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.

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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.

 

 

Recent Audio Stories

 

For some reason I’m having trouble adding these to the “audio gallery” page, so for now, here they are on their own page.


YOUNG WIDOWS OF NEPAL

The World – September 2015

Bishnu & Ayusha w photo

 

 

 

 

 

 

 

 


ANIMALS AND THEIR HUMANS

The World – August 2015

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SHELTER

The World – July 2015

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Birth vs. Wedding

 

I’ve been in Nepal for a week now, and just yesterday I attended a shotgun wedding in the middle of the night at Vindivasini Temple.  The excitement started when I came home from the office and found Bhinaju with his knickers in a twist.  He was trying frantically to charge his cell phone, and something about the connection wasn’t working right, and every two seconds the phone was ringing, but the battery was almost dead.

Bhinaju’s nephew Bishnu is scheduled to be married this month, as are many other betrothed, because according to an array of astrological indicators, this is an auspicious time of year for weddings.  As per tradition, Bishnu’s marriage was recently arranged and the engagement confirmed by an exchange of tikka, the red dot you’ve seen Hindus wearing between their eyes. And once the tikka has been exchanged, there’s no going back. The deed must be done.

All this was already in the works when, yesterday afternoon, a pregnant relative of Bishnu’s went in to labor earlier than expected.  Custom dictates that if the relative has the baby, the entire extended family is banned for eleven days from various ritual activities—including, inconveniently, weddings. And – stay with me here – eleven days from now, we will be past the astrologically auspicious marriage window, which won’t come around again for another year, which, since Bishnu and his bride have already exchanged tikka, would just be a violation of the entire system of everything.

And this now brings us to the heart of the matter, which is me holding Bhinaju’s phone charger in the socket to suck out all the electricity it can muster, and then all of us tripping on our shoes as we run out the door to hail a taxi at 9pm, buy some oranges and flowers, and rush to Vindivasini Temple for Bishnu’s wedding before some baby, somewhere, is born.  It is now a matter of birth vs. marriage; we can’t take the risk of waiting till morning.

Vindivasini temple is usually crowded with people and priests and marriages and fruit, but at 9:30pm it is absolutely deserted, with nothing but two police officers and a cold breeze blowing over the laid stones.  Aidan and Pascal think this is the perfect place for me to teach them some taekwondo, and we pass the time running in circles and doing flying side kicks in front of the frozen statues.

Just as we’re losing interest in this adventure, Bishnu, his bride, and an entourage of people in puffy coats show up with the priest.  We all stand around shivering and trying to take iPhone pictures in the pitch dark (nobody had time to bring a real camera) as the priest rushes them through a series of rituals. I am struck as always by how abstract the bride and groom seem at these weddings, and this is even more apparent tonight: Bishnu and his bride are at the center of the marriage, but it is not about them at all.

Is it over? Is it over? Everyone is freezing. Bhinaju’s brother has a van. Everyone piles in to take the girl back to Bishnu’s house an hour away in Lumle, where the family will take turns “showing their faces” to the new wife. I almost never turn down a chance to be part of a face-showing ceremony in Nepal in the middle of the night, but this next phase is going to last till morning and I have nothing with me. I’m tired and I catch a ride back home.

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Dubai

IMG_4085My layover in Dubai was eight hours.  Long enough to trek back and forth many times along the glaring fluorescent strip of duty free shops betwen terminals one and two.  It was daytime in Dubai, but for me it was the no-time that happens during a trip from one hemisphere to another.

I wandered in to one of the bathrooms and soon found myself looking for an earring that had dropped.  A young employee who’d been sitting idly when I walked in came over to help me.  As I was shuffling through my belongings she noticed a coin.

“This is from Nepal,” she said.  “Have you been?”

Yes, I said, I’d been.  We got to talking in Nepali right away.  I wasn’t surprised to find out
that Mandira is 26 years old with a 1-year old baby she left in Nepal with her in-laws and her husband, who is also waiting for a visa to travel abroad.  When I asked what she’d paid a manpower company to broker her position in the Dubai Airport bathroom, I already knew roughly what the answer would be: about 10,000 dinars.  Her salary: 900 dinars per month.  It would take her a year to pay off her loan to the company before she started earning anything to send back to her family. It will be a few more years more before she can afford the 3.5 hour flight home to see her then four-year-old child.

It’s a typical story but it’s still amazing to see it in action without having to try. This kind of position has become so preferable to looking for local employment in Nepal that I don’t even have to leave the duty free section of the airport to find Mandira.

The flight from Dubai to Kathmandu is a special kind of cultural experience.  You step out of a hip multinational terminal in to a waiting area where almost everybody who isn’t a white person wearing hiking boots and tie-dye is a Nepali person returning home from a labor contract.  For many it is the second flight of their entire lives.  A large percentage of passengers have none of the practiced movement that comes with routine air travel.  There’s a lot of helping each other find seats, opening and closing latches to see what they do, gazing out the window at baggage trucks, calling to one another across the rows to look at this or that.  It’s about as close as you can get to walking out of an airport and getting on a city bus in Kathmandu that launches in to the air.

On the plane I immediately leaned against the window and tried to sleep.  I’d been traveling for 20 hours.  The young man next to me was quiet and stared straight ahead, and I assumed that he, too, was an amateur passenger just surviving the journey.  After an hour of half-sleeping, I sat up, and as I jostled my position, we exchanged a few words.

“My father just died,” he said.

I drew in my breath.  “I’m so sorry,” I said.

“I came straight from duty.  I don’t have a bag with me or anything.  I came straight to the airport and bought a ticket.”

“What happened?” I asked.

“He was in the U.K.  I work at a hotel in Dubai.  My family just got back to Nepal with his body.  After we land I have to take a 10 hour bus ride home, because they are waiting for me to start the rites.”  He stared ahead. “I usually talk to him quite often, but we hadn’t talked in about three days.  I don’t know why.”

The snack cart came along.

“Can I get you something?” he asked.  I declined, but he asked a few more times, and I declined again.  He bought a sandwich for himself. He asked the boy in the aisle seat – who didn’t look any older than 18 – what he wanted.

“Many of the new ones are scared,” he explained softly.  “So we help them out.”  He bought the boy a cup of tea.  “Are you sure you don’t want anything?”

“I’m really okay,” I said.

He opened and closed his sandwich.  “I’m not supposed to be eating this food,” he said.  “We have traditions – it’s called kriya.

I know about this of course.  It’s not just the sandwich.  The death of this young man’s father should have immediately been followed by 13 days of eating food cooked as part of a series of rituals, without salt, and by wearing only white clothes with no seams, and by sleeping on the ground, and by drinking special water, and by not touching any other people, and by daily pujas and bathing. He should have shaved his head.  But he was crammed next to me on a floating bus.

He took a bite of the sandwich.  “I haven’t had anything to eat or drink since yesterday,” he said.  “Actually, I haven’t talked to anyone.  Now I’m talking to you.”

“I can’t imagine how hard it must be in this strange situation,” I offered.  “It will be good to be in the right place with your family where you can do…all the things.”

“Are you sure you don’t want any of this sandwich?”

“I’m sure.  Thank you.”

“I usually talk to him often.  I don’t know why we hadn’t talked the last few days,” he repeated.

He gazed over the sandwich again to the back of the next seat.  “There’s no point in being sad now.”  He ate a chip.  “I can’t think of what to do.”  He offered me more of the sandwich.

I asked after the details of how he’d get from the airport to a friend’s house to the bus to his house.  It seemed like the only relevant thing to discuss.  Everything else was either too small or too big.

“So you will be with your mother and siblings by morning,” I said. I told myself that things would make more sense then. I wanted to believe that it would be better when he knew what to do.

“Yes.”  He gave the rest of his sandwich to the trash pick-up.  “But when I get there, you know…it will be real.”

 

 

Between Worlds

Read this series here.

IMG_2479Over the years, I have witnessed many passages in Nepal.  Marriages, coming of age ceremonies, births of animals and people, and deaths of many kinds. The weather itself has a careless drama about it, demanding reverence for the seasons and relentless passage of time…when it is hot, it’s time to plant millet; when there is a full moon, it’s time to fast; when a distant glacier becomes heavy, it’s time for it to break apart, time for the river it lands in to overflow in a torrent, time for an entire village to be swept away.  When it is morning, it’s time to get up and cook breakfast.

The intimate relationship between people and cycles in this part of the world is one of its most moving qualities.  I think it is a hard thing to see if you have always been inside it. But I am outside of it.  And peering in, I am endlessly preoccupied with how a single human existence can be subtly accepted as a grand and meaningless expression of a larger constellation of forces and relations and nature, awesome because it is small, not because it is unique.  I only notice this because I learned to see myself as separate from the moment I came in to the world.  In the West we gain power, intelligence and purpose from our individuality.  But it’s something I can’t explain to Aamaa.  There simply isn’t a vocabulary to say that my life possesses a greater idea than the idea of the universe itself.

I know I’ll never be comfortable with this fact.  Instead, I am perpetually drawn to these rites of passage, which integrate our small lives with those of our ancestors, with the cosmos, with God and with the future.  Perhaps it’s like continually trickling cool water into a wound that will always burn.

This winter I’ve decided to start a project that has been some time in the making. Since I first began coming to Nepal in 2002, young men have flooded out of the country for migrant labor in gulf countries; last year, over 300,000 people left for that purpose alone.  A surprisingly large number of these young men die abroad, and when they do, normal mourning rituals are turned completely upside-down.  Many of the essential features of customary mourning become impossible.  My project will document the way that families have adapted ritual grieving when their sons die overseas.

Nepal’s funerary customs in the weeks that immediately follow a death are called kriya.  There is great intelligence and beauty in these rituals, which provide a structured role for the community and extended family in sharing grief, reaffirming ties, and placing the life and death of the deceased in to a coherent cosmic story.  Many aspects of kriya are austere and demanding, putting physical and mental purification above comfort, and imposing isolation as a sanctuary for the emptiness that follows loss.  When the kriya period ends, other rituals last weeks, years, and in some cases, forever.  Aamaa, a widow since age 23, hasn’t worn red in 35 years.  Anyone who meets her can immediately know without a word that she is widowed – if they are attuned to this custom.

Stories of grief and loss in other places have immense importance for us. Ritual grieving in American culture is increasingly short-lived and mainly the private domain of the bereaved.  Death as a matter of politics or policy or violence is in our media every day.  But mourning, the outward expressions by which we integrate death in to the un-ended lives of the living, seems to be on the periphery of our inquiry, at best.  In some ways, mourning is treated as an obstacle to our collective concern with affirming and carrying out our individual significance.

But mourning is a choice we make to ascribe meaning to our grief. It is a willful sanctification of our mortality.  We hope for the grace to extract from this some kind of redemption, something beautiful about life.  Or perhaps simply the courage to keep living.

In the course of this series, I hope to honor the beauty of Nepal’s kriya traditions, as well as a generation of young people caught in the ambiguous place between a world that has shattered and one that does not yet exist—at the threshold, in that empty uncertainty, where we are reinvented.

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Read this series here.

The Middle Girl

Aamaa talks often about my departure now. She’s worried about being left alone when Didi also leaves to join Bhinaju in Pokhara, which will be happening any day now.  And of course, Bishnu will stay in the city as long as she can, to study for her 12th grade exam.  It’s so strange to think that when I first arrived a year and a half ago, Aamaa and Didi and Bishnu were so intimately bound here in Kaskikot, and now Didi is married, and Bishnu is studying, and we are all wondering what Aamaa will do when I leave for the U.S. in a few weeks.  It’s strange that despite everything, it’s my departure, of all things, that will thrust her in to real solitude for the first time.

The wheat harvest, with the lack of fanfare it has produced, has been a kind of seal for us.  It’s fun to be exotic to one another.  But as crazy as it sounds, one day we looked around and found that something had tipped over.  Today I did housework on my own most of the day, with no direction: watering the buffalo, doing dishes, pounding wheat, moving goats.  Just because it was there and needed to be done.  The fact that nobody’s all hot and bothered about these feats anymore feels…strange.  It’s an entirely new reality, for all of us.

“Everyone is saying to me, ‘Don’t let your mailie go,’” Aamaa said in the late afternoon, while Didi and I were lying on the beds inside, writing, and she was on the porch pounding wheat.  Mailie means middle girl.  “Your maile does all this work around the house,” they’re saying.  “She brings you good food, she helps you all the time.  Don’t send her to America.”

Didi interrupted Aamaa mid-sentence to ask me something from her book, but Aamaa doggedly re-commanded my attention.  She wanted to make her point.  I looked at her through the doorway.

“Other people have said that?” I asked.  Despite myself, I was delighted. I realize I had no business being here, but that doesn’t change the fact that I’ve taken some knocks.

“A lot of people,” Aamaa sighed. “When you go, I won’t be able to say anything, so I’m saying it now: raamro sanga jannus, eh?

Go well, okay?

I lay on my tummy on the bed with my head near the door, where Aamaa resumed pounding wheat.  I was writing a poem and story and speech I’ll recite at my school farewell if I get one.  And then where will I go?  Where on earth does a person go from here?

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Family