Politics and Poets

 

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

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

Are you with me so far?

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

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

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

We wait.  It is very hot.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“The Secretary,” Muna mutters.

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

 

 

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.

*

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.

*

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.

Meticulous Serendipity

I’m already in the last week of my visit, and as usual things have flown by too fast.  This monsoon has been more spirited than last year’s, blanketing us in torrential downpours every night and through each morning.  Finally this week the weather seems to have calmed down, but I’m missing the cool and comforting feeling of the rain closing us in with its clattering and clanging.

The main focus of our summer has been a new foray into the world of health care advocacy.  We have a model for rural dental medicine, and we want Nepal’s government to fund dental clinics in all of its village Health Posts.  Our idea is that if the government would set a standard at which it will finance rural dental services in the national health care system, then the global development industry will start doing what we’ve doing: training, mentoring, supervising and auditing rural dental technicians so they meet the standard (which we can help define).  As far as I know, we’re the only organization in Nepal working on this particular topic in this way.

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Salyan Dental Clinic at the Salyan Health Post

Like many developing world countries, there’s a complicated and often mutually distrustful relationship between the aid sector and the government of Nepal.  This largely results in aid agencies privatizing their projects as much as possible; I’ve done this myself, because it’s easier to just do something right yourself than manage a hassle of hectic and sometimes exploitative bureaucracy.  Mean time, weak governments spin out more and more self-serving regulations against a flood of foreign funding that is trying to silo itself.  Ultimately, it’s development itself that suffers, as decades-old aid industries, still chasing down base level poverty, make apparent.  So something that excites me about what we’re doing now is that, setting aside dental medicine itself, I see the process we’re in, if it works, as a strong example of effective collaboration between the private sector, which is great at risk-taking, innovation, and raising money, and a developing-world government, which, at least in Nepal, is by far the best option for scale and stability. I like to think this is a version of life where we all do what we’re good at, with respect for the reality that we need everybody if we’re going to think big and get somewhere.

Now then.  Should you choose to work on rights-based health care policy in the developing world, which you might have been considering, here is your primer on how to get started (after refining your particular service of choice for 10 years).

Our advocacy happens at three levels, beginning with the village level, where we’ve been pushing for permanent local government funding.  This is not for the faint of heart and best suited for people with a good sense of humor.  You’d better be down for a ride that’s 90% culture and 10% policy, and heavily focused on navigating relationships, social dynamics, and weather.  The village level is where we’ve focused most in the past, so we’re reasonably adept at this…except that the reality is that institutional services just aren’t very stable at this level.

Next is the district government, where we’ve previously had only very simplistic coordination, such as required letters to required people.  But it’s the district government that sanctions and distributes village budgets, so without support here, it’s a lot harder to get anywhere at the local level. The other day we had a District Coordination Meeting where our program director and I presented (in Nepali!) on the role of the government in extending our oral health care model to its predominately rural population, filling a gaping hole in the primary health care system. This meeting exceeded our expectations – we received a lot of positive feedback and useful criticism.  I was lavishly complemented, of course, on my village accent.

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Lastly, the day before I leave Nepal, we’ll have our first workshop at the central level in Kathmandu, and with this, we’re leaping in to completely new territory.  But this is ultimately where it’s at: it’s the central government that fixes funding priorities and distributes earmarked budgets through the national health care system.  Recognition of our model at this level would set up a standardized place for rural technicians in Health Posts, providing a framework for agencies with a lot more money to invest in creating rural dental technicians who can then be permanently staffed by Nepal’s own government.

We’re feeling emboldened and encouraged after learning a lot from each and every meeting we’ve had so far.  Despite my own resistance in the past to clunky public systems, at this stage of the game, I’m finding some of the cumbersome government procedures to be oddly reassuring.  They give us steps to take.  We’ve met some very decent and hardworking public officials over the summer, even if they receive us with skepticism and give us some hard knocks. I think this has actually grown our confidence.  We can wait for the meetings, answer the questions, submit the documents, do all the things, because we have confidence in our product.  There’s also the humbling reality that the government has plenty of reasons to be cynical of the social work sector, so if we have to prove ourselves, that’s fair.  It’s forcing us to be both meticulous and more adaptable…eventually, we’re responsible for creating our own good luck.

Besides that, rice planting season concludes with a wonderful festival where everyone puts on green bangles and paints their hands with henna.  Kaskikot’s premier henna-drawer has become none other than yours truly.  What did you expect with an activity where people let you doodle on them with temporarily-staining plants?!  Govinda’s porch had an hour long wait for these skillz on Saun 1.

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The best thing about the henna designs is that you start with an idea, and then it becomes a meditation that designs itself, following a pattern in the creases and borders of someone’s palm, incorporating smudges and wayward marks in to unexpected flowers and vines.  You just can’t say before you start exactly what you’re gonna make.

Doodle doodle doodle…

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In the Trenches

 

This summer I’ve been spending a lot of time sitting at a computer, in our lovely bright office, which is definitely a first.  Last summer, for example I was hiking for 10-12 hours a day in the hot sun visiting earthquake-affected homes in Lamjung, and in general, my time in Nepal is spent covering ground, carrying things, and changing elevations.  Well finally, today was a more typical day in the trenches.

We had scheduled our advocacy meeting with the Health Post committee in Bharat Pokhari.  We’re holding these meetings to push for local funding like we did in Sarangkot.

I woke up at home in Kaskikot.  I had to meet Dilmaya at the bus station in Pokhara at 8:30am, and the local bus from Kaski leaves too late and goes too slow to get me there on time, so I’d cleverly arranged a ride with a neighbor in Kaski who drives a taxi.  However, the road between where he lives and our house is totally washed out with the monsoon, so I woke up at 6am – POINTS FOR ME, THAT’S THE MIDDLE OF THE NIGHT IN MY WORLD – and walked 20 minutes to the other side of the muddy section to meet him at 7:05.  Naturally, I discovered at this point that we were still waiting for another passenger, an ill lady slowly making her way to us.  While I got nervous and then annoyed that I’d be late, there wasn’t much to do.  This is why you don’t stay in your village instead of in Pokhara the night before catching an 8:30am bus for an important meeting.

Naturally, we made it to the bus station on time despite all signs to the contrary.  Dilmaya and I took 1.5 hr very, very bumpy ride out to Bharat Pokhari, cutting over some intervening foothills.

After another 20 minute walk up the road to the Health Post, and we had arrived by 10am for a 12:00 meeting.  No sweat – two walks and two vehicles later, all before breakfast.  Aamod came bouncing up the road on his motorbike and, with plenty of time to pass before the meeting, we went in to visit Bharat Pokhari’s weekly clinic.

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Bharat Pokhari was handed over just this past spring, which means that its protocols are up to date, subject only to how well they’re being observed.  But funding wise, things are in limbo.  The clinical team has been showing up and working without pay, trusting that between us and their local government, someone is going to come through.  In all transparency, we signed a funding agreement with Bharat Pokhari before we launched the clinic, as we do everywhere.  But seeing these through is challenging in every single place, so realistically, we’re in basically in negotiation with Bharat Pokhari’s leaders about it anyway.

We’ve already met with both the Health Post Chairman, a young and ambitious Public Health graduate, and the Village Chairman, who is older and more traditional; these two hold the main influence, technically speaking, over how funds get budgeted.  We’ve briefed both of them extensively over coffee in Pokhara.  The Health Post Chair was very much down with the idea of piloting a new health service in Nepal’s rural system, and as a public health specialist was easily oriented to the larger vision about what this would mean; but, like many Health Post leaders, he’s an appointed transplant who will be moved to a new location within the year.  By contrast, the Village Chairman is very, very local, with social clout and a more complex set of competing interests.  Any meeting is functionally meaningless without both of them present.

At 12, nobody had arrived yet to meet us.  We used the time to mill about Bharat Pokhari’s Health Post, an impressive, hefty hospital-like building constructed with foreign funds, in which many rooms appear to be empty or minimally used.  At 1, we were still waiting in a spacious meeting room with one very talkative local leader who discussed with us, at length, how difficult it is to get everyone together for a meeting.  We agreed.

Around 1:30, this wonderful looking man came in, and it turns out that in addition to being on the Bharat Pokhari government committee, he is our dental technician’s 86 year old grandfather – a magnificently venerable age for these parts.

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1:45pm, we were still waiting for the Village Chairman, who, in theory, had called the meeting.  But then he had apparently been summoned urgently to the municipality in Pokhara.

By 2pm we decided to go for tea with anyone who would come with us, and there we finally got in to a vibrant conversation with some of the health post staff, local leaders, and passers-by about the permanence of the dental clinic.  It dawned on me as we talked “informally” over tea that we weren’t even ready for a meeting of 10 or 15 social leaders in Bharat Pokhari, and that in Sarankgot we were lucky with how quickly things got organized.  Here, we’re still lobbying individual people.  It was probably advantageous that we ended up in a public space, chatting in a tea shop with locals sitting around about how the village should be using its public funds.

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Bharat Pokhari Health Post

We returned to the towering Health Post with our precarious baby clinic inside.  It sits across from a similarly built community center that the same international agency is building; when I asked for what, I was told, “community things.”  I sighed and, knowing it was a bit too simplistic – but nevertheless, true at this moment – said to Dilmaya, “It’s so easy to build something one time and go, isn’t it?”

By 3:15 we decided we had made the most of our day, and climbed on to bikes to head home: me with Aamod, and Dilmaya with the Health Post Chairman, because, we’re in Nepal.

At 3:30, as we were literally rolling down to the road, the Village Chairman showed up.

We got off the bikes.

All of the positive talk from our earlier coffee with the Village Chairman seemed to have dissipated. Tired, we began again at the beginning, making the same case we’d made just a week ago.  We’re realizing that’s just part of how it works.

Finally, around 4pm, Aamod and I left Bharat Pokhari on his motorbike, which is 9 years old and regularly stalls out.

“Should we take the short road?” he asked.  I know this is a trick question that translates to, “I am planning to take this steeper, bumpier short cut, and I am letting you know that we will not be going the other way, which is only for sissies.”

The bike stalls out.

“Well, why take the long road if there’s a short road?” I oblige. “I don’t really know any of these roads.”  Actually, those things are all true.

The bike starts.  We take the short road.

About ten jostling minutes down the short road, just as we are yelling loudly over the bike about how our day of meeting-hazing in Bharat Pokhari was a necessary step in which we feel we put the time to good use, a bike comes up in the other direction.

“The road is closed below!” says the Guy Going Up the Hill.

“What do you mean ‘closed?'” Aamod asks.

“No road,” the Guy Going Up the Hill explains.

I mentally sigh; now we will have to ride 10 minutes back up the bumpy short road, and then down the long road.  We still have a coffee scheduled at 5:30pm with the Village Chairman from Lwang Ghalel.

“I think we should see it,” Aamod says.  “I mean, how closed can it be? I came up this road this morning.”  I know this is a trick question that means, “I don’t want the road to be closed, so I’m going to ignore the obvious and keep going.”

“Well, if you came up the road this morning, what does ‘no road,’ really mean, anyway?” I oblige.

We pass another bike coming in the opposite direction.

“THERE’S NO ROAD BELOOOOOOOOOOOoooooooooooo…w!” he zooms by.

“Maybe there’s no road,” I suggest traitorously.

“Let’s just see,” Aamod replies.

We pull up to some construction workers – the ones turning around all the bikes.  Presumably the same people responsible for the missing road.

“No road below!” the construction workers inform us.

“None at all?” Aamod asks, because, we should be sure.  “Can a bike cross?”

“Absolutely nothing,” they confirm.  Finally.

“Let’s just have a look,” Aamod says.

“I think it’s going to be closed,” I confess.  “Maybe we should just turn around here, we’re wasting time.”

“How closed can it be?” Aamod asks.

So it takes us about 30 minutes to drop Aamod’s extremely heavy bike down this seven foot trench, maybe cut for concrete piping, roll it across the uneven loose dirt and rocks at the bottom, and get it back up the other side.  I now have a lot of dirt and exhaust up my nose.  But, we have won the road.

“That was definitely faster than going back up to the long road,” Aamod points out as we set off again.  I know this is code for “I never suggested we wouldn’t get drenched in sweat and that rolling this five ton bike out of a ditch wouldn’t be part of the process, and it was still worth it because we have won the road.”  He calculates the amount of time each stage of the going up would have wasted, and, indeed the total is longer than the half hour we have spent in the trench.

“Yes, that’s true,” I agree, mildly confused about my final evaluation of having won the road.  “It would have taken way too much time to go back up.”

“You know, the thing is in Bharat Pokhari,” Aamod shouts over the wind, “is that if they just give us a fixed challenge, we can solve it.  But if the challenge keeps changing, it’s gonna be really hard.”

He’s definitely right about that, and we discuss it as we zoom down the short road.  If there’s a real and defined obstacle to overcome to sustain our clinic, we can strategize through it, but if the landscape keeps changing and people aren’t really working with us, we’re pretty much doomed.

“What’s wrong with these people?”

“Yeah,” I shout over the wind.  Politics in Nepal is a whole special level of screwed up, I think.

“They just dig a trench across the road and leave it like that.  They at least need to lay a walkway across before they go.”

“Oh that,” I call out.  “I thought you meant—”

And then my sentence trails off.  The short road presents us with:

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Trench Number Two

Now we’re between two trenches.

“Well, we have no choice but to cut across this one too,” Aamod states.

“That does seem to be the case,” I agree with happiness and enthusiasm.  It’s either this one, or the first one again.

A bike comes up the road on the other side of the trench and, peering over the opposite side, turns around in dismay. We, however, roll Aamod’s heavy bike in to the trench – for a second time – and lay stones, gun the motor, push the thing from behind, the hot exhaust huffing hot on to our ankles.  I eat a lot more dirt.  I am not very effective at this, so Aamod is doing most of the work, although I get exertion points for lifting a heavy bike at the wrong time and pushing it in the wrong direction, and also for laying stones behind a cloud of exhaust.  And then we are through.

We set off again.

“It’s cause you said that thing about the obstacles,” I offer.

“We should stop for a snack,” Aamod says.

As we finally get near town, we stop for pakora and knockoff Redbull.  We deserve it.  I rinse the dust out of my mouth and wash my arms and shins.  Our 5:30 meeting!  Aamod calls the Lwang Ghalel Chairman.

No answer.

It starts to rain.

We sit for forty five minutes, talking strategy, thinking about new clinic launches, considering how to adjust the initial setup and benchmarks along the way, based on what we’re rapidly learning now.  We still have three other post-handover sites and four mid-term sites to manage.

Aamod calls the Lwang Ghalel Chairman again.  No answer.

More rain.

“Can we call it a day?”

“He’s not coming.”  That was a day all right.

We get back on the bike.  It stalls out.  We restart it.  Aamod drops me off in Pokhara.

Good night.

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Hopeful in Sarangkot

 

Yesterday we met with the Sarangkot Health Post Chairman and a committee of local leaders.  Our goal is to advocate for Sarangkot to invest government funding in their dental clinic, our longest-running one.  This is part of a larger strategy of bringing rural dentistry into Nepal’s nation-wide Health Post network, which we’re only really beginning to dive in to deeply now that we’ve sorted out the clinic model itself.

A normal meeting in Nepal will begin, at best, 30 to 60 minutes after the stated starting time.  In villages, it is not unusual for this to be doubled: our Oral Health Coordinator trainings, which involve teachers from all over the village, frequently start at least two hours late.  It’s just a given, and if you’re Nepali you are pretty down with the long waiting period prior to your carefully planned program.  If you’re me, you basically never get used to the feeling of dread that nobody has shown up, all is lost, nobody cares about anything, and you were way overly optimistic to be in this line of work anyway.  Inevitably, just when you’ve chewed your nails down as far as they will go, people show up and casually take their seats.

Amazingly, however, when the four of us arrived at the Sarangkot Health Post on two motorbikes at 1:25pm for a 1:30pm meeting, about 10 local leaders were seated and waiting patiently for us in the chairman’s office.  I think I’ve seen that happen…maybe never.

It’s important to know that Nepal has not held elections at the local level since the early 2000’s. Instead of an elected local government, most villages have a handful of people – probably 95% men – who are socially (or self) appointed to make decisions, plus a village chairman and a Health Post chairman, who are both appointed by the district government.  These village Committees have power over spending but have no direct obligation to represent the needs or desires of local residents.  For us, that means convincing a committee of influential people and two all-powerful officials that the dental clinic is not only worthwhile, but should be a spending priority. If there’s a code to crack on getting village residents to apply pressure, we haven’t found it yet.

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Our meeting with Sarangkot went amazingly.  Aamod and I had invited the Health Post chairman for coffee a few days earlier and he received us with some expected concerns and doubts, but with an open mind.  A few days later, we found the committee gathered in his office to be genuinely interested in talking with us and quick to acknowledge that, notwithstanding the flush torrent of external funds in to Nepal, any new health service for rural people is not truly stable unless it can be incorporated in to the government health care system.  Our proposal was that we would invest $1000 in new supplies and training for the Sarangkot clinic, upgrading it to our current infection control standards, if the government agreed to pay the salaries of the technician and assistant.

They said yes.

Not to the amount we’d hoped for – $1000 per year – but to a lesser amount that is reasonable (our original hope was a serious long shot, given that the district and central levels do not recognize oral health as a funding priority, and they finance village budgets).  After a lot of discussion, we came to a decision that was duly recorded in the meeting minute book and signed by everyone present.  This involves a commitment for the local Committee to include oral health in their requested budget for the next fiscal year starting in July 2017 (which gets submitted in November), and for the intervening year between this July and next, to submit a proposal to the municipality for an emergency amount that will help bridge the gap.  They are also preparing to move the dental clinic in to another room that is bigger, cleaner and more secure.

There are still many unknowns – meeting minutes definitely aren’t action, and they definitely aren’t funding.  Some critical steps are up to people higher up, where we are also moving in to advocacy.  It will be important for us to monitor and collaborate in this process, following up on the agreed timeline, offering support to Sarangkot’s funding proposals.  There are lots of places where things could fall through.  BUT, we got through an important step one more successfully than any of us expected, which is that everyone appears to have agreed it’s worth trying.

In the short term, the new room is to be ready in two weeks.  We supplied paint and set some other requirements: secure doors and windows, removal of storage that is not related to the dental clinic.  After that, we will provide various supplies and training in stages, at pace with the progress of Sarangkot’s investment in the people.

Good start.  Now, on to Bharat Pokhari!

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Dipendra and a vigilant mom at the Sarangkot Clinic in 2016.