Airport Gymnastics

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

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

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

Well then.  This is awkward.

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

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

…Tick tick tick…check in closes.

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

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

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

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

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

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

Is it there?

How about now?

We may have to carry on our bags.

…Should we call again?

……Is it there yet?

……..How about now??

TADA!

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

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

I write Selina back after we land in Da Nang.

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

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

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

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The Primacy of Snack Time

 

We have had a pretty hectic couple of weeks here, trying to establish good connections in the new province government and chasing meetings that sometimes materialize with little advance warning.  There’s been a lot of dashing about, creating documents that seem like they should be important to somebody, getting signatures and holding coffees with the hope that these activities are all adding up to the “right process.”  The general pace of the office workflow is that the four of us disperse to our desks, and periodically throughout the day we magnetize together in our common area to touch base, update one another on who has had calls with whom Out There, and pump each other up before expanding back out of the common room to our desks.

It has been really nice for me to have this time here to get a feel for the flow of our office without the glare of a tight visiting timeline or imminent program.  This has revealed, among other matters, the primacy of snack time.  Each day Sangita didi arrives around 1:30 and begins a poll on what we want for snacks. Discussion ensues, various viewpoints are considered.  I advocate strongly for buckwheat or rice flour rotis with Nutella and peanut butter, an argument that has recently been strengthened by the purchase of a jar of jam (although, honestly, since when do Nutella arguments need strengthening?).  Others point to the benefits of salty foods such as chowmein and charput (trust me, I realize this should be a non-starter when there’s a vat of Nutella in the kitchen). There are only four of us, but this deciding is nevertheless a substantial process.

In the last three weeks, snacks have been enhanced by the arrival of my friend Ann from Israel.  In the first few days, after I advised her that snack time was the best time to visit our office, and Ann turns out to be a quick study: she arrived promptly on time for the snack poll.  Then–just hours after Ann’s arrival in Pokhara–Sangita put her to work and they hit it off immediately. Ann set learning to make buckwheat rotis while Sangita taught her Nepali words by announcing snack-related vocabulary extremely loudly and waving her hands.  As I mentioned, our office isn’t that big, so from our respective rooms we were all treated to a live cultural soundscape while the two of them, who have an overlapping vocabulary of about two words, tried to communicate the nuances of slicing potatoes and dropping hot batter on to a sizzling frying pan at Sangita’s base-level volume.  Ann, who has the patience of a monk, rose to the occasion by not only making some spectacular rotis, but also by picking up a whole set of Nepali phrases (largely related to eating) amazingly fast. She continues to come over regularly at snack time to help cook rotis while Sangita ecstatically yells words at her.

Who said that Nutella and peanut butter couldn’t get even better?

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Politics and Poets

 

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

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

Are you with me so far?

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

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

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

We wait.  It is very hot.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“The Secretary,” Muna mutters.

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

 

 

Borders

 

It’s another newsletter repost, so please forgive me if you get both….

Dear Friends,

It is the first day after the solstice and the monsoon is is still trapped up in the clouds, pressing the heat heavy on to our heads. In a few weeks the sky will break and we will be deliciously soaked for weeks and weeks.

I arrived in Nepal a few days ago after graduating from my Master’s in Social Work this spring, and it is a pretty interesting point in time to be here.  Over the course of the last year, the government of Nepal has gone through a major restructuring, with power being distributed from the central level out to newly-formed provinces.

We have a front-row seat to this transition: working with local level governments in rural areas.  Our big goal is to impact policy and establish oral health services at the community level throughout the public health system in Nepal, so we are constantly getting new footing based on changes in Nepal’s ever-shifting government. The fiscal year ends in mid-july, so during this season our tiny staff of four is busy riding around on motorbikes and variously getting out to the villages we work in to meet with local leaders who are planning their health budgets for next year.  The key mission of course is to make sure that funding gets allocated to sustain the dental clinics we’ve set up in rural government health posts.

The twist is that at the moment, with the entire Ministry of Health changing, all the rules are up in the air.  Who is responsible for allocating funding from the federal to provincial governments?  What are the budget headings?  When will funds be provided to provincial governments?  Will the District Public Health Office still exist in the second quarter of next year?

Nobody is entirely sure.

So anyway, that’s what we’ll be working on this summer.

From my side, today was the first day I arrived at our office in Pokhara, and we had a long jam session trying to predict how political forces in the country will affect health care in rural villages.  Then it was time for the main show- heading home with some tennis rackets, DVDs, and a lot of candy.  My first order of business was getting Aidan and Pascal to play tennis inside the house, because I can be relied upon to help with childcare, and then we went to play frisbee in the square and eat ice cream.  We’ll go up to Kaskikot tomorrow.

It has to be said that as I re-enter beautiful country that has welcomed me as a daughter without asking any questions, the borders of the U.S. are heavy on my heart.  As always, I casually purchased my visa upon arrival in the Kathmandu airport.  At our office, everyone wanted to know what on earth is going on in America. The papers say that New York is receiving many stranded children, including in Harlem just a stone’s throw from where I lived and taught art in schools for many years. I find myself thinking about the years I have spent in Nepal, and how they began one afternoon when I arrived at two-room plastered mud home and Didi was standing by the sewing machine and I asked if I could move in to the house. The best spaces were cleared out for me. The tiny rice pot went from thirds to quarters. I could have been anywhere on the planet, I wasn’t running from anything, I had alI needed and nobody asked why I presumed to eat out of that little pot, which was filled with food that had been laboriously cultivated from the ground.  I had nothing to offer except my curiosity.

It is particularly jarring to look back across the ocean at the news from here; in a way, the politics blur with distance.  But the shame is crushing.  This world is so very magical when its doors are open.

The summer has begun…stay tuned.

Laura, Aidan, Pascal, Didi, Prem, and the Jevaia Foundation Posse on Soon-to-be-muddy-bikes

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You’re White. It’s Fine, But Own Up.

 

It’s no secret that I am not a big proponent of health camps – for all the obvious reasons.  Despite the very quantifiable benefit of a rapid delivery of emergency care in remote places, we’re working in a different space, trying to uproot transience, lack of accountability, saviorism, and the indignity that in the final reckoning still goes with things like…well, health camps in rural developing world communities.

I know this seems unrelated, but I remember a day back in 2004 when I had made my morning run to the junction at Naudanda, and a bus was just pulling up along the Bagloon Highway.  Some tourists got out and they had a collection of enormous plastic bags from which they began extracting articles of clothing.  A crowd of people gathered around, reaching for the anonymous pieces, irrespective of size or relevance or history or purpose.  Just in case something was useful.  As I stood watching, my running shoes expelling wafty dust from the dry road, there was no analysis or judgement that went through my head; I was just frozen by a wave of shame in my heart.  For the indignity, the dehumanization, the unspeakable power differential before my eyes, in which I was complicit.  For the participation we are all assigned before we’ve even arrived: savior, beggar, observer.

There was never a time in my life when I thought, you know what my passion is?  Dentistry!  Working in oral health was something that grew out of being assigned the observer role, which turned out to be very uncomfortable.  I’m more in the business of looking at casting and lines, of trying to rewrite parts of the script.  Oral health is an ideal area to be working on this because disease is so prevalent, chronic, and preventable, with services disproportionately skewed toward upper classes (globally, not just in Nepal). This is an area where it is entirely possible to create a system that does not rely on helicopter interventions organized to address the greatest volume of teeth, but relies, instead, on structural accessibility and strong public health policies.

I’ve had a decade and a half to grapple with the problem of myself as a white person working in an underprivileged country.  What I realized pretty early on is that the only way to handle that is to embrace it with all four of your limbs and hang on tight for the whole ride. Centuries of colonialism have conferred on my skin and nationality a power and predicament that none of us, in the current act, created or can do away with, which only leaves us the option to be honest about the whole clumsy issue.  The way this translates is that I think carefully about when and how I show my white face, and in fact, this is not an uncommon topic of discussion in our office when we are planning fieldwork. Over the years I have mostly built myself into a behind-the-scenes role, while Nepali people fill all the stage characters. But when it’s strategic, our team openly brainstorms over how my whiteness and Americanness (two, not one, power plays) can be leveraged to bring legitimacy to others or bend things in favor of a local agenda. That is what these privileges should be used for.  In fact, shirking that opportunity seems almost as problematic as not knowing when to stay out of the way.

So, if you are staying with me here, we have on one spoon some peanut butter (health camps, with their historic problems) and on the other some jelly (colonialism, lending power and privilege to white foreigners), and we are about to make a kickass sandwich.  Are you ready?  Welcome to the promotional community-based dental camp. We did this last year in Hansapur, almost by accident, when we arranged for fifteen foreigners to go do a survey, while six Nepali dental technicians set up a field clinic and treated 300 people. The result was that Hansapur asked us to help them start a local dental clinic and school-based oral health programs with providers of their own.

YOU GUYS, we thought. This is a good idea.  This is an excellent use of a brigade of white people.

So this year, for Nepal Smiles 2.0, we flipped the agenda.  The purpose of the camp is promotional, and in the mean time, we’ll do a survey, treat some patients, get extra supervised field training for our technicians to cap off their week of professional development.  But the primary goal is to expose a rural community to resources we can help them develop, while a large group of outsiders adds legitimacy by being part of the process.

Welcome to the village of Dhital.

In the promotional community-based dental camp, our agenda was explicitly not to save all the teeth in Dhital. This is quite a different stance than your typical health camp.  We limited patients to fifty, so that technicians would be able to properly go through the entire respectful assessment and treatment planning process they had practiced all week. We invited politicians and social leaders in Dhital to observe the treatment room and meet our field teams from other villages. All services at the camp were provided by technicians and assistants from surrounding villages while Dr. Bethy consulted on the learning from the week, lending her stature as well as her expertise. As patients came through the camp, we treated a limited number within the constraints of this approach, and then provided referrals to our partner hospital in Pokhara.  We accept these limitations because we are also laying out a pathway for Dhital to launch its own similar services.

 

 

 

 

 

 

 

I have been mulling over this quite a bit and would love to see this conversation happening out in the world.  What do you think?  How do we negotiate a racial story that has been hundreds of years in the making, and leverage it to make a more equitable world?  Surely, there are people out there ready to rip this conversation to pieces.  But we should have it.  What I see daily is that, for rural Nepali health care providers like those we train, being associated with people from California and New Zealand confers legitimacy. Hand-wringing over this is less useful than taking responsibility for these roles we’ve been cast in, and unflinchingly examining how we play them in a way that ultimately deconstructs them, chips away at the hard shell of racism and colonialism, and eventually, creates new a revised and more just theater. This is not something that happens by accident, or quickly or easily, or without mistakes.  And definitely not without calling it out in the first place.

Here’s us, having our imperfect go.

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Out of Crisis, Into Treatment Planning

 

While half of us were out in rural areas doing focus groups and school/shopkeeper observations, all the technicians and clinic assistants were back at the hotel doing a week-long professional development training with Dr. Bethy. They spent each morning in classroom learning and each afternoon treating patients. (Thank you, Kidasha, for partnering with us and allowing us to work with children and adults in your program during our practical sessions!)

The basic training that is provided to our dental technicians was developed by the World Health Organization and is called the Basic Package of Oral Care. It’s just a few weeks long and focuses, logically, on teeth. Trainees learn how to place atraumatic glass ionomer fillings without electrical instruments, and to provide certain types of extraction. Over the years we have done a lot of innovation to take the Basic Package of Oral Care and contextualize it in a rural clinic, developing our own infection control and clinic-setup protocols. Last year when Dr. Bethy and Dr. Keri came for the first time, we added to the treatment package fluoride varnish and an arrest-carries technique with silver diamine fluoride (which, having just been approved by the FDA., is up-and-coming as a new treatment in the U.S. but has been in circulation in developing countries for a long time). With this range of interventions, our dental technicians can address a wide array of conditions in the remote areas where they work.

Beginning last spring with Dr. Keri, we started looking beyond teeth at treatment of the person. This means addressing not only a problematic tooth, but the disease process that is happening as a result of infection, lifestyle, and other factors. It requires looking at the entire mouth, including early-stage decay that might not yet be bothering someone, and setting up a plan to restore the health of the individual through a combination of comprehensive treatments and lifestyle adjustments. This way of practicing the Basic Package of Oral Care represents an enormous leap forward for our dental technicians and for the care delivery model we are trying to establish.

Over this last week, Dr. Bethy’s training took the skill of treatment planning to a whole new level. The technicians and clinic assistants got five and a half days of theory and practice in which they examined case studies, developed a treatment planning form, and explored how to make treatment decisions with a scared or resistant patient. Continuing with Keri’s lessons from last summer, the training examined ways to respectfully and sensitively approach children, who are often terrified to have someone examine their mouths, much less conduct treatments.

Our goal with all of this is to move out of crisis management and in to disease management in a way that looks at the entire person – yes, even for the rural poor, in regions with no running water or electricity.  I really can’t understate how progressive this approach is in an environment that trends at every institutional level toward delivering short-term, emergency relief for millions of people living in rural poverty.  Following this winter training, technicians will now complete treatment planning forms for each patient, allowing them prioritize and schedule interventions over a series of visits. In addition, working with Dr. Karen’s group has infused our program with a new focus on nutrition and lifestyle contributions to oral disease, so our children’s programs are going to start including junk-food free school zones and collaboration with shopkeepers to sell healthy snacks.

 

 

 

 

 

 

 

This is all still very much a work in progress, but when I came to technician training on Saturday, I filled with pride. The fact that our technicians are grappling with these questions is itself innovative. Back before this project even had a name, it was about elevating human dignity through access, consistency, and respect. That’s why it didn’t matter that none of the founders were expert medical practitioners. That we are having five-day trainings with community dentistry experts on how to factor in the amount of time it takes someone to get to the clinic, or their age or belief system or level of fear, is a remarkable level of sophistication. And yet, I firmly believe that this can and should be a system-wide standard.  As much as this is a set of clinical skills, it’s fundamentally a mindset.

And it’s doable.

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Better Questions

 

After getting our first study with UCSF-Berkeley students under our belt last winter, this year I had the chance to work more closely with the lead student, Tanya, to help design a qualitative research project I’ve been wishing someone would do for a long time: conduct focus groups in rural areas to explore people’s lived experiences of their health care.

The reason I was hoping that Tanya would use her fellowship for qualitative research is that there seems to be a lack of rigorous investigation of health practices from the perspective of populations like those we work with in Nepal. In a talk I gave at UCSF last spring, I suggested that research agendas tend to be set by institutions that are far removed from marginalized communities, even when those communities are the target of the research (a phenomenon that is, in fact, its own area of critical analysis in human rights literature – no points to me for coming up with that).

Focus group prep with students and JOHC field staff

The result is that too often, resources are directed at research that serves the researchers instead of the development of better health care structures in places like Nepal. Worse still, whether or not we realize it, academics sitting in California or Ohio or Connecticut designing research questions about people in Rupakot, Nepal, are inevitably influenced by implicit biases about rural, non-western, non-white poor people. The result is an overage of studies on things like shamanism and use of medicinal chewing branches, and a lack of documentation on what drives people to practice inadequate oral hygiene even though, in point of fact, modern hygiene products like those in your own bathroom are widely available in rural Nepal and people already know how they should be used. This bias in research then translates to poorly conceived interventions such as distribution of free dental care products and lessons on personal hygiene, even though that’s not addressing the causes of disease. From a human rights standpoint, this result is demeaning.  And the overall dynamic preserves research institutions from the voices of marginalized communities and a responsibility to legitimize non-academic perspectives.

This year Tanya and I worked together to design focus group questions that would lead to conversation among rural residents about their actual beliefs and practices around health care. In Jevaia we’ve seen through years of trial and error that understanding people’s perceptions of their resources is as important as what those resources are. The focus groups will look at how much residents feel oral disease matters and why, and try to break down the choices that villagers make about both daily hygiene and seeking of treatment services. Knowing how little up-to-date research of this kind exists in Nepal, I am really hopeful that Tanya’s study will provide a foundation for more relevant, application-oriented quantitative research in the future.

So here you have it – our focus groups! The first was actually a presentation of last year’s study to the villages where last year’s students collected the surveys, in Puranchaur and Hanspaur. Then we had a lengthy and very informative discussion with leaders and teachers from those areas about the meaning of the study results.

The second and third focus groups were in two areas where our project has completed the two year seed cycle and the clinics and school programs are continuing in the handover phase.  We did two parallel focus groups in each location, and our Jevaia field staff took roles as facilitators and note takers, which is was a great professional development experience for them (and me!).

Bharat Pokhari

Salyan

 

 

 

 

 

 

 

 

The fourth pair of focus groups was in an area where our program will soon be launching, in the district of Parbat.  Finally, the last was in an area we’ve never worked in before, called Dhital, during our promotional camp.  By this time, our facilitator Sujata and I were really in the groove…

Note taking at the Dhital focus group facilitated by Sujata

In each of these, I took a job as an official note-taker, which gave me an awesome opportunity to listen in closely to what participants had to say. I learned that there is a very high level of awareness that sweets and junk food cause oral disease, and also that parents largely feel helpless to control their children’s junk food intake. I heard some things I expected, such as that basically everyone already knows you are supposed to clean your mouth twice daily, and that products to do this are available and affordable, but that for some reason, people don’t do it anyway. Some of the groups began to get in to nuanced discussions of why that is which were totally fascinating.

Important for us, many groups talked about treatment-seeking behavior. There was categorical agreement that this only happens when there is pain that is impacting someone’s ability to function. People felt that traveling to a city was a significant burden and that proximity of services was a major determinant of what kind of treatment they would seek. There was a widespread awareness that dentistry is a vaguely dangerous and poorly regulated practice, and that you can never be certain that a provider is qualified.

A few of the groups I was in veered in to more practical brainstorming once the official “focus group” discussion was over. These conversations ranged from funding their local clinics to requesting clarification around beliefs raised in the focus group (for example, dangers of blindness from dental care). One group even asked for a proper brushing lesson, so our Sarangkot Clinic Assistant Renuka, who was acting as a note taker, got up and gave an excellent demonstration right there in the focus group!

All around, this was a GREAT learning experience for all of us, and I hope it will produce some pretty solid qualitative data on health beliefs and practices in these areas.  Super proud of our whole team, especially Muna, Gaurab and Rajendra in the office, who organized an insanely complex tapestry of logistics to to make this happen.

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Welcome Back, Universities!

 

TADA! The Berkeley-UCSF-UP gang has arrived, and today we had our all-team orientation to the upcoming week. Look how many of us there are!! I can’t tell you how much I love this. Some of the field staff joining us this week are from villages where our program has been closed down for a year or two and is soon to be restarting, and I haven’t seen them in a while. Seeing them walk through the door with smiles and hugs was glorious. There is nothing like watching our team leaders and technicians and clinic assistants trickling in to a hotel in Lakeside from three districts, and then sitting interspersed with international students as the expert parties on rural oral health promotion in Nepal. Just the fact of seeing all these people in one place makes my heart soar.

We’ll be running five concurrent projects this week:

  1. Four-day Clinical Training for JOHC technicians and clinic assistants with Dr. Bethy
  2. Oral health focus groups in rural areas
  3. Observations of schools and shopkeepers in rural areas to assess nutrition habits
  4. An oral-health status survey conducted by a British student joining us from Barts and the London School of Medicine and Dentistry
  5. A promotional camp where students will do a survey on maternal and child health and nutrition, and technicians will treat patients to demonstrate our rural dentistry model and finish off winter clinical training

At our orientation, Dr. Karen shared the results of last year’s study, and I presented our program model to the visiting students. We played games to get to know each other and went over the plan for the week. In the afternoon, we divided in to groups according to project stream, and the technicians began their first half-day of clinical training with Dr. Bethy.

And, the shirts fit. PHEW!

Nepal Smiles 2.0

 

I’ve just arrived in Nepal for our second research and training collaboration with students and faculty from Berkeley, UCSF and the University of Puthisastra in Cambodia. Last year, this was a blast, brought me amazing new friends, and created my first chances to present our work internationally in California, India and Cambodia. This year we have a big group of sixteen people descending in to our Pokhara valley to five overlapping projects over the course of a week.

Getting ready for this research collaboration is, and was last year, somewhat like putting on a Broadway show. In the office we currently have just three full time staff, and they are responsible for getting all of the necessary government permissions in place, mobilizing unofficial social leaders whose support we need in rural areas, recruiting hundreds of participants for focus groups and surveys, securing transportation to remote villages (the entire group fills two buses), organizing food in rural areas where we can only eat at people’s homes, and not least of all, coordinating with our nearly 20 field staff to make sure everyone shows up from their respective villages for a week. On top of that, we need to design and print 40 logoed shirts, get hundreds of survey printouts, and translate multiple documents between languages. Our amazing office team of Muna, Gaurab and Rajendra manage to steamroll through all of this while keeping our regular work afloat across ten villages.

My role is to keep the different project streams sorted and to bridge between our foreign visitors and the reality of the ground situation in Nepal. I have an excel file featuring no less than ten tabs, tracking everything from hotel rooms to project leaders and bios to budgets. This is because, let’s say we need to buy 40 printed sweatshirts. That seems simple (nope), except that we have people ranging in size from Soba, our Team Leader in Sindure who is about the volume of a pencil holder, to me at 5’8” and a dozen foreign students of various heights and widths. So figuring out what sizes to order and then finding someone who can give us such a large quantity of them and print them on time is an entire spreadsheet. Everything gets more hectic when you are multiplying gaps in planning by 40, dropping them in the gap between two languages, and adding in the overall entropy of the Nepal environment. Do you know what happens when you show up with three dozen people for a project at an empty community building at the top of a hill and you didn’t think to plan ahead how many chairs you might need there? Or, let’s just say you don’t have enough pens?

Chaos, my friends. Chaos happens.

Appreciate my spreadsheet

Appreciate my spreadsheet

I will write about the different project streams of this year’s collaborations in upcoming posts. But they include focus groups, observations of schools and shopkeepers, a survey on maternal and child oral health and nutrition, an oral health status survey being conducted by a British student who has also joined us, and last but not least, an ENTIRE WEEK OF TECHNICIAN TRAINING which I am so excited about I can hardly handle it.

For now, here we are just after I arrived in the office yesterday. I sat down to debrief with the team and doled out Amercian candy and Race to the Rock tshirts. Within a short time, my two favorite creatures came busting through the door and started stuffing all of the office candy in to both their faces and their pockets. Before the performance begins this week, it was lovely to land here in our red-carpeted office and find this cheerful team, to listen and observe as they jammed about how hard they’ve worked to support each other with this complex preparation, and to see the pride they are taking in seeing things come together. It is a wonderful feeling to see our tiny but mighty team take on a cohesive identity as host to visitors, and I especially enjoyed the trill that these three were getting out of how much more they know about doing this than they did last year.  We are all on a steep and exciting learning curve as we introduce the world to the efforts we’ve been making here over these years.

Ok ok ok ok…bring it on!

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