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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The Art of Not Knowing

 

(Re-posted from my June Newsletter – thanks for bearing with me if you are on my mailing list and are receiving this twice!)

Welcome to the Summer 2017 edition of American in Nepal Doing Dental Care and Other Impossible Pursuits.  This season will feature a number of high profile guests, including my cousin Sara and a return to the set by Dr. Keri the Pediatric Dentist from UConn.

Additionally, we have a nail-biting plot lined up for you.  First of all, last month Nepal held its first local elections in about 20 years.  Why are you biting your nails over this?  Because in working to change the health care system in rural villages in Nepal, the posse of bandits that is Jevaia Foundation spends a great deal of time building relationships with local government leaders, a quest peppered with uncertainty, adventure and drama. Presently, in addition to a fleet of newly elected politicians all over the country, there has been some government restructuring, and now nobody is totally sure about things such as who is in charge of distributing funds that were allocated last fall for stuff like, oh I don’t know…let’s just say rural dental clinics.  So, we literally have no idea what government we’re dealing with on day by day basis, and that’s about 75% of the reason we exist.

On that theme, two weeks ago I gave a short talk at my Williams College Reunion called The Art of Not Knowing (beginning at 29:45).  The other women on this panel were powerful ladies pioneering in the fields of journalism and feminism and are well worth a few minutes of time to listen to.  In my ten minutes, I talked about being a restless college student coming from privilege, women as athletes, and the impact of 9/11 happening my senior year of college as these things relate to my work in Nepal.

Back to other coming attractions.  In July Dr. Keri will be leading a second training for our technicians and clinic assistants, along with – TADA! – our new Medical Coordination Officer, hygienist Rajendra Sapkota.  With Rajendra’s help, we’re going to be strengthening our referral system with city hospitals.  We’re preparing for the launch of just one new clinic this year, in Hansapur, and the rest of 2017-18 will be devoted to revisiting our 8 established clinics, upgrading technician skills and equipment, and going back over the community and school programs in all of those villages.

Keri teaching, winter '16

Keri working with technician Megnath Adhikari last winter

And now it’s time for…a plot twist!  Three weeks ago, I’m in the car when Bishnu calls and tells me that she applied for a visa for Aamaa to come see her graduate from her Master’s program in Information Technology (that’s our Bishnu!).  And somehow, in some inexplicable alignment of cosmic unlikeliness getting turned around and coming out possible instead, Aamaa has scored a five year multiple-entry visa to the United States.  She now has the best visa in the family, and it appears that I when I land back in the US in two months, I will have Aamaa in tow.

[Insert sounds of Laura sitting in her car in the parking lot of Walmart, picturing Aamaa in her apartment in Hartford, yelling, “WHAT IN THE – HOW IS – HOW CAN – TH – WH – I – ” (etc.).]

I can comfortably say that there is not one step of that journey that I can visualize once we get on the bus that leaves Kaski.  Aamaa has never even been to Kathmandu.  The furthest reaches of my mind cannot conjure what she will think of JFK airport.

At my Williams talk, an audience member asked if it is “lonely” to live in the ambiguous territory between two incongruous worlds.  My answer was yes.  But also that I was in that between place before I ever left home: uncomfortable, questioning. This bridging is a rare gift I didn’t earn, but each year, I gain more perspective on the importance of staying uncomfortable, especially if you don’t have to.  Bridging keeps you malleable.  When you have to reconcile competing
worlds, you see how quickly things become stuck, how easily even small power becomes narrow-mindedness and false complacency disguised as expertise or experience.  I have been thinking about this a lot.

In my final blog entry last summer, I wrote about visiting a mosque in Kazakhstan, having been mostly isolated from the news for two months, and how I wondered that the most urgent fixations in one place are completely irrelevant someplace else.  I have the same feeling now as I shift back in to the part of my life where my own obsessions in the U.S. are passing trivialities.  If I stayed in one location, they would become deeper and more rigid.  But I have been given this lucky between.  It is rice-planting season, and we hope the rains will be full.  But we won’t know until the sky breaks, so all we can do is prepare seedlings and roll up our trousers.

Ready for action, y’all.

*

P.S. School teachers starting dental programs? Fo’ shizzle.  I would love to hear what all of you out there think about the presentation I gave at UCSF’s Global Oral Health Symposium last March (beginning here at 54:30). It focuses on human rights and uprooting academy-based (*cough, elitist*) approaches to solving health care disparities in developing countries.

Hittin’ the Big Stage

The chain of events that led to the UCSF Global Oral Health Symposium included, somewhere in the middle, a very serendipitous conversation about baskets.  But let’s start at the beginning.

Two years ago, when our work was going through a big transition and I was trying to identify exactly what it was about in the long-term, I happened to meet Tula Ram Sijali. He leads a research organization based in Pokhara and was a trove of knowledge about the broader health care system in Nepal, including well beyond our focus area of oral health. When we changed our name to Jevaia Foundation shortly afterwards, I asked Tula Ram to join an informal advisory group.

A few months later, Tula Ram introduced me to his boss, Michael, who was in Pokhara overseeing a project. We’d been hearing about Michael for about a year: he was a public health researcher at Berkeley who was the principal investigator on a few studies in Nepal. At the time, I was pulling my hair out trying to set up a research partnership with a university. So when Tula Ram brought Michael to our office on one of Michael’s visits to town, Aamod and I prepared ourselves to meet a bigwig academic from the prestigious halls of Berkeley. Michael turned up wearing sandals, easygoing and friendly, and sat on the roof drinking tea with us and talking about how much we all love Nepal.

We told Michael about our work in oral health (ok fine, I gave him a thinly clad pitch for Berkeley to start doing research on oral health in Nepal) and Michael told us that he waslaunching a new project.  He’d been shocked to see women in rural Nepal carrying heavy loads twice their own size, slung from their heads by ropes, and wanted to study the impact of this on their bodies.  But seriously, had I seen this? It looked brutal! Michael had already purchased a basket and rope and brought it back to an ergonomics lab at Berkeley.

Listen, I said, you really need to know me.

Also, if there’s a basket study happening, I need it in my life.

As you can see, we hit it off quite well.

When Michael got back to Berkeley, he introduced me by email to the head of Global Oral Health Programs at UCSF. Who turned out to be…my classmate Ben Chaffee from Williams College. Now he’s Dr. Ben Chaffee and he introduced me to Dr. Karen Sokal in the Joint Medical Program at UCSF and Berkeley, and Karen was responsible for organizing our university research collaboration last winter. The rest is history.

Mean time, to return to the punch line of this story, Dr. Chaffee invited me to be a keynote speaker at UCSF’s annual oral health symposium in March. This year’s theme was to be “global perspectives on the health care delivery team.” I would be the second of two keynote speakers.  The first was by Dr. David Nash, who I’d heard of and met the evening before the event.  He’s a congenial doctor from Kentucky working to advance the role of dental therapists in the U.S., a comparable effort to what we are doing in Nepal, although our version takes some decidedly unconventional turns.

All of this brings me to the podium in front of over a hundred academics at one of the best medical schools in the country, barely a year after Tula Ram introduced us to Michael, and just two short years after I was feeling rather lost about our long-term goals.

I spent weeks preparing my talk, but I also understood there was only one presentation I could give. As soon as Dr. Chaffee invited me to present, I said so. Mainstream professionals don’t always warm up to our work because it challenges established definitions of expertise and seeks to reorganize institutions that many people are invested in. Put simply: if you spent eight years going to dental school and getting a PhD, you might not clap your hands at the idea of community health workers in rural Nepal taking a two week training and then opening dental clinics. And I can understand why.  However, that’s also the only thing I can talk about.

There’s also the reality that the Academy, like other structures central to the development of medical systems, is oriented around various credentials that I don’t have. While the other speakers were medical professionals and researchers, I have a Master of Fine Arts in creative writing. I can really only claim to be a storyteller.  But Dr. Chaffee assured me that it would be a welcoming, progressive audience, and of course it was a huge honor to be invited. So off I went.

Most of the time, being a little bit of a weirdo outsider is basically just awkward. But every once and a while, it’s completely exhilarating. The response to my presentation, Rural Oral Health Care in Nepal: A Rights-Based Approach, was, from my point of view, comparable to arriving at a party wearing stilts and discovering that everyone had been, without entirely realizing it, just hoping somebody would show up on stilts. The talk can be viewed here beginning at 54:30. I barely had time to eat a strawberry at the reception because so many people wanted to ask me questions. I was invited to co-lead a workshop called “Delivering Improvements in Oral Health in Low Resource Settings” at a conference in Delhi next October.

But it was also so much fun. There were the photographs of our technicians, team leaders, teachers, and the kids in our school programs, a collection of images I’ve essentially memorized, projected on a large screen before a brand new audience.  As I said in my discussion, these are communities that do not get a voice in the ivory tower. What I realized was that it was the perfect moment to be a storyteller. To be able to talk about something that you do partly because you think it’s a good idea, but mostly because you love the people.  Anyone can disagree with a thing, but how can anyone disagree with people?  I saw how much eagerness there is for something surprising, human, and manifest.  I felt like what I had to say was not tolerated but welcomed.  Maybe that shouldn’t have felt as odd as it did.  But I’ve spent so many years plugging away in Nepal that it was a bit of a shock to watch the story unfold here in California, and realize how…much of it there is.  I think I was the most surprised person there.

And at the same time, I guess wasn’t.

I also got to reunite with Michael, who provided an update on the evolving basket-carrying study.  Dr. Karen and many of the students from last winter attended the symposium, and Bethy was in town for a conference that began the next day. She and Karen and I had coffee together after the talk, and then I lay on a bench in the sun, collecting my thoughts. My heart filled with gratitude.  I had the feeling that over a decade of work had come lightly to rest on a bench under the sunny San Francisco sky, and for just a second, this whole journey made sense. There have been so many false starts, disappointments, rejections and failures.  Here was one of those rare instances of rest.  We’d landed on something.

Then, I got up to wander the city for a few hours.  You can’t just sit there, or the magic evaporates.  Besides, it was a lovely afternoon, and surely there were gems on the sidewalks.

*

 

The Power of Catching a Goat

 

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

1. Grab Your Desire

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

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2. All the Religions at the Same Time

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

3. The Power of Power

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

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

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

4. KP’s Dental Technician Henna Tattoo 

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

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5. The Power of Catching a Goat

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

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

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

6. Paragliders in the Mirror

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

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7. It's My Shit

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

8. The Prime Minister on a Tractor

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

I mean, What?

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

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

8. The Power of The Stage

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

9. These extremely uncomfortable mannequins in Kathmandu Mall.

Why, world? Why? Who approved this?

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Evidence. FINALLY.

 

Sada Shiva Primary, 2004

Sada Shiva Primary, 2004

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

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

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

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

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

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

 

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

Let’s say that again.

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

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

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

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

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

Also…it was really fun.

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Real Work in the ‘Hood

 

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

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

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

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

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

What?  We needed a lot of water.

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

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

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Shuckin' Corn

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

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Too Much Good

 

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

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

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

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

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

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

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

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

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

Are you keeping up here? That was day three.

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Over the Mountain and Up to the Clinic

 

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

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

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

…Anything?

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

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

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

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

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

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

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