Keys and Threes

 

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

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

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

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

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

“Yep.”

“Today?”

“Yep.”

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

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

“Yeah,” I laughed, “it has.”

“Tell Bishnu hello from me,” he said.

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

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

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

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

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

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

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

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

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

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

*

Auspicious Leaving

 

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

Problem.

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

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

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

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

“Laura, set your alarm for 3am.”

“I set it.”

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

“Did you set the alarm?”

“I set it.”

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

“Aamaa, wake up.”

“Hadjur?”

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

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

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

*

Our Health Care is Not a Playground

 

When I was at the Sindure dental clinic a few days ago, a 60-year-old woman I’ll call Mina arrived with three family members.  The family had walked an hour and a half from the next ward over because, after trying shamanism and home remedies for Mina’s dental pain, and they heard about Sindure’s dental clinic from neighbors.  All four of them wanted to be seen.

Sindure is our remotest clinic. The clinic assistant Biju has to walk about a quarter mile to fill a bucket of water at public tap for use inside the clinic. When our technician Jagat examined Mina, he found that she needed two teeth extracted but also that she had low blood pressure. A discussion ensued: given Mina’s age, medical history, and low blood pressure, should Jagat perform the extraction? Our office staff had taken a five-hour bumpy private jeep ride to get to Sindure. In the monsoon, it would take this family the better part of a day on public transportation to reach a hospital, where, possibly, the dentist would or wouldn’t be in.  They might or might not be able to return home the same day. The hospital might or might not perform an extraction on a patient with low blood pressure.  In the best case scenario, the cost of transporting the whole family, paying for treatment, and maybe overnighting in the city would be significant.

In the end, Jagat treated Mina with silver diamine fluoride, a noninvasive carries-arrest technique that turns decay black and hard, safely slowing and often halting the disease.  He advised her to return the following week, and if her blood pressure looked better then, he would extract the two teeth. The treatment cost her sixty cents. In all except one or two of Nepal’s hospitals, silver diamine fluoride is not in practice, although in the U.S. it has now been approved by the F.D.A.

Later, we posted the case to our private JOHC clinical page, where all of the rural technicians can discuss case questions with Dr. Bethy and Dr. Keri. What blood pressure is too low?  Does the patient’s age matter?  How do we factor that realistically Mina is extremely unlikely to seek urban care even if we refer her?  What role does patient counseling play?  What other things determine whether such a patient can safely have an extraction done in a rural dental clinic, and how do we progressively bring different levels of care together over time?

What about the grandchild who was with Mina, probably not more than eight, whose access to a hospital is burdensome enough that it only makes sense to go there for emergencies, not simple procedures like silver diamine fluoride or glass ionomer fillings? Why should an eight-year old have to let a disease progress until it’s an expensive emergency in order to be worth caring for, when early intervention can be made accessible?

Mina’s situation is an excellent example of why we are trying to get the national health care system in Nepal to adopt primary dental care in rural health posts and school brushing programs in the education system. It seems kind of obvious, but in fact our approach is very uncommon, even outside of oral health (where there is literally nobody working on a systemic innovation in Nepal).  The majority of rural public health programs we see either focus on a single, one-off hospital with unique resources, or try to please donors by scaling up over whole districts at the expense of rigorously exploring single instances of a model.  By contrast, we’ve added a few rural dental clinics each year and iteratively improved the design and process of creating-community based oral health care. Now we have a strong if imperfect proof of concept to present to policy makers. We think that what we’ve done in eight places like Sindure could be done in all 3500 of Nepal’s health posts, bringing sustainable primary dental care to about 20 million people.

Anita working at her clinic in Katuwachaupari, Parbat

It was last summer in 2016 that we first presented this model to national level policymakers, and our slides immediately struck a hot wire.  The reason is that, although you never knew it, dentistry is an amazingly political topic. This is true even in the U.S., where there’s been a movement to create dental therapists who can provide a limited scope of practice in remote and underserved areas where doctors with $600,000 in student loans will never set up clinics. But who poses the most forceful opposition to dental therapists? Dentists.

Dentists are not the only professionals to oppose what is perceived as the degradation of their trade by mid-level providers with less training, but they are particularly energetic about their turf.  I recently read a Washington Post article that compared the dental lobby in the United States to the gun lobby.  The disagreement is framed as protecting the poor from low-quality treatment, but in practice, the position protects the wealthy from competing investment in effective treatments that could reach people without the ability to pay.  There are a good number of such treatments that have been well-studied and do not require pricey providers with PhDs to administer them.

In dentistry the problem is made even worse by the discipline’s roots as a cosmetic discipline.  Dentists used to be barbers!  Even now, the field is separated from the rest of medicine, with dental students educated outside of medical school. If you’re American, dental insurance is probably an appendage on your main health coverage. Even though medical science has long since understood the importance of oral health in overall health, dentistry remains siloed in its own world with its own rules. Therefore, it is also elitist – yes, I said elitist – because as “bonus” medicine, only those who can afford it get it.

The road back from Sindure…not so easy, even in our jeep!

We’re facing the same situation in Nepal, but the ratios are vastly different. Here, about 80% of the population lacks access to oral health care, and oral disease is one of the most widespread health problems in the country. Dental clinics are exclusively in urban areas, and mostly in the capital, but the majority of the public is dispersed across remote hills. With bazillions of dollars going in to nutrition, maternal health programs, cardiac care and diabetes, all of which are directly related to oral disease, there are almost zero dollars being spent on oral health care…because, even in the year 2017, it is still widely viewed as a cosmetic issue.

Like American dental therapists, our dental technicians provide appropriate, high quality basic dental care in rural areas, but in Nepal that’s almost everywhere.  They also refer to secondary level care, providing an access pathway for people like Mina who, without at least getting a local referral first, would be extremely unlikely to take herself to an urban center for dental medicine.  But when we go to policy makers to promote this model, the dental lobby counters with concerns that dental technicians are poorly trained and won’t stay within their scope of practice.  Which is a real concern when there is no regulation, but is not what our evaluation last winter showed when technicians practice within the structure we’ve created.

Yesterday, Aug 2017, was our second central level advocacy meeting.  This year we were joined by two of our dental technicians, K.P. and Anita, who both work in clinics that received local government funding this year.  They’ve treated thousands of people in their villages.  We were prepared for some heated debate…recently, the Nepal Dental Association shut down a government training in the Basic Package of Oral Care that provides the basis for the work our technicians do.  The topic is currently so frantic that nobody from the government attended our advocacy workshop! So it was just us, some open-minded dental professionals and social workers, and a very strongly opposed contingent of the NDA.

The first two hours of the workshop were very polite.  K.P. and Anita each spoke about their experiences – for example, Anita’s clinic runs on Mondays, and she told a story of an elderly man calling her on a Tuesday asking how he’d make it a week. So she knowledgably instructed him to pick up two medications at the Health Post, and the following Monday extracted the tooth to his great relief.

The push back started cordially, and then came a torrent. “Little knowledge is a dangerous thing,” one young dentist pointed out, telling a story of a minimally-trained provider he had once observed performing a procedure incorrectly. The discussion period morphed into a rapid-fire series of dissenting speeches framed as questions:

How are these “technicians” selected?

You say they get two years of training and supervision. What is this training? What is this supervision? 

You know they will only work for your organization for a while, and then they will leave and go open illegal dental practices. 

Why do you call them technicians? Technicians are people who fix chairs.

One time, I saw a patient with an extracted tooth who turned out to have cancer. What if it’s cancer?

You say the dentists won’t go to rural areas.  I have been to Ruswa, and Dhading, and Humla!  We have all been!  Who are you to say we will not go to rural areas?

Dental students all do internships. We can staff rural dental clinics with interns on temporary rotations.

You’ve spent all this money over the years. Why didn’t you put that money in to setting up one proper referral center with equipment? The dentists will come to it, if you place the setup there. 

Extraction is an invasive technique requiring anesthetic and primary care does not include invasive techniques.  These unqualified imitators are practicing secondary level care.

Somewhere in this deluge of critical questions a most interesting declaration fell out of the sky:

Our health care system is not a playground!

This criticism was aimed at our technicians, and these are all objections we’ve heard before, and we expected them. They frame a convenient, self-referencing argument:

The exclusion of poor people from health care is for their own protection from under-trained hacks.

I was given “three minutes” to respond to a barrage of about forty questions.  Mina crossed my mind, and all I could think of was, our health care system is not a playground.

Indeed.  While we are all here navel gazing, real people are needlessly suffering.  There is a big difference between visiting a place for a day, I pointed out, and sleeping next to someone suffering from pain and fever with an infection, a day’s bus ride from the nearest badly-regulated public hospital that may or may not have a doctor who can treat the problem.

What about the use of resources to build sustainable providers instead of randomly placed dental clinics for imaginary doctors to flock to?  If only there weren’t so many rusting supplies sitting in rural places, waiting for people to come use them.  If only the professional medical lobby put the same effort in to supporting, monitoring, regulating and creating referral systems with community-level providers as it is putting in to obstructing them.  Just think what we could have achieved by now.

Our health care system is not a playground.

Here’s the thing.  Nobody wants your interns, your mission camps, your adventure dental care trekking, your once-a-month community service, your charity. We want dignity. We want providers who are appropriately trained for their settings, who know their communities, who will answer phone calls on Tuesdays, who are there for the long haul and not as a resume builder on their way to something better. We want specialists and we want them in the entire country, for everybody, not in the one community where self-congratulating people established a referral center that, happily, expands their own reach. We want something that can actually be implemented, afforded by the government, where there will be a willing workforce, something that is sustainable.

Our health care system is not a playground.

No, it’s not.  Little knowledge is a dangerous thing.  Somebody answer to Mina.

*

The JOHC mob-squad on the way to a central level advocacy meeting. Program Director Aamod Shrestha; technicians K.P. Acharya and Anita Subedi; Medical Coordination Officer Rajendra Sapkota.

 

 

Another Room in Heaven

For someone who has spent 15 years in Nepal, I’ve travelled very little in the country, choosing instead to burrow further and further in to a single community, a single home, a place where now twelve year olds have always thought of me as a part of their world. It was only a few years ago that I suddenly thought: I’d like to explore. I’ve started stetting aside a few days every few years to go climb out on a spine of rock some place, in some location that percolates on a back burner in my mind until it bubbles over and asserts itself: this is the time, go here.  Then life adapts around it.

The Way to Muktinath

One way to travel is to go to see things that are new and unfamiliar and exciting or challenging – like that time I went to Murad Khane in Afghanistan, or when I floated in the Dead Sea, or the month I spent in New Orleans doing oral histories for StoryCorps after Hurricane Katrina.  But this is something else, a magnetic pull to a place that is already inside me, a dot on a primal map created a long time ago.  In 2013, Prem and I went to Mardi Himal by a little-traveled route comprised largely of goat trails snaking along a blade of snowy ridge that rims a basin of Annapurna giants. It was winter, everything wide and blinding, the sunrise spilling pomegranates and mandarins and pineapple juice all over the jaws of the cold earth. When I got there, it made sense.

Now it is summer. Muktinath sits north of Pokhara between Lower and Upper Mustang, a stone’s throw from the Tibetan border, and houses a famous complex of Buddhist and Hindu temples. For some time now I’ve been pulled north, toward the areas of Nepal influenced by Tibetan culture, and also where the landscape climbs up and stays high, where the trees fall away and leave a desert mountainscape that stretches off to the Tibetan plateau, a mystery, an uncrossable border. In the winter even local residents often come down from Mustang to the valley to escape the unforgiving snow and cold.

Prem Bhinaju and I met a bus by a curb in Lakeside early on Friday morning. It was headed to Jomsom, which is only a 15 minute flight from Pokhara, but unlike crystalline winter, the summer is dense and foggy and flights have not come or gone from Jomsom in a week. That leaves us with what should be a ten hour bus ride. You know where this is going.

There’s the obligatory 2.5 hour delay when a bearing that has to do with steering left needs fixing, and magically, the Bagloon Highway produces an auto shop strewn with hulking shells of buses and tractors and cars and unidentifiable transport components, so we pull over to fix the bearing. We set off again around noon under ten-ton heat, but I am relieved to be on the move with my day pack and with Prem, my most familiar travel companion. The road winds upward and the Kali Gandaki River drops below us, black and rumbling with coal-colored silt that will settle by the time the torrent gets to in Pokhara, where it is called the Seti Gandaki, or White River. The road becomes a road story that I can’t tell because my mom reads this blog, but even passengers local to Jomsom are praying and squeezing their eyes shut while we loll side to side on a road that, from afar, looks like a child dragged a pencil across triangles of high mountain forest and then got distracted with a sandwich. In the end, aside from knuckles white from clinging to the seat in front of me as if that can save me from a long descent in to the Kali Gandaki – one of the deepest gorges in the world – I come out fine. Prem and I arrive in Jomsom at 7:30pm.

I know I’m in Nepal, but Jomsom looks like a ski town and I have to keep reminding myself that this is Mustang. We clomp along a stone-laid main street with quaint local shops and hills rising up behind them. In the U.S. we’d call the hills mountains, but in Nepal, the mountains are the sheared white rocks twice as tall that are currently lost in monsoon cotton one row further back on the horizon.  It is hard to believe anything could tower over the already looming hills – I remember thinking the same thing at Ground Zero, knowing that Lower Manhattan’s massive skyscrapers had been dwarfed by the Twin Towers.  It is impossible to imagine land up in the middle of the sky, but I know Diligiri is there, behind the clouds, a thousand stories high.  We settle in at a hotel.  Local plum wine.

Our walk to Muktinath starts the next morning and takes two days, one long day up and one long day back. We walk along the Kali Gandaki in a landscape created contradictorily by the upward smashing of tectonic plates and the downward gouging of receding glaciers. The result is a desolate, heaving geometry, eons of history piled atop one another and laid bare straight from river to the sky. Dwellings impossibly carved out by people who once migrated southward from Tibet are clustered in the sweeping rock face, and the occasional modern village is a patch of irrigated greenery in a borderless expanse of brown. This should be the province of giants, but we are just tiny people, our feet sliding over bazillions of even tinier rocks, where fossils casually present themselves because nobody has owned them yet. They were once underwater and they have been here forever and ever and ever.

The climb starts. No houses, no villages, no ancient dwellings for hours. Prem Bhinaju finds a fossilized creature with gold flecks in it. Uncharacteristically , I haven’t exercised in weeks and my legs feel like playdough, but it’s cool. I have an actual fossil in my pocket.

We arrive in Muktinath around five, eat something, and rest for a while. Then, because tomorrow will be a long day and we’ll be pressed for time, we go out to explore the area around the outside of temple complex.  That will leave us time to go to the temple itself in the morning.  I leave most of my things behind except for my SLR camera and rain jacket. Now that it’s evening a slight mist is drifting downwards, uncommitted to getting us fully wet. Dusk turns dreamlike and enchanted.

Prem says we’ll walk up to the place where the path to Thorong-La pass starts. We would need a whole extra day to get to the 5,416m pass, but there is time, at least, to lay eyes on its direction. We circle the wall of the temple complex, and two nuns are just leaving, one wearing hot pink sneakers. I ask if the nuns if they were born here in Muktinath and they say yes, and even though that is a completely unremarkable fact, to me it seems incredible because I am so far away from the world I know. They bustle off to the nunnery.

We climb quietly past parts of the complex wall that have cracked and broken in the earthquake two years ago, and emerge in a widening field that slopes upward and disappears in to a fog. “The way to Thorong-La,” Prem says. He says we are at 2800m. I say, obviously, we should walk up another 200m, so even though evening is turning denser, up we go in to the haze.

Some ways ahead, a walking bridge is slung across the gorge to our left and we climb until we reach the concrete block anchoring the bridge to the ground on our side of the river. Without any comment, Prem sits and I follow, and then I lie back and stare in to the unremitting white sky. No variations in density or color, no dragons or bears or wizard faces, just an endless, depthless white.   Further up the green rocky slope, on the other side of the embankment of fog, is the path to Thorong-La; below us is everything we’ve come from.

Quiet.  I am filled with a profound gratitude for Prem’s company, his silence, the easy way we can walk up to this concrete block and sit on it at dusk and do nothing at all.

After fifteen minutes, I decide to cross the bridge, for much the same reason we walked up 200 meters. We’re on one side of a bridge, so it should be crossed.  The first step out over the edge ofthe gorge sends a thrill through my nerves, and then out I plod out over the wires, which undulate a little with my steps, until I am standing directly over the water gushing down from the high mountains.  A thunderous cloud of sound rises up through my bones and engulfs my senses; I can barely hear my own breath. It feels like the river is running right through me, and when I shout or chant the water picks up the sound and rumbles away with it taking my voice down down down down to all the places we were.

The instant I step back on to the concrete block the mountain silence envelopes me again; magically, the roar of all that water is audible only between the walls of the gorge. Prem takes a turn on the suspension bridge, and then we head back down the green slope and circle around the other side of the giant temple complex.  Night is creeping in slowly, as if stalling a little to give us just enough time to see one more wonderful thing.

We come to an area of the hill I have been viewing from below in the mist: rows and rows and rows and rows of prayer flags strung behind small white structures scattered high up on a hill. I studied Tibetan Buddhist funerary rituals for a course I took this year, and throughout the evening, my sights have been trained here. When we passed the nun in the hot pink shoes, I pointed this way and asked if it was okay to pay a visit. She said yes. Prem and I make our way over the hill toward the fluttering prayer flags.  He walks down toward the road, and with barely a word, I go up.

I’m expecting to see signs of sky burial, but I realize quickly that this is a land burial site. Everything feels unified and still, but also light and high. There are small cairns everywhere, placed for passed spirits to find refuge to heaven, and as I walk between the grave sites, it suddenly occurs to me to ask Prem, still at an audible distance, if he thinks I could build a cairn. Why not, he says, and sits down on a rock facing out over the endless prehistoric topography while I climb higher up and find a patch of ground abutting the faded squares of color calling tut-tut-tut as the wind tugs them from their strings.

Prem never asks why. He just waits.  And when I have built it, a stack of stones among all the stones and fossils, another room in heaven, and when I have sat over it and cried for some minutes, I walk down the hill and we leave.

Night falls at last.

 

*

 

Between the Corn and the Millet

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

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

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

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

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

“What?” I said.

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

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

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

I can’t even explain that to you.

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

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

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

“Sure seems like it, right?”

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

“What is the name of your District?”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

We arrive at the fabric shop.

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

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

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

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

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

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

*

The Ritual of Goodbye

 

I decided to take the jungle path up to Kaski, which I normally travel multiple times during any visit, but haven’t been up or down yet during this hectic winter. I set off late and as I climbed up, the scramble of things fell away and I was alone on the stone path.  Where there is time to climb and think.

It’s been a few years since the forest was cut here (for grass, firewood) so the way is lush and clustered with greenery.  I always wear flip flops and the contours of the rocks feel close under my feet, even in winter.  At intervals, I came upon dustings of red powder laying bright on the rocks, a trail I suspected had been left by a recent funeral procession headed in the other direction down to the river.  Midway up the path there is a natural spring that has been organized with laid stones, and one large flat rock with a groove in the middle serves as a ledge channeling a steady stream of water for drinking. When I come this way with the kids, they cup their hands under the trickle and funnel the water between their lips, like something out of the Secret Garden. The spring always feels like a sacred place, a steady tributary of water that started who knows where, up high in the mountains, probably, and falls there at our feet as we pass.

As I made my way up from the valley to the ridge, I had that granular awareness of time passing behind me, and it seemed so strange that at any moment I was on one stone, and then I would be on the next one, and just that way the whole path would be behind me and I would be up in Kaski, the secret water tap and everything far below where I’d just been.

img_1031By the time I climbed up the last step to the ridge top, I was a combination of chilly and sweaty in the January dusk. I walked the spine of the ridge, which curves along our cubby of village as if along the top row of a stadium. Little Narayan caught sight of me up along the ridgetop, and yelled out from way down in the first row where he was visiting a neighbor, LAURA DIDIIIIIIIIIIIIIIIIIII!!!!! before launching in to a sprint and leaping up over terraces to come walk the last bit of the way by my side. We made a right turn at our row in the top section of the stadium, and strolled out to the house sitting in the wings, where the fire was lit and Aamaa and Hadjur Aamaa were waiting.

We had some popcorn and hot tea as sunset approached. Narayan’s brother Amrit came over and in the yard we practiced taekwondo and played chungi, which is basically Nepali hackey sack using a ball of rubber bands, while Aamaa cried out at us to calm it down and I riled everyone up. Govinda dai came over and we sat with Aamaa in the kitchen while she made anadi paste, a rice dough with ghee that is healing for sore muscles and bones, and then we ate it and it made our hands sticky with ghee. Saano didi came over, and then Mahendra’s mother came over. We transferred to the big room with all the beds, and while our visitors took seats around the room to hang out, I jumped under the blankets with Hadjur Aamaa, and with us both lying down, my long limbs rested against the soft jumbled folds of her sari.

Aside from ritualized procedures and ceremonies – tikka-giving, astrology-reading, mala-making — goodbyes are wholly unfashionable around here. So what usually happens on my last day or last morning in Kaski is our closest neighbors come over to chat, but nobody talks about the fact that I am leaving, going to another world, and won’t be back for a long time. If we do, it is in the form of asking about the trajectory of my flight, how long I’ll be in the air, what they give us to eat during such a long journey, and whether or not it is colder where I’m going than where we are. We discuss what season it will be when I come back (summer), and what fieldwork we’ll all do together (millet planting and rice planting), and this leads us to reminisce about what a klutz I was when I first arrived, and how many things I know how to do now. At some point, people wander out mid-conversation. Because the course of events is set, both the leaving and the returning, and since there is nothing to be done, there is no point in becoming uncomfortable. I understand this ritual of goodbye, and have become grateful for it.

churning milkAfter most people had left, Govinda stayed while I churned milk so I could bring buttermilk to Pokhara tomorrow for the family. Govinda took photos of me, which is kind of nice because I don’t have many photos of myself since I’m always the one taking them – but then, people, he posted them on Facebook and two days later I would discover that this photo album is wildly more popular than anything I’ve ever posted of myself trying to be useful or worthy. What does it all mean?

When the milk was churned, Govinda dai left to go home and Aamaa and Hadjur Aamaa and I got ready for bed. It’s always been a nightly habit of mine to go out after everything is quiet and look at the stars, across the village stadium at Kali with her arms stretched out under her cloak, and study the positions of the constellations amassed around her. I usually walk out along the garden, and sometimes I climb halfway up the hill to the ridge and look back at the house with its golden porch light, a warm square in the broad, cold darkness. Even when I am far away from Kaski, I often feel my self located there, outside in the silence, looking back at the still, lit house in its expansive darkness. That spot is a place of gratitude and wonder, of tiny-ness and huge-ness at the same time: my little self, with coordinates in the galaxy.

It was another January night, clear and chilly, the stars laid out overhead like dust. I went out to the yard to brush my teeth, and for whatever reason, instead of going out along the terrace, I stood in the square of light cast off the porch and looked out in to the dark. In the summer, the yard is hemmed in by towering corn stalks, but in January, there are no walls against the yawning night.  I stared out in to the blackness, past the edge of the yard, and all I could see was the outline of trees under the stars, and an opening in the blackness at the top of the hill where the path gives way to the ridge.

It occurred to me that in all this time, I’ve never looked at it this way. I studied the inscrutable night, brushed my teeth, and threw my eyes up to the sky for a moment to make sure Orien was where I expected him.  Then I went back in to the house, placed the wooden bar across the inside of the door, got under the warm covers, and drifted off to sleep, safe against the morning.

*

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Between

 

On my way home (by way of Delhi…woe), I have stopped over in the city of Almaty to visit my college friend Freeman, who works for the State Department in Kazakhstan. I know you almost certainly have no idea where Kazakhstan is, and that’s fine. It’s a former Soviet state that shares part of its eastern border with China and its southern border with Kyrgystan and Uzbekistan. Kazakh culture is heavily Russian with a mix of other influences from China and central Asia, and people are predominantly Muslim.  There’s also a significant Korean population, and the art and food maintain a lingering fragrance of the old Silk Road.  The eastern and southern borders are braced by the upper parts of the Himalayan mountain range that eventually makes its way down through Pakistan, India and Nepal.

That Crazy Russian Alphabet

That Crazy Russian Alphabet (bonus: Camca = Samosa)

Basically, Kazakhstan is a gorgeous cultural crossroads, surrounded by mountains, where everything is written in that crazy Russian alphabet that looks like English after a rough night.

On the first day, Freeman and I used a combination of gondolas and hiking to get up to Talgar Pass at 3200m, just outside the city. Later we had an amazing dinner at a Georgian restaurant. Cause also, Georgian.
Talgar Pass, 3200m

Talgar Pass, 3200m

The second and third days we went sightseeing around Almaty. In the Green Market we browsed all manner of essentials including fruit displays from Mars, sacks of rust-colored spices, butt-pad underwear, and a vibrant expanse of fermented Korean goods stretching off nearly to Korea. We spent some time wandering “the area of cheap goods from China, which are the same everywhere,” according to Freeman, who was our only expert in this situation.

One of the most interesting things about Almaty is the mash up of quaint, European-like streets lined with chic cafes and flower gardens, combined with austere Soviet-era concrete fortresses dotted throughout the city: apartments, offices and municipal buildings. On one hand, Kazakhs have enacted such delicate flourishes as distributing mountain runoff over the natural downhill slope of the entire city to create a delightful canal system that sends fresh, cooling streams of water gurgling down the sides of the manicured city lanes. On the other hand, we walked these lovely streets to get to the Central Musuem, which turns out to be housed in the Citadel of Sauron, beamed over directly from the Middle Earth.

 

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“When the Russians build something, they go big,” Freeman explained.

Inside the Central Museum we saw two of my favorite things: mesmerizing spearheads made by prehistoric humans tens of thousand of years ago, and extremely detailed ideas on advanced cosmonogy world organization, painstakingly translated for English speakers.

I was enthralled when we visited a candy store lined with bins of billions of dazzling wrappers in every color, which, it’s candy store-ness notwithstanding, Freeman pointed out had retained a very typical Soviet-era setup, whereby customers wait in long lines while employees put goods in to containers for them. Of course, we’re talking about candy here, and an endless supply at that; under the Soviet Union, basic goods and food were often in short supply. Freeman said it was similar in China, and when he first came to the U.S. at age 11, it was incredible to him to enter a grocery store and be allowed to touch the food.

 

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See, I never thought of that.

As I come to the end of my summer travels, I appreciated the complexity and diversity and contradictions of Almaty. At night, we tried to watch the Olympics, but Kazakh TV was only showing the things where Kazakh athletes were competing, so we attempted to be riveted by the race walking marathon – YES, A WALKING MARATHON – TRY TO STAY RIVETED – and the trampoline competition. When race-walking got to be a lot, I flipped occasionally to the BBC or CNN, where the U.S election is the only thing on, far away and too close, oddly irrelevant, and yet more relevant than ever.  During the time I’ve been in Nepal this summer, there has been an onslaught of international terrorist attacks and domestic racial violence in the U.S….the other day, a friend posted a photo he captured at a Connecticut political rally (where he was protesting) proclaiming “Diversity = White Genocide.”

Mean time, Aamaa has no idea who Barack Obama is, and a major event of our summer was that I acquired some new sheets of corrugated tin to replace the 25-year-old kitchen roof, which was leaking directly into the cooking fire.  How is it possible that a person can go from one side of the world to the other in barely a day?

Nepal is my full-time work, not a summer excursion. Nevertheless, during these transitions from one continent to another, I’m gifted with the chance to be between; to float over the globe and feel the intensity of tiny things, like the drops of water falling where Aamaa sits by the fire, and also the drifty arbitrariness of all of it, how the most urgent fixation somewhere is irrelevant somewhere else, how everything is swallowed in sweeping expanses of destruction and renewal and passages of time. We are so small, yet there are so many treasures to find.

 

Aamaa's cooking fire, Kaskikot, Nepal

 

Maybe that’s why my favorite stop in Kazakhstan was the Central Mosque, which we visited just after the color and chaos of the Green Market. Before we went through the gates, I draped a sheer pink shawl over my head, and while Freeman entered the cavernous men’s side, I made my way around to the smaller women’s side. I removed my shoes and entered a hushed, carpeted room just as a row of women was moving through a series of prayers playing over a speaker.

Standing in the back, I was vaguely aware of myself, a white American Jew standing aside in a Kazakh mosque, a cultural transplant who seems to be at home everywhere and nowhere. I hope these women will forgive my vanity in sharing the over-exposed photo I snapped of their meditation, because at a time with so much violence outside the walls, it was such a soft and sanctified place.  The natural thing was to move to the center of the room and join in the late morning prayer, and it was easy to follow the succession of standing, bowing, kneeling, and bending to the floor. I’ve offered prayers in so many different kinds of temples and situations and settings, these fleeting spaces sometimes feel more like home than many other places where we live.

 

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I don’t speak Arabic, of course, and I’m no more Muslim than Hindu. But with the U.S. border emerging over the horizon, CNN flashing in my head, and the world marching under us, I heard words announce themselves in my ears as I put my forehead to the ground one time and then the next, the pink shawl falling comfortingly around my face.

Please humble our hearts.

Please bring solace to those in sorrow.

Please give wisdom to our leaders.

Please guide us to our better selves.

Please strengthen us through our differences.

Please make me an instrument of peace.

See you soon, USA.

*

IMG_9726

The Contract of Attaining

 

I have been working on rural dental care in Nepal since 2003.  That’s thirteen years.

When I began, the iPhone had not yet been invented.  To call home from Kaskikot, my choices were to wait while Shiva’s dai’s mother rigged up the satellite phone in Deurali, or take what was then a 2.5 hour bus ride to Pokhara and call from an internet cafe.  Now I can Facebook chat while taking breaks during firewood chopping outings.

Our first dental program at the Kaskikot Sub-Health Post, for Sada Shiva Primary School, on May 9, 2004

Our first dental program at the Kaskikot Sub-Health Post, for Sada Shiva School, May 9, 2004

Now in July 2016, Kaskikot’s dingy sub-health post has been upgraded a few times and is a full-scale Health Post.  Someone from almost every house has  left for migrant labor in Malaysia, Dubai, Qatar, or another gulf country, leaving swaths of flush green rice paddies overgrown with grass.  An insurgency overthrew Nepal’s monarchy back in 2006, and the country is still figuring out how to operate a democracy in a place where the young are mostly literate and the middle-aged mostly are not, where rains cut off whole villages from road access during the summer and snow isolates other regions in the winter.  Wireless has long since outpaced plumbing.

Nepal still does not have McDonalds.  Or a majority of schoolbags with zippers that last longer than a year.  Or regularly scheduled elections.  Or, even though it’s the most prevalent disease in the world and influences many of Nepal’s core public health problems, any medicine for dental decay at all in rural places.  Which is still most of the country – and will be for a long time yet.  (See, Wireless vs. Plumbing.)

To the best of my knowledge, our nine rural dental clinics are the only ones of their kind.  There are many aid-funded health care facilities in Nepal, but our clinics are operated by Nepali providers, local to their villages, who practice specialized rural dentistry techniques that are sustainable in limited-resource settings.  We didn’t invent these techniques, but we contextualized them by adding in other pieces like school-based prevention and technician mentoring.  More recently we’ve focused on asking what standard of care these dental technicians can and should be held to within the limitations of environment and training. As a result, we’ve developed considerably more rigorous protocols than are typically applied to permanent rural health services.

Lwang Ghalel Clinic, 2012

Lwang Ghalel Clinic, 2012

This concept is known in international lingo as “rights-based health care.” It’s just the argument that people are entitled to the highest attainable standard of health care within the limitations of context.  This isn’t a new idea, but actually manifesting it through innovation requires a level of patience and detail that could really make you wish you’d gone into a career of monastic asceticism instead.

Fortunately when Roti’s mother came over writhing with a toothache in 2002, I didn’t know I was getting in to a career at all.  At that time I was looking for something I could tell my neighbors in Kaskikot to do when they showed up moaning in pain, which was whenever, not when somebody happened to be rolling by in a mobile clinic.  The answer had to be viable, respectable and available on any random day.  As it turns out, this way of thinking is, by definition, the pursuit of human rights: it seeks a permanent and dignified answer for people, not the implementation of a prefabricated idea.

P1030500That’s how we started combining localized clinics with community awareness programs.  But it took years to realize that wasn’t enough…we had to bring these clinics into the existing health care system of Nepal, a centralized government system that provides a rural Health Post in each village. Basically, our clinics needed to become part of these Health Posts, without losing the benefits of specialization we’d developed.

Nice puzzle.

 

Since 2012, the biggest challenge we’ve faced in this project is handing over our clinics to local ownership after a two-year set-up and supervision period.  Our first clinic in my own adopted home of Kaskikot, the very place I was motivated to have answers for people, ultimately folded after we ran it for SIX YEARS, treating hundreds of people.  The local government wouldn’t run it.  

Honestly, our advocacy strategy was nonexistent in Kaskikot.  Worse yet, I was the American neighbor-kid, and my efforts were seen as personal.  In Kaskikot, I learned the taste of letting go and swallowed a bitter but essential lesson.

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Our second clinic, in the neighboring village of Sarangkot, inched forward.  It’s been operating on its own since 2012, mostly due the persistence of the dental technician, Dipendra, and clinic assistant, Renuka.  They continue to go to the Sarangkot Health Post every single week, and whenever I’ve visited, they have at least 5-10 patients in a day.  But Sarangkot’s local government only “kind of” funded their clinic.  When I sat in a room full of Sarangkot politicians back in 2012, conducting a (kind-of) “handover” ceremony, there was a Washington Post reporter and photographer present while officials explained that the government just didn’t have any money for this clinic.  I had to say bye and hope for the best…and against the odds, another NGO stepped in and donated a moderate dental budget to the Health Post.  Which allowed the Sarangkot clinic to survive, but saved the health care system of the burden of evolving its priorities on a deeper level.

It’s a quandary, so let’s call the problem like it is.  It feels good to do something and see a result.  But when you have an aid state like Nepal, the do-ers are part of an entrenched structure of dependency that absolves Nepal’s public systems of responsibility.  This has been extensively documented, and everyone always seems very dismayed when they’re documenting it.

Okay, but, everyone knows this is the explicit Contract of Producing.  Things mostly run better when the people who decided to start the things are the ones who keep doing them, which mostly is what those people want to do anyway (so that it’s done “right”), and of course the people who didn’t start these things, and probably don’t want to run them, prefer the very same.  Once that’s the way it works, that’s basically what everyone expects and signs up for.  As far as exposés go, it’s not super material.

I am acutely aware of my reluctant participation in this arrangement.  And I too could raise money forever, operate dental clinics one by one in Nepal, and help us all feel like heroes.

But what about the right to the highest attainable care everywhere else?  And besides, what’s “attainable?”  Nepal has a national public health care system that has two key qualities: stability and scale. It’s not famous for quality or agility, but is it capable of incorporating the creations of social innovators and risk-takers to improve its performance one round at a time?

Yes, it has to be.  But only once you break the explicit Contract of Producing.  Instead, there has a be a Contract of Attaining, and then making better things more attainable, and then attaining those.

I think.  I’m still working on this theory before I publish.  But actually, I’m pretty sure about it.

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Salyan Dental Clinic, July 2016

In any case, here we are in 2016, billions of dollars of foreign investment later.  In our corner, we’ve decided to revisit all nine of our dental clinics and focus on their permanent integration in to the government health system.  They’re are all at different stages, from nebulous commitments of local funding to full halts to pre-handover.  We’ve begun by brainstorming with the technicians, and then meeting for coffee with individual village leaders.

Our first stop: Sarangkot…scene of the 2012 Kind-of-Handover.

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Sarangkot Clinic, Post Earthquake

I’ve never visited Sarangkot’s weekly clinic and seen it without patients.  At this point, Dipendra has more specialized experience in rural dentistry in Nepal than pretty much anyone other than the trainers.  He’s treated thousands of children and adults in rural settings, taken refresher trainings, and had at least two clinic audits by a dental surgeon.  But since the kind-of-handover in 2012, we’ve significantly upgraded clinic standards, and the Sarangkot clinic is isn’t supplied for our present quality protocols.  In fact, it’s also being used as a storage room, and the earthquake last year did some interior decorating…and, dusty books. The decor doesn’t really convey, “awesome and critical.”

But here’s our idea. Let’s imagine Sarankgot’s local government was to allocate funding for Dipendra and Renuka, and in exchange, we put about $1000 in to refurbishing the clinic and providing further mentoring.  Sarangkot becomes one of nine places we can invite policy makers in and say: look, this works.  This is awesome and critical.  Here’s another one in Bharat Pokhari, and one in Lwang Ghalel, and…see?  The central health ministry should allocate funding for a rural dentistry specialist in all of its Health Posts.  These progressive village governments are doing it already on their own.

No sweat.  Chop chop.

But it’s important, not just for our issue, primary oral health care, but in principle.  The Contract of Attainment is fairly unpopular, because it’s unmarketable, and we’d all rather feel like heroes.  Somebody has to champion it for its own sake.

IMG_8867Therefore, we’ve spent two long afternoons in the office strategizing, and tomorrow, we’re off to a meeting with local politicians in Sarangkot.  All four of us – me, our Program Director Aamod, and our field officers Dilmaya and Gaurab – are going.  None of us are particularly schooled in political lobbying, but hey, as far as advocating for dental clinic funding in villages in Nepal, I think we’re as good as it gets.  When we met with the Health Post chairman yesterday, he was much more positive than I expected. But things can sound different in a room of people with competing agendas.

So this is where we are in 2016.  We’ve all been thoroughly self-schooled in Virex disinfecting procedures and gloving-regloving infection control, as well as of course the difference between upper molar forceps and an enamel spoon, and we are now embarking on an in-depth immersion experience in citizen advocacy in emerging democracies.

It’s like a career in…in…

…a career in attaining?

Wish us luck!  Time to jump in.

*

Salyan Dental Clinic, 2016

Salyan Dental Clinic, 2016

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

In the Clouds

Dear Mary,

First of all, don’t worry, this isn’t setting an annual precedent–it’s not like I’m going to write to you every single year on June 26th, which you would find dreadfully contrived. However, I have a few things to tell you about the past year, and I’m thinking about you today.

A year goes by so fast.

Remember those four college guys you told me I should totally convince my parents were okay to stay in my apartment while I was in Nepal last summer? That didn’t work out so great. They threw beer cans in my neighbor’s garden and now my neighbor won’t talk to me. In fact, my neighbor, who chain smokes cigars but used to bring me fresh vegetables from his garden, told me that if I put my recycling in the wrong bin, he’ll take it out and relocate my recycling to my porch. Still, no major damage inside the apartment, and I got a solid month’s rent, so on the whole, I’d say the renters were a win, for me if not my neighbor. You’ll definitely take my side on this one.

The little memory card from your service is on the bookshelf across from my desk. I flip it every few months between your photo on one side, and the picture of the cloud that looks like a hand holding the sun. One afternoon, when you were really exited that you’d taken that picture, we sat in your living room and you tried to show me how the cloud was shaped like a giant hand reaching down from the sky, but I couldn’t make it out. Right here, you said, this is the thumb, going along like this, and the other fingers go along like this. I squinted and turned the paper around and I couldn’t find the hand of God anywhere. You didn’t seem particularly amazed that I couldn’t see this image that was so obvious to you. Eventually, we moved on to something else. Now when I look at it each day I can’t see how I missed it. The hand of God is right there. I can’t not see it.

Just a few days just after I returned from Nepal last summer, I was driving to Wallingford and couldn’t believe you weren’t there.  I consoled myself by deciding we would build all the bamboo houses again.  That would fix things.  We’d hike for days in the hot sun, negotiate with tin vendors and take long bumpy tractor rides, surf waves of despair followed by hope followed by despair and hope, again. We’d be confused all over and learn it all over from the beginning. I’d hike up to that airy ridge in Lakure in the burning sun and drink knockoff Redbull, again. Yes. But when I got up the next day, nothing had changed. The bamboo houses were still standing, and you were still gone.

Often I think about all the people that have died. The list that has grown even this year, when I couldn’t call you. Fifty people were just gunned down at a club in Orlando. So many people die violently or young or right in the middle of dinner. You had a long life full of beautiful things, you were at peace with yourself and the world, you left a tapestry of all of us who love each other because of you and in your memory. I tell myself I should be grateful, and I am. But I miss you anyway.

You are still in the “favorites” in my phone because I can’t delete your name from the list. Once, I was getting in the car and without realizing it I tapped your name and dialed your phone. You picked up your voicemail and started talking to me right there in my car and scared the crap out of me.

VERY FUNNY, YOU TURKEY.

Also, listen, things have gotten really hectic in politics, and I think Bill and I should consider going out as a presidential ticket. I haven’t asked him yet but I think he’ll consider it.  We sometimes watch the debates together on the phone, the way you and I used to have wine dates in our kitchens when it had been too long since our last visit. While Bill and I watch the debates we text and afterwards we debrief till 12 or 1am and I explain all the reasons that I’m right and I represent the future. I am pretty sure that if we ran – of course we’d have to decide which of us was going to be the president – but anyway if we ran, I’m pretty sure we’d have much better ideas than a number of the people who have been running. We’d make you absolutely crazy and you’d roll your eyes over dinner.

Next year I start a field placement for social work school. I’m going to work with Cambodian refugees. This is something we should talk about for a long time. I know I’ll do my internship without you, but it just won’t be the same.

I never did the follow up talk I had planned in the library, and I never tried to get on Fox news again, after that adventure where you convinced me to call and get myself a TV interview about the earthquake in Nepal. I just couldn’t bear the thought of being back in the television studio where I texted you, and especially not the thought of standing before a crowd at that same podium in the library meeting room, looking at the door you sat behind. But strangely enough, I walk past the other side of that door every time I go in the library to get my parking ticket validated. I glance over at the spot where you and Bill sat listening to my talk, and then hustle past it.

Why do I feel better when I’m missing you the worst? I think you should have explained this to me before you left.  The absence is in the shape of you, right where you fit here. I think more people should be made aware of this. It’s a real fucker, as you’d say. You wouldn’t say “fucker” though. You’d make the “f” with your teeth and squish up your nose and then jab the air with your pointer finger, and then slide your gaze sideways from the imaginary fucker back to me. Like this thing about this fucker is slightly classified information that I get to know because I’m with you.

The clock would gong in the living room, and we’d say, it is getting so late!

Also, can something be slightly classified? Isn’t it all or nothing?

Isn’t it all or nothing? 

I’m going to declassify everything. But there are just so many things we didn’t get to.

I think you would approve of how I’ve grown this year. We don’t have a lot of time to spend being afraid or making ourselves small. My life is very blessed with family and friends and challenges of merit. After our visit to Tripureswor Ward #6 last summer, just days after you died, I came home early for your memorial service, but my friend Anne stayed behind. She and Saila dai did a puja for you in his magnificent temple garden. Anne saved prasad for me, a tiny branch with two tear-shaped leaves. She mailed this delicate offering to me months later from Moorehead, Minnesota. Isn’t it an amazing thing to have friends like that? The branch sits on my mantle next to the hand of God. It connects me to you, and Anne, and Saila dai, and those hot and trying weeks after the earthquake, to the bamboo houses, which I can’t trade for you, which is not a deal you’d take anyway.

Well…maybe you’d consider it.  You had a pretty good time here I think you’d take another day.

You will always be one of my favorites. Call, ok?

I love you kid,

Laura

p.s. me trying to get you to sing “imagine that” while listening to it through headphones…first the song, in case you need to reference the lyrics up there

..and this, which I can’t listen to without laughing

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And one from Nepal I think you’ll like…

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