Puranchaur Clinic

 

Today I made my first visit to our clinic in Puranchaur, which launched a year ago in winter 2015. We rode motorbikes – I hopped on one with our program director Aamod, and I stuck my friend Freeman on the back of the other bike with our field officer Gaurab. Freeman lived in rural Afghanistan for two years and his training involved things like “how to drive through a blockade,” so I figured it would be okay.

FYI, re: riding on the back of a motorbike:

  1. Paved road –> plus side: fast / minus side: scary
  2. Rutted dirt road –> plus side: good workout, bracing / minus side: rather sore bum, dust
  3. Previously paved road that has deteriorated and broken up in to a patchy mess with some dirt packed around in it –> plus side: there’s a road, so you’re not walking / minus side: everything else

IMG_6319The way to Puranchaur comes in at a solid #3 for a vigorous 64 minute joy ride.

Fortunately, we were greeted at Puranchaur by the sight of a very well-built Health Post. All of our clinics are in buildings provided by the community, and where possible it is ideal if the building can be in or next to the existing government Health Post. But Health Posts aren’t usually this nice.

It was immediately clear that we’ve received good local support at this stage of the game in Puranchaur. There was a lively crowd of patients waiting on the balcony, and this clinic is run by one of our more experienced technicians, Megnath.

See for yourself:

We went through our supervision checklist, which includes a rigorous infection control protocol that I wrote myself by talking with dentists and rural trainers, then making modifications based on my own knowledge of the environment, because I realized that none of the existing guidelines were really adapted for these conditions. Amazingly, the only existing protocols I could get my hands on were for dental hospitals with electricity and technology – think, UV disinfection – or, alternatively, unwritten procedures used in temporary dental camps, which presume very high patient volume and the lack of any stable infrastructure. Can you believe that I could not locate a single infection control protocol designed for a permanent rural dental clinic in Nepal? 80% of Nepal’s population and nearly all the government Health Posts operate in rural conditions!

Which is why now I know more than I ever planned to about gloving and re-gloving, positioning of safety boxes, and timing of Virex disinfection, among other topics.

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Our rewarding visit to Puranchaur has me thinking more and more about the larger idea of our project. It’s great when we’re able to establish these services and it sure is gratifying to come all the way here, after hours and hours of sitting at a desk, meetings on Skype, researching oral health data, giving talks and raising money, and see patients coming in to a clinic in Puranchaur on a Wednesday afternoon. It’s also awesome to me that none of these people associate their clinic with me or my slideshows or any kind of charity, which is not what these services are intended to be. All that is good stuff.

On a bad day it seems like it just isn’t enough. There are so many problems here. A toothache is definitely one of the worst things in the world if it is in your mouth…but it’s not as bad as child trafficking. These clinics don’t solve problems of violence or lack of basic security or opportunity. Sometimes it seems like a lot of effort to still end up in a world that has those problems anyway.

But one thing I think we’re isolating bit by bit has to do with recouping lost opportunities for self-determination. Something our little project does increasingly well that I don’t see very often in this sector is to understand and respect the present capacities of individual people and the communities where we work on all levels. That means letting go of the UV disinfection, but it also means having a proper replacement and monitoring it. It means making services accessible, but then holding people accountable for accessing them by choice, rather than spoon feeding and disempowering everyone for our own gratification. It means that explaining to an old lady that she will not be blind if we pull her tooth out, and making the service psychologically available, is just as important as having a dental clinic that’s physically available.

This is hard to do. It requires an unreasonable amount of patience and the willingness to constantly sort out where to impose control and where to throw everything you think is correct out the window. Inevitably, there are moments where it seems like you’re dong everything wrong and it’s all for nothing.  At some level, I think it only works if you find people as interesting and challenging and curious as the problem you are trying to address.

That’s what has me wondering what we’re really getting at here. I’ve always felt like, even with the visible services this dental project provides, for me as a person, it’s an exercise in something else I haven’t understood yet. Maybe this is just a story I tell myself after a good day, but we would live in and more dignified and peaceful world if we cared as much about actual people as we do about ideas of people.

Today, one old lady with a toothache spent a good bit of time explaining how she’d treated it by putting tobacco in there.  The tobacco helped. Megnath couldn’t extract her tooth because she had complicating heart issues that require referral to a hospital – but he had a nice long conversation with her about the tobacco, anyway.

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Possibility of Tin

 

The first part of the group left for Archalbot on Thursday: Robin and Colin, the French volunteers, and our field officer Dilmaya. I came a day later because I was working on IMG_9463getting our new office set up. Actually I was busy repainting it with the wrong type of paint, so before I left for Archalbot on Friday, I had to call a painter to redo my redo.

On Friday I rode out to Bote Orar, where the road to Archalbot turns off the main highway between Dhumre and Besisahar. When I arrived at about 5pm, the earth bag house already had a one-meter deep rectangular foundation.  Not bad for one day’s work.

As dusk fell, Dilmaya and I accompanied some of the young men to a clearing on the edge of a terraced field for a community meeting. We sat across from the tarp-shelter in the field.

We’d explained the plan to our local organizers, Kripa and his cousin Surya: anyone who builds a shelter gets a tin roof from us; the earth bag house is a sample building style and we can provide materials if anyone else wants to do it; the family in the field will be a sample building project where the community works together build a bamboo house in a day. Kripa and Surya were getting a lot of questions about who would get tin for what, and they wanted to gather their neighbors and discuss this plan in front of us, to protect themselves from future accusations of greed or favoritism.

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With night falling around us, the discussion that unfolded was amazing. It basically boiled down to: “This organization is here to give us tin roofs for completed shelters. How are we going to help each other complete shelters?” They discussed the order of priority in the village – everybody agreed that the tarp family in the field was the top priority – and other matters such as where and how to get enough bamboo. Even the tarp family made their way over to the meeting, but they seemed guarded, unsure whether to believe us and everybody else. It was their neighbors who explained the plan and assured them they needed to start collecting bamboo.

People kept turning to us and saying, “How many houses are you going to build? Tell us and we’ll figure out who should get them.” And Dilmaya and I kept saying, “You tell us how many houses you’re going to build, and we’ll bring one bundle of tin per family. If we have the problem of too many people building, we’ll deal with it later. That’s never happened.”

Dilmaya did a great job of continually redirecting the discussion back to that point, that everything depended on their planning, and we’re there to meet them wherever they can get to. One guy asked if large families would be able to get more than one bundle of tin. We replied that’s not up to us; our allotment is one bundle of tin per family, and people can add more area with re-used tin or natural materials. “On the other hand,” we said, “as a community, if you guys tell us that a certain household really needs more tin than that, we’ll believe you.”  Because nobody’s going to be the jerk who tries to make off with unneeded extra tin under the scrutiny of the entire village.

There are still many of steps between this meeting and a rebuilt bamboo village in time for monsoon. But I’ve been doing community work in rural Nepal for nearly a decade, and this was as good as it gets at this stage. What you hope is that your attention will mobilize existing capacity and snowball in to a collaboration that combines the best of what we have with the best of what local people have. When we can frame our “aid” as an incentive, even though we want to give it away, people start to ask each other, How are we as a community going to capture the possibility of tin?  Our responsibility is to maintain a consistent and intelligent presence, to keep redirecting ownership back to the community, to closely monitor to make sure nobody’s taking advantage, and to live up to our word. We bring in a small quantity of crucial expertise in building, plus the final critical hardware: a new roof.

There’s also the simple value of spending time with people.  When we arrived, the corn field that needed to be cut down to make the earth bag house was still standing, and the family slashed it in half an hour–but IMG_9492they weren’t going to do that until they saw us standing there for real.  Kushal, the twelve year old boy we met during our assessment, called me almost every morning between Monday and Thursday, and he never had anything to say. He just wanted to see if I’d pick up.  Millions of rural poor go unseen by the world unless they are in the midst of a thrilling crisis that offers the chance for airdrops, mass collection of first aid materials, teeth-clenching field medicine, and smoky photos of catastrophe. But the persistent plight of invisibility and systemic disenfranchisement is too complicated and time consuming for most of the world to attend to by looking people in the eye.  It’s not the habit of our global society, of our governments or social organizations, to sit down in a clearing and say, “We’ll stay here and work on this with you. What do you think?”

I understand why large aid agencies can’t work like this. It’s not their job. They have the budget and infrastructure to strategize to best possible average and cast a wide net; their purpose is to get to the highest number of people, not to reduce the amount of waste or increase the amount of human connection. And Nepal needs them.  An organization like ours could never hope to reach any reasonable fraction of those in urgent need using our approach. But I’m reminded how much groups like us matter, even in the face of a gigantic task like building half a million houses in a few weeks. Because the best possible average still leaves out a lot of people, and for each one of those people, their house is 100% of the problem.

This strategy doesn’t always work, and I don’t know how things will turn out in Archalbot, although I admit I have a good feeling about it. But the hardest part is that you have to be willing to walk away if the community can’t carry its weight, and that’s devastating when it happens, because you and your team have put your heart in to it. You sit in the grass with people while they work things out. You tell them you are there for them and that you respect the wisdom they bring to the process as well as the result. When it falls through, it doesn’t just hurt your budget, it hurts your sense of hope and capability. It’s not something you write up in a report and send up the chain to management. You just go home and cry.

But what am I talking about?  Here’s to you, Archalbot.  We’ll stick it out for better or worse.  Show us how it’s done.

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