that might have been happening today, the whole community was gathered at Butu Bouju’s house for the last day of kriya. As the sound of the priest reading propagated over the arrival and bustle of visitors, Butu bouju’s house had that particular feeling of the world being unveiled after a deep and intense period of ritual mourning. Aamaa and Pascal and I pulled up plastic chairs in on the patio, where many relatives had come to pay respects. So the chance for us to be with family and community before our departure across the world was brought about by a death.

“How are you both? Laura, when did you arrive, when are you leaving?”

“We’re leaving for America today,” we told everyone. “We’re both going.”

Bhim arrived. We haven’t seen each other in probably three or four years. This November will make fifteen years since Bhim first brought me to a small house around the corner, where a widow and her daughters were living, and offered to have me move from his household to theirs.

“You’re taking Aamaa to America?” Bhim asked.

“Yep.”

“Today?”

“Yep.”

Bhim shook his head and smiled with that ironic twinkle he gets sometimes when I’m just not figure-outable. Which is a lot of the time.

“This has been a long story,” Bhim concluded.

“Yeah,” I laughed, “it has.”

“Tell Bishnu hello from me,” he said.

We left the kriya and went home to finish organizing. I’ve left this house nearly twenty times, and always the leaving is leaving Aamaa. After that, it’s just physically departing from Nepal. Bringing Aamaa along feels like bringing the house, and I’m not to sure how to pack.

Something else strange – the quiet. One of the things I remember from when Bishnu left in 2008 is how crowded the house was with people on the last night: neighbors, uncles, relatives I’d never met before and have rarely seen since, they were all crowded on to two beds, talking and laughing. In most households, when a family member is going abroad – “outside,” is the word people use – there is a great deal of activity. But Aamaa’s house is not a usual household. There’s nobody else in it.

So as mid morning became afternoon, it was just us, wondering how to ready the house to be without its mother. I swept and Aamaa put the mattresses up. It was unclear what else to do; I just wanted it to look organized. Like we’d prepared something.

Sonom sir came down from the Resort. I’ve bought six packets of local tea that he grew in the resort gardens behind our house. I hang out at the Resort now and then, to jump rope or do qigong, to chat with Sonam sir and his wife and nephews. Many of my friends have stayed there over the years while visiting me. Sonam sir’s family is from Solukhumbu, and like me, they are outsiders who have their custom-made place in Kaskikot.

“Good journey,” Sonam sir said, giving Aamaa and I each a kata in the Sherpa tradition.

Throughout the prior evening and afternoon, there was one person who spent a good amount of time sitting with us: BAA!, Mahendra’s father. Our cranky, sarcastic, exhausted neighbor, the one whose missing teeth prompted my career in delivering rural dentistry to underserved people. From the time I first came to Kaskikot, BAA! seemed unapologetically resentful of my unearned privilege in the world. He and Saano didi’s husband often function as the men in our house, chopping branches or negotiating social matters that require representation by men. Over the years I’ve spent a lot of time with BAA! collecting branches or chasing the chicken while he watched me fumble or drinking tea and admitting that I don’t have any explanation for why the world is crap. That God gave me easy and he got dealt hard was never to be smoothed over or ignored. On some unspoken level, it wasn’t my fault, but I didn’t deserve any credit for being ahead, either. So we just collect branches and sip tea and that’s how it is. I took to calling him BAA! because he would point at himself and say, kind of demandingly, BAA!  Father. That’s how I was to address him, even though Bishnu and Didi call him “dai” or brother. At least he would be in charge of that.

Often our closest neighbors simply wander off when I’m leaving Kaski, as goodbyes are uncomfortable and pretty pointless, anyway, and at some point in the afternoon BAA! had indeed wandered off, and that was that. So I was surprised when he reappeared holding two silky white katas. He gave one to each of us.   BAA! will probably never see America, or probably anywhere outside Nepal. All the tourists come and go from this village and he is getting old with fewer and fewer teeth that I could not save, either.

“Go well,” BAA! said. “Take good care of Aamaa. And bring me back a son-in-law.”

After we’d done whatever we could think of to do, Aamaa changed in to the clothes that she’d hung outside in the shed the night before. Once her travel clothes were on, she couldn’t go back inside.  It’s also inauspicious to leave the house for a long journey in threes, so Aamaa left first, her bag packed with cucumbers and ghee and the CDMA phone for Didi and almost nothing to take America. In one of the strangest moments of my adulthood, Aamaa walked out of the yard and around the garden of cut corn stalks while I stood on the porch with Pascal, watching her go.

Then Pascal took a key out from around his neck and jammed it in to the wooden door. With that, he and I followed Aamaa up the little path, to the road, to the bus that will take us to the other side of the world.

*

Auspicious Leaving

 

Our flight to America was scheduled for a Monday night, but finding a day to leave the house in Kaski was a problem. Generally speaking, Saturdays and Tuesdays are inauspicious days to leave one’s house for a long journey (although on Tuesdays, you can get away with it, but ideally you shouldn’t stay at the house you are going to). Plus, Aamaa has a special restriction on Mondays that doesn’t necessarily apply to everyone: she is so much a part of her house, so rarely leaves it, that Mondays are off limits too when it comes to locking the door and saying goodbye. That left us with Sunday morning they day before our flight from Kathmandu as the only viable date for departure. And then it turned out that was ahmse ko chatujasi, a monthly position of the sun that is inauspicious for leaving one’s house. Sunday was a non-starter.

Problem.

The solution we came to was that Aamaa would put her packed bag outside the house in the early hours of Saturday morning, before it was fully Saturday.

I arrived back from Cambodia on Friday evening with Pascal in tow, and found the corn cut down. We did all the usual things – making dinner, playing with Amrit and Narayan from next door, chatting with neighbors passing through. Aamaa set to arranging things in a small shoulder bag. Two saris, two blouses and a petticoat to wear with them, and the two new kurta salwaars we had had made. What else should she bring? The bag looked disconcertingly empty. I show up in Nepal with two large duffel bags every time and most of my wardrobe lives here. What do I usually have in there? Can that give us any clues as to what Aamaa should add to her bag?

A sweater for the plane, I suggest. It is cold in the plane.

Mostly Aamaa was concerned with what items we would bring to Didi in Pokhara tomorrow. An enormous cucumber the size of a cricket bat. A bottle of heavy ghee (and a collection of smaller bottles for Bishnu, Mom and Dad, Ricky’s family, and me.). Aamaa’s CDMA telephone needs fixing, and besides, someone might call it while we are in America – we were to leave the telephone with Didi. Most of Aamaa’s bag was filled with things to be left in Pokhara.

“Laura, set your alarm for 3am.”

“I set it.”

The evening wore on, our last evening, the one where normally my bags sit threateningly zipped and ready, signaling the splitting of our worlds. Instead we just fell asleep, wondering what is going happen next.

“Did you set the alarm?”

“I set it.”

We drifted off. My dreams wove in and out, waiting for the alarm. Finally I opened my eyes. It was 4am.

“Aamaa, wake up.”

“Hadjur?”

“The alarm didn’t go off. It’s 4am, go quick.”

Aamaa took her hand bag and hung it outside in the shed. The phone and other belongings were allowed to finish the night in the house, but the clothes she would travel in needed to leave before daylight betrayed them.

I drifted off again, the feeling of uncharted territory hanging softly in the pre-dawn.

*

Between the Corn and the Millet

I try to imagine Aamaa’s life as it was back then, when the water springs in Kaskikot weren’t concrete taps but delicate pools that stirred up silt if you took from them too quickly. As a girl and young wife of 13, she sometimes had to sleep overnight in line while other women had their turns gently lifting the water jug by jug. By the time Aamaa was 22, she was a widow with two young girls of her own, and it would still be years before a bus came to Kaskikot, or a door was put on the entrance to her one-room house.

There have been many impossibles in Aamaa’s life. She raised two educated daughters who could split wood and carry twice their weight by grade school. The civil war started, but it was elsewhere, in other villages. The electric mill came; the bus came; the tourists came; other people converted their houses to homestays and restaurants. Aamaa’s house is off the road in a cul-de-sac of mountainside that nobody wanders past by accident. Even after some foreigners bought the patch of land on the hill behind the house and built a fancy hotel there, passers-by from Korea and Israel and Japan and Australia hiked past with their eyes straight ahead on the sprawling white peaks, rarely looking down to notice Aamaa and Didi and Bishnu there in the sunny yard, drying grain.

The likelihood that I would wander through the door one day has always seemed both insane and inevitable.  And over the last fifteen years, I’ve mostly thought of my life opposite Bishnu’s.  We were the two girls born at the polar ends of the universe, the ones who looked at each other and thought, what if I were her?  She’s been in the U.S. for eight and a half years now, while I spend significantly more time in Nepal than she does.

Aamaa was always more like the soil: everywhere, earthy, constant, essential.  She has all the nutrients and produces all the food and water and shelter.  Aamaa keeps the house alive, the field and gardens fertile from cycle to cycle, the fire crackling.  No matter how many people show up, Aamaa feeds us all. And no matter how many people go away, no matter how empty this house gets or how many of her birthdays pass, she keeps the water jugs full and the seeds sorted in dusty bottles. Aamaa has spent five decades in this village.

I had no idea Bishnu had applied for Aamaa to get a tourist visa to the U.S. to see Bishnu graduate from her Master’s program in information technology. Nobody told me that Prem and Didi took Aamaa to Kathmandu for the very first time last May to go to the U.S. Embassy, or that on the way there, Aamaa didn’t eat any cooked food because she couldn’t be sure who had prepared it. A few weeks later, I answered my cell phone in the parking lot at Walmart, and Bishnu announced that Aamaa had been given a five-year multiple entry tourist visa to America.

“What?” I said.

“For my graduation!” Bishnu explained ecstatically. She hasn’t seen her mom since 2013.

This explanation failed to explain all the questions I couldn’t think of.  Obviously the idea of having Aamaa make this trip has floated through my brain millions of times, but it was the ultimate what if ever.  The craziest version of everything.  Part of me thought that maybe this was all kind of a whim – a thing that might happen next year, or something. But Aamaa had sold the buffalo within a week.

On my way to Nepal in June, I tried to imagine having Aamaa with me on the way back. First I tried to digest the most obvious and superficial matters. For example, how would I explain the enormous statue of a teddy bear bent over with an apparent stomachache dramatically bottom lit in the Doha airport?

I can’t even explain that to you.

When I arrived in Kaski, everybody’s greetings had adjusted to the most up-to-the-minute state of affairs. “Laura! You’re here! How long are you staying? So, you’re taking Aamaa back with you, eh?”

Only Aamaa and I seemed cautious and uncertain with our excitement. The whole thing is so surreal that even the discussion feels like an entirely new and foreign continent. For fifteen years Aamaa and I have had what is now a very well established routine: I come to Kaskikot, we eat together in the kitchen, we go plant things with neighbors and churn milk and carry water from the tap, I fix up some things that need fixing in the house, we gossip about family here in Nepal and all the far away people not in Nepal. Aamaa knows them all – my whole extended family and a good number of my friends who have been to visit – largely through stories. But she’s the stable point, not just for us, but for herself also.

“So we’re going to America, huh?” Aamaa says as we are sitting on the porch, as if testing out the statement.

“Sure seems like it, right?”

We stare out at the tall curly corn stalks, crowding out the grassy millet that’s planted between them.

“What is the name of your District?”

“Pascal, do you know how many states there are in the U.S.?” I ask, and he doesn’t know, so I explain again about Virginia and Maryland and Connecticut and North Carolina.

We discuss departure dates because I have to change plane tickets that currently have me going home from Cambodia, where I’m visiting Bethy in August; Amaa knows Dr. Bethy, because she’s been here too. We mull over how long Aamaa’s trip to America should be. A month would probably be good – she might be bored after a month?

“I’ll go after cutting down the corn, and I’ll come back to cut down the millet,” Aamaa suggests with sudden firmness.

That seems good, I agree.  That is more orderly – maybe because we can see the corn.

Long silences. What, exactly, should we should be planning?

“Bishnu suggested I should get some kurta salwaars made,” Aamaa says. “I guess you aren’t really allowed to wear a sari in the U.S.”

“You’re allowed Aamaa. But a kurta salwaar might be more comfortable.”

“Ok we’ll plan a day to do that in Pokhara,” Aamaa states. “I guess we have to leave time to have it stitched and everything, right? We should go soon.”

“It only takes a couple days, but we can go soon.”

“Nah, you should just pick something out and I’ll meet you at the tailor,” Aamaa adjusts. “I don’t know anything about picking fabric.” Honestly, in sixty years, Aamaa has never walked in to one of Nepal’s fabric shops and picked out material for an outfit, which is how literally everybody in Nepal gets their clothes.

“No no no,” I insist, “I think you should definitely get to do the fabric choosing. Pick your own color, something you like.” I have to talk her in to it.

A few weeks later Aamaa takes the bus to Pokhara and waits for Pascal and I to come meet her at a chautara in Chiple Dunga. She can find her way to Didi’s house, but for the most part she prefers assistance to get around the city. Between the three of us, Pascal is the only one who can properly read in Nepali. We set off up the road to go to the fabric shop.

Laura chiama, let’s have some ice cream,” Pascal suggests wisely, because I am the sucker who will pretty reliably buy us all ice cream. As we pay, Aamaa has sat down on the low wall at the foot of the store, which is not a seating area, and Pascal and I go with it. I hand Aamaa her first ice cream cone.

“Do I eat this bottom part, the biscuit?” Aamaa asks.

“Yes, but don’t eat the paper,” Pascal instructs.

“I’m not going to eat the paper,” Aamaa says.

I can’t even remotely transpose any of this to Connecticut. I ask a passer-by to take our picture, and as you can imagine, she looks at the three of us – the Aamaa who has very obviously just beamed in from the village, the entirely incongruous American, and this regular Nepali boy being raised in the city – and gets a huge grin as she takes our picture. What could our story possibly be?

We set off again. Aamaa has brought along a broken umbrella from the house. “Laura, where’s a place that we can fix this umbrella?” she asks. I blink, there must be an answer to that, but I’ve never thought about an umbrella-fixing place.

“We should probably just replace it,” I say, feeling guilty for my wastefulness and mental laziness. I don’t have the energy to try to figure out where the umbrella fixer might be and there’s really no excuse for it.

As we wander to the center of town I’m distracted and disoriented because everything is inside out. When I first came here I couldn’t say a word or do a single thing for myself, and in Kaski, Aamaa runs everything.  We get a few kilometers off her turf and suddenly she is the foreigner and I’m the one who knows what we’re doing. She has also brought with her a heavy bag of cucumbers and other items for Didi and Bhinaju and the boys, and she’s carrying it on her shoulder, the way people do in the village where nothing is flat.  Pascal is twelve and he goes sprinting out in to traffic as we cross the street and I pay him no heed whatsoever because I’m dodging people to keep eye on Aamaa, having no calibration for how much I do or don’t need to hover over her in traffic. We probably haven’t walked through the city together more than two or three times in a decade and a half, and never just us – not once.

We arrive at the fabric shop.

There are hundreds of colors and textures of cloth to choose from. Aamaa looks hopeful that I will take over. As a young man begins removing options from the shelf she bends over them. He throws one on top of another and another and another and another. Her hands settle on a jubilant orange outfit.

“I like this one,” she suggests. She looks at me as though asking if that one is a good one to like.

Within ten minutes, Aamaa and Pascal and I are pawing through dozens of kurta salwaars, trading opinions on what Aamaa should wear in America. She picks two, and we take them to the tailor, who takes out his tape measure. He’s going to make something just for her, in her size and shape, to wear between the corn and the millet.

“I think you should do short sleeves,” I say. “Definitely short sleeves.”

“I don’t know – I think they should be a bit longer. To the elbow,” Aamaa says. The tailor agrees – maybe longer sleeves for an Aamaa. No way, I say, short sleeves look best on a kurta and it will still be hot in September. Aamaa studies her arms for a minute, apparently imagining them in a very standard piece of clothing she’s never had.

“Yeah. That’s how I want them,” she concludes. “To the elbow.”

*

Laura Chiama

 

I’ve been here a week and by yesterday it was time to head to Kaski for the weekend. Pascal and Aidan have their exams this week, but I like taking one or both of them with me when I can.  In Pokhara, there is too much sitting. When Didi and Bishnu where 9 and 11, they spent all their non-school hours working, carrying, cooking, washing, or studying by the little kerosene lamp. Aidan and Pascal should examine bugs and trip on roots while running over the terraced fields.

Pascal said he wanted to come along, so I told him to show up at 4:30 the room I’m renting this summer.  He was here and ready at 4, and Aidan showed up a few minutes later. While I put my things together, they explored my little apartment, and I suggested they take the opportunity to try out the private shower with its shiny hot and cold faucets. The boys are used to bucket bathing. Pascal gave the shower a go (very refreshing, Laura-chiama), but Aidan ran out of time. The sky was gathering a storm and we had to get to the bus park.

We arrived just in time to cram ourselves in to the last Friday bus. The bus to kaski is always crowded and always an adventure, but Friday evenings are the worst. I found a spot up near the front of the bus with my back to the driver – I was sitting, so that’s a plus – and Aidan wiggled up on to my lap.  The bus was packed well beyond capacity, every knee and elbow and hip bent to accommodate a body part belonging to somebody else, a situation made worse by the rain that had started.  With all the windows closed it felt like oxygen was being consumed faster than it could be collected, and the window panes fogged up with body heat, leaving everything slick and heavy. Aidan was hot on my lap, and I wished I’d shoved him in to the shower. Then again, he was my only shield against the sea of limbs and sweaty brows, and at least his sweat is familiar. For a 5’8” American, I can pack myself in to a pretty small space in a crowded Nepali bus, but this ride was set to put my capabilities to the test.

Up we went. Switchbacks.

By the time I peeled Aidan off my lap in Kaski, dusk had settled soft and blue on the hills. We emerged outside into the cool wide air, suspenseful with pending rain, and ran through the corn stalks to the house (Laura-chiama, the corn is so much taller than you!). Aamaa put dinner on our plates, and sitting on the floor, we arranged our knees to fit in the narrow kitchen. The electricity went out.  The very same kerosene lamp Didi and Bishnu studied by all those years (my single favorite object in the house) lit up the clay walls and the boys’ faces in the kitchen, where I feel happy.

Aidan and I are both partial to the new kitten, a bony sliver of a thing that always seems hungry and cold. Aidan likes to pet its fragile spine with two fingers, the only thing I’ve ever seen him do gently.  Normally Aidan moves too fast, is covered in bruises, and breaks everything. But he feeds the kitten little bits of rice on the clay floor while we eat. When we get in bed, the kitten wants to cuddle with us and I let it nestle on to my shoulder while I read. It purrs in to my neck. Aidan is delighted, but Aamaa and Pascal are displeased. The cat is a feral beast with no business in a bed. It is here to eat mice. Poor little thing.

During the night, I wake up every time I have to roll over because I don’t want to smush the kitten. Aidan jabs his knee in to my back.   Around 4am, the kitten poops exuberantly onto the blanket. I take the kitten and the blanket off the bed and go back to sleep.

I wake up my favorite way: gradually, lazily, inside the conical mosquito net drifting up to the ceiling, with rain pattering on the tin roof.  Aidan is already gone out of bed.  Saturday stretches out before us, a long summer meadow rustling and flowered.

Narayan with his other American gift

I come out on to the porch and Aamaa is serving milk tea. Milk tea! Aamaa sold the buffalo a few weeks ago and we are milk-less.Where did the milk come from? But Aamaa knows that I forget about black tea halfway through, and it gets cold sitting on the porch.  Somehow this morning she is pouring creamy milk tea in to a tin cup and everything is perfect.

Narayan comes over from next door, and within a few minutes, Aidan has broken the toy I gave Narayan: a set of Velcro pads and a Velcro ball to play catch with. The boys set to fixing it. Aidan recruits some tape from someplace, I can’t imagine where, and Pascal has taken a sickle to a piece of bamboo. He is making a walking stick. They want to watch TV and Aamaa tells them that’s fine so I unplug the TV and hide the remote and tell Pascal to go wield a sharp object too close to his hands, like the rest of the kids.

I walk over to Govinda dai’s house for is sarad, the anniversary of his mother’s death.  I get there just as  the priest is arriving to start the puja, and he asks after how I am doing. The priest knows me partly because I stick out, and also from my project documenting death and mourning rituals. I have sat and listened to him and taken his photo and written about him and sought explanations from him often. The house fills with incense and stillness and an oil lamp is lit. Sulochana doesn’t want me to leave; she asks for some henna on her hands, and I’m surprised this is allowed on sarad, but Govinda’s father doesn’t seem to mind.

In the afternoon little Narayan takes a break from his exploits with Aidan and Pascal to bring me down to his mother’s fields where Aamaa is helping plant rice. I follow his tiny frame along the edges of the flooded rice paddies, and through the part of Kaskikot where the students I taught in 2003 are from. Their families know me as Laura-miss, and I spend less time in this area, so people might only see me every couple of years, but I sense a certain look of recognition when I pass somebody who knows me as the teacher of their kid. “Eh!! Laura, Laura right?” She is going to cut rice, they shake their heads, isn’t that delightful? Yes yes, it’s Laura. I have a weird life, I think, and it is pretty great. After all this time, it is still magical to be known on a wooded stone path winding down to the rice paddies.

 

We pass our neighbor Butu bouju. Laura! Did you have milk tea this morning? Aamaa wanted to pay for the milk, Butu bouju says, and I said no, Laura is here from America. Aidan and Pascal are visiting from Pokhara. They should have milk.  How was the tea?

For three or four hours, Saraswoti and I stand shin-deep irrigated mud, planting one sprig at a time.  The gleaming hills stretch out across the valley, monsoon humidity draped over their shoulders.  The edge of my left leg will get burnt below the knee, where my rolled up trousers cease to shield skin against the hot sun. Mostly we work together in silence. Every once and a while Saraswoti looks over and murmurs, bhay chha Laura, bhay chha, it’s good. Or, Laura, how much does a plane ticket cost to get to America? I bet it is scary, being on a plane. I ask if Saraswoti has ever been on a plane, even though I know the answer. Does she think it would be scary? Probably, I think. It would be scary, I guess. Splash, plop. Bhay chha, Laura.

Last Saturday, I think, I was in Connecticut.  I try to remember what I was doing…errands?

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Downpour.

Starting around 4pm, we could barely hear ourselves for the rain pummeling the tin roof.  Sulochana and Narayan were both over.  I decided Aidan still needed a shower and began to goad him in to going out in the deluge.  Narayan, who is even more of a spaz than Aidan, launched himself into the center of the patio with all of this clothes on and was immediately soaked.  Aamaa began screeching at all of us.  In this weather! Get inside!  Everybody on the beds with the windows closed!  Aidan changed in to shorts and came running on to the porch, alight with glee, while Aamaa scolded him loud enough to cut through the noise of the pounding water.  There was a curtain of rivulets dripping off the corrugated tin all along the edge of the porch.  Aidan stuck his hand out, stuck his toe out, and then finally

I dried Aidan off.  See, Aamaa?  Now he’s clean-ish.

Narayan spent the rest of the afternoon without his shirt on.

I lay down on the bed to read by the gray light of an open window, because we’d unplugged all the lights and turned off the electric sockets.  Lightening has ended more than one life in this neighborhood; in Saano Didi’s family, it was inside the house.

Laura-chiama!  Let us use the henna!  Please please please….I allow Aidan, Narayan, and Sulochana to decorate my outstretched left arm with henna while I use my right arm to hold mybook on my chest.  The three of them hover intently over their work by the light of the window, while the rain continues singing loudly over our heads.  It tickles.  Sulochana has been learning by watching me, and she makes a lovely flower in my palm.  I take my eyes off my book and notice Aidan squeezing the tube of henna lusciously in to a pile of brown goo under the spot where he has scratched out my name below the elbow.  Later, this will become a bearded LAURA hat looks like a large bruise.  Oh well.

Aamaa and I debate all afternoon over the boys’ exams.  They haven’t brought their books, she says, and they should have gone back to Pokhara today to study.  Aamaa comes up with all kinds of nonsensical plans such as walking them to Naudanda an hour away to catch the bus.  I say that if they want to get on the 3:30 bus from Kaski, we can send them off and Didi will meet them at the bus park.  I say we are leaving at 7:30 am tomorrow morning on the first bus.  Aamaa says they shoudl be reading now.  I ask Pascal how old he is and he says almost twelve and I say, “Do you know you have an exam on Sunday?” and he says yes Laura-chiama!  And I say, see Aamaa?  They decided not to bring their books and that’s up to them.  Aamaa says the bus could be cancelled tomorrow morning, and I say there could be a flood or alien space landing or invasion by Mongols, but generally speaking, the bus leaves Kaski every single morning at 7:30am.

It pours torrentially all night.  Waterfalls, oceans, tidal waves coming from the sky, filling every bucket, drum, jug, pot; washing the stones clean; overflowing the planted rice paddies.

Aamaa wakes us up at 5:30am.  I scold her from inside my mosquito net.  Aamaa!  I set my alarm for 6:30am!  Why do we need to get up in the middle of the night?!  Grumpy, I stay in bed until 6:15.  When I get up, the boys are eating heaping plates of rice, vegetables and daal that Aamaa has cooked before 7am.  Like she does for me when I am leaving at 9am for the office, when I eat rice because I know how much it matters to her to feed us before we leave the house for the day.

MILK TEA.  I fill up my cup twice.

Aamaa wants us to make the hour long walk to Naudanda to take the bus to Pokhara.  I roll my eyes.  There is a bus leaving from right here at 7:30am!  The road will be washed out, Aamaa says, the bus could break down, a million problems could occur.  We could be late.  The boys have their exams, they haven’t even studied, why don’t we walk to Naudanda?  Has Aamaa spoken with my mom lately, I wonder?  Moms are all the same.

We go backwards through the drenched corn stalks to Deurali to wait for the bus.  Prem sir greets us.  The bus is not going this morning, Prem sir says, because there have been some small landslides and the road is blocked.

We have to walk to Naudanda.

Laura-chiama, we have to walk to Naudanda!!  HAHAHAHAHAHAHAAAAAA!

Everything is soft and cottony in a mist that makes us unsure whether or not it has stopped raining.  Even though there is no water coming down, the air is wet, our hair is damp, the road is full of puddles, and the hills float in and out of a white sky.  We take photos of the mythical landscape.  We find sparkles of radiant purple and red poking out of the clouds in our hands.  Some vehicles pass, taking, like us, the opposite route to town this morning due to the blocked road, and I could stop them, but now we are not in a hurry.

Was there a hurry?

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Hittin’ the Big Stage

The chain of events that led to the UCSF Global Oral Health Symposium included, somewhere in the middle, a very serendipitous conversation about baskets.  But let’s start at the beginning.

Two years ago, when our work was going through a big transition and I was trying to identify exactly what it was about in the long-term, I happened to meet Tula Ram Sijali. He leads a research organization based in Pokhara and was a trove of knowledge about the broader health care system in Nepal, including well beyond our focus area of oral health. When we changed our name to Jevaia Foundation shortly afterwards, I asked Tula Ram to join an informal advisory group.

A few months later, Tula Ram introduced me to his boss, Michael, who was in Pokhara overseeing a project. We’d been hearing about Michael for about a year: he was a public health researcher at Berkeley who was the principal investigator on a few studies in Nepal. At the time, I was pulling my hair out trying to set up a research partnership with a university. So when Tula Ram brought Michael to our office on one of Michael’s visits to town, Aamod and I prepared ourselves to meet a bigwig academic from the prestigious halls of Berkeley. Michael turned up wearing sandals, easygoing and friendly, and sat on the roof drinking tea with us and talking about how much we all love Nepal.

We told Michael about our work in oral health (ok fine, I gave him a thinly clad pitch for Berkeley to start doing research on oral health in Nepal) and Michael told us that he waslaunching a new project.  He’d been shocked to see women in rural Nepal carrying heavy loads twice their own size, slung from their heads by ropes, and wanted to study the impact of this on their bodies.  But seriously, had I seen this? It looked brutal! Michael had already purchased a basket and rope and brought it back to an ergonomics lab at Berkeley.

Listen, I said, you really need to know me.

Also, if there’s a basket study happening, I need it in my life.

As you can see, we hit it off quite well.

When Michael got back to Berkeley, he introduced me by email to the head of Global Oral Health Programs at UCSF. Who turned out to be…my classmate Ben Chaffee from Williams College. Now he’s Dr. Ben Chaffee and he introduced me to Dr. Karen Sokal in the Joint Medical Program at UCSF and Berkeley, and Karen was responsible for organizing our university research collaboration last winter. The rest is history.

Mean time, to return to the punch line of this story, Dr. Chaffee invited me to be a keynote speaker at UCSF’s annual oral health symposium in March. This year’s theme was to be “global perspectives on the health care delivery team.” I would be the second of two keynote speakers.  The first was by Dr. David Nash, who I’d heard of and met the evening before the event.  He’s a congenial doctor from Kentucky working to advance the role of dental therapists in the U.S., a comparable effort to what we are doing in Nepal, although our version takes some decidedly unconventional turns.

All of this brings me to the podium in front of over a hundred academics at one of the best medical schools in the country, barely a year after Tula Ram introduced us to Michael, and just two short years after I was feeling rather lost about our long-term goals.

I spent weeks preparing my talk, but I also understood there was only one presentation I could give. As soon as Dr. Chaffee invited me to present, I said so. Mainstream professionals don’t always warm up to our work because it challenges established definitions of expertise and seeks to reorganize institutions that many people are invested in. Put simply: if you spent eight years going to dental school and getting a PhD, you might not clap your hands at the idea of community health workers in rural Nepal taking a two week training and then opening dental clinics. And I can understand why.  However, that’s also the only thing I can talk about.

There’s also the reality that the Academy, like other structures central to the development of medical systems, is oriented around various credentials that I don’t have. While the other speakers were medical professionals and researchers, I have a Master of Fine Arts in creative writing. I can really only claim to be a storyteller.  But Dr. Chaffee assured me that it would be a welcoming, progressive audience, and of course it was a huge honor to be invited. So off I went.

Most of the time, being a little bit of a weirdo outsider is basically just awkward. But every once and a while, it’s completely exhilarating. The response to my presentation, Rural Oral Health Care in Nepal: A Rights-Based Approach, was, from my point of view, comparable to arriving at a party wearing stilts and discovering that everyone had been, without entirely realizing it, just hoping somebody would show up on stilts. The talk can be viewed here beginning at 54:30. I barely had time to eat a strawberry at the reception because so many people wanted to ask me questions. I was invited to co-lead a workshop called “Delivering Improvements in Oral Health in Low Resource Settings” at a conference in Delhi next October.

But it was also so much fun. There were the photographs of our technicians, team leaders, teachers, and the kids in our school programs, a collection of images I’ve essentially memorized, projected on a large screen before a brand new audience.  As I said in my discussion, these are communities that do not get a voice in the ivory tower. What I realized was that it was the perfect moment to be a storyteller. To be able to talk about something that you do partly because you think it’s a good idea, but mostly because you love the people.  Anyone can disagree with a thing, but how can anyone disagree with people?  I saw how much eagerness there is for something surprising, human, and manifest.  I felt like what I had to say was not tolerated but welcomed.  Maybe that shouldn’t have felt as odd as it did.  But I’ve spent so many years plugging away in Nepal that it was a bit of a shock to watch the story unfold here in California, and realize how…much of it there is.  I think I was the most surprised person there.

And at the same time, I guess wasn’t.

I also got to reunite with Michael, who provided an update on the evolving basket-carrying study.  Dr. Karen and many of the students from last winter attended the symposium, and Bethy was in town for a conference that began the next day. She and Karen and I had coffee together after the talk, and then I lay on a bench in the sun, collecting my thoughts. My heart filled with gratitude.  I had the feeling that over a decade of work had come lightly to rest on a bench under the sunny San Francisco sky, and for just a second, this whole journey made sense. There have been so many false starts, disappointments, rejections and failures.  Here was one of those rare instances of rest.  We’d landed on something.

Then, I got up to wander the city for a few hours.  You can’t just sit there, or the magic evaporates.  Besides, it was a lovely afternoon, and surely there were gems on the sidewalks.

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