The Power of Catching a Goat

 

At the end of each of my visits to Nepal, there is usually a collection of ridiculous, entertaining, and lovely things that haven’t found a home in any of my blog posts, but deserve to be known to the world. Herewith is enclosed this winter’s box of treasures.

1. Grab Your Desire

Signage is a very reliable source of amusement in Nepal. This is definitively the most awkward hotel welcome sign ever, surpassing even Hotel Touch Nepal, a winning entry from last summer. And yes, the hotel is actually shaped like an octagon, which under the circumstances I assess to be both logical and insane.

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2. All the Religions at the Same Time

Because Santa suit and Nepali pop song and traditional (Tamang?) dress.  This is how we do the Christmas street fair, y’all.

3. The Power of Power

For the entire decade and a half I’ve spent in Nepal, there’s been an ever-increasing amount of load shedding due to lack of electricity. The flashlight and solar power industries are enormous; our own office has $2,000 worth of back up battery power just so we can keep the lights and computers on. Everybody simply takes scheduled power outages to be a fact of life, familiar as rush hour traffic–in the winter when hydropower is lowest, load shedding lasts for up to 16 hours a day.

So apparently, just this fall, a new minister was appointed to the Energy Department, and revealed that the load shedding problem is, well, entirely due to collusion between the government and the energy industries. ENTIRELY.  Therefore, he simply declared load shedding to be over. After fifteen years, the lights went back on, and that was the end of it. I am telling you, there wasn’t more than 5 hours of load shedding this whole month, in the dead of winter.

I asked my friends why everyone isn’t absolutely up in arms about this. The answer was simple: everyone’s just glad the lights are back on. And besides, if anyone gets annoyed, they will probably be turned off again.

4. KP’s Dental Technician Henna Tattoo 

On the closing day of our university screening program, we discussed lessons learned, watched a slideshow of our week, and traded contact information. I had asked our technician Anita to bring some henna, and I did henna tattoos as people filtered out. Our technician KP demanded to have one placed on his chest, so obviously, he got K.P. and a tooth. His biggest UCSF fan, Helen, approved.

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5. The Power of Catching a Goat

My last morning in Kaski I got up and, as per routine, wandered outside to brush my teeth. As I was puttering around in the yard and splashing freezing water on to my face, I looked up to the terrace behind the house to see our 11 year old neighbor Amrit creeping up behind his goats, trying to catch and tether them to their posts, while muttering in a sinister tone: “DON’T UNDERESTIMATE THE POWER OF CATCHING A GOAT.” He would pounce just as a goat slipped through his hands and clomped off a yard or two away before losing interest and lazily looking around for something to chew on. Then Amrit would creep again, intoning, with intense focus: Don’t underestimate the power of catching a goat.

I highly recommend this as idle morning entertainment while brushing one’s teeth.

When I woke up the next day in Pokhara thinking about Amrit and started giggling hysterically in bed, Aidan and Pascal explained that there’s an action hero called the Blue Cat Man, who apparently goes around saying, “Don’t underestimate the power of the NILO. BIRO. MAN.”  It’s like the power of power, but with blue cats.  I unfortunately didn’t take a picture of Amrit with a goat, so here’s me with a goat.  You want to catch a goat now too, don’t you?

6. Paragliders in the Mirror

On Saturday afternoon following the closing program of our screening camps, when our field staff left to go back home, I went for a run to clear my head. The paragliders who we often see sailing down from Sarangkot make their landings in various spots by the lake in the valley, and every now and then I happen upon them at the moment they float down to the ground. That afternoon, as they drifted out of the sky, they were perfectly mirrored by other paragliders rising to the surface edge of the lake. The paragliders came down and attached themselves to their own feet, like Peter Pan and finding his shadow.

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7. It's My Shit

During their week of clinic audits and past patient assessments, Bethy and Keri came to spend a day in Kaskikot, and in the evening, we got to singing with Grandma. Thanks to Keri’s choice to blast “Holla Back” off her laptop, we ended up teaching Grandma to say, “It’s my shit,” and I did post a link to this before, but I am embedding it here because when you watch Grandma declaring that her shit is hers and not to be messed with, you will see why this is an absolutely brilliant thing to have happened.

8. The Prime Minister on a Tractor

The other night I looked up to see an evening news broadcast of Nepal’s Prime Minister inaugurating this tractor. He is covered in celebratory marigold malas far past the tops of his ears, making it hard to achieve either neck rotation or peripheral vision. In the TV broadcast, the gathered audience shuffles tenuously along on the muddy ledge around the paddy, clapping admiringly as the Prime Minister drives the tractor for about a full minute on the evening news, with no background commentary or voiceover whatsoever from the news anchors.  He stops and disembarks, and then the segment ends, while I squeal and point at the TV, my dinner forgotten on my plate, and the rest of the family is going…”What?” I present you the photo that was published in the Himalayan Times, with its caption.

I mean, What?

Prime Minister Pushpa Kamal Dahal plants rice in a field using a modern tractor during the inauguration of the Super Zone programme under the Agriculture Modernisation project, in Baniyani VDC of Jhapa district, on Tuesday, January 3, 2017. Photo: PM Secretariat

Prime Minister Pushpa Kamal Dahal plants rice in a field using a modern tractor during the inauguration of the Super Zone programme under the Agriculture Modernisation project, in Baniyani VDC of Jhapa district, on Tuesday, January 3, 2017. Photo: PM Secretariat

8. The Power of The Stage

Our sweet Pascal is 11.  He is named for the little boy in The Red Balloon who makes a strange and magical friend that leads him to see the world.  While Aidan is our Joker, Pascal is serious and perceptive.  He and I have always had the bond of The Observer, that sensitive creature who is perpetually catching up with the world on the outside, but seeing a little more than the next guy on the inside.  One night during this year’s holiday street festival in Pokhara, Pascal came to the hotel to find me and we spent some time walking around in the crowd.  We came upon a stage where kids where dancing until the scheduled performers came out.  Pascal paused a moment, and then jumped up and…he’s on the back left in the striped shirt.

9. These extremely uncomfortable mannequins in Kathmandu Mall.

Why, world? Why? Who approved this?

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Evidence. FINALLY.

 

Sada Shiva Primary, 2004

Sada Shiva Primary, 2004

The very first oral health program I organized with Govinda, at Sada Shiva Primary, was in the spring of 2004.

We launched the Kaski Oral Health Care Project in 2006.  Over the years we’ve gradually refined our approach, added in pieces that address culture and product availability, vastly improved our integration with the government and with schools, and pushed the standard of care in our clinics as best we know how.  We have our own unique sanitation protocol that I put together doing my own research. We’ve learned not to take the status quo for granted, and to seek more information about what is legitimately possible in low-resource settings. We’ve learned to recognize complacency: I’ve had to get comfortable with being told things should be done one way, and then seeing with my own eyes they should be done a different way.  But up until now, we’ve basically been doing this on our own.  We try to do annual medical audits of our clinics with local dentists, but our clinics are, increasingly, unique entities.  As a result, there isn’t really a solid barometer of care in Nepal, because we set our own standards – OR internationally, because, well, we’re in rural Nepal.

In 10 years, I’ve never had foreign dental professionals come to witness, much less rigorously assess the care provided by our clinicians.  For that reason, the most promising part of this whole collaboration was what came this week: clinic audits and evaluation of patients who have had fillings done in our clinics some time in the last eight years.

From a human rights standpoint, this is an incredible opportunity for research.  JOHC technicians are nontraditional health care providers offering a technical form of medicine that is totally absent in rural Nepal.  If we can get hard data showing that their treatments are safe and effective, we have a rigorous foundation for arguing that similar clinics should be incorporated in all 3,000 of Nepal’s health posts.  This kind of data isn’t that easy to get, because you’d have to search pretty far to find other patients who were treated 5 or 7 years ago by rural dental technicians in real, remote contexts, rather than by visiting doctors doing controlled research.  In fact, I don’t where you’d find that at all.

With that in mind, I am thrilled to say that, in addition to visiting four of our clinics to provide general evaluations and technician feedback, Dr. Keri and Dr. Bethy screened over sixty past patients.  Both of them use glass ionomer extensively in their own practices; Keri is a pediatric dentist in Connecticut and Bethy is currently doing a PhD incorporating similar techniques in to schools in Cambodia. So these two ladies are like space aliens from another dimension…they know SO. MANY. THINGS.  We invited the past patients for assessment and then the result was out of our hands.  I was excited and nervous.

Their evaluation focused only on glass ionomer fillings, taking close up photos that show how the treatments have held up.  The fillings were anywhere from a few months to 6 years old.  Here’s the screening in Sarangkot, our longest-running clinic:

 

Bethy and Keri were able to screen past patients in three different locations, documenting outcomes from of three out of six of our technicians. What they found is that these treatments have provided objectively, measurably positive health benefits.

Let’s say that again.

What they found is that our rural dental technicians, who are Nepali people working locally in their own villages to offer the only sustainable rural dental care in Nepal, have provided objectively, measurably positive health benefits for their patients.

In fact, given the conditions in which they are working, they appear to be getting EXCELLENT results.  And with the photo documentation that we have, it will be possible to do a fairly in-depth look at exactly what that means–hopefully, something publishable.

There are also ways these outcomes can be improved, and this process allowed the doctors to pinpoint some very specific methods for how.  For example, our technicians should be provided with additional hand instruments that will allow them to improve the cleaning of the tooth before the filling is placed, so that it will last better.

We did clinic audits and past patient screenings in Bharat Pokhari, Sarangkot, and Salyan.  We also went to see a school seminar in Rupakot.  So over the course of the week, Bethy and Keri got to work intensively with all of our technicians, even if getting to every clinic was not possible.  They gave us feedback on supplies and setup that can continue raising the standard of safety and quality in our clinics, which all use the same supplies, so we can generalize that feedback even to the clinics they weren’t able to reach on this visit. We’ll also be starting a Facebook page for technicians to continue learning from Bethy and Keri.

Every night, we’d come home from one jeep ride or another, and these two would still talking about ideas to support our technicians and strengthen outreach to schools. They just KEPT THINKING OF THINGS, and in the morning I’d wake up to find that they had gone to have coffee, where they were still talking about instruments and procedures and lights and glasses and training videos and possible articles to write.  It was INCREDIBLE.

Also…it was really fun.

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Real Work in the ‘Hood

 

After our week of screenings in Puranchaur and Hansapur, I took our university teams up to Kaskikot. We didn’t arrive in until late on Sunday night, after visiting our Bharat Pokhari clinic during the day.  Everybody stayed in the hotel behind the house, but most people came down to hang with me and Aamaa and Hadjur Aamaa for a while.  We had tea, chilled in the kitchen, and of course I put some Henna on Neha and Justin.

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The next morning, we said bye to Karen and the Berkeley/UCSF crew.  It’s been so special hosting these guys, and we’ve all learned so much from them.  First of all, we had an immersion week in the science of oral health and nutrition, and also in research and evaluation.  But it was also so invigorating for our field teams to get to work with Dr. Karen, Dr. Madhurima, and the students they brought, and I can’t wait to see all of these guys later this spring out in California!

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Keri and Bethy are sticking around for another week, which began with a trip to Sarangkot to screen past patients and do a clinic audit, which I’ll write about in another post.  We came back to Kaskikot on Monday night so that after this marathon week, we’d have the next day to just hang out.  In the evening, we lay around in bed exchanging songs with Hadjur Aamaa.  She wanted to see some dancing, and Keri turns out to have an amazing workout mix on her laptop, so that kept Hadjur Aamaa solidly entertained for quite a while.  In exchange, she allowed us to teach her some lyrics from “Holla Back.”  This is Hadjur Aamaa learning to declare, “It’s my shit.” (Video credit: Keri.)

First thing in the morning, I put Bethy and Keri to work churning milk, while Aamaa bustled back and forth past us over and over again, saying we were going to ruin it, which was a possibility, and I replied that everything was going to work out just fine, the foreigner way.  Which basically gave Keri and Bethy the full experience of my life.

Next, of course, I commandeered the dentists carry to water in baskets, which was well worth it just for this fantastic piece of documentation.

What?  We needed a lot of water.

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We hiked up to the Kalika temple and had a photo shoot.  I’m not even gonna explain how this happened…Bethy was in the New Zealand military and has superpowers.  I just had a good photographer named Keri.

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We came home and spent a couple hours in the yard with Aamaa and Hadjur Aamaa shucking corn.  TBT to the time my family came to visit in 2004, and we shucked corn in the yard:

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Shuckin' Corn

Tomorrow we’re on to a school seminar in Rupakot, and then Salyan for another clinic audit.  But this was a pretty swell stop, in my unbiased opinion.

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Too Much Good

 

The village of Hansapur is adjacent to Rupakot, one of the villages where we’re nearing the end of our two-year program and preparing to hand over the clinic later this spring.   We’d asked Dr. Madhurima if she would conduct her study on mother/child oral health and nutrition in one of our non-working areas to allow for comparison.  It’s an anecdotal comparison of course, because Hansapur and Puranchaur have many differences besides the presence of JOHC in the health post and schools, but it’s something.

Our morning once again consisted of a bouncy bus ride, singing, and this time an extra jeep carrying some folks from another health agency joining us today.  Partway along, Helen had the img_4824idea to jump in to the back of the jeep, and she was soon joined by our Sindure technician Jagat, our Salyan team leader Nar Bahadur, and me. We bobbed along with the fresh air and hills rolling by and the dust billowing up behind us on the dry winter road.

Since we don’t have a clinic in Hansapur, today’s program was held in a schoolyard.  It was challenging getting this screening day set up because we didn’t already have a network of teachers and an existing relationship with the community to help with turnout. But with the high attendance in Puranchaur, we felt a little less pressure, and just went hoping for the best.

So, like, about 350 people showed up.  It was INSANE.

This was the kind of success that, in Nepalenglish, we call “too much good.” A little less good might have been gooder.  The technicians had no time to pee, and Dr. Bethy and Dr. Keri ended up treating patients all day instead of mentoring, because there were just so many people to get through. When we finished the last patient, it was night time.

But of course the high attendance had a many up sides too.  First it was awesome for Madhurima’s study, which we were concerned about.  And a few hundred people also got treatment and fluoride varnish from local technicians.  We observed that childhood oral disease in Hansapur was significantly worse than in Puranchaur, and while that can’t be attributed off-hand to our school brushing programs and outreach in Puranchaur over the last two years, it doesn’t hurt to know.

But the thing about this day that I most appreciated was that it only took until about 1pm before Nirmala, the local organizer who’d helped us get setup, sat down with Aamod and me and announced that she feels our full program is needed in Hanspaur.

thumb_img_1144_1024This represents a major turn of tides for us. We’ve always had to do a lot of running around to create demand in the villages where we start. Then we keep at it for two years, hoping that at the end, the community and leaders will still be convinced enough to make good on promised long-term funding. We’re now realizing that we’ve developed enough infrastructure to provoke interest by just showing up and doing our stuff.

So our plan from here on out is to start only in villages that pay the technicians locally from day one. January is the month where villages throughout Nepal submit next year’s budget to the district government. For the first time, we’re positioned to invite places like Hansapur to co-invest in health post dental clinics from the start. In other words, this epic day of screening and treatment doubled as a 1-day free trial, and now local officials can sit and decide whether to allocate funds in a long-term solution for which we’ll provide the architecture, training, set-up and supervision–so that it comes out right, reflecting everything we’ve learned in the last 10 years.

Are you keeping up here? That was day three.

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Over the Mountain and Up to the Clinic

 

Yesterday morning all 30 of us piled in to a bus to head out to our first day of screening in Puranchaur. I kept being worried that someone on our field staff would bail out, get a flat tire, have a sick buffalo, or need to attend a last-minute puja at an uncle’s house. But everyone made it on to the bus. And it took very little time before bus songs began, complete with Live Traditional Dance By Dental Technician.

Thank goodness I have 12 years of Race to the Rock under my belt. I knew to have a map of our planned camp flow, and I hoped that, as we’d been assured, the needed chairs and tables were already at the Health Post waiting for us. I’d printed out this camp-layout-2high-tech map for everyone in their welcome packets, and I brought an extra copy of the map with me since I knew most people would leave their welcome packets at the hotel, and this series of actions allowed me to answer most questions in either language from any one of 30+ people with: “Ah. Have a look at the map! Oh that’s okay. I put a copy of the map over there. It will answer all your questions.” Tricky, right?

We are aiming to have 300 mother/child pairs for Madhurima to screen in the next three days. That is a lot of people to mobilize in a rural area where people are busy cutting firewood during this season, and especially when you consider Puranchaur already has weekly dental services available, plus we’ve done outreach in schools already. We’re hoping that will work to our advantage, and that the teachers assigned in each school to run the brushing programs will bring students and mothers. But it’s also exam time, so we knew things would be slow till mid-morning. Once everything was set up, there was that familiar lull…would anything happen?

…Anything?

Then suddenly we looked out and saw this line of primary school kids in their uniforms winding our way over the hills towards us. If this isn’t the cutest thing you’ve seen related to dental care outreach programs in mountainous regions, you have no heart.

I want to explain how we organized this project using a human-rights design, because it seems obvious, but actually, a lot of these details are rarely prioritized. What we care about with JOHC is the development of dignified, sustainable, high-quality health care for rural Nepali people. It was important to me to set up this collaboration in a way that promoted the development of local services, which meant not only studying interventions or issues in the abstract, or providing a transient benefit to participants in a study, but building the manifest capacity of local providers and institutions.

Fortunately, although JOHC is small it is mighty, because we have those providers and are already working with all the schools, the local government, and the local img_4484Health Post in Puranchaur. The involvement of our team leaders and clinic staff in this project was a great development opportunity for them – and therefore the communities they work in – and as long as consciously nurture it, that benefit occurs regardless of the outcome of the research.

We were also able to set up this collaboration as an opportunity to strengthen and test our community relationships. Our preparation involved a great deal of mobilization, largely done by our team leader in Puranchaur, who is himself a local resident. We’ll still be in Puranchaur when the week is over, so we’re accountable and vulnerable to the way in which the program impacts the community and its power structures. Which is as it should be. In short, the project is about Puranchaur and the other villages where our teams work, not about us, and that’s what I care about.

Of course, we still had our breaths held all morning. We had kids, but would we get mothers? But as the day went on, the pace picked up. Things got so packed in the clinic upstairs, where our technicians were providing their usual treatments plus the new fluoride and silver fluoride treatments, that by the second day, we needed to move to a large training hall. On the second day, as word got out, we got even more people – about 140. Bethy and Keri were able to provide intensive oversight to our technicians as they worked; our team leaders were collaborating with the UCal students to conduct surveys, help with dental exams, and provide the same oral health and brushing instruction they do already in their home villages. On the ride home that evening, our team leader Kasev, who had been conducting interviews with mothers, said that many participants referenced the school brushing programs when talking about their health practices.  It was as awesome a day as we’d have dared to hope for.

Tomorrow we are off to Hansapur, a non-working area where we had to apply our best strategies to get the word out.  It’s a great chance to get some anecdotal evaluation of differences between an area where we work, and one where we haven’t yet.  Let’s hope we get as good a response as we did today!

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Welcome Research Teams!

 

The troops have descended.  I woke up and headed down to the pair of hotels that are housing our mob.  One one side of the street is a group of twelve people from UC Berkley, UCSF, UConn and UP in Cambodia.  The group includes three dentists, a pediatrician, and a gaggle of dental and undergrad students.  Across the road is almost our entire JOHC field staff: 6 technicians, 5 clinic assistants, and 5 team leaders covering nine villages.  I stopped in both hotels to make sure breakfast was happening and then went down to our training hall about 10 minutes before we were scheduled to start.  Naturally, I found that the hotel staff had just begun to clean the hall, and that this process involved spraying copious amounts of air freshner in to a room with large, closed windows.  I requested a halt to the air fresher and opened the windows, which looked pleasantly out over the lake.

It was crazy watching everyone filter in to the training hall.  I know all our technicians pretty well, but the team leaders and clinic assistants I don’t see often besides in photos.  I’m only in Nepal for 4-8 weeks at a time and there’s no way to get to every site during every visit, so sometimes I won’t see field teams for over a year.  And the technicians collaborate with each other at big school programs, but the rest of the field teams don’t get many chances to see each other after their initial training, and even then, usually only in the cohorts they started with.  Then, on the other side of the equation, I’ve spent a lot of time on email and skype with all the people from the universities, but the only person I’d met in person Dr. Keri from UConn.  Now here was everybody, all together, in a very air-freshened room, sitting down in actual chairs.

We immediately encountered a projector obstacle.  Namely, the projector was not working.  Dr. Karen got everyone occupied with an introductory activity while I frantically tried to deal with the projector, which eventually led to a hotel guy running down the street with admirable good-will (he might have been fleeing from the crazy American going WHY? WHY ISNT IT WORKING WHYYYYY?) to have someone swap out a cable, while 40 people were distracted on a scavenger hunt looking for other people who had never had a cavity or who inappropriately eat sweets for breakfast.

The projector obstacle went through a number of other iterations that I’ll skip; eventually, it worked.  Aamod and I gave a presentation on our JOHC model and human-rights health care for the visiting research teams.  It was really fun to see our field staff get excited when photos of their clinics or programs came up on the screen.  Then Madhurima and Karen presented on the relationship between nutrition and oral health, which was super interesting and will make great material for our teams to incorporate in to their school education programs.

After lunch we split in to two groups.  Our team leaders went with Madhurima and Dr. Karen to learn how to conduct surveys tomorrow.  I am pretty sure from the one photo I took and the minute I spent watching that this involved a lot of everyone trying to figure out what everyone else was saying, which I’m sure will work out just fine.  They’ll be assisting the UCal group with a study of oral health practices and nutrition, and we set up some of the screenings in Puranchaur where we operate, and then in one of our non-working areas, Hansapur, to see if there are any differences between these two areas in oral health knowledge or practices.

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While that was going on, our technicians and clinic assistants had an amazing training with Dr. Keri, a pediatric dentist at UConn, and Dr. Bethy from New Zealand, who is doing her PhD in Cambodia.  They had an in-depth orientation on pain diagnosis, and then learned techniques for fluoride varnish and silver diamine fluoride, a substance which is used to arrest carries with no invasive techniques or anesthetic.  During the upcoming screenings this week, our technicians will begin using these techniques under supervision, in addition to the fillings and extractions they already do.

So while this was all happening, we encountered a fleece jacket situation.  I realize you feel that there are many reasons to believe we had overcome all components of the fleece jacket situation.  I understand how you feel.  I really do.

But by late afternoon, we still had no jackets.  Also, obviously, there was a random shutdown of travel in the middle of the day in one part of the city, so the Man In Charge of the Fleece Jackets couldn’t get to his printing factory.  Because, these things happen.  They really do.

Therefore, I kept leaving the pain diagnosis training to make calls about fleece jackets.  Finally Muna looked at me and declared, “We will get the fleece jackets.”

Me: “But–”

Muna: “Go upstairs.”

Me: “By–”

Muna: “We will get them.”

Oh Muna, bless your heart.  Back to pain diagnosis.

Muna and Gaurab got the jackets, using the magic and unknown powers of being not me.

Five PM.  Photo op!  Selfies.  Also staff hug.  We survived training day!


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Dance Parties, Sticky Notes and 1000 Goves

SO FAR SO GOOD!  We arrived at the office today to find that the internet wasn’t working, and I discovered that I’d left the house last night with one of my flip flops and one of Prem’s, and there was no time to swap them out today, so I’m still wearing till two different shoes.  Basically, our final preparations for the arrival of our Cal / UConn / UP Research Team included:

1. A beginning of the day de-stressing office dance party.

2. A discussion about the value, or lack thereof, of name tags.  Everybody else in the office thought I was nuts to insist we pick some up, because apparently sticky name tags are not a thing in Nepal.  I spent about five minutes trying to describe a sticky name tag and then advocate for its value in life, only to have everyone get very excited when Muna ran in to her office and then came out triumphantly with a sticky note, which she planted on my shoulder to the raving approval of the rest of the staff.  I countered that, aside from the fact that a sticky note is not a name tag, this made me look like an inventory item, and stuck it to Muna’s face to prove my point.

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3. Rearranging the dowry couches gifted to us by our landlord, and cleaning the office.  Ready for visitors!

Ready for visitors

5. Reviewing the schedule, completing our welcome packet, confirming hotel reservations and a training hall and a bus, organizing the inventory so it looks like a wax library, picking up everyone at the airport and sorting supplies in the hotel!  Want to know the best part?

Dr. Sokal brought NAME TAGS!!!  Basically, I won, and that’s what counts.

Welcome to Nepal!!

 

 

 

 

Fleeced and Ready

 

So we’re in the final countdown before 20 of our field staff and 12 dentists, public health specialists, and students arrive here on Monday night.  As I’ve previously explained, we are trying very hard to steel ourselves against the persistent unraveling of planning that seems to occur despite all efforts to the contrary in this neck of the woods.

This steeling involves checking and rechecking that hundreds of people will show up in rural locations for dental screenings, and that our own field staff will make it here by Monday night (our best hope that everyone will be on img_0886time for the start of training on Tuesday morning…very crafty).  We’ve combed through a detailed inventory of supplies – mind you, none of us are dentists, yet we are in charge of the 2% Chlorhexidine solution – and we still have to shop for 50 teaspoons (don’t ask, this is my life, it’s real).  We found a training hall and a bus for forty people, and there are currently no political strikes or holidays scheduled.  I reviewed the whole thing with Dr. Sokal on skype and drew a layout of our workflow complete with the number of chairs and tables we need.  We booked nine people on one flight from Kathmandu to Pokhara, and hopefully, the flight will not be cancelled.

So this week it snowed in Connecticut, and with the bad weather, Dr. Discepolo, a pediatric dentist coming from UConn, missed her flight.  Because even Connecticut starts going haywire when Nepal gets involved.  Fortunately, Dr. Discepolo was scheduled to come in a day early, and will be here Monday instead, so we are ALL SET.

Today while Aamod and Gaurab were in Puranchaur meeting with people in the local health ministry about the upcoming project, and visiting primary schools (again) to make sure they’ll be sending mother/child pairs for screening, Muna and I were at the office fielding other essentials.  Among which was printing jackets for everybody, which we need by tomorrow night.  But after the Nepal Health Research Council and the 10-tab spreadsheet of budgets and reservations?  Jackets – no sweat!

We’d picked out a few samples on friday, and Muna called the printing press this morning to ask if we could send photos to inquire which jackets could be silkscreened.  The printer told us he had to physically see them.  So we went to the shop to get the jackets, and while Muna took a taxi to the printer to show them a puffy vest and a fleece, I commandeered basically everyone in the store to help me take 40 more puffy vests out of little stuffing bags so I could check off sizes on a spreadsheet.  Then we finished that and I tried on option two, the fleece number, so I’d know what sizes of those we’d need if the vests didn’t work.

Muna texted: “They said they can’t print on either type.  I am coming back.”

We put everything away again.

Muna returned.  “They told me, even if someone says they can print on this vest or this fleece, don’t let them.  It will be ruined.”  Ok then.  Back to the drawing board.  We tooled around looking for something else that could be printed on.

The store owner came in.  “I can bring this vest to my Son-in-Law,” he announced. “He has a factory, and I’m sure he can print this.”

“But the other printer said–”

“My  Son-in-Law can do it,” the owner declared.  “Even if we have to stay up all night, we will print your jackets by tomorrow evening.”

We considered.  It was decided that I would go with the store owner to visit the son-in-law’s factory to review the case.  But only after lunch.  The store owner had not eaten since early in the day.

Muna returned to the office to call all 20 of our field staff, again, to remind them when and where to appear tomorrow night, and I took my computer next door to the jacket shop to work on a Welcome Packet during lunch.  (I say it’s Welcome Packet, but in point of fact, I think I just need the list of 40 participants and the screening layout and the schedule where I can see it at all times.  It’s for me, forty times.)  After lunch, the store owner pulled up in a car and took me to his son in law’s factory.  We presented the vest option and the fleece option.  The vest proved unprintable, but the fleece was a definite.  Definitely a definite doable printing job.  I poked my head in to the “factory,” which was, in top Nepali style, basically a living room.

“I will take you to the printing shop to arrange the logos on the computer,” said the Son-in-Law. “We have to wait for my colleague to go ahead on his bicycle.”  Courteously, we waited for the colleague to get a ways ahead on the bicycle, and then we caught up on a motorbike.

We entered the printing shop and presented a sketch of the layout to be arranged for the jacket.

“Yes, I have this pattern,” said the printer.   He pulled up our jacket on his computer.  “This, right?”

Me: “…?”

“The young woman was in here earlier,” he explained.

I texted Muna.  “I’m back at the same printer you took the sample to this morning.”

Muna: “WHAT?  They said they couldn’t do it.”

Me: “…? …I know, right?”

It takes about an hour an a half to arrange the logos, mainly because one of our visiting dentists teaches for a Cambodian University, and their logo has Khmer lettering that won’t come out right.  The printer guy painstakingly recreates each picture of the Khmer lettering in the logo for the Cambodian University.  He arranges all the pieces of the printing for our jacket and prints it out on laminate.  The son in law comes back and gets me and the laminate on his bike.  He deposits me on the main road so I can take a bus back to the store to get the rest of the jackets out while he prints a sample at the “factory.” I seriously have no idea how this day would have turned out if not for the shop owner and his son-in-law, who basically saved our butts.

It’s now 4pm.  I take out my spreadsheet again.  The entire staff of the store that Muna and I entered at 11:30am today begins taking out fleece jackets from various unpredictable locations.  Fleece jackets appear from every heap and rack of mountain-wear, and they are sorted in to piles while I read from my spreadsheet, again.  Everyone is concerned that the men are not to wear hot pink fleece jackets, and this must be accounted for.  The floor is is covered in fleece jackets.

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I leave for an hour and a half to go do an interview with a local paper, and come back at 8pm.  The son in law has brought a sample jacket with him.  The only problem with it is that the whole thing is too high, and the hood falls over the printing.  Also, while putting the print on, they accidentally melted off one of the drawstrings at the hood and pressed it in to the shoulder of the jacket.  This too must be corrected.  They promise not to melt any parts of any of the other 39 jackets, which I send off in 4 oversize plastic bags.

At 8:45pm I head home for dinner.  Among the things I did not do as planned today: write a training schedule; print referral tickets; send an abstract to UCSF.

Why are you so late? Bhinaju asks.

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Hope Against Entropy

(Editor’s note: apologies if you’re on my email list and receiving this a second time.  It won’t happen too often.  If you’re not on my email list, you should be!  Please write “SUBSCRIBE” to laura@jevaia.org).vision-nepal-global-exposure-workshop-088-2

Good morning from sunny Pokhara!  I arrived yesterday and enjoyed a nice homecoming tour of all my regular haunts. Since August, Pascal has rigged up a home-made antenna on the roof, Aidan’s other front tooth has finally come in, and the corn has been cut down in the garden in front of our office, replaced with new seedlings.  I absolutely love this season in Nepal – the cold, wide air, the clear mountain skyline which is obscured by fog during the monsoon, the evening snuggles with my nephews under warm blankets.  Tonight I head up to beautiful Kaskikot to see Aamaa.

photoI’m so excited to tell you about our plans for this winter.  After 10 years of chipping away at all this, we are just days away from a two-week collaboration with dentists, researchers, and students from Berkley, UCSF, UConn and the University of Puthisastra in Cambodia. It is a strange and wonderful feeling to be preparing for such a large and qualified group of visitors after so many years of working away with few outside witnesses to our efforts.  There are many great things wrapped up in upcoming this ball of projects.

The first is helping to implement a UCSF/Berkley study of oral health and nutrition in mothers and their children.  Our own JOHC field teams will get to work with the researchers to conduct this study in one of our villages.  The second project is training our technicians in some new techniques, which they’ll incorporate in to their sustainable clinics.  Third, we have the chance to bring dentists to our rural clinics for medical audits.  Believe it or not, after an entire decade, this will be the first time we’ve had foreign dentists come to visit our clinics.  

And finally, we’re going to pilot an evaluation of past patients who’ve been treated by our technicians over the years.  If you don’t think that sounds like Christmas, listen here! This means comparing the outcomes achieved by our local dental technicians to the results produced by fully credentialed dentists in prior studies of the same treatment techniques. img_3285 This is a HUGE step towards our goal of having Nepal’s national health care system adopt rural dental clinics in to all of its health posts. Why? Thank you for asking!  Because the main criticism is that community-level health workers aren’t qualified to perform dental medicine…even though that excludes millions of people from care.  But we’re making the case that, rather than write off local health workers, the medical field must find ways to properly train them to provide the best care possible in their settings.  And that’s what we’re doing!

Ok, so those are the technical points.  Now let’s talk about me organizing for fourteen people to show up next week from California, Connecticut, India and Cambodia.  We have a schedule, a budget, a training plan, hotels, flights, and t-shirts.  We’re doing our best to keep things under control.  But we are up against the entropy of Nepal, people.  THE ENTROPY OF NEPAL.  Pretty much anything could derail our plans and contingency plans: a wedding, a political strike, rain, someone’s grandpa dying, a forestry meeting, a buffalo falling ill.  A buffalo having a baby.  A traffic jam.  A flat tire.  Lost luggage.  Fog on Sunday afternoon.  Somebody decided to drive this point home for me at the recently renovated, lusciously carpeted arrival terminal in the Kathmandu airport, which has a new row of fancy kiosks for visa filing:

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On the plus side, sometimes fate works to your advantage.  Consider our office.  This fall, our landlord’s son got married.  The son received a number of couches by way of dowry.  They don’t fit in our landlord’s apartment, so I arrived to find them in our office, which now looks rather like a furniture store.  If you have any idea how much I have obsessed over the setup of our office, you will especially appreciate this stroke of….er….luck…

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Well, in solidarity, I think I’ll leave you there on the edge of your seat.  Except for sharing a photo of this year’s Race to the Rock, which was one of our best yet.  If you missed it, please consider Jevaia in your end of year giving.  After all, we’ve made it this far – through many political trials combined with road mishaps, fuel strikes, weddings, earthquakes, and baby buffalos – almost exclusively on the wings of individual donors, and here we are entering a very exciting new chapter.  Thank you for being a part of the ride with me and all of us.

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