Water Works

 

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.”

*

 

 

 

 

 

 

 

 

Aging

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.

*

 

Cash on Delivery

 

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?

*

Airport Gymnastics

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.   

*

Professional Ceiling Clouds

 

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

 

 

 

It’s Not a Problem to Deliver Your Underwear

My friend Ann is here in Pokhara for the summer. She is an IMT therapist and has begun volunteering at the Kaskikot health post, working with the Health Assistant to treat patients using integrative manual therapy. Whenever somebody comes to visit me in Nepal for the first time, I briefly have a renewed sense of chaos, of how from a western sensibility, there is an unnerving feeling of inefficiency and an opacity around how problems get solved. For the most part you don’t rely here on public services, or even private businesses, to pop up with specialized solutions or knowledge in a pinch. You rely on someone’s cousin. To the uninitiated, it’s unclear what people do when things need fixing, and this leaves one with a sinister feeling that small irresolvable inconveniences will accumulate until everything is a hopeless mess and all is lost forever. Therefore, in the presence of first-time visitors I can’t help feeling as though I need to account for a mild but pervasive sense of anarchy that they cannot describe but which, I know, they feel. I don’t know how to explain that there is a different kind of intuitive coherence with other rules.

As for Ann’s visit, everything is basically going great, but one hitch happened early on when she left the bag that contained all her underwear at a hotel in Kathmandu. Also, Ann said it was perfectly fine if I wrote a blog post about her lost underwear. The underwear, while inconvenient but replaceable, was not as much of an issue as the bras that were in the forgotten bag: Ann said her bra size is not that easy to find, and she also said that it’s fine if I write about her bra size too. Replacement of the odd size bras in this environment is one of those opaque things that appears to have no viable solution. The bag needed to be retrieved.

We called Ann’s hotel in Boudanath and determined that they had located the bag of underwear and put it in storage. This was a positive start, however, the next opacity was how the bag would get moved to our district when the mail system exists but doesn’t work according to any particularly obvious or accessible processes. Happily, I was scheduled to go to Kathmandu about a week later. So we rang up Ann’s hotel again and I asked Dorje, the proprietor, if he could hire a taxi to send the underwear to the hotel where I would be staying in Kathmandu. Regarding my hotel, I had previously stayed at the Tibet Peace Guest House only once, but last week after I had called a few times in the process of reserving a room, the hotel clerk and I were officially pals, and when I would call he would answer, “Hello, didi.” I asked the Tibet Peace hotel clerk if he would mind fronting the taxi fare for Ann’s underwear, so that I wouldn’t have to coordinate an exact meeting time with the driver. He said, “Sure didi, no problem.”

“Ann, I have hired a chauffeur for your underwear and the clerk will receive it at my hotel,” I told Ann. She was so excited. Especially for the bras.

I got to Kathmandu and had my meetings and Dr. Bethy arrived and the next day we boarded the plane to Pokhara.

“AH, SHOOT!!” I cried, bonking my forehead against the inside of the double-paned window. A French tourist sitting behind us, who was playing her ukulele in the airplane, became alarmed. She stopped playing her ukulele and leaned forward with her eyes wide.

“Is everything okay?” She asked luxuriously, concerned.

“I forgot Ann’s underwear!” I cried. “Shoot shoot shoot!” Now how would we get it?

The French tourist leaned back and resumed her ukulele playing, and also some singing. The plane was very small, and luckily she was quite a good singer.

Once we’d landed, I called up Ann’s hotel again. Had they forgotten to transport the underwear, I needed to know, or had I left it orphaned for a second time, now at the Tibet Peace Guest House?

“Hello Dorje sir, do you still have my friend’s underwear?” I asked. Dorje revealed that he had planned to send it a day later, today, because the hotel was located in Bouda, a bit of a hike from downtown Thamel where my hotel was, and today they had a driver making an outing anyway. “Oh, I am back in Pokhara now,” I said. “Now what?”

Dorje sir and I pondered the problem for a moment.

“If you know anyone who can bring it to Pokhara, I’ll get your friend’s things to them,” Dorje sir promised. “I will deliver it myself!”

“Ok, I have an idea,” I said. I hung up and walked over to Adam Travel in Lakeside, where we are friends with the owner. Prem often hangs out here in his free time and they book all my tickets. Once, I got to attend a travel agency exhibition in the U.S. with the owner Basu sir.

“Hello Laura didi,” the Adam Travel guys said when Bethy and I walked in. “Ah! Bethy! Hello!” They naturally always know who is traveling with me; the same guys had booked Bethy’s tickets a day earlier, too.

“Hi guys, I was wondering if your Kathmandu office could arrange to have my friend’s underwear sent over. She left all of her underwear at her hotel in Bouda.”

The Adam Travel guys told me that their Kathmandu office is now closed, but the people who used to work at there now work at the Sacred Peace Hotel. Those guys would arrange it. Adam travel proceeded to call Surjet at the Sacred Peace hotel. Surjet said he had some friends at a bus company.

“So,” Adam Travel told me, “They need to bring the items to the Sacred Peace hotel, and you’ll pick it up here. It’s going to be $5 for the cab to the hotel and $5 for the bus to Pokhara. You pay $10.” Where would this be paid? I asked. We’d pay Adam Travel, they said; other people would pay other people in the middle and the debt would accumulate and then we’d pay it off here. No problem.

Sold! I put Adam travel on the phone with Dorje and they discussed all the intermediary checkpoints where someone knows someone who will help reunite the lost underwear bag from Bouda with Ann in Pokhara by Wednesday. We’ve solved the matter within 8 minutes. I wondered why I hadn’t just done this before.

“So there’s bad news, and there’s good news,” I announced that evening to Ann. “The good news is that your underwear will be at Adam Travel in 48 hours. The bad news is I forgot it in Kathmandu.”

“How’s it going to get here?” Ann asked.

“…FedEx.”

*

Politics and Poets

 

With the Nepal government undergoing a major restructuring, a big goal for us this summer is to figure out how the newly formed provincial government works and establish relationships with influential decision-makers.  We’re just getting started, and as I’ve described elsewhere, so is the government: most of the province-level officials are quite new to their desks, and in many cases the scope and processes of their jobs are still being decided.

So let me give you an idea of how this works.  Honestly, this is my real life.  I begin with a friend of mine in Kathmandu, who I was introduced to through an organization that gave us a grant a few years ago.  This friend refers me to a colleague of hers, who I’ll call Sam, who works inside the new Province #4 government office in Pokhara as a representative of a big nonprofit doing policy work on another topic.  So Sam is not exactly a government employee, but he’s connected to people in the Province office because he works in the building, and most happily, he is someone I can ring on his cell phone.  I set up an appointment.  It’s our first trip to the Province offices and we’ll just have to go meet Sam and see where we get.

Are you with me so far?

Muna and I walk about a mile from our office in burning July sun, and meet Sam in his office at the new Province building. Sam is a friendly, energetic and smart guy, and he begins to orient us to the structure of the Province government (we tried to google it–maybe you’ll have better luck). He combs through our present bureaucratic challenge: obtaining official endorsement for a workshop we want to host to train new dental technicians (who will of course work in Government Health Posts).   In the absence of clear procedures, we mull over who best to take this to next.  Sam makes a call to the Province Health Coordinator, an obvious choice, but the Health Coordinator is out today.

Eventually – and this is only possible because Sam is helping us, and because we’ve made a satisfactory case to him – he gets us an invite upstairs to meet direclty with the Minister of Social Development, who holds the highest office in the Province, something like a governor.  This is great news.  Muna and I follow Sam out of his office, and by this act Sam is adopted into our quest and ordained as our guide.  Without him Muna and I are just random people in the hallway. We stroll through the almost-finished government building, which like most government offices outside Kathmandu has a concrete austerity produced by minimalist decoration and a building style that leaves stairwells in the open air.  Even the walls look somehow unfinished, expectant.

At the top of the stairs we move down an echoey corridor and come to the mouth of a room crowded with men.  Peering through the door frame, I see a tall, lean Official sitting at the other end of the narrow office, the throng of visitors clamboring for his attention.  Sam and Muna and I are directed to the room across the hall to wait.

We wait.  It is very hot.

After some time, we are brought back across the hall to the Minister’s office.  It is stuffed with as many black faux-leather couches as the room will allow, and as per standard Important Office decorating style, they are situated perpendicular rather than parallel to the desk where the Official in question is seated. I can’t explain this, but it’s the set up of almost every Important Office I’ve been to in Nepal.  The halls are empty and the offices are packed with extreme quantities of couches, which are almost always lined up along one wall so that visitors find themselves talking to the Official they’ve come to see at an angle, while the Official gazes past their knees at empty space.  A perk of today’s office is that, with the July heat pawing at the walls, the ceiling fan is turned on to the highest setting.  I am seated directly under it.  It feels wonderful for about ten seconds, and then I realize I am doomed to suffer in a singularized typhoon for the length of our Important Meeting.

The last of the previous visitors is just leaving as we get seated, and when the previous callers have cleared out, Sam introduces us to the Official.  Muna and I – mostly Muna – describe Jevaia and explain the authorization letter we are looking for.  We say are “seeking suggestions on how to properly coordinate and align with the new government.”  We don’t say we are already pretty sure that these procedures are not defined yet; in fact, the inquiry itself is probably the best formal step available.

After some time, the Official falls silent. In my opinion, the Official Silent Phase is one of the great tests of mettle in this line of work, particularly for impatient foreigners.  From a western sensibility it’s completely perplexing: for about five mintues, the Official taps on his laptop and gazes past our knees without saying anything. The fan blasts the top of my head and wooshes through my ears, and I command my self to sit properly through the Official Silent Phase, like Sam and Muna are doing, without fidgeting or asking to turn the fan off.  Take note, impatient American Person With An Agenda.  If you come here on a schedule, it will be silently and inexorably bled out of you. The people on the faux-leather couches don’t own this timetable no matter how bombastic and fantastic their ideas are, and let me tell you right now that nobody else is in a hurry.  It never occurred to me I might need a jacket to get through our first Province government visit in the dead middle of the summer, but I surely wish it had.

Suddenly, the door flies open and an elderly man in traditional daura-suruwal dress walks through the door.  He waves his walking stick at the foot of the couch.

I don’t have a picture of the Poet, so here’s an internet photo of a man in a daura surulwar.

“Son, get up and move over there, I’m just gonna have a seat,” the old man says to Sam, who graciously leaps up from the seat closest to the Official desk, and moves down the line of couches to a spot near the door.  The old man sits down and leans in to the corner of the Minister’s desk with a twinkle in his eye. He begins reciting a legnthy poem.

The Official is, by old man terms, a junior “son” like Sam. In an instant, the hierarchy of the room is reorganized. The Official leans back in his chair with a grin and sets to listening to the poem. All of a sudden, we are all in school.

For forty five minutes–no, I’m not exaggerating–the Official and the Old Man engage in philosophical conversation while the fan hammers my head, Muna waits politely and Sam cycles through expressions of interest.  I won’t find this out until after the meeting, but the old man is the son of a famous poet, and himself a reknowned scholar. More men–all men, Muna and are I the only women for miles around, it seems–wander in to the room to listen while he holds court.  The poet leans dramatically forward and back on the faux-black leather couch, swaying to his recitations, swiveling his attention from the Official to us to other would-be meeting-seekers near the door, and unleashes a reverent Islamic lyric.

“So tell me,” our Official says, with somber studiousness. “I want to know something.  You’re a Hindu man.  But you speak eleven languages and you’ve studied Islamic poetry extensively.  How do you reconcile those who eat cow meat?”

I shiver and try to casually hold my hair out of my eyes.  I look enviously at a corner door, where more men are periodically filing in and out of the room, and notice that Sam seems distracted by the door too.  Why can’t the Minister just tell us whether we can have a letter, or what we have to do to get it?  Why can’t he release us from bondage, and THEN listen to poetry?

“Let’s have another poem,” the old man says. He turns to Muna, who, following Sam’s relocation, has ended up on the couch seat beside the Poet.  Leaning toward her, the old man brightens, saying, “Would you like to hear a Hindi Poem?”

“Nobody properly understands Hindi,” the Official interjects, boldly. “How about a Nepali poem.” I am well aware that we will need to hear all the poems if we want to find out about our letter.

Another gaggle of men comes out of the corner door, and suddenly Sam says, “let’s go.”  Go where? I chatter.  The Minister hasn’t answered our question yet.  I’m confused.

“This way,” Sam says, motioning toward the corner door.  Why are we leaving?  But with no choice, I get up and follow Sam and Muna through the mystery door.  We enter the next room, and there, in a grand office, behind a hefty wooden desk flanked by the National flag, sits the actual Minister of Social Development.  She rotates on her chair, adjusts her sari over her shoulder, and waves us to sit down on two spacious couches where she can examine us directly from across the carpet.

Who was that guy? I whisper to Muna. Suddenly I am afraid I’m about to start giggling uncontrollably.

“The Secretary,” Muna mutters.

“So,” the Minister of Social Development commands, wasting no time and leaning forward on her clasped hands.  “Who are you?”

 

 

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.

*