Category Archives: Nepal Life

Nepal Life, Oral Health Care Project, Work

Mothers Just Up the Road

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Our most recent clinic launched in the village of Deurali, where Hira runs a clinic at the Health Post every Wednesday. We were in Deurali a few weeks ago for a supervisory visit–or more specifically, a veteran technician K.P. was visiting Hira for mentor supervision, Rajendra our medical coordinator was supervising K.P.’s supervision, and I was there to see Rajendra supervising K.P. supervising Hira. So as you can see we’re doing our best to address any issues around lack of supervision and monitoring for primary care operators in rural Health Posts.

Hira’s been doing awesome in her clinic and already has a week of post-certification professional development under her belt, but we’re still working on building the patient flow in Deurali. This is no surprise; everywhere in the world, people are slow to seek dental care, especially for preventative and early-stage treatment. Rural Nepal is no different, and Health Post dental clinics don’t get much traffic unless paired with strong outreach and a referral system. We’re still getting rolling in Deurali, and this month the local Team Leader, Prashanna, organized an outreach gathering for a local Mother’s Group where his wife is an active member.

We piled in to a car at the office and arrived in Deurali mid-morning, having looped through the neighboring village of Rupakot to pick up Kamala, a talented clinic assistant who works in the Rupakot dental clinic and came to assist Hira for the day. Hira packed up a field kit from the Health Post, and we unloaded the supplies a short walk up the road at the Mother’s Group community building. This building was damaged in the 2015 earthquake, so we found ourselves in a completely normal half of a building with half a roof. The other half was open to both sky and the sweep of surrounding hills, not to mention that the road had recently been bulldozed and taken a chunk of the hillside with it, so the concrete floor dropped off precipitously, in mid-air, creating the effect of a film set on the edge of a cliff.

Behind the half-building, people began setting up a plastic chairs and stringing up a tarp for shade. Because it was the first adult outreach program in Deurali, our two education coordinators Bidhya and Shreedhar had come from the office to lead the workshop and model it for the local team leader Prashanna, who will soon become Deurali’s master of ceremonies for such events. Bidhya and Shreedhar are also new to our team, so this was their first adult outreach too, and they’d spent a good deal of time going through our teaching protocols and creating clever new materials to use. Hira and Kamala set up the treatment area to provide free screening, limited treatments of fluoride varnish and silver diamine fluoride, and referral tickets to the regular Wednesday clinic up the road.

People began to trickle in, take their seats, and chat. When the chairs were full, Prachanna and the primary health worker from the Health Post kicked off the morning. Then they handed the session off to Bidhya and Shreedhar, who inaugurated their roles on our team by doing a phenomenal job by engaging the crowd in an animated discussion. They covered everything from oral hygiene to junk-food-free schools to explanations of Hira’s available services in the Health Post.

I really love this example of Bidhya working what’s called “people-centeredness.” People-centeredness actually specific a term used by the World Health Organization as part of its quality-of-care framework. But what does it mean in practice? Health care that is attuned to lived experiences, that is easy to relate to, that is compatible with the physical and cultural environment. People may not leap out of bed to go get dental care, but they often have no problem talking at length about their teeth and the stories inside of them. What I saw watching Bidhya and Shreedhar work the crowd was not a lecture, but a dialogue not so different from the way that Aamaa and I sit around with Saraswoti and Saano Didi and Maya Bouju in the evenings, cataloguing the day and comparing notes about the world. There is a wealth of available wisdom already present in any community.

After the presentation, people waited as long as four hours for a screening in the half-of-a-community building. There was a 104 year old man, a woman with a difficult home life that made it challenging to arrange an initial screening at the Health Post, and a series of patients perfectly timed for interventions recently covered in our Professional Development Seminar on Aging. Watching as residents passed the time in plastic chairs, waiting their turn and talking about their teeth and other life topics, I pondered the fact that the Health Post, which offers the exact same services plus more, with the exact same provider, every week and ten minutes up the road, has struggled with patient flow. But the plastic chairs under the tarp was people-centered.

Hira screened about sixty residents before the wind picked up and began blowing rain in to the wallless clinic space. Before we repacked everything, she gave out forty referral tickets and delivered a swath of preventive fluoride treatments. I think she’ll keep busy in her clinic the next few weeks!

*

Aamaa, Aidan and Pascal, Didi and Bishnu, Family, Kaskikot, Nepal Life

The Family of Harry Prasad Caray

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This week, my cousins Lynne and Neil came to visit from Chicago. We usually see each other once a year at a family holiday gathering in December that Lynne and Neil have been hosting since I was in college, when they took the job over from my Aunt Peggy. Our Spero family reunion is usually about three days of of extended family bonding in Chicago: walking the dogs by Lake Michigan, making our grandmother Gaky’s icebox cake, spending lazy afternoons sitting around while the Bulls play on TV, and long evenings talking in the kitchen until one in the morning. We’ve been having the annual family reunion in Chicago our whole lives.

But when Lynne and Neil said they were coming to Nepal, I was thrilled by the idea of getting to have my cousins see me in my natural habitat. In the wild.

They arrived on a Friday afternoon just as we were finishing up at the office. It was a bit surreal to see them transplanted from the suburbs, sidling up the walkway past Maya didi’s garden, and then sitting in our common room. They unloaded a collection of toys and books to keep under the coffee table (between the small people attached Sangita, Muna and me, we are badly in need of some kid-friendly distractions for workdays when school is off). They produced a jar of Nutella and then five gourmet chocolate bars which I immediately transferred to a secure location.

Then Neil pulled out a pair of oversized plastic glasses. “So, while we’re here, I need some photos of people wearing these glasses,” he said.

“I see,” I replied.

Next thing I knew, Neil and Lynne were excitedly talking over each other about this guy Harry Caray, who apparently I didn’t know about only because I live in a village in Nepal. Harry Caray is a superfamous Major League sportscaster for the Cardinals and the Cubs whose statue is erected at Wrigley Field, and every year on his birthday, fans celebrate – mostly be honoring the way Harry Caray liked his booze and sang drunk tunes off key and, furthermore, my cousins explained breathlessly talking very fast almost at the same time but somehow not directly over each other while our medical coordinator Rajendra tried to figure out what to do with the slinky on the coffee table, furthermore, Harry Caray had a mysterious connection to Nepal, for example (Neil pulled out his phone and began reading), he was the first major league sportscaster to say “Holy Cow” on air and in Nepal cows are LITERALLY HOLY.

“I don’t really understand how this slinky works,” Rajendra puzzled.

“Hang on, we have to take it outside to the stairs,” I said.

“–AND THIS MONTH IS HARRY CARAY’S BIRTHDAY, AND–”

“–PICTURES ARE BEING SHARED ALL OVER THE INTERNET–”

“–THE CUBS WON 108 YEARS AFTER THEIR LAST WORLD SERIES AND 18 YEARS AFTER HARRY CARAY DIED AND IN HINDUISM 18 IS A LUCKY NUMBER AND–”

“–SO WE HAVE TO TAKE PICTURES OF PEOPLE WITH THESE GLASSES–”

“–IN KASKIKOT, AND IN AMAZING MOUNTAIN PLACES IN NEPAL–”

“–LORD KRISHNA DIED ON FEBRUARY 18 AND HARRY CARAY DIED ON FEBRUARY 18–”

“–HOLY COW!–”

“–AND ALSO OMGOSH ALSO–”

–Neil produced a handful of full-size face cutouts of Harry Caray, who’s head then began bouncing around excitedly as my cousins completed their explanation.

“–AND WE HAVE TO SEND THE PHOTOS TO OUR FRIEND GRANT DEPORTER–”

“–AND HE’S GOING TO SHARE THE PHOTOS ON THE INTERNET WITH EVERYBODY FOR HARRY CARAY’S BIRTHDAY!!!!!”

“Rajendra, don’t tangle the slinky, or it will be ruined before we can do anything with it,” I said. Harry Caray’s shock of white hair and full-toothed smile sat perched on Neil’s hand, waiting.

“Ok, got it. Big glasses. White guy cutout. Take photos with mountains. I think we can make this happen fairly easily…all the components seem to be available.”

Then we moved on to the business of introducing the cousins to my natural habitat. We packed up a some snacks and wine, picked up Aidan and Pascal and Didi, and spent the afternoon on a paddle boat and visiting the Barahi Temple. The next day we had planned to take the jungle path up to Kaskikot and hang around carrying and chopping things and getting astrology readings all day. But at the last minute, Aamaa called to tell me that we absolutely had to change our plan.

“There’s a family picnic,” Aamaa said. “Everyone will be there. Like literally everybody in the whole universe. Two or three thousand people.” Ok that’s an exaggeration, except for the two or three thousand people part. That’s actually what Aamaa said.

“So it’s like a family reunion?”

“It is going to be so much fun,” Aamaa cooed. The picnic would include descendants of five brothers – The Grandfathers. One of The Grandfathers is Didi and Bishnu’s grandfather. That Grandfather alone had nine children, of which Aamaa’s husband was the youngest. So my point is, it’s a very enormous family.

“Don’t you think Lynne and Neil might be bored?”

“Who would be bored?!” Aamaa cried. “There will be two or three thousand people!”

“Do you want to go to a family reunion?” I asked Lynne and Neil. Having a picnic with the descendants of The Grandfathers would mean compressing our schedule in Kaskikot a little.

“Basically what it comes down to,” said Lynne, “is that a family reunion is always a thing to go to.”

We met Didi and Prem and Aidan and Pascal at Hollan Chowk at 8:30am to wait for a family reunion bus. (Neil and Aidan, who turn out to be roughly the same age, commenced exchanging shoes.) One of the buses started in Kaskikot and Aamaa called with updates of its progress as it rambled down through the hills and wound through the valley, picking up uncles and cousins and great-aunts at Milan Chowk and Simpani and Harichowk and Vindivasini.

The Family Bus arrived and drove right past us at Hollan Chowk. Pascal took off down the road with all his limbs waving, the rest of us jogging along behind him and dodging tourists out for their morning coffee in Lakeside. Luckily, due to Pascal’s dedicated flailing, family bus huffed to a stop and we climbed aboard.

Lynne and I squeezed in to the back row of seats with Didi, Prem and the boys, while Neil sat up front and got in to a conversation with our first cousin Ram Chandra Dai. This struck me as extremely entertaining: my first cousin Neil from Chicago, shooting the shit with my adopted first cousin Ram Chandra Dai, on a bus driving out to a family reunion in Chisapani. We ambled on past the edge of Phewa Lake and into the valley along the southern edge of the Kaskikot hills. The cut wheat fields yawned dry and dusty in to the distance.

After about an hour and a half, we arrived to find a shade tarp and plastic chairs set up in the hillside. Music thumped over a speaker. We set our things down and people starting flocking over to welcome us, grabbing my hands. “Laura! Isn’t this wonderful! A family picnic! Everybody is here!” Many were neighbors and longtime friends in colleagues in Kaskikot – Butu Bouju, Bhim sir and Krishna sir and Indra sir, Maile Bouju – whom I’d never really had the chance to mentally arrange as family relations.

Of course in Nepali culture people aren’t called by names, but by a relationship like Didi so I didn’t know almost anybody’s name. But it made introducing Lynne and Neil exceptionally easy.

“My Didi and Bhinaju are here from America!” I’d say.

“Oh, Didi and Bhinaju!” the thousands of relatives (who probably numbered about 200) would reply. After explaining a few times that Lynne was a cousin on my dad’s side, I learned to introduce her as my “banja-didi,” which literally means my father’s-older-sister’s-daughter. As my Banja-didi and Bhinaju, Lynne and Neil were instantly organized in to their places at the family reunion and that was that.

Cousins: Lynne and Neil with Ram Chandra Dai and Aamaa

As we wandered about the grounds, I motioned over to where a goat’s head was being prepared.

Banja-didi and Bhinaju looked alarmed.

“Most likely they brought the goat here this morning and slaughtered it nearby,” I offered. It bears mentioning that I’m the near-vegetarian in the group, but Lynne and Neil took this news hard.

Soon we were scattered about the field, seated on the plastic chairs and chatting over breakfast. I kept being worried that my cousins would get bored. I went and found Lynne.

“How’s it going?”

“Pretty good!” She pointed to Neil.

I’m going to say it was only minutes before Neil had people passing around the oversized glasses and Harry Caray’s head was bobbing up and down around the plates of chickpeas. And that’s how this happened

“Time for the program, time for the program!” somebody announced. We were all summoned to the foot of an empty garden terrace that was to act as a stage.

I didn’t really know what to expect. Our family is very musical and our reunion always includes an ad-hoc music concert in Lynne and Neil’s living room. Uncle Gus plays a spoof he wrote called the Russian Number. The younger kids plunk out notes on whatever instrument they’re learning. For about a million years, my brother had to sing Mr. Grinch in his booming base that would later anchor his college a capella group. Our cousin Greg, who is an actual rock star and jazz composer who played keyboard for Halsey, eventually takes over from the amateurs and the evening dissolves in to a combination of improv and mulled wine and Christmas music played in Jewish minor keys.

“First up, Grandfather Number One!”

A collection of relatives shuffled up on to the barren garden. I realized what was about to happen. The patriarch of Grandfather Number One’s branch of the family introduced the entirety of Grandfather Number One’s descendants to the rest of us. Photos were taken. Discussion was had. I understood what we were doing.

“This is brilliant,” I thought, as each branch of the family was called up and a senior member meticulously mapped out its relational geography. We were here to keep the books organized: to name the membership, introduce new additions, and have a long, solemn moment of silence for those no longer here, like Bishnu and Didi’s dad–Grandfather Number Four’s youngest son, born to his second wife.

It came time for our branch of the family. I dragged Lynne and Neil up with us on to the garden stage, where we stood packed in near Didi and Aamaa before the crowd. Ram Chandra Dai began an accounting of each of Grandfather Number Four’s offspring. Eventually he came to Aamaa and Didi and Bishnu (“who is living in America”), and then, to me.

“And of course Laura, Aamaa’s middle daughter. We take Laura in the family just as Bishnu and Malika. And today Laura’s Didi and Bhinaju are here from America.”

I poked Lynne and Neil and they waved, so that it would be obvious which were the three American people at the family reunion in Chisapani.

Neil looked expectant and hopeful like a puppy with a chewed up ball. I leaned forward and stood up on my toes, which made me three times the height of everyone else on stage.

“Um, thank you everybody,” I said to the crowd. “And, um, there’s just one thing I’d like to do. See, Bhinaju here, it’s his friend’s birthday. And his friend wears these glasses, and his name is Hari.” Hari is a very common Nepali name so this seemed like the simplest path to internet fame. “And Hari really liked Nepal. So, um, we’d like to have a family picture of people wearing these glasses and holding Hari’s picture and saying happy birthday to him.”

We passed out the glasses and Neil ran down in to the crowd, where he stretched his arms out over the descendants of the other four Grandfathers and snapped pictures on his phone, while we waved Harry Caray’s head around and cried “Hari! Hari!”

Man, I thought, I can’t believe anyone listens to the manic things that I say. This is actually working. Lynne and Neil looked ecstatic.

Then someone tapped my shoulder.

“We should be saying Hari Prasad,” she told me matter-of-factly. The oversized glasses and random photos of the white guy didn’t seem to faze her at all.

“Why?” I asked.

“That’s our Grandfather’s name,” she said, “Hari Prasad Subedi.” Then she rejoined the chant. “HARI! HARI!‘

*

 

Aamaa, Family, Kaskikot, Nepal Life, Uncategorized

It’s Definitely Stronger

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The roof of the house is 40 years old and leaking. Aamaa has placed little containers on the wooden beams in the attic, and they catch droplets that sneak through the same holes where sunlight drives dusty spindles inside when it’s not raining. The stone shingles were laid back when the house was first built, and in addition to the leaking, the rough hand-cut wooden beams that hold up the roof up are rotting. The whole thing needs an upgrade.

In past years we’ve replaced the stone roof over other areas of the house, and the uppermost part that covers the attic is the only one that hasn’t been converted to corrugated tin. I wanted to restore the beautiful old shingles, and we called builders in to give us an estimate. But it was clear that Aamaa had already imagined the house covered in shiny new tin. She wanted the royal blue kind.

Before I continue this story, I need to say first that anybody who’s spent time in Nepal but is not from here will tell you that, and I don’t mean to generalize, but literally all Nepalis, I mean every single one, are obsessed with keeping stuff in the packaging. Everything. I remember once my friend Anne telling me that when she noticed the family she lived with chopping vegetables before every meal with a dull knife, she gifted them a fancy new cooking blade from the U.S. They kept it in its plastic armor and hung it on the wall.

To take this further – stay with me here – if things like, say, a vacuum cleaner or cell phone do need to come out of a box, the packaging still gets kept. You can totally normally have entire storage areas taken up just by boxes and covers. Not a mere two shelves of the pantry, like I have in my apartment in Connecticut due to an inability to throw out satisfyingly sturdy takeout containers, but whole storage spaces like the one under the stairs in our office, stuffed with the likes of vacuum cleaner boxes. Every time I arrive in Pokhara, I end up dragging a variety of packaging out to the dust heap from there.

“Why are we keeping the box for our WiFi router?” I’ll ask.

“In case we need it.”

“For what?”

“You never know.”

“Are we going to resell our router?” We use the router all day, every day. It’s attached to the wall.

“It’s a good box. Let’s just keep it.”

Even the furniture stays stays covered, sometimes in real cloth covers but at least as often in the actual factory plastic. I arrived in Sindure once to find our dental chair still wrapped in cling wrap, a patient lying atop its torn and receding shards while having an exam.

Etcetera.

But let’s come back to the leaky roof.

I met Aamaa in Pokhara and we went to the tin shop. Needless to say I know far more about corrugated tin than I ever expected to. An uncle met us there, and he and Aamaa loaded up ten sheets of royal blue tin on to the bus. Aamaa kept pretending to defer to us – “I don’t know anything about it, I’ll do whatever you say” – but in fact I could tell Aamaa knew exactly what she wanted. We tossed some bags of long, thick nails to the driver, and sent the roof up the hill.

I really, really hoped to be in Kaski during the days the roof got dismantled and replaced. We’ve had some great adventures together. On the outside, the stone shingles are beautiful, each one representing a journey from another place, fitted and laid by hand. I hated to see them go, but if they had to, I wanted to help. And then there was the inside, in the attic, where the underside of the stone shingles are exposed.

I slept in the attic for the first year I lived in Kaskikot, when the house was smaller. I loved it up there. I felt protected but open to the world, which was visible through the slatted window that I had to bend over to peer through even when seated on a mat. Even now, when I climb the increasingly creaky ladder and poke my head through the attic floor, I feel a rush of nostalgia that nearly knocks me back down to the basket of millet by the kitchen door. When I lived in the attic, Nepal was completely new to me, but so was the sensation that I had always been on my way and now I had arrived. I had been looking for the attic forever, and I’d found it. In the renovation, two massive raw wood pillars that hold up the hefty stone roof would be rendered obsolete and removed. The attic would feel different; more spacious, and more tinny, I imagined.

Despite my hopes, the renovation occurred while I was in Pokhara. It only took three days to remove all the heavy stones from the roof, break down rafters, remove the boxy supports, and replace everything. By thursday it was finished. I arrived on Saturday morning.

I came over the hill eagerly, feeling the arrival momentous. The appearance of our roof over the crest of the ridge is always a kind of solemn performance, the overture to my favorite symphony, grand and dependable, a confident transition from the chaotic street to the hushed and orderly theater.

One cue, the gleaming blue roof emerged through the trees. But something looked funny. I squinted at it.

It looked like there were logos all over the roof.

We got tin with logos printed all over it? This is something I was sure a tin company would do. I mean, all the doors in my apartment in Lakeside still have factory stickers on them that were clearly never designed to be removable. Sometimes houses by the highway get huge ads painted on to them. There’s nothing too out of the ordinary about having logos all over one’s house. I came running down the hill, around the edge of the terraced wheat, and met Aamaa in the yard.

“Aamaa why does the roof have printing on it? Doesn’t this–” I scratched at an extra section of tin that was on the buffalo shed, digging my nail in to the logo.

Back it peeled.

“Hold on a second.” I scratched more. A long strip of plastic peeled away.

“Aamaa did you leave the roof in the wrapping?” I asked.

“What do you mean?” She replied innocently.

“This sticky plastic is supposed to come off.” I felt a prickly, alarmed feeling at the base of my head.

“It is?”

“Aamaa, the house is wrapped in plastic!”

“Oh.”

“Why didn’t the builders——”

“Honestly Laura, it’s stronger this way,” Aamaa finally admitted.

“It looks crazy!”

“No it doesn’t, it looks fine. The rain will eventually peel it off anyway.”

“That’s why we should just peel it off ourselves,” I proclaimed.

“This way is stronger,” Aamaa insisted.

A debate ensued. This is an activity Aamaa and I are highly practiced at. How it goes is, I declare that our roof should be unwrapped and that I am going to unwrap it. Aamaa tells me it’s fine as it is. We keep having this disagreement while I climb up on to the house, clomp across the section of tin roof over the porch, pull myself up to the next level over the bedroom, and for the forty minutes it takes me to strip back the factory plastic while squatted on the highest part of the house like some sort of possessed gargoyle. I scratch madly at the logoed plastic until I can get an edge free, and then use all my counter bodyweight to stretch it upwards while trying not to slide myself downwards, on to the lower roof, and splat in to the yard. Each yank makes an uproarious and lengthy honk, as if to express the gravity of the situation. The plastic is covered in lettering that reads: AFTER INSTALLATION REMOVE THE GUARD FILM.

Saraswoti calls out from her yard, which is about level with me when I’m squatting on the roof like a possessed gargoyle.

“Whatcha doin’ Laura?”

“Unwrapping the house.”

“It was stronger in the wrapping!” (Aamaa from the yard)

“It says ‘remove this plastic’ right here on the plastic!” (Me from roof)

“HHHOOOOOOOOONNNNNNNNKKKKKKKKKKK.” (Plastic)

“Aamaa, Laura’s unwrapping the house?” (Saraswoti, pot-stirring)

“Laura, whatcha doin?” (Saano-didi’s husband wanders in to the yard)

“She’s taking off that nice plastic!” (Aamaa to Saano didi’s husband)

“I didn’t think it looked bad.” (Saano didi’s husband)

“It looks crazy!” (Me to Saano didi’s husband)

“Giggling hysterically” (Saraswoti)

“I started taking it off yesterday and then told Aamaa to leave it on….It’s stronger this way?” (Saano didi’s husband, pot stirring but also unsure what’s real anyway)

“HHHHOOOOOOOONNNNNNNNNNKKKKKKKKKKKKKKK”

“Pascal! Get my camera and take a video will you?”

*

 

Aamaa, Aidan and Pascal, Family, Kaskikot, Nepal Life

Water Works

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It used to be that, in the winter, we’d sometimes get up at four AM to fetch water. When the tap nearby in Deurali would dry out due to the dry weather, or the tenuously protected pipe sourcing it would breaksomewhere along its many kilometers between Dhampus and Kaskikot, we’d have to go further downhill to the natural spring in Rotepani.

Deurali

In the summer, Rotepani was so rich with water that people filled their tin water jugs freely under gushing, splashing geysers while others bathed and did laundry and on the surrounding rocks, submerged up to the knees, cooled in the August heat. But in the dry season, sometimes even Rotepani would slow to a trickle from two out of three pipes that protruded from a cemented tap. The gushing natural spring that pours directly over the rocks would evaporate. Sometimes the line for water took half the day.

During those times, Saano didi and Neru would wake up before dawn and come up the path to our house. Aamaa and I, and Bishnu while she was still here, would join them with baskets slung from our heads and loaded with every jug and bottle in the house. We’d pick up Maya Bouju as we passed her house and walk single file along the edge of Gita Bouju’s wheat field. With the hills still shadowy along the southern horizon we’d cross the dirt motor road, make our way down a steep stone walking path to arrive at Rotepani in the dark, and help each other fill all the containers trickle by trickle. Then we’d walk back up the hill, pour the water in to slightly larger vessels in each of our homes, and turn around to do it again. Each trip took about 45 minutes, and we’d make three or four visits before the sky stretched open its arms to deliver another morning.

There have been times when water takes up the majority focus of attention in the household functioning. When pipes break in Deurali, when the weather is dry, when the buffalo is ill, when there many guests, or when there are very few residents to share labor; all of these lead to an immediate and exacting calculation of how much water is in the house, how long it will last, and what amount of physical labor is required to replenish it.  Sometimes it’s one person’s job to ferry water for hours at a time. When I’m here, I tend to gravitate toward the water carrying—a fairly straightforward, essential, and never-finished chore.

Over the last year or so, recent changes in the government have led to mumblings about piping water to the yard of each individual home. In sixteen years, I’ve seen many changes come through Kaskikot…new two-story cinderblock houses, paved road, the occasional wifi connection, a completely transformed economy from subsistence to remmittance. Cellphones, Facebook, TVs, hotels, cars.  Many of the houses around us in Kaskikot have already rigged up pipes that they can attach to the Deurali tap when it’s not in use, offering a continuous stream of water that passively fills an enormous polypropylene tank in the yard. But water still lords great power over us.

In our case, we’ve had a tank for years, but like the enclave of about four houses near us—including Saano Didi’s and Mahendra’s houses—we still have to carry water to it, the regular way. Our water situation remains basically unchanged. We still take baskets five minutes up the road to fetch our water from the tap in Deurali. When Deurali is dry, we still go to Rotepani, 15 minutes away. On occasion, when Rotepani is too busy or the flow of water is almost dried out, we walk winding footpaths half an hour down to the fields in Dadapari and use a cup to lift water from a natural pool under the rocks.  A few times, I’ve accompanied Aamaa to do a household of laundry on flat stones there.

Aamaa, of course, is sixty-two and lives alone most of the time. So by “we,” I mean Aamaa.

Last summer as I was leaving in August, somebody rigged up a pipe that had been brought from Deurali up to the crest of the ridge by our house. Its mouth wasn’t in our yard, but it was only a up on the ridge, about seventy-five yards away instead of all the way in Deurali. The day I was leaving for the U.S. was the same morning that this new pipe was first hooked up, and all our closest neighbors clamored about filling buckets and oil gallons and jugs while Mahendra’s father presided over the fray. Whenever the pipe was unattended, it sprayed wild streams of water that swirled into muddy rivulets, spilling down the side of the hill and into Khemraj sir’s corn field. Little Narayan and Amrit were ecstatic with the newfound responsibility of presiding over a line of eager adults and aiming the unruly three-headed pipe head as it washed dirt off the footpath and over the terrace.

When I arrived back this week in January, I discovered this setup slightly relocated but similarly conceived. With water more spare in the winter, each household has been assigned to use the pipe on alternating days. Today was our assigned day; Aamaa began fretting about it last night. I assured her that I would take water duties in the morning, which is pretty straightforward, but the problem is that for reasons I couldn’t determine, Aamaa wanted to get cracking at dawn…and one thing that’s changed in the last ten years is that I am no longer so interested in proving something that I’m motivated to get up before dawn. I am happy to prove my value during daylight hours.

Lucky for both of us, for some reason the water didn’t become available this morning until 9am. Having slept until American hours and had my tea, I dutifully began the water retrieval process. Pascal helped me bring all the water jugs and bottles and even buckets up the hill, where we set them down beside Maya Bouju’s house to wait our turn.

Saraswoti was there of course, and Jivan’s young wife Bal Kumari, and Mahendra’s father. Everyone had brought literally any item in their house that could hold liquid. The issue–and the thing is, I’m American, I’m trained to spot potential matters of inefficiency and to fret about them–was that the pipe itself was barely producing a trickle. So filling the army of receptacles from our three households was a phenomenally lengthy task that quite literally involved watching water drip for long, yawning minutes. And minutes. And more minutes.

I squatted down next to my pals Saraswoti and Bal Kumari. They were perfectly happy with the distraction, the pace of the task, the opportunity to sit on a hill and chat or not chat and pick at blades of grass. I was like, “Yo you guys, it’s going to take me approximately one million years to fill all this stuff.” My gaze drifted to the footpath.  Four minutes away was a perfectly functional, largely unmanned water tap.

I calculated that in the time it would take Saraswoti and Bal Kumari’s water jugs and buckets and bottles and gallons to fill in front of mine, I could easily take a jug to Derail, fill it, bring it home, and bring it back here for a second filling.

“Just wait, Laura, it won’t take too long,” Saraswoti assured me, despite the fact that this was plainly inaccurate advice.

“I’m just going to go…um, fill this jug and come back,” I said. I did. When I came back, my other six jugs and buckets and bottles were still waiting in line. Bal Kumari had left and Saraswoti was taking her turn.

“Have a seat, Laura,” Saraswoti said. I sat. Saraswoti and I watched the water drip lazily, its splashy pitch changing as the surface level crept up the inside of the tin jug. The winter mountains pierced the entire panorama of the northward sky, and to the south the hills were clear and fresh. When it was my turn, I filled our jugs, took them home, dumped them in to the tank, and began the whole process again.

Of course, Bal Kumari was back.

“Laura didi, it won’t take long,” she and Saraswoti assured me. Given that the water hadn’t become more abundant, this statement had also not become less untrue. I couldn’t take it. I took one jug off to Deurali, repeating the entire process as before.

As my trips accumulated, so did the various filled containers in the yard. The tank filled. Aamaa has recently installed a recycled oil barrel that comes to my chest; it was filled. At intervals, Pascal was reluctantly cajoled in to retrieving filled bottles and buckets from and dumping them out at home and returning them to our muddy hill. The tubs and emptied kerosene gallons were filled. Each time I thought I was done getting water, Aamaa would find another centimeter of space inside some container or another and make an entire four liter tin jug of water disappear in to it. I started to get annoyed, and then I started to giggle. The teapot, after all, was still empty.

I couldn’t help but think of when our only containers were two tin jugs, a leaky plastic box, and two small lotos. By comparison, there was now enough water in the house for all of us to bathe five times and do a midnight water puja under the moon. But Aamaa kept finding more spaces to add water and sending me back to the maddeningly dripping pipe by Maya Bouju’s house.

“Aamaa, I think–” I wanted to point out that the tap in Deurali was currently available daily. Why was I an indentured servant to the drippy pipe by Maya bouju’s house, today, just because it…existed?

“It’s so much closer,” Aamaa said. “If the tap dries up, I’ll be without water,” she explained. I found this both entirely logical and entirely illogical at the same time. It couldn’t be solved. It reminded me of the time that Bishnu and I had dozed off in the middle of the afternoon with Pascal lying between us when he was a baby, and we woke up to find the lights on in broad daylight amidst the ruthless load shedding schedule; Bishnu yawned groggily, “Hey when the electricity is available, we have to utilize it.” This immediately launched me in to fits of hysterical laughter for the next ten minutes and I would lose it every time I thought about it for years. Now, I also knew the only thing to do was keep getting more water from the pipe on this, our assigned day. The opportunity was not to be missed, irrespective of any broader analysis about overall benefit. And while I claim to have nothing left to prove in Kaskikot, let’s face it: where the rubber meets the road, I still have too much pride to throw in the towel early.

The only way out was to prove this labor was unwarranted.

“Aamaa, are you gonna take the cups out of the kitchen and have me fill them up too?!” I cried, half joking and half serious. Truthfully, I wanted to sit around and read. I resented this unreasonable purgatory, even though I not only signed up for it voluntarily, but also understood that it technically started and ended far away from the pipe by Maya Bouju’s house. I didn’t want Aamaa to have to haul water tomorrow or really ever. It just seemed to me, like, you know, we totally had lots of water.

Finally, when our entire yard was ringed with anything that could be turned in to a basin or pitcher, each brimming so high that the act of dipping a cup in it would spill a few steps worth of hauled water, I put the basket and rope down on the porch.

The buffalo honked lazily. It was mid-morning, and the day stretched bright and clear in front of us.

“They say,” Aamaa mused to nobody in particular, “that we’re each going to have our own water tap. I brought the pipe here already. But I’m not allowed to connect it up to the yard.”

*

 

 

 

 

 

 

 

 

Kaskikot, Kaskikot, Nepal Life, Oral Health Care Project, Work

Aging

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The second half of our winter professional development is focused on treatment of older adults. Even though a lot of treatment that dental technicians do is in schools, during the weekly dental clinic at the Health Post, they mostly get adult patients. And since most rural adults have had little or no dental care, and likely weren’t exposed to fluoride toothpastes or other preventative measures for their first few decades of life, some of the conditions that present in our rural clinics are pretty extreme. Besides that, tooth loss in older age is common enough that it’s more or less expected.

Of course, our technicians can refer older patients to higher care, and they do. But following up on referrals isn’t always that easy, especially for older folks with reduced mobility. Not to mention that rehabilitation of many mouths we see in elderly patients would require months of ongoing, expensive, complex treatment even in a state-of-the-art dental hospital–something that’s simply is not feasible for the majority population even in a first-world city. So here we are in rural Nepal working in primary care, which is about disease prevention and improving quality of life. But save for the occasional extraction, older adults are mostly left out of the process when it comes to primary oral health care: directly related to the ability to eat, sleep, and participate socially. If we can relieve pain and preserve teeth longer, that seems like a solid contribution.

With this in mind, we wanted to develop a professional development workshop on how the simple techniques that we’re already using – glass ionomer, silver diamine fluoride – can be used to help relieve the diseases experienced in older populations in Nepal. By “we” I mean Bethy since she’s the one obviously who did this because I write stories about teeth and she is a public health dentist. And even if you’re not a dentist or especially interested in cariology, I have to say that how this turned out is really pretty cool.

A few years ago, Bethy and Keri took photos of about 65 people who’d had restorations done in our clinics, and we used these as the basis for a quality-of-care assessment. It resulted in a few different things. One was adding some missing instruments. Another was noticing an apparent pattern among older adults where, around middle adulthood, adult teeth begin to wear rather than decay. It might be caused by anything from an acidic diet, to abrasive brushing with spices, to a lifestyle change like a new medication. The lower part of the tooth near the gums wears down and become loose, causing sensitivity and difficulty eating, and gradually, the teeth simply fall out. These are the adults who, right now, are getting no care at all besides the occasional extraction.  They were the focus of our training.

Our technicians practiced placing glass ionomer restorations on the root-surface lesions, near the gums, that so often lead to tooth loss in older adults. Bethy explained how an event in the life of a middle-aged adult, such as an illness, can cause a simple change like dry mouth that alters the whole environment and leads to deterioration of a previously resilient set of teeth over the next period of years.

I loved this workshop. For the first two hours, instead of looking at teeth, Bethy brought in pictures of older people and the clinical teams simply talked about aging. What makes people old? Are all old people the same? Do they have the same priorities and daily demands and ideas of self? What do we assume when we see someone who we think is “old”? How does a person’s identity factor in to how we work with them to improve their lives? What is our responsibility to someone’s dignity?

In preparing for the workshop, Bethy and I mined our respective photo archives for pictures of elderly people in Nepal and Cambodia. One by one their faces stared out at our group of clinicians, suddenly daring: Who do you think I am?

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In the beginning, most participants had a sort of default position that older people are weaker and less capable of handling dental treatment. But as we went through the photos for well over an hour, stories blossomed. In some cases, they were people whose backgrounds we knew- my neighbors in Kaskikot, steely women I’d photographed during our work after the earthquake in 2015, caretakers and weavers and shopkeepers who’d given interviews in Bethy’s surveys in Cambodia. Bethy used a clever framework called “Go-go, go-slow, no-go” to talk about what each of these people might be expecting or hoping for from a medical professional. I got to laugh about how Hadjur Aamaa has basically no teeth left and gets around pretty slow, but she’ll put one foot in front of the other to get to the house and then frets the entire day, every day, about the dishes or the peas that need to be shelled; it is absolutely vital to her human essence to be busy with something useful. By the end, our clinical teams were musing over what their patients might be thinking about, who they depended on, and who relied on them, what made them human and alive in the world. This was probably a go-slow patient, like Hadjur Aamaa; this one likely a go-go patient ready to sit there all day and get her teeth fixed; this patient probably wasn’t really about treatment, and mainly needed to have his discomfort acknowledged.

The next day, we returned to the same school in Kaskikot to treat patients age 45 and over. (We’re in rural Nepal, 45 is approaching the pre-elderly group…60 is safely considered “aged” and the point is to catch people BEFORE their teeth are gone.) It was exciting to see the same situations we’d learned about the previous day in the real lives of real people and to be able to offer simple treatments that have the potential to forestall tooth loss for years. The teams continued using the App, entering patient data digitally along side the paper forms.

While patients were waiting outside, the father in law of our local Channeler came by for a checkup. I’ve been to see our Channeler a few times – she lives down near Laushidunga, in the direction of Sada Shiva where I taught primary school for a year.  The story that’s told about the Channeler is that she suffered terribly from a kind of delirium for a period of time. She was treated in a hospital, but nothing helped. Then she began to channel spirits. She rebalanced. People travel from all over to see her; I’ve brought a handful of visitors there to connect with people they’ve lost.  Before Bishnu left for the U.S. in 2008, she went to see the Channeler to connect with her father. The Channeler’s husband has a bum knee, and once I gave him my knee brace from CVS, and he always greets me with an old familiarity when we meet in the road up in Deurali.

Anyway, at some point in the afternoon I couldn’t find our technician K.P., and I walked outside to find he was having his palm read in the waiting area. The Channeler’s father in law spent about an hour reading almost everyone’s palm for fifty rupees each. Everyone–our office staff, the field teams, the schoolteachers and other patients–exclaimed over the things he knew: who’s father had died young, who was still to be married, who was destined to successfully stay with one line of work for a long time (one of our clinic assistants! yay!). I didn’t get a turn because by the time I was ready – I’d had my 50 rupees in my pocket for like an hour – he’d had enough with palm reading. Palm reading was over.

Still, my most favorite patient of the day was a 93 year old woman who arrived alone. She was frail, used a walking stick, and barely spoke to anyone even to ask them to move out of the way as she plodded through clusters of people like Moses parting the sea. She wore a jaunty white knit cap that stuck up boisterously on her head. Her entire mouth was completely empty except for one jutting molar with an expanse of exposed root.

“How can we help you?” Hira, the Deurali technician, asked.

“This tooth hurts,” the woman said simply.

 

Hira treated the one tooth with silver diamine fluoride, a completely painless procedure that will hopefully preserve it a while longer and ease her suffering. Then the woman stood up, picked up her walking stick, parted the seas and went home without a word.

*

 

Around Town, Nepal Life, Oral Health Care Project, Work

Cash on Delivery

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As the start of our winter Professional Development session approaches, it’s time for me to bite the bullet and shell out a bunch of cash for a pile of tablets for an App we’re developing. Teaching clinical teams how to use the app will be the focus of the first part of our upcoming workshop.

The problem is the tablet-acquiring part is…a bit intimidating. At home, I’d search options on the internet and then probably order a few different options, which would arrive at the door with an option for 30-day free returns. But I will shamelessly admit that when it comes to Nepal, I have no idea how to do this. I know how to do stuff that involves baskets, ropes, and misplaced stretches of mud…but I do not know how to do a normal officey thing I am in charge of, such as acquire some expensive pieces of unfamiliar technology.

I asked Muna, our Program Manager Who Literally Fixes Anything, how and where one buys a pile of tablets in Nepal. We were hoping for something with a little flexibility on standard retail price, since we’d be needing 5-7 of them to start.

Muna, did I mention she Literally Fixes Anything, told me about a site called Daraz.com where I could order things on the internet to my house. Or our office. I was floored. Internet ordering is a thing in Nepal? Where the heck have I been? Muna explained to me excitedly that they literally bring it TO YOUR DOOR.  Right to your very own door! And then, you pay for it there. If you don’t want it, you return it with the courier.

“The courier?”

“A person brings it.”

“You order it on the internet and a person brings it? But how do they find you?” I was pretty sure this wasn’t happening through the regular mail system.

“They call.”

I just want to point out that, while a postal service certainly exists in Nepal, most houses don’t have street addresses, and a minimum of streets go by name (that anyone uses or that command street signs), and a large percentage of the houses and streets that do exist were only recently built, and in the majority of the country there are a minimum of streets altogether.

“Are you sure this works?”

“I use it all the time,” Muna said, becoming excited again by the phenomenon of internet ordering. “It’s cash on delivery.”

We looked on daraz.com and ordered five $280 tablets to Ravi’s office in Kathmandu. I arrived in Kathmandu a day later, a week before our training was to start, intending to return with both our trainer (Bethy) and the highly necessary tablets. By this time Daraz.com had called Muna, and Muna began relaying messages between the company, Ravi, and me. At first everything seemed fine. Then Daraz explained that they had the five tablets, but needed to get them out to a store where the courier would pick them up and bring them to Ravi’s office. Or my hotel. Or wherever we asked them to come on the day that they would call us, some time soon, having secured the assets through the official processes.

“Are these going to get here on time?” I asked Muna. She knows things. Admittedly we’d ordered the tablets at the last minute, and even on-time things are almost never fast things. And I seriously doubt that Daraz often receives orders for a heap of five tablets at once.

“Let’s see?”

While the tablets whereabouts remained uncertain, Bethy did arrive as planned from Cambodia.  We spent an afternoon with Ravi to map out our training plan for next week. By Sunday, I was starting to worry. I started calling around in Kathmandu to see about buying some tablets from a show floor, something that in my mind was randomly assigned as a more feasible activity in Kathmandu than Pokhara.  We ended up locating a completely obvious strip of cell technology stores around the corner from New Road. I called Muna and told her we were going on an expedition to find the tablets ourselves.

“If I find them, we can cancel the order, right?” I asked her.

“I called to ask, and they said that when the courier shows up, we just say we don’t want them.”

My mouth opened and closed for a few seconds. “It’s seventeen hundred dollars of merchandise!”

“I know, it doesn’t make any sense, but that’s what they said.”

Just to be clear, I’m not telling this story as a lesson in how things don’t work in Nepal. To the contrary, this is exactly how things work in Nepal. The internet company wasn’t trying to give us the run around, they were just trying to figure out how to find a guy who could get his hands on the pile of pricey tablets we wanted and get them to our guy in a short period of time. Without street names. In a cash economy.

Bethy and I set off to New Road to begin the in-person search. If I’d been more savvy, I’d have known from the start that we should have gone to New Road: as we rounded a corner, there before us, like Oz, was a fairlyand of Samsung and Oppo and Huwaei stores packed together for a block and a half. We walked in and out of them pricing out different tablets, including the one we’d possibly or possibly not ordered online, and when we thought we’d settled on a winner, we wandered in to one last alley for a final try.

There we met Ravi #2, who presented us with our final and ultimately champion tablet, a simpler and smaller version than everything else we’d located. At about 40% of the price.

“I’m a movie star,” Ravi #2 said.

He is. Look him up.

“Here’s a video of me,” Ravi #2 said offhandedly, handing us his phone, his Bieber coif spilling over his brow glamorously but without obstructing his vision. We bent our heads over the small screen, which showed our tablet salesman serenading a beautiful woman on a bridge.

“I’m not the singer,” Ravi #2 admitted. “Just the actor.”

I withdrew a heap of cash from the ATM and forked it over. While five separate people bustled about unpacking our tablets in order to fill out warranty cards, add screen covers, and repack them, we waited and chatted with Movie Star Ravi. He reclined on his stool, a physically not possible thing that only Nepali movies stars can do.

“Do you know my pal Mahesh? He’s a movie star also,” I volunteered.

Why yes, Ravi #2 did know Mahesh, the brother of our field officer Gaurab (the human). Gaurab and Mahesh are both from Kaskikot and I’ve known Mahesh since he was a kid, and even produced a radio story about his robot-making career before he was a movie star with Ravi #2. His father Thakur was one of the founders of Jevaia Oral Health Care back when it was Kaski Oral Health Care, a bazillion years ago.

“Small world,” I said. “You should consider a further discount, considering that Mahesh’s family is closely involved with the very worthy project that these tablets are for.”

“Sorry,” Ravi the Movie Star said. “But here’s my number. Call if you have any problems with the tablets and I’ll get them fixed right away.”

We needed tablet covers.

Ravi the Movie Star didn’t have any tablet covers, but he gave us the name of a shop in another part of the city about a mile away. Obediently I put it in my GPS and Bethy and I set off at a fast clip, racing against the gathering dusk, the new tablets in my bag. In no time the main thoroughfare of Cell Phone Oz had narrowed, then faded away behind us and deposited us in to the heart of Kathmandu’s old, cloistered Newar alleys. Ornate wooden windows leaned precariously in over our heads, while vendors presided over every vegetable and shoe and devotional item imaginable, and as we dashed alternately through crowds and crowded passageways it seemed unlikely that we were headed closer to tablet covers. Night fell, and the cobbled paths and squares became lit by yellow squares falling out of spice stalls, flickering lamps dotting the pavement where vendors had spread out their treasures. We sped through, dodging colored blobs in our path like marbles rolling through a game.

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Out the mouth of a maze we arrived, suddenly, at the destination on Ravi the Movie Star had directed us to, and Lo and behold, there before us was a shop with exactly the name he had provided.

It sold a lot of stuff, but none of the stuff was tablet covers.

We turned around and went back in to the din. We wove about, passing up vacuum cleaners and suitcases and incense and frilly skirts. Surely, somebody, somewhere among all these objects, had some simple tablet co—-

And there it was. Bending off the laid stone path and its hoard of pounding feet was a harshly lit corridor of electronic gadgetry shops that contained four bazillion types of cell paraphernalia. At the end of it, positioned in such a way that suggested anybody arriving must surely be doing so at the end of a great pilgrimage, was a casual shop crammed with phone covers. A woman sat among them as if, obviously, we had been on the way and due to arrive at some point, whenever.  Inexplicably, she had only one type of tablet cover, in one size, and it was a size that fit our efficient little mini-tablets.

“We’ll take five,” I said.

We packed them up, shoved them in our now very full backpacks, and set off on the last part of our expedition through Bishal Bazaar and Ason, butter lamps burning what seemed like everywhere in the lively chill.

“Muna,” I said over the phone a little later, “I’ve secured our tablets. We can cancel the online order.”

“Where did you find them?” she asked.

…You know…streets?

*

Around Town, Nepal Life, Oral Health Care Project, Work

Airport Gymnastics

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Bethy and I are on our way to Thailand to present at the International Association of Dental Research Conference in Da Nang, Vietnam.  We are on a panel about “Behavioral Science and Health Sciences,” me to present about Jevaia as a social justice project and Bethy to talk about a system she developed for school-based health care in Cambodia.  Between us, let’s call Bethy the scientist. She plans ahead. She calculates things such as time and has an external battery pack with every configuration of port imaginable and a rubberized exterior that could withstand a nuclear attack, and she brings it with her almost everywhere.  Bethy is a prepared and organized kind of person. I’m what we could call…the artist. I hit snooze 4 times and borrow chargers from nice people along the way. I don’t travel without chocolate.

We meet in Thailand, the mutual transit point on our respective journeys from Nepal and Cambodia to Vietnam.  The next afternoon, at Bethy’s urging we’ve arrived at the airport a solid two hours before our short international flight from Bangkok to Da Nang.  How planny of us. As we are checking in, the clerk asks us to display our visas for Vietnam.

We are both surprised.  Even the scientist! With our American and New Zeland passports, we thought we could purchase visas on arrival in Vietnam.  This is somewhat true, the airline agent tells us. However, there is a new process that requires visitors to submit an online application ahead of time and bring an electronic visa approval to immigration upon landing.  Without the approval, we aren’t allowed on plane.

Well then.  This is awkward.

The Airline Agent informs us politely that we have 47 minutes before check in closes.  I get my phone connected to the WiFi and start googling around for how to apply for a visa to Vietnam.  I find a website called Vietnam Visa Online (lovely name, quite to the point) that says this can be done with approval rushed to one hour, for a fee of only $500.

While I’m poking at my phone looking for a less pricey extortion option, Bethy assures the Airline Agent that we’ll definitely have no problem completing the required process in 47 minutes or less.  I tap madly at my phone screen, and we decide to go for a rush fee that’s only $100 and might or might not get us the visas in time. I click send. Bethy stalls with the Airline Agent. The check-in line shrinks, I hit refresh on my phone, and by now our window has diminished to 13 minutes.

…Tick tick tick…check in closes.

But not before Bethy casually softens the Airline Agent in to printing out a document that shows we arrived on time, and woos her in to walking us over to another desk where we can stare at my email waiting for the visa approval to arrive on the basis of our $100 rushfee. A new Airline Agent looks delighted that our problem has been moved over to her counter, where I set down my phone and Bethy and I peer deeply in to its icons.  We wait.  Airline Agent #2 waits.

An email!  Is it our visa approvals?  No. It’s a reply stating that due to the fact of today being Saturday, urgent processing isn’t possible.  However, we do have an attractive option to pay another $300 to get the visa approval today, or we can certainly wait in Thailand until Monday.

We kind of have no choice but to do the extra-special saturday rush fee, which has been specifically designed, after all, for suckers like us.  So we pay the fee, and then the screen freezes, and we can’t tell if we’ve paid $300 or not. I get an email saying that we can call an office in Vietnam with questions. But honestly, who has questions?   

Calling Vietnam would be a fine idea except that neither of us has phone cards that work in Thailand, so I ask Airline Agent #2 if she can call the Vietnam Visa Online from a land line.  She says the airline has no way to make international calls.  “But you’re an airline,” I point out. This doesn’t change anything, since apparently Asia Air actually cannot make an international call to a mysterious Visa processing office in Vietnam. I deduce this because eventually, Airline Agent #2 takes pity on us and gives us her personal cell phone.  We call Vietnam Visa Online and induct a fourth person in to our lair of chaos.

Mean time, I still can’t tell whether the payment has gone through on my credit card, and my credit card password isn’t working (or theoretically it’s possible I haven’t used it in a few months and I can’t remember it) so I can’t log in and check. For the next twenty minutes, the clock ticks down to our departure while I toggle between my phone and tablet trying to figure out if I’ve paid the fee, and Bethy toggles between Airline Agent #2 and the newly inducted lady from Vietnam Visa Online, whom we have to keep calling from the Airline Agent #2’s personal cell phone.  The voice in Vietnam talks us calmly and assuredly through various steps, which I tap out on my phone, as if we are diffusing a bomb.

Eventually, all three of us–Airline Agent #2 is all in now—are leaning anxiously over my phone, hitting refresh, waiting for the document with our visa approval to show up from the Helpful Voice in Vietnam.  Whose name turns out to be Selina.

Is it there?

How about now?

We may have to carry on our bags.

…Should we call again?

……Is it there yet?

……..How about now??

TADA!

The email arrives.  All three of us bounce up from my tablet screen and give a shout.  Airline Agent #2 triumphantly passes our boarding passes over the counter and we run to the gate.  I won’t see it until we’ve already arrived in Vietnam, but another email has popped up from Selina at Vietnam Visa Online.  It is highlighted in an alarming fluorescent yellow the color of a radioactive duck.

HAVE YOU RECIEVED YOUR VISA YET? IS EVERYTHING OKAY NOW? PLEASE ADVISE!

I write Selina back after we land in Da Nang.

We are here in Vietnam and everything is fine! I didn’t get your mail until we landed. Thank you for all your help today!

We’re aware that it would be responsible, at this stage, to be upset about the insane amount of money our visas just cost, but instead we are delighted with the exchanges of the day, the managing and wooing and reassuring and eventual co-conquership with strangers of our last-minute visas. In fact, we were so irresponsibly pleased by this accomplishment that Airline Agent #2 didn’t even seem bothered when I wanted to take our picture, regardless of the fact that we were holding up an otherwise orderly process of reasonable people getting on a flight from Bangkok to Da Nang.  

And we were able to recharge our tired devices on the fly.   

*

Kaskikot, Nepal Life, Oral Health Care Project, Work

Professional Ceiling Clouds

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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!

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Kaskikot, Nepal Life

Farmer vs. Medic: Mountain Carry

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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