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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Race to the Rock ’17

When I returned home from my first year in Nepal, I decided to train for a marathon.  I needed people to train with, so I signed up with Team in Training, an organization that raises money for the Leukemia and Lymphoma Society.  As part of the team, I had to raise about $2,000 for cancer research.  I tried asking people for money; I tried going door-to-door and asking people for money; I tried thinking about asking people for money.  I raised about $200.

It was fall and the 2004 elections were in full swing, taxing people’s interest in solicitations.  One day while I was thinking about asking people for money, I had the idea that I could invite people down to a small green in the neighborhood to do a run or walk on Thanksgiving, and ask my neighbors to donate to cancer research as part of that event.  I didn’t set an entry fee or advertise; I just started knocking on doors and saying we were having a neighborhood walk/run on Thanksgiving, and would you like to make a donation for cancer research?  The next thing I knew, I’d raised $2000 and surpassed the goal. We did the first ever Race to the Rock in 2004 with basically no props or ceremony; everybody just got together, walked around the block, and donated funds to the Leukemia and Lymphoma Society.  It was nice to spend the morning out in the neighborhood, doing something charitable.

Well, I thought.  Hmmmm.  Innnnterrresting.

The next year I adapted the idea to start raising money for the projects I had begun in Nepal, and in the intervening decade, Race to the Rock has grown in to a run with fifty business sponsors and printed t-shirts, but where we still run a course inside the neighborhood and time people on cell phones.  I still go door to door to fundraise for this event, but after thirteen years of doing that, people invite me in to ask how it’s all going and catch me up on what’s going on with their kids and jobs. We chat about current affairs and the state of the world. Honestly, in this day and age, how often does anyone walk house to house in their neighborhood, sitting in people’s kitchens and living rooms, talking?

Sujil with his Himalayan Heritage food truck

I also do the same thing with businesses in the area, and as a result, I now know a lot of the local business managers and owners in Bethesda by name.  For example, there’s a restaurant nearby called Himalayan Heritage that’s run by a Nepali guy named Sujil.  He always buys an ad in our race program, and this year he showed up at Race to the Rock with a food truck, and gave out free food.  In the thirteenth year of this little neighborhood run – which has a $40 entrance fee, or $15/person for a whole family – we raised $22,000.  About half of that came from local businesses, and the rest from people in the community.  I find this whole relationship to be totally wonderful: at the beginning, I was working on a small non-incorporated project in the single village of Kaskikot.  Now, my neighborhood and the surrounding Bethesda area have basically supported the growth of that project in to a public health program courting the National Health Care system of Nepal…by running around the block with race numbers written on mailing labels, crossing a finish line at a tree with posters that say PLYMOUTH ROCK stapled to it.  And the best thing is that people are totally in to it.  We tried using race bibs one year and everyone was like…what is this?  You want me to do four safety pins? Are you serious?  Give me my mailing label.

The Race to the Rock organizing committee consists of me, my parents, and some incredibly helpful neighbors who hand out fliers and get the word out.  My dad puts up the tents and signs, an intricate feat with complex and demanding steps that derive from his doctoral studies in Engineering Physics. I have tried to short cut this process. Just don’t.

On the business side, my mom gets a bazillion donations from local businesses and organizes a silent auction that includes gift certificates, jewelry, tickets to all sorts of events, donated services, and chachkies of all kinds.  The weekend prior to the race, we host a Mamma Lucia pizza party at my parents’ house and kids come over to make posters for all the business sponsors (thank you Williams Crew ergathon for formative experiences in college, where I got that idea!).

I thought I’d share some photos of this year’s Race to the Rock, which was one of our best yet.  We had lots of great entries in the costume contest (you have to race in your costume) and the Useful Item contest (you have to race with an item that would have been useful on the Mayflower…past winning entries include deodorant, limes, and puzzle books).  We had beautiful weather and there was a great vibe with lots of people in the community coming out and enjoying the morning together.  We raised about a quarter of Jevaia Foundation’s annual budget too, which makes for a nice day.

And for us, what a special opportunity to see the best side of people: connected, optimistic, playful, and generous.

Happy Thanksgiving from Bethesda!  Bwk bwk bwk bwk!

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Our Health Care is Not a Playground

 

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

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

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

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

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

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

Anita working at her clinic in Katuwachaupari, Parbat

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

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

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

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

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

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

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

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

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

How are these “technicians” selected?

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

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

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

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

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

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

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

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

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

Our health care system is not a playground!

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

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

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

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

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

Our health care system is not a playground.

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

Our health care system is not a playground.

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

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

 

 

Technician Training

Last winter, for the first time ever, we had foreign dentists meet our technicians, supervise them treating patients in the field, and assess their treatment outcomes. This has been an enormous opportunity for us as an organization and for our technicians who are working hard to provide the only dental care in their villages. This week, we had Dr. Keri back for a second training based on findings from last winter.

Our refresher training included two days of classroom work and a one-day treatment camp at a school. Keri covered topics related to infection control, pain diagnosis, pediatric behavior management, informed consent, treatment planning, and charting. Based on the results of our study of treatment outcomes in fillings placed by our technicians, we introduced a new instrument used to prepare a tooth for a restoration.  On day two, we had a few patients come in for practicals, including Aidan and Pascal.

 

 

 

 

 

 

 

 

 

 

 

 

On day three, we treated about 100 children and adults with supervision from Keri and from Dr. Kafle from our referral hospital, Kantipur Dental Hospital. This gave the technicians and assistants a whole day to apply the concepts from the classroom training to many different types of patients.  I was worried we might not have enough patients during summer vacation…but that was definitely not a problem.

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Over this last year, I’ve realized how far JOHC has moved in to new territory in the oral health care world in Nepal, and really, in to the health care world generally. I’ve come to appreciate that our technicians are true specialists in low-resource dentistry, with training and institutional support that has allowed them to venture in to realms of sophistication not typically expected of providers serving the rural poor. I’ve always been committed to making sure their scope of practice remains safe and appropriate, and at the same time, I recognize that there’s been far less time and money invested in identifying how safe and how good a service can be when the customers are millions of people who cannot rely on reaching a conventional health care setting. Such questions are asked only from the perspective of established institutions and well-funded people in power; that this leads to widespread, unnecessary suffering for the vulnerable is very obvious.

The other side of the same coin is that it inadequate services can be easily excused because they fit a conventional mold.  While Keri was here, we took time to visit the dental section of the public hospital.  We met some great doctors, many of whom are only one or two steps removed from hospitals or people we work with.  But they are working in an underfunded environment with rusted instruments; we observed numerous breaches of infection control in our short 20 minute visit.  The sanitation and safety measures used in our rural clinics are significantly stronger than those we saw in the dental ward of the hospital, even though we are working in a much simpler setting.  Why?

Something else that’s magical about this newfound opportunity for more training and collaboration is getting to know our field staff better, and as a group.  Our clinic assistants – all women (also, on all of our teams, either the technician or team leader must be female) – are these incredible women who tend to listen quietly and then, with very little fanfare, make everything run smoothly.  Without them our infection control protocol would be hash.  They are always the first people to show up at a training or field program.  Biju is raising four children and managed to complete the rice planting in her fields the day before she made the six hour trip to Pokhara from Sindure with her nine year old in tow.  Renuka and Pabitra are always smiling, never miss a thing, and both have put in long stretches of work without pay while we straighten out agreements with their local governments. Sita is upbeat, diligent and ready to toggle between different roles without being asked.  They are just SO AWESOME.

It was a good week.

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