Mothers Just Up the Road

Our most recent clinic launched in the village of Deurali, where Hira runs a clinic at the Health Post every Wednesday. We were in Deurali a few weeks ago for a supervisory visit–or more specifically, a veteran technician K.P. was visiting Hira for mentor supervision, Rajendra our medical coordinator was supervising K.P.’s supervision, and I was there to see Rajendra supervising K.P. supervising Hira. So as you can see we’re doing our best to address any issues around lack of supervision and monitoring for primary care operators in rural Health Posts.

Hira’s been doing awesome in her clinic and already has a week of post-certification professional development under her belt, but we’re still working on building the patient flow in Deurali. This is no surprise; everywhere in the world, people are slow to seek dental care, especially for preventative and early-stage treatment. Rural Nepal is no different, and Health Post dental clinics don’t get much traffic unless paired with strong outreach and a referral system. We’re still getting rolling in Deurali, and this month the local Team Leader, Prashanna, organized an outreach gathering for a local Mother’s Group where his wife is an active member.

We piled in to a car at the office and arrived in Deurali mid-morning, having looped through the neighboring village of Rupakot to pick up Kamala, a talented clinic assistant who works in the Rupakot dental clinic and came to assist Hira for the day. Hira packed up a field kit from the Health Post, and we unloaded the supplies a short walk up the road at the Mother’s Group community building. This building was damaged in the 2015 earthquake, so we found ourselves in a completely normal half of a building with half a roof. The other half was open to both sky and the sweep of surrounding hills, not to mention that the road had recently been bulldozed and taken a chunk of the hillside with it, so the concrete floor dropped off precipitously, in mid-air, creating the effect of a film set on the edge of a cliff.

Behind the half-building, people began setting up a plastic chairs and stringing up a tarp for shade. Because it was the first adult outreach program in Deurali, our two education coordinators Bidhya and Shreedhar had come from the office to lead the workshop and model it for the local team leader Prashanna, who will soon become Deurali’s master of ceremonies for such events. Bidhya and Shreedhar are also new to our team, so this was their first adult outreach too, and they’d spent a good deal of time going through our teaching protocols and creating clever new materials to use. Hira and Kamala set up the treatment area to provide free screening, limited treatments of fluoride varnish and silver diamine fluoride, and referral tickets to the regular Wednesday clinic up the road.

People began to trickle in, take their seats, and chat. When the chairs were full, Prachanna and the primary health worker from the Health Post kicked off the morning. Then they handed the session off to Bidhya and Shreedhar, who inaugurated their roles on our team by doing a phenomenal job by engaging the crowd in an animated discussion. They covered everything from oral hygiene to junk-food-free schools to explanations of Hira’s available services in the Health Post.

I really love this example of Bidhya working what’s called “people-centeredness.” People-centeredness actually specific a term used by the World Health Organization as part of its quality-of-care framework. But what does it mean in practice? Health care that is attuned to lived experiences, that is easy to relate to, that is compatible with the physical and cultural environment. People may not leap out of bed to go get dental care, but they often have no problem talking at length about their teeth and the stories inside of them. What I saw watching Bidhya and Shreedhar work the crowd was not a lecture, but a dialogue not so different from the way that Aamaa and I sit around with Saraswoti and Saano Didi and Maya Bouju in the evenings, cataloguing the day and comparing notes about the world. There is a wealth of available wisdom already present in any community.

After the presentation, people waited as long as four hours for a screening in the half-of-a-community building. There was a 104 year old man, a woman with a difficult home life that made it challenging to arrange an initial screening at the Health Post, and a series of patients perfectly timed for interventions recently covered in our Professional Development Seminar on Aging. Watching as residents passed the time in plastic chairs, waiting their turn and talking about their teeth and other life topics, I pondered the fact that the Health Post, which offers the exact same services plus more, with the exact same provider, every week and ten minutes up the road, has struggled with patient flow. But the plastic chairs under the tarp was people-centered.

Hira screened about sixty residents before the wind picked up and began blowing rain in to the wallless clinic space. Before we repacked everything, she gave out forty referral tickets and delivered a swath of preventive fluoride treatments. I think she’ll keep busy in her clinic the next few weeks!

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Aging

The second half of our winter professional development is focused on treatment of older adults. Even though a lot of treatment that dental technicians do is in schools, during the weekly dental clinic at the Health Post, they mostly get adult patients. And since most rural adults have had little or no dental care, and likely weren’t exposed to fluoride toothpastes or other preventative measures for their first few decades of life, some of the conditions that present in our rural clinics are pretty extreme. Besides that, tooth loss in older age is common enough that it’s more or less expected.

Of course, our technicians can refer older patients to higher care, and they do. But following up on referrals isn’t always that easy, especially for older folks with reduced mobility. Not to mention that rehabilitation of many mouths we see in elderly patients would require months of ongoing, expensive, complex treatment even in a state-of-the-art dental hospital–something that’s simply is not feasible for the majority population even in a first-world city. So here we are in rural Nepal working in primary care, which is about disease prevention and improving quality of life. But save for the occasional extraction, older adults are mostly left out of the process when it comes to primary oral health care: directly related to the ability to eat, sleep, and participate socially. If we can relieve pain and preserve teeth longer, that seems like a solid contribution.

With this in mind, we wanted to develop a professional development workshop on how the simple techniques that we’re already using – glass ionomer, silver diamine fluoride – can be used to help relieve the diseases experienced in older populations in Nepal. By “we” I mean Bethy since she’s the one obviously who did this because I write stories about teeth and she is a public health dentist. And even if you’re not a dentist or especially interested in cariology, I have to say that how this turned out is really pretty cool.

A few years ago, Bethy and Keri took photos of about 65 people who’d had restorations done in our clinics, and we used these as the basis for a quality-of-care assessment. It resulted in a few different things. One was adding some missing instruments. Another was noticing an apparent pattern among older adults where, around middle adulthood, adult teeth begin to wear rather than decay. It might be caused by anything from an acidic diet, to abrasive brushing with spices, to a lifestyle change like a new medication. The lower part of the tooth near the gums wears down and become loose, causing sensitivity and difficulty eating, and gradually, the teeth simply fall out. These are the adults who, right now, are getting no care at all besides the occasional extraction.  They were the focus of our training.

Our technicians practiced placing glass ionomer restorations on the root-surface lesions, near the gums, that so often lead to tooth loss in older adults. Bethy explained how an event in the life of a middle-aged adult, such as an illness, can cause a simple change like dry mouth that alters the whole environment and leads to deterioration of a previously resilient set of teeth over the next period of years.

I loved this workshop. For the first two hours, instead of looking at teeth, Bethy brought in pictures of older people and the clinical teams simply talked about aging. What makes people old? Are all old people the same? Do they have the same priorities and daily demands and ideas of self? What do we assume when we see someone who we think is “old”? How does a person’s identity factor in to how we work with them to improve their lives? What is our responsibility to someone’s dignity?

In preparing for the workshop, Bethy and I mined our respective photo archives for pictures of elderly people in Nepal and Cambodia. One by one their faces stared out at our group of clinicians, suddenly daring: Who do you think I am?

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In the beginning, most participants had a sort of default position that older people are weaker and less capable of handling dental treatment. But as we went through the photos for well over an hour, stories blossomed. In some cases, they were people whose backgrounds we knew- my neighbors in Kaskikot, steely women I’d photographed during our work after the earthquake in 2015, caretakers and weavers and shopkeepers who’d given interviews in Bethy’s surveys in Cambodia. Bethy used a clever framework called “Go-go, go-slow, no-go” to talk about what each of these people might be expecting or hoping for from a medical professional. I got to laugh about how Hadjur Aamaa has basically no teeth left and gets around pretty slow, but she’ll put one foot in front of the other to get to the house and then frets the entire day, every day, about the dishes or the peas that need to be shelled; it is absolutely vital to her human essence to be busy with something useful. By the end, our clinical teams were musing over what their patients might be thinking about, who they depended on, and who relied on them, what made them human and alive in the world. This was probably a go-slow patient, like Hadjur Aamaa; this one likely a go-go patient ready to sit there all day and get her teeth fixed; this patient probably wasn’t really about treatment, and mainly needed to have his discomfort acknowledged.

The next day, we returned to the same school in Kaskikot to treat patients age 45 and over. (We’re in rural Nepal, 45 is approaching the pre-elderly group…60 is safely considered “aged” and the point is to catch people BEFORE their teeth are gone.) It was exciting to see the same situations we’d learned about the previous day in the real lives of real people and to be able to offer simple treatments that have the potential to forestall tooth loss for years. The teams continued using the App, entering patient data digitally along side the paper forms.

While patients were waiting outside, the father in law of our local Channeler came by for a checkup. I’ve been to see our Channeler a few times – she lives down near Laushidunga, in the direction of Sada Shiva where I taught primary school for a year.  The story that’s told about the Channeler is that she suffered terribly from a kind of delirium for a period of time. She was treated in a hospital, but nothing helped. Then she began to channel spirits. She rebalanced. People travel from all over to see her; I’ve brought a handful of visitors there to connect with people they’ve lost.  Before Bishnu left for the U.S. in 2008, she went to see the Channeler to connect with her father. The Channeler’s husband has a bum knee, and once I gave him my knee brace from CVS, and he always greets me with an old familiarity when we meet in the road up in Deurali.

Anyway, at some point in the afternoon I couldn’t find our technician K.P., and I walked outside to find he was having his palm read in the waiting area. The Channeler’s father in law spent about an hour reading almost everyone’s palm for fifty rupees each. Everyone–our office staff, the field teams, the schoolteachers and other patients–exclaimed over the things he knew: who’s father had died young, who was still to be married, who was destined to successfully stay with one line of work for a long time (one of our clinic assistants! yay!). I didn’t get a turn because by the time I was ready – I’d had my 50 rupees in my pocket for like an hour – he’d had enough with palm reading. Palm reading was over.

Still, my most favorite patient of the day was a 93 year old woman who arrived alone. She was frail, used a walking stick, and barely spoke to anyone even to ask them to move out of the way as she plodded through clusters of people like Moses parting the sea. She wore a jaunty white knit cap that stuck up boisterously on her head. Her entire mouth was completely empty except for one jutting molar with an expanse of exposed root.

“How can we help you?” Hira, the Deurali technician, asked.

“This tooth hurts,” the woman said simply.

 

Hira treated the one tooth with silver diamine fluoride, a completely painless procedure that will hopefully preserve it a while longer and ease her suffering. Then the woman stood up, picked up her walking stick, parted the seas and went home without a word.

*

 

The App Frontier.

This winter our professional development has two parts. Part one is learning to use a new App we’ve been developing with a local startup called Wiseyak. Part two will focus on treatment of older adults in a rural setting. 
Our still-to-be named App is designed for use with the Basic Package of Oral Care in Health Posts (or potentially any primary care center in a rural, limited-resource setting). Bethy and I have been meeting with the developer, Ravi, for a few months, discussing how an App can be most beneficial our environment, where public health needs are paramount.  What exactly is the role of technology in a Health Post in rural Nepal? Should it help with smart diagnostics? Facilitate “telemedicine” where midlevel providers in remote areas consult with doctors (a hot area of tech innovation that I feel some feelings about)?
We weren’t trying for either of these. I felt strongly that the greatest need in our rural clinics isn’t producing technical magic between provider and patient. For one thing, the logistics are scratchy: most Health Posts can’t rely on a stable cellular connection, much less fast WiFi. But the main reason is that dental technicians should have good training and expertise equivalent to their responsibilities. Why invest in an app instead of improving the skills and abilities of the operator? 
Instead, our App is simply designed to provide excellent documentation. Good digital record keeping offers a wealth of valuable opportunities.  It can help us track specific conditions at population level (in case you’re into dentistry, which I’m kind of not, that would be things like decay on first permanent molars in schoolchildren). Rather than medical technology to help to diagnose disease, it’s designed to facilitate documentation of treatment plans over multiple visits and make it easy for technicians to follow-up with patients in their villages. The App should also be able to spit out referral lists to higher care and provide urban centers with referred patients and contact information. And last but not least, as a health surveillance tool, it will allow us to scan aggregate data and identify specific needs in different areas–and because we are using a community-based and rights-based design, the issues we’re tracking are those that can be addressed with skills that the technicians provide right there in the primary care system (again, in case you’re in to dentistry, that would be things like silver diamine fluoride, ART and sealants).
So in a sense, our App is a much as social justice technology as a medical or public health technology.
It was kind of a thrill to kick off our training on the App yesterday. Bethy gave a great orientation and had meticulously prepared case studies and patient ledgers for the clinicians to practice entering in to the tablets that we acquired in a great feat of shopping conquery. As is becoming our usual training format, first clinical teams practiced applying the concepts using case photos, which they used to go through the diagnostic process, write the treatment note on paper, and then in this case transfer the note it on to the app. In the afternoon, real patients joined us and the teams worked at super slow speed with lots of time for questions, consultation, and App usage.

The next day, we went to Kaskikot to treat students at a primary school and field test the digital data entry process. Gaurab the Bear joined us and he was an enormous hit. I took some close up photos of young children with severe levels of disease in their mouths, and the next day, the teachers spent a few hours meeting with Bidhya and Shreedhar, our filed coordinators, about re-launching the school brushing program and junk food free school.

We left with a sizable list of adjustments to be made to the App, but it was incredibly gratifying to see how quickly everyone took to using the tablets. We’re aiming to use parallel paper and digital systems for about six months before – hopefully – switching over.

*

 

 

 

Cash on Delivery

 

As the start of our winter Professional Development session approaches, it’s time for me to bite the bullet and shell out a bunch of cash for a pile of tablets for an App we’re developing. Teaching clinical teams how to use the app will be the focus of the first part of our upcoming workshop.

The problem is the tablet-acquiring part is…a bit intimidating. At home, I’d search options on the internet and then probably order a few different options, which would arrive at the door with an option for 30-day free returns. But I will shamelessly admit that when it comes to Nepal, I have no idea how to do this. I know how to do stuff that involves baskets, ropes, and misplaced stretches of mud…but I do not know how to do a normal officey thing I am in charge of, such as acquire some expensive pieces of unfamiliar technology.

I asked Muna, our Program Manager Who Literally Fixes Anything, how and where one buys a pile of tablets in Nepal. We were hoping for something with a little flexibility on standard retail price, since we’d be needing 5-7 of them to start.

Muna, did I mention she Literally Fixes Anything, told me about a site called Daraz.com where I could order things on the internet to my house. Or our office. I was floored. Internet ordering is a thing in Nepal? Where the heck have I been? Muna explained to me excitedly that they literally bring it TO YOUR DOOR.  Right to your very own door! And then, you pay for it there. If you don’t want it, you return it with the courier.

“The courier?”

“A person brings it.”

“You order it on the internet and a person brings it? But how do they find you?” I was pretty sure this wasn’t happening through the regular mail system.

“They call.”

I just want to point out that, while a postal service certainly exists in Nepal, most houses don’t have street addresses, and a minimum of streets go by name (that anyone uses or that command street signs), and a large percentage of the houses and streets that do exist were only recently built, and in the majority of the country there are a minimum of streets altogether.

“Are you sure this works?”

“I use it all the time,” Muna said, becoming excited again by the phenomenon of internet ordering. “It’s cash on delivery.”

We looked on daraz.com and ordered five $280 tablets to Ravi’s office in Kathmandu. I arrived in Kathmandu a day later, a week before our training was to start, intending to return with both our trainer (Bethy) and the highly necessary tablets. By this time Daraz.com had called Muna, and Muna began relaying messages between the company, Ravi, and me. At first everything seemed fine. Then Daraz explained that they had the five tablets, but needed to get them out to a store where the courier would pick them up and bring them to Ravi’s office. Or my hotel. Or wherever we asked them to come on the day that they would call us, some time soon, having secured the assets through the official processes.

“Are these going to get here on time?” I asked Muna. She knows things. Admittedly we’d ordered the tablets at the last minute, and even on-time things are almost never fast things. And I seriously doubt that Daraz often receives orders for a heap of five tablets at once.

“Let’s see?”

While the tablets whereabouts remained uncertain, Bethy did arrive as planned from Cambodia.  We spent an afternoon with Ravi to map out our training plan for next week. By Sunday, I was starting to worry. I started calling around in Kathmandu to see about buying some tablets from a show floor, something that in my mind was randomly assigned as a more feasible activity in Kathmandu than Pokhara.  We ended up locating a completely obvious strip of cell technology stores around the corner from New Road. I called Muna and told her we were going on an expedition to find the tablets ourselves.

“If I find them, we can cancel the order, right?” I asked her.

“I called to ask, and they said that when the courier shows up, we just say we don’t want them.”

My mouth opened and closed for a few seconds. “It’s seventeen hundred dollars of merchandise!”

“I know, it doesn’t make any sense, but that’s what they said.”

Just to be clear, I’m not telling this story as a lesson in how things don’t work in Nepal. To the contrary, this is exactly how things work in Nepal. The internet company wasn’t trying to give us the run around, they were just trying to figure out how to find a guy who could get his hands on the pile of pricey tablets we wanted and get them to our guy in a short period of time. Without street names. In a cash economy.

Bethy and I set off to New Road to begin the in-person search. If I’d been more savvy, I’d have known from the start that we should have gone to New Road: as we rounded a corner, there before us, like Oz, was a fairlyand of Samsung and Oppo and Huwaei stores packed together for a block and a half. We walked in and out of them pricing out different tablets, including the one we’d possibly or possibly not ordered online, and when we thought we’d settled on a winner, we wandered in to one last alley for a final try.

There we met Ravi #2, who presented us with our final and ultimately champion tablet, a simpler and smaller version than everything else we’d located. At about 40% of the price.

“I’m a movie star,” Ravi #2 said.

He is. Look him up.

“Here’s a video of me,” Ravi #2 said offhandedly, handing us his phone, his Bieber coif spilling over his brow glamorously but without obstructing his vision. We bent our heads over the small screen, which showed our tablet salesman serenading a beautiful woman on a bridge.

“I’m not the singer,” Ravi #2 admitted. “Just the actor.”

I withdrew a heap of cash from the ATM and forked it over. While five separate people bustled about unpacking our tablets in order to fill out warranty cards, add screen covers, and repack them, we waited and chatted with Movie Star Ravi. He reclined on his stool, a physically not possible thing that only Nepali movies stars can do.

“Do you know my pal Mahesh? He’s a movie star also,” I volunteered.

Why yes, Ravi #2 did know Mahesh, the brother of our field officer Gaurab (the human). Gaurab and Mahesh are both from Kaskikot and I’ve known Mahesh since he was a kid, and even produced a radio story about his robot-making career before he was a movie star with Ravi #2. His father Thakur was one of the founders of Jevaia Oral Health Care back when it was Kaski Oral Health Care, a bazillion years ago.

“Small world,” I said. “You should consider a further discount, considering that Mahesh’s family is closely involved with the very worthy project that these tablets are for.”

“Sorry,” Ravi the Movie Star said. “But here’s my number. Call if you have any problems with the tablets and I’ll get them fixed right away.”

We needed tablet covers.

Ravi the Movie Star didn’t have any tablet covers, but he gave us the name of a shop in another part of the city about a mile away. Obediently I put it in my GPS and Bethy and I set off at a fast clip, racing against the gathering dusk, the new tablets in my bag. In no time the main thoroughfare of Cell Phone Oz had narrowed, then faded away behind us and deposited us in to the heart of Kathmandu’s old, cloistered Newar alleys. Ornate wooden windows leaned precariously in over our heads, while vendors presided over every vegetable and shoe and devotional item imaginable, and as we dashed alternately through crowds and crowded passageways it seemed unlikely that we were headed closer to tablet covers. Night fell, and the cobbled paths and squares became lit by yellow squares falling out of spice stalls, flickering lamps dotting the pavement where vendors had spread out their treasures. We sped through, dodging colored blobs in our path like marbles rolling through a game.

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Out the mouth of a maze we arrived, suddenly, at the destination on Ravi the Movie Star had directed us to, and Lo and behold, there before us was a shop with exactly the name he had provided.

It sold a lot of stuff, but none of the stuff was tablet covers.

We turned around and went back in to the din. We wove about, passing up vacuum cleaners and suitcases and incense and frilly skirts. Surely, somebody, somewhere among all these objects, had some simple tablet co—-

And there it was. Bending off the laid stone path and its hoard of pounding feet was a harshly lit corridor of electronic gadgetry shops that contained four bazillion types of cell paraphernalia. At the end of it, positioned in such a way that suggested anybody arriving must surely be doing so at the end of a great pilgrimage, was a casual shop crammed with phone covers. A woman sat among them as if, obviously, we had been on the way and due to arrive at some point, whenever.  Inexplicably, she had only one type of tablet cover, in one size, and it was a size that fit our efficient little mini-tablets.

“We’ll take five,” I said.

We packed them up, shoved them in our now very full backpacks, and set off on the last part of our expedition through Bishal Bazaar and Ason, butter lamps burning what seemed like everywhere in the lively chill.

“Muna,” I said over the phone a little later, “I’ve secured our tablets. We can cancel the online order.”

“Where did you find them?” she asked.

…You know…streets?

*

Gaurab the Bear

Recently, Bethy was in Thailand and discovered that someone there has been making teddy bears with a full set of teeth.

In my life, this is a very interesting and exciting finding.

Bethy decided to order some teddy bears with teeth for health centers in Cambodia that are running an early childhood hood oral health program, and I figured I would bring a teddy bear over to Nepal. It was fairly simple. In brainstorming the idea, we got to thinking about the enormous contribution that Jevaia’s Education Field Officer Gaurab has made in our organization, beginning long before we had a name. Gaurab was our first Clinic Assistant in our first clinic in Kaskikot. He volunteered for years as a teenager in school seminars, teaching kids about about oral health. He became one of our field officers in 2015 and has walked literally countless miles, up and down hills, in the rain, after dark, and in just about every crazy situation possible to promote oral health in schools in Nepal.

We decided our first teddy bear with teeth should obviously be named Gaurab.

When I arrived recently in Cambodia, Gaurab the Bear had completed the first leg of his journey, from Thailand to Cambodia. He came with frens.

We were so excited to meet him!

We hung out in Cambodia for a while, and then Gaurab’s frens said goodbye

And we left for the airport.

We took a tuk tuk.

Gaurab seemed to like the airport

and he really blended in with all the other travelers.

Especially while waiting for his flight.

He settled in, clutching his ticket to Kathmandu

And we enjoyed perusing very expensive jewelry that isn’t really less expensive even though it’s Duty Free, in Kuala Lumpur.

Honestly we were pretty tired by the time we finally arrived in Kathmandu and Gaurab tried to be patient with the visa process but he was ready for a nap.

The next day, refreshed for our flight to Pokhara, we made some NEW Frens in the airport!

You can imagine Gaurab’s anticipation on the flight west…

And finally, upon arrival we were greeted by some real big fans.

Finally, after meeting the rest of the team, Muna and Rajendra,

 

 

 

 

 

 

 

Gaurab was united in the office with Gaurab!

Welcome to Nepal Gaurab!!

Airport Gymnastics

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

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

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

Well then.  This is awkward.

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

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

…Tick tick tick…check in closes.

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

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

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

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

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

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

Is it there?

How about now?

We may have to carry on our bags.

…Should we call again?

……Is it there yet?

……..How about now??

TADA!

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

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

I write Selina back after we land in Da Nang.

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

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

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

*

Professional Ceiling Clouds

 

For the year and a half, we’ve been extremely lucky to be able to provide bi-annual professional development for our dental technicians and clinic assistants.  It has quickly become one of my favorite parts of our project.  Jevaia dental clinics deliver the Basic Package of Oral Care, a collection of dental procedures that was designed in collaboration with the World Health Organization for limited-resources settings.  The BPOC was developed by Europeans, and it has mostly been used in developing world settings as aid or transient care.

Since we train local dental technicians to provide the BPOC in Health Posts instead of temporary camps or outreach programs, we’ve had the chance think about applying it as a sustained primary health care strategy–especially since we started working with Berkeley, Dr. Bethy and Dr. Keri and other collaborators in 2016.  I suppose that kind of thinking is one difference between aid, or any kind of temporary relief, and human rights, which entitles people to a consistent standard of health care.

Our past three professional development workshops have focused on the use of Silver Diamine Fluoride; infection control tailored to rural Health Posts; and treatment planning (one thing about a stable primary care provider is: they can actually plan!).  This summer, Dr. Bethy is teaching our professional development on school-based treatment planning, so we can shift to a more systematic school-based oral health care model with local dental technicians.

Dental technicians in JOHC already conduct monthly school seminars to do school-based screening and treatment for children and parents.  We call these “seminars” rather than “camps” because they are run by a local provider and they help connect people with the Health Post dental clinic. Unlike most “camps,” seminars don’t aim to treat as many teeth as possible in the shortest time, but to build relationships with the technician and raise public support for a government dental clinic and community outreach programs.

Our 2018 summer professional development was seven days long for veteran technicians and ten days for new technicians. It kicked of with technicians and assistants examining photos of real ART fillings (like the kind they do) organizing them in to acceptable and unacceptable outcomes. Then the clinicians had to use the photos to diagnose why the unacceptable treatments had partly or fully failed, which lead to a review of practice technique. It was really gratifying to see how this impacted everyone’s thinking a few days later, when we were back in a school placing fillings.

Since the BPOC was originally conceptualized as crisis management, a challenge of our project establishing a quality of care standard in a stable primary care setting. At this year’s workshop Bethy helped introduce a competency framework.  During the three days of classroom work, our new technicians supervised old technicians in a “simulation seminar” where they had to demonstrate each technique using the competency checklist.  When we moved to the three-day school setting with live patients, new technicians were supervised through ten of each procedure and had to pass the competency checklist ten times.  Veteran technicians performed one of each technique under a doctor’s supervision and we used the completed checklists to award “competency certifications” that are valid for 18 months.  We even created a framework for technicians to review their competency certification every 1-2 years.

 

 

 

 

 

 

 

Overall, the workshop was meant to guide our clinical teams toward a more rigorously informed, holistic approach to school-based health care, where JOHC technicians work as members of the primary care system rather than visitors. The training emphasized taking time to slow down and connect with patients rather than blowing through a line at the door.  Dentistry can be scary and rather than jumping straight at a kid’s teeth, the intake leaves time to comfort frightened children and to learn about their lifestyle habits and disease risk factors. In turn that information is used to provide more complete and well-informed care, instead of just treating as many teeth as possible. It seems obvious, especially for primary care practice, but in reality that’s not usually how dentistry is done in our setting (or often, in general, if we’re being honest). As part of this, the clinical teams spent a good amount of time reviewing cariology (the biology of oral disease) which unlike the practicalities of how to mix cement and apply it properly, informs which techniques should be used when.  In other words, without adding in more high-technology interventions, we are focusing on more effective deployment of the conventional BPOC.

For me as a non-clinician, it’s super interesting to see how these minimally-invasive techniques can be used not only for emergency management of foregone problems, but for early intervention and prevention of disease in the whole child.  In all children, actually.  This same package of care can be used in service to population level public health needs where resources are a practical limitation, and yet there has been little focus on applying it that way. My dream is that one day it will be rural technicians and assistants presenting to academics at conferences on how they’ve adapted and improved these innovations to benefit their communities in the real world.

An incredible thing happened on the third day of our practice seminar in Kaskikot.  The school we chose is next door to the Health Post.  The third day was reserved for parents so that technicians could apply the training concepts to adult patients.  I was waiting out in the stairwell when suddenly I saw a face I could never forget: Nisha, one of the students I taught for a year at Sada Shiva Primary when she was in fourth grade, a million years ago.  It was with Nisha and her classmates that Govinda dai and I ran our first ever school oral health program back in 2004.  At the end of that day, we took a photo of all of us in front of the Kaskikot Health Post, which at that time was just one simple building that today is fully dedicated to our Dental Clinic.  Nisha had come to our seminar because her daughter is a student at the school where we were running the training in 2018–with five dental technicians, seven assistants, and an international expert in public health dentistry as trainer.



 

 

 

 

 

 

Finally, the icing on our professional development cake was a world-class makeover for the Kaskikot Clinic.  My friend Maelle who lives in Pokhara started an organization called We Art One that paints murals and does art programs in schools.  We asked We Art One to turn our Kaskikot Dental Clinic in to something bright and welcoming.  They took it next level, putting this exuberant mural on the outside and literally building a ceiling mobile inside for patients to gaze at while lying in the chair. It’s made from hand-cut wooden clouds that Maelle painted.

I know not every rural Health Post in the world can have clouds and rainbows hanging from the ceiling.  But I think they all should and I think we should try. The only reason we need is that every patient in the world is a person.  Those of us with choices would never choose health care in an unfriendly, cold or unwelcoming environment, especially for medical treatment that can be scary like dentistry. I don’t know why we seem to believe in some kind of false economy that suggests it’s not realistic to afford that dignity to everyone.  This beautiful artwork was not expensive or difficult; it was just a decision.  It mattered more than doing something else for some other purpose.

So that was our summer.  Two new clinics and nine veterans are open for business, if anyone out there needs an appointment!  Come visit us soon!

2004:

2018:

 

 

 

 

 

 

 

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?

*

 

 

Confidence Under Construction

 

For about a year now, the Government of Nepal has been undergoing a decentralization of power. The country has been divided in to five provinces and outfitted with new government employees at the state level. It’s an exciting moment for a project like ours, which is aimed at capacity building in the government health system. Right now entire tier of government in Nepal is literally undergoing construction for the first time.

In the mean time, a large number of essential items are not yet decided even as the new government is deploying its duties. The desks are purchased and people have been assigned to sit behind them – literally – but exactly what these people are responsible for and how their responsibilities are to be executed is still a work in progress. Many operational policies are still not in place, and decision-making power isn’t yet clearly defined between different levels of government. Basically, we are in a car that is being built while rolling down the highway. You’ve probably been there too, right? And I accept that many people would find this alarming.

These people, however, find it AWESOME.

This a great time to be a grassroots organization in Nepal that has been working on health care with previously less-empowered leaders in villages. Oddly enough, Jevaia Foundation now has a lot of specialized knowledge on a key primary health issue that few if any other organizations are working on in Nepal. We have policy ideas that we’ve already modeled in multiple health posts, and there are elected officials in lower levels of government with an interest in getting this model supported by the ministry of health. And right around the corner from us in the capital of Province #4, the policies, budgetary headings, and guidelines that will decide these matters are currently being created.

Our hope is that in coming months, we’ll be able to play a role in influencing some of the new health policy. Currently oral health care in Nepal is available almost exclusively in private practice. The ministry of health doesn’t even have a budget heading for oral health at the primary care level, and in the villages where we work, leaders have cobbled funds from other budget categories to run dental clinics in their Health Posts. In the new provincial system, we’re hoping to organize local officials and communities to demand the creation of oral health budgets from the Ministry of Health at the province level.  Cool, right?

So even though everything’s a bit weird here at the moment, a time of change and uncertainty is of course always, potentially, a time of heightened opportunity. It is certainly a million times better than an unyielding stasis, as anyone who has been in one of those surely knows.

Now let’s bring this all back down to the ground for a second, in my home village of Kaskikot, where the newly elected village leaders reopened the dental clinic we started…which had been closed for SIX YEARS. (Here’s the Washington Post story about our handover of the Kaskikot clinic in 2013.) The new Kaskikot clinic is fully integrated in to the Health Post and financed by the village government. Patients register in the main building and then take a registration ticket to the dental room. Data on patient flow and treatments provided is maintained just like all other primary care services delivered in the government Health Post. Our job is now confined to monitoring quality of care and technical support. It’s AMAZING.

In order to garner backing for this example and its variations in other villages, we’ve been hard at work over the last few weeks meeting people behind desks in the new province government, and then meeting with other people they suggest we meet with. It’s so refreshing to talk with these newly appointed officials and to brainstorm with folks outside government who, like us, have been chipping away at sticky issues for a long time and are trying to sort out what the new system means for these bigger goals. The confusion of the moment is offset by what feels to us like a sense of possibility and movement.  At the same time, it’s important that everyone carry on with a grand performance of confidence, even though nobody is sure what is going on. So, ok, we’re doing that.

For example, recently I thought to invite a couple folks we’d met up to Kaskikot to see the dental clinic one Sunday. They agreed to come. I immediately began worrying over how to make sure that they’d be there on a busy day. The Kaskikot clinic is generally seeing about 8-15 patients a day, which is getting close to full capacity…but it’s also the busy planting season, and it’s raining, and….and anyway, it would just be a bummer if we invited Important People to our clinic and there were not a lot of patients when they arrived.  Maintaining confidence under construction means pulling out all the stops.

Fortunately, the Kaskikot clinic runs on Sundays, and I spend Saturdays at home in Kaskikot. I decided to invest in some advertising. Here’s where we move this story from Important Offices to Aamaa’s Kitchen.

“We’re going to the clinic tomorrow morning,” I informed Didi and Aidan and Pascal over dinner. They were in Kaski last week for school vacation. Didi protested that she needed to leave early morning to cut grass for the buffalo because Aamaa’s leg has been sore. Also, she pointed out, What if it rains later in the day? I told her I was 100% certain that it never rains on Sundays and that, in conclusion, we were all to leave for dental exams at 9:30am sharp.

On Sunday morning I started my rounds early, at Saano Didi and Saraswoti’s houses. Nobody looked like they’d been planning on a dental checkup after breakfast. “C’mon guys, we’ll go together, it will be fun. Malika Didi is coming,” I begged. With dignity, of course. For the greater good.  Then, walking down the ridge toward Deurali, I ran in to Mahendra sauntering home.

“I need you to come to get a dental checkup today,” I said.

“A dental checkup?”

“At the health post. There are some important people coming to see it.”

“Ok Laura didi.”

“Really? You wouldn’t lie to me.”

“I wouldn’t lie to you Laura didi.”

“Hey and bring some of your friends,” I added, testing my luck. Mahendra has a posse of bros that move as a pack.

“Ok Laura didi.”

Mahendra and Saila

“Really?” It seemed suspicious.

“I’ll be there Laura didi.”

“Around 11,“ I said, and continued down the ridge.

I came to the yard of Saili Bouju, who’s married to our local shaman, Bauta Dai, our local shaman. Since I pass  their front yard every time I walk home from the main road, we check in pretty regularly. When I’d arrived on Friday, we had already made a plan to go to the dental clinic Sunday morning.

“Saili Bouju, we’re going for a dental checkup today, right?”

“Yes, yes Laura,” she assured me in her deep raspy voice.

“I’ll be by at 9:45,” I said. “With Malika didi.”

I continued up the walk to the the next two houses, where I made my pitch to Barat’s two sisters-in-law and their families over tea. Ambika Bouju happened to stop by as I was rinsing my teacup.

“Ambika Bouju, come for a dental checkup today.”

“Hey, I’ve been meaning to do that,” she replied, to my great happiness. “I need to take my son in.”

“Today’s the day! There are some Important People coming from Pokhara to see it. We need a crowd.”

“Ok, I’ll be there,” Ambika Bouju agreed.

Out at the main road I came upon Amadev bouju in her yard. She can’t hear very well. “Bouju, let’s go to the health post today,” I said. She smiled and nodded and said, “Sure, Laura.” She’s an overall positive person.

“Really?”

“Ok, ok,” Amadev Bouju said.

“To get your teeth checked.”

“Yep!”

I had a feeling we might not be talking about the same thing, so I hopped down in to the yard to discuss the matter at a shorter distance.  “COME TO THE HEALTH POST WITH ME TO GET A DENTAL EXAM,” I repeated.

“Oh! Dental exam? My teeth don’t hurt.”

“A checkup is important!” I proclaimed. Amadev Bouju rolled over fairly easily. She said she’d meet us at the clinic.

I made my way toward Butu bouju’s house.  Back in the day, when her daughters were younger, we used to have sleepovers and make chocolate chip pancakes over the fire.  Butu bouju was out in the yard and tried to impose more tea upon my already full-of-tea stomach. I was delighted to find out that she’d been thinking to bring her grandkids to the health post for a dental checkup at some point. “I’ll be by with Malika didi to pick you up,” I said, making sure that Didi would have no out now that I’d advertised her all over the village, and headed home.

“I’ve rounded up most of the people in Deurali,” I announced over breakfast. Didi replied that she was going to cut grass. I countered withthe importance of oral hygeine, and of my schemes, and how she loves me. And so on.

We set off mid-morning. Narayan and Amrit, who over to play with Aidan and Pascal, were rounded up and I shuttled the whole gaggle along the edge of the cornfield. They disappeared in to the tall stalks and I turned around to make sure that Didi was following close behind.

Somehow, by the time we got to Govinda Dai’s house, I was already alone again. Didi had peeled off to go retrieve Butu Bouju. Saili Bouju said she had a headache and would go another time, and only after much cajoling said that she’d meet us there in a little while, which I was pretty sure was a way of pacifying me and sending me on my way. When I passed Ambika Bouju’s house, she was nowhere to be found, and even though her daughter said she’d be up the road shortly, it seemed improbable. All four boys—Pascal, Aidan, Narayan and Amrit—had taken off ahead of me down the road while I was trying to recapture our patients, and by the time I reached Govinda’s house in Dophare they were nowhere in sight. I walked in to Govinda’s yard alone, not seven minutes after mission launch.

“Ok Dai, let’s go,” I resigned.  I’d been in this moment at least a thousand times before: everything looks static and bleak. There are no people. It is foggy or rainy or dark or something else that generally conveys that you are all alone. Well, something would work out, or it wouldn’t.

As Govinda dai readied his umbrella, I looked in the road and saw that Mahendra had appeared out of thin air, with a friend. They were carelessly posted by the side of the road, sullen and awesome as usual.

“I told you I was coming, Laura didi,” Mahendra said with casual authority. “You guys go ahead. We’ll be along.”

Near Maula, we caught up with Aidan and Narayan. “Where are Pascal and Amrit?” I asked. “THEY WENT HOME,” Aidan declared triumphantly, beaming. I sighed. Oh well. “I’m going to call your mom,” I said, and took out my phone to dial Didi, who was missing in action. “I HAVE MOMMY’S PHONE,” Aidan proclaimed ecstatically. “IF YOU CALL MOMMY IT WILL RING RIGHT HERE!”

I thought morosely that Didi and Butu Bouju most likely got to chatting and weren’t coming along.

We arrived at the Health Post in a thick fog. The previous night’s rain had left everything squishy and slick. Durga, the clinic assistant, was just getting through the morning disinfection and setup process. The technician Dipendra was nowhere to be found. It was 10:40 and our visitors where scheduled to arrive at 11.

10:50. Dipendra rolled up on his bike.

10:53. Pascal and Amrit came tumbling out of the fog through the gate to the Health Post complex. They tore across the lawn, jumped over the wall, and went back out in to the road to play by the pond until called for their exams.

10:57. Didi materialized from the fog at the gate. Behind her, Butu Bouju was walking and chatting with her grandkids, like spirits emerging out of a cloud. I blinked. There was Saili Bouju behind them.

11:10. A line of non-recruited folks had taken tickets and were awaiting appointments. The bench outside was full, not just with my neighbors, but with the natural flow of weekly patients.

11:15. Ambika Bouju arrived with her son.

11:20. Mahendra and his bros sauntered in to the yard.

11:30. Our two visitors showed up to find a full clinic with a long line of adults, children and elderly patients sitting out a roughly 40 minute wait. Inside the clinic room, Dipendra demonstrated the treatment planning form that was developed during our last professional development in December. I pointed out our infection control protocol on the wall and other features of the clinic protocol that we’ve added to the Health Post setting, like floor coverings, dress, tray numbers and documentation.

We retreated to the local government building next door to talk about our next steps at the province level. By the time we came back outside to get in a car back to Pokhara, it was about 12:00, and the line outside the clinic has grown even further.

“Saili Bouju!” I call across the lawn.

“I told you I was coming!” Saili Bouju shouted back.

*

(p.s. I have no idea what’s going on with my weird knome-hairdo in this photo)