Category Archives: Work

Kaskikot, Nepal Life, Oral Health Care Project, Work

Professional Ceiling Clouds

, , , , , , , , , , Leave a comment

 

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

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

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

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

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

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

 

 

 

 

 

 

 

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

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

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

 

 

 

 

 

 

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

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

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

2004:

2018:

 

 

 

 

 

 

 

Oral Health Care Project, Work

The Primacy of Snack Time

, , , 2 Comments

 

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

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

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

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

*

 

 

Kaskikot, Oral Health Care Project

Confidence Under Construction

, , , 10 Comments

 

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

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

These people, however, find it AWESOME.

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

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

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

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

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

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

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

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

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

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

“A dental checkup?”

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

“Ok Laura didi.”

“Really? You wouldn’t lie to me.”

“I wouldn’t lie to you Laura didi.”

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

“Ok Laura didi.”

Mahendra and Saila

“Really?” It seemed suspicious.

“I’ll be there Laura didi.”

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

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

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

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

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

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

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

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

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

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

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

“Really?”

“Ok, ok,” Amadev Bouju said.

“To get your teeth checked.”

“Yep!”

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

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

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

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

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

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

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

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

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

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

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

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

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

10:50. Dipendra rolled up on his bike.

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

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

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

11:15. Ambika Bouju arrived with her son.

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

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

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

“Saili Bouju!” I call across the lawn.

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

*

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

Around Town, Nepal Life, Oral Health Care Project, Work

Politics and Poets

, , , , , , , Leave a comment

 

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

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

Are you with me so far?

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

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

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

We wait.  It is very hot.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“The Secretary,” Muna mutters.

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

 

 

Aidan and Pascal, Didi and Bishnu, Family, Oral Health Care Project, Work

Borders

, , , 1 Comment

 

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

*

Oral Health Care Project, Reflections, Work

You’re White. It’s Fine, But Own Up.

, , , , , , , , 24 Comments

 

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.

*

This slideshow requires JavaScript.

*

Oral Health Care Project, Work

Out of Crisis, Into Treatment Planning

, , , 5 Comments

 

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.

*

Nepal Life, Oral Health Care Project, Work

Better Questions

, , , , 1 Comment

 

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.

*

Oral Health Care Project, Work

Welcome Back, Universities!

, , , , , 4 Comments

 

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!