December 24, 2019Around Town, Nepal Life, Oral Health Care Project, Work

A Piece of Christmas Cake

All The Piecesadvocacy, basic package of oral care, government, human rights, office, rights based health, rural dentistry, technician training 2 Comments

For about two years now, we have been hard at work lobbing the new province government for health policy that includes primary oral health care. I’ve found myself hesitant to blog about many of the twists and turns in this aspect of our journey because political issues feel so sensitive while they are unfolding. And yet this phase of our adventure has produced some of the most colorful, absurd, harrowing and triumphant experiences we’ve ever experienced. Advocacy is, after all, a combination of showing up at government offices, making connections, making connections from connections, inviting people out to see our work, giving presentations, writing policy recommendations, rewriting policy recommendations, cajoling officials for meetings to discuss policy recommendations, and drinking tons and tons of tea and coffee over many coffee tables. These activities are exciting enough in a well-established, stable government. We are working with a government that is has been in perpetual transition for decades, with roads that wash out, with wise men and power saris, with astrological events that dictate the movements of both presidents and wedding parties.

I mean, all kinds of things happen. It is a shame not to tell you about some of them, some of the time.

Recently, we had a breakthrough: Province #4, ours, re-established a previously defunct “Basic Oral Health Training” for primary care providers. We spent almost all of the summer of 2018 madly campaigning for this training. The five provinces of Nepal and the provincial government structure itself had at that time only recently been established – prior to 2017, the federal government was sub-divided by 75 districts – and it would still be some time before personnel had their job parameters defined in the new structure. But our efforts that summer eventually paid off, and recently, through a winding chain of events and people, writes and rewrites, submissions and resubmissions, and patience possible only thanks to some amount of beer, a province-level Basic Oral Health Training budget training descended from the heights of government.

The training is not actually designed yet, so it is fragile and easily gutted, but this also our first major policy breakthrough at a high level of government. It taught us a ton about collaboration, persistence, and the emerging structure of Nepal’s new decentralized governance structure. Even this small-big step would have been impossible to accomplish by working alone.

So this winter, our sights are trained on the Province Training Centre, where the official Basic Oral Health Training will be delivered. This training has a long history in Nepal that I will share at a later time; suffice to say that the essential focus of Jevaia over the last decade has been implementation of care after health care workers have taken Basic Oral Health training that’s provided outside our organization. So by nature, our role has involved a lot further training and refining of skills. If there’s one thing we’ve been up to our, um, teeth in (sorry it was too easy), it’s training and professional support for midlevel providers to do “basic oral health care” in Nepal’s primary care system. That’s why we exist, and it’s how all of our health post clinics and community programs survive against tremendous headwinds.

Now, as you can see this is all very serious business, and our recent meeting at the Province Training Centre rose to the gravity of the occasion. With this shiny, hopeful budget allocated, it is essential that we lobby for a training program that reflects what we’ve learned in over a decade of up-skilling midlevel providers to deliver rural oral health care. So we printed out materials. We reviewed key strategic points. We went to the Province training center.

“You guys!” Rajendra, our Medical Coordinator, cried as we crossed the threshold of the Province Training Centre, examining his feet with a mix of alarm and delight and curiosity that is unique in this world to Rajendra. “I’ve worn the office slippers!” He giggled, and then looked shocked, and then giggled again. Indeed, a brief review of Rajendra’s feet confirmed that he was in fact wearing a pair of the shower shoes we use inside our carpeted office, and his sneakers were still safely stowed on the shoe rack by the office door.

I began to giggle too. “Maybe nobody will notice?” I said.

“Sita Ram sir!” Rajendra announced to our Program Director, excitedly. “I’m wearing the office slippers!” He couldn’t help it. He’ll agree with me when he reads this.

We were led in to the office of the government’s oral health Training Coordinator, where we left our shoes and shower slippers at the door, conspicuously not blending together.

We had a lengthy, complex, and sometimes coded meeting with the Training Coordinator. We were thrilled to find out that a technical working group is to be formed and we are invited to send a representative. The Training Coordinator requested that we also submit an evidence basis for our recommendations, and I will spend the next week compiling a selection of scientific literature around an “augmented Basic Package of Oral Care.” (For you nerds out there, the BPOC was developed with the support of the World Health Organization back around 2003 and is well documented in the literature; meaning we didn’t invent it, our business is to translate it in to practice in the face of real-world challenges.)

From the Training Centre, we re-donned our shower slippers and moved to the Health Division, the government department the Training Centre sits under. There, at the door, we ran in to none other than our past Jevaia program director! Nabaraj now works as a training coordinator in the province offices – perhaps a hopeful sign for us. We were warmly welcomed and led in to a cavernous office with an enormous with a desk at one end, and, per Standard Operating Procedure, tons of couches arranged against all free wall space. The couches were populated by a dozen or so visitors, people we didn’t know, who were both together and separately in an ambiguous state of meeting with the official we had come to see: The Health Directorate.

We took up arbitrary seats on couches where seats were available. This scattered Sita Ram far on a westward couch, while Rajendra, Rajendra’s shower slippers, and I secured side by side perches on an eastward couch. From there on out, in order for us to talk to Sita Ram, we had to either sign or speak very loudly over cross-talk from the northward visitors, who occupied the longest line of couches and either were or were not meeting with the Health Directorate, and may or may not have all been a single group with a unified agenda. There was no way to tell. Luckily, our former director Nabaraj was able to sit nearby me, on the adjacent westward couch, with only a fat faux-leather arm separating us, which made for good chatting and time to assess the situation.

We remained in this configuration for some time, until the room quieted and, based on a cue I could not identify, the Health Directorate affably invited us to introduce ourselves.

All of the people on all of the couches remained at their stations as we took the floor from our arbitrary seats among them.

Sita Ram went first, and then Rajendra. And then it fell to me to introduce myself and provide a general history and outline of our project, and why we were at the Health Division. In Nepali, with all the important couches watching.

The Health Directorate was gracious and curious. He asked us a series of astute questions about the need for primary oral health services in Nepal and about evidence and evaluation for our project model. He has a PhD in the sciences and absorbed our answers thoughtfully.

“You are here,” he said, “at the right time.”

We held our breaths. This was a good start.

Suddenly, the door opened and a group of men walked in.

All the heads on all the couches rotated toward the door.

“Namaskar, sir!” exclaimed a young, brisk man at the front of the group. The Health Directorate rose to meet them.

“We have brought you” –the young man held out a package, importantly– “a Christmas Cake!”

A murmur rippled across all of the couches of people. The Health Directorate reached out to receive a festive box. He thanked the men profusely. Without disrupting our key role as a riveted audience, I was able to lean over to Nabaraj and deduce that the men had come from a local hotel where the government hosts many of its meetings and gatherings.

“A Christmas Cake!” exclaimed the Health Directorate. “How wonderful!”

“How wonderful!” hummed the Couch Sea.

It was decided in short order to adjourn to the next room for Cristmas Cake. The entire room of people rose and passed through a door behind the Health Directorate’s desk, which led us in to a board room with a long, shiny table. The Health Directorate sat down at the head of the table; Rajendra, Sita Ram and I took seats all the way near the other end, and the as-yet-unidentified substantial company filled up the positions in between. The hoteliers huddled around the Health Directorate and bowed their heads over the Christmas Cake box, which was opened delicately to reveal a white iced fruit-cake with a neat candy-cane trim.

Paper plates were produced out of nowhere.

The Health Directorate began the careful process of dividing the roughly 6-inch cake in to precisely calibrated slices for the large room of attendees. Each offering was gravely placed upon a paper plate and passed to the right. Each person then continued passing the plate until it had circulated the long board table and ended up with the person sitting to the left of the Health Directorate. The Christmas Cake circulation continued thusly until all had been served. To the best of my knowledge, there was not a single Christian in the room, including me.

“What delicious Christmas Cake,” we cooed in turn.

Back at the office later, everyone wasted no time in celebrating the shower slippers for their trip to the Province Offices today. “How’d it go?” the rest of the team asked.

“Amazing,” we said. “We have no idea what happened.”

I sat down at my desk to begin compiling our package of research articles.

July 14, 2018Around Town, Nepal Life, Oral Health Care Project, Work

Politics and Poets

All The Piecesadvocacy, culture, customs, economics, government, Pokhara, rights based health, rural dentistry 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?”

June 22, 2018Aidan and Pascal, Didi and Bishnu, Family, Oral Health Care Project, Work

Borders

All The Piecesgovernment, migration, rights based health, travel 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

August 11, 2017Oral Health Care Project, Reflections, Uncategorized, Work

Our Health Care is Not a Playground

All The Piecesadvocacy, dental technicians, government, kathmandu, policy, rural dentistry 4 Comments

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.

December 21, 2016Oral Health Care Project, Work

Over the Mountain and Up to the Clinic

All The Pieceseducation, government, Nepal Smiles, Puranchaur, research, rights based health, rural dentistry Leave a comment

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

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

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

…Anything?

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

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

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

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

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

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

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August 11, 2016Oral Health Care Project, Work

Meticulous Serendipity

All The Piecesadvocacy, culture, government, Kaski, rights based health, rural dentistry 2 Comments

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.

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.

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.

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…

July 24, 2016Around Town, Nepal Life, Oral Health Care Project, Work

In the Trenches

All The Piecesadvocacy, Bus, community organizations, government, rights based health, travel 2 Comments

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.

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.

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.

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:

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.

May 26, 2015Earthquake, Work

Throwing stones at Tin houses

All The Piecesculture, disaster relief, environment, government, housing, Life and Death, politics, transitional shelter Leave a comment

Last Thursday, our meeting with two district officials in Lamjung was so encouraging that I’d been energized all weekend. I talked with a friend at home who did her thesis on post-earthquake housing in Haiti. My dad helped me get in touch with the inventor of earthbag building. I pored over diagrams on the internet and learned the term “waddle and daub.” I was looking for every possible way to supplement a government housing kit consisting of tin roofing and tools. And of course, I talked with a few people about my safe-box idea.

Aamod and I made our second trip out to Lamjung on Monday, for the shelter cluster meeting. (Relief coordination between large iNGOs and the government is divided in to clusters of which shelter is one). We somehow managed to be an hour late again, which this time meant entering a room of a few dozen government officials and representatives from big international organizations.

We sat down in the corner and I took out my notebook. A slide up on the projector showed the names of about six multinational agencies, the villages where they’d been assigned to provide housing, and the number of households covered by each agency, which ranged from about 900 – 1500. Then on the bottom row was our name with two blank columns next to it – no villages yet assigned – and “100” in the righthand column under number of houses. Well, A for effort, anyway.

Besides, with the possibility of using the government’s housing kit, we were hoping to get that number up to about 300.

But the next hour was nothing like either our personalized visit with Lamjung’s district officials a few days earlier, or the big health cluster meeting I’d attended in Kathmandu. Today we were in a room of local politicians talking about use of resources. And my prior enthusiasm was quickly put in check.

Within minutes after we arrived, a discussion about reassigning some villages from one organization to another turned in to a 15-minute debate over whether aid agencies should be allowed to flash their logos while working. After all, it’s the government that should come out with the recognition – is housing aid to become no more than advertising anarchy?

All the big iNGOs have Nepal offices with all-Nepali staff. As I watched the Nepalis representing those agencies negotiate this discussion, even I started to get lost as to who was allied to what cause. I basically understood why these folks engaged a conversation about who would get credit instead of pointing out the more urgent matter of thousands of homeless people in Lamjung; let’s call that standard operating procedure, a necessary hurdle to eventually getting back to housing.

But when someone from one of these NGOs suggested that the Chamber of Commerce should broker
the massive upcoming procurement of corrugated tin roofing, I couldn’t keep up. This guy was working for a huge iNGO that needed to get tin in order to help build shelters. To put this in context, Nepali villagers can build anything out of anything. The overall approach being used with transitional housing is to provide a critical piece of hardware – THE ROOF – and let people build around it.

Foreigners in the room had already explained why their agencies were working on getting corrugated tin from multiple sources to meet the need as fast as possible. Why would this guy, tasked with representing his iNGO to the shelter cluster, encourage all these government officials to control and inevitably slow down the process? Was he bluffing? Maybe he knew his suggestion would never work out, but would satisfy egos and clear the way. Or maybe he meant it. It was either brilliant or terrible, but I still don’t know which.

Finally, one of the European aid workers spoke up. I’d noticed him sitting off to the side, a burly, hearty looking man with clear blue eyes and a tousle of graying hair. He captured all my biases – obviously a disaster professional, not a Nepali-speaker, here for Earthquake and that alone, bored with these talking games that I’ve come to sort of enjoy as sport. He was keeping a feel for the pulse of the conversation while mostly ignoring it, looking rather peeved.

In a few swift paragraphs, this guy listed the amount of corrugated tin available in Lamjung district, and in Nepal as a whole – about 10% of the tin needed for the number of houses destroyed. He knew exactly the number of trucks he needed to transport housing materials to his coverage area; the amount of square footage needed to store all the supplies. He pointed out that accomplishing all this was a massive task and that the monsoon will be starting imminently.

“If we could please finalize which of us are taking which areas, than we can all get to work,” he said.

Silence.

Even I was taken down a good notch, as I am so accustomed to all this politicking in Nepal that I’ve come to expect it, even though we’re in an emergency.

Corrugated Tin Roofing

And there’s more. The government has established a policy to give two sheets of tin to each family that needs to rebuild – but there isn’t nearly enough tin in Nepal to deliver on this quickly without a lot of smart planning and international coordination. So instead, Nepal’s government has decided to give everyone $150 in cash to buy their own tin.

“And when you do that,” said the burly aid officer, “the price of tin is going to skyrocket, because there’s not enough tin available in the local market.”

“We have controls for that,” said an official.

“You can’t control that,” pointed out the aid officer. “When you put money in to a market where there isn’t enough product, the price will triple.”

The matter was never totally resolved.

Later, Aamod and I discussed why on earth Nepal’s leaders would willfully do something like that. The only reason can be to to pacify constituents quickly with cash rather than sorting out the more complex problem the population is actually facing. People will be pleased with receiving $150 and they won’t realize it’s useless because the thing they most need is nowhere to be found, or is now worth $450.

I wonder if this cash reimbursement matter is getting any coverage in the U.S. The only reason it won’t cause an economic collapse in Nepal is because there’s no more room to fall; people literally have nothing. So instead it will just put the most urgently needed commodity – sheets of corrugated tin, for goodness sake – out of reach by displacing the government’s responsibility to provide it on to people who can’t possibly solve a material shortage.

I actually watched a group of politicians look at each other, confront this fact, and, from what I could tell, decide to do it anyway. It felt as though this inflation matter was a good point, but a lot of trouble to solve. It’s a perfect example of the structural rot that weakened this country long before an earthquake shook its softened beams to the ground.

Just to put icing on the cake, before we left, we found out that the district had changed its mind about providing a government housing kit for us to use. In fact, the friendly engineer we talked with the other day – Pradeep – a genuinely sincere guy who seemed to like our idea of collaboration, said the official policy is now that government is only to deliver its tin (or $150) in places where NGOs are NOT working. As for the entire housing kit, which includes things like nails, wire and hammer…that’s just a suggested kit. The big multinational agencies will use it, but the government won’t.

I knew it had all seemed to good to be true. Didn’t I say it was a miracle?

I made a hard pitch to Pradeep that he and I had the opportunity to set an example for how community organizations can collaborate to achieve the work of the government. There are countless groups like Eva Nepal running around providing aid with tremendous energy. He actually liked my idea a lot, but said I’d have to write a proposal and send it up the chain. We all know how long that will take, and in the mean time, people are living under tarps. It’s not the time to play games.

Looks like if we want to work on shelters in Lamjung, we’ll have to bring in all the materials ourselves.

. . .

May 24, 2015Earthquake, Nepal Life, Oral Health Care Project, Work

Discovery of Shelter Kids

All The Pieceschief district office, disaster relief, district health office, earthquake, environment, government, housing, Lamjung, Life and Death, nature, roads, survival, transitional shelter Leave a comment

Lamjung district borders Kaski immediately to the East, and shares its other border with the district of Gorkha. The Lamjung/Gorkha border was the epicenter of the April 25 earthquake.

At 7:30pm last night, Aamod and I made a plan to drive out to Lamjung today and meet with the district government. We wanted to find out what plans the government has for transitional housing and who else is working on it.

As per Nepal style this plan was finalized only late yesterday evening. My job was to type up two official letters for the two government offices we’d be visiting. So got that done by 11pm, and I was planning to print the letters out in the morning, but at 6:15am my phone rang. Aamod had realized the letters should be in Nepali, and I can’t read or write in Nepali. So I emailed the English version to him and went back to sleep. Aamod translated the letter and emailed it to Neha, who was home sick, but nevertheless braved out to her office, but the electricity wasn’t working at her office, so she texted to say I should meet her at a cyber on my way out of town. But when I arrived at the cyber Neha was only just opening up Aamod’s translation, and there were problems with the computer and network and printer and….1.5 hours later, we printed two copies of the letter.

By the time we finally left Pokhara it was 1:45 instead of 11:30. We picked up Aamod in Damauli, and in Dhumre, turned off the east-west road between Kathmandu and Pokhara, and headed northward toward Lamjung. It began to rain.

As soon as we started toward Lamjung we found ourselves trundling along behind a line of relief trucks covered in orange tarps. Once we passed them, I watched the blooming green hills rolling by on the other side of a lush valley and was soothed at being on the road, moving toward some kind of answer, however small, after weeks of anxiety. The flying scenery seemed to catch some speeding thing in my mind and race alongside it, leaving me momentarily still.

The road went on and on. It began to feel very late. And in the front seat, Aamod was sifting through the letters Neha and I had printed out in the morning. There were some mistakes.

Yep. Mistakes. Not kidding.

Now I personally felt that if we had letters with stamps on them, they would surely fulfill procedure. But one must remember that I couldn’t read these letters, so I might have been biased. On the other hand, it was starting to feel like we were never actually going to arrive at our meeting with the District Health Office, and government offices aren’t known for staying open past working hours.

We pulled in to Besishar no earlier than 3:45pm. And Aamod, God bless him, had become committed to finding a place to reprint these blasted letters. We curbed up at a cyber, shoved my pen drive in the computer, Aamod hastily typed in some changes, the cyber owner went to click print…and the power promptly went out.

No reason. This wasn’t a scheduled outage for load shedding. Just good luck.

We wait for a minute to see if the power will come back on. It doesn’t. We leave and look for another cyber. Eventually we find a one and now I am running between the cyber and the taxi with Aamod’s bag while people in the street in Besishar are looking at the tall foreigner sprinting down the road in flip flops with Aamod’s backpack. The revised letters are finally delivered like manna from a printer in to Aamod’s hands. He gently tri-folds them, slides them in to some envelopes, and stamps our organization logo on the front. We jump back in the cab and drive to the District Health Office in Besishar.

Now it’s well after 4:15. As we pull in, the sun comes out, and suddenly it seems early in the day again and things are possible.

We sat down on a couch, and Aamod reached in to his backpack, pulled out an envelope, and handed it formally across the desk to the District Health Officer. This immediately made me want to start giggling like a six year old, because the letter had just gone IN the envelope about five minutes earlier.

Next, we waited quietly and watched the officer read the letter. This is the protocol. The District Health Officer was an affable guy and he took us to the office of the Chief District Officer, the head official of Lamjung. Where, of course, Aamod placed the second letter on the second desk, to be read in silence while we watched.

Just as we began talking at long last, with the late afternoon sun getting lower in the window, we were interrupted by the entrance of an animated employee, who strode in with a huge file and thunked it on the CDO’s desk. He then launched in to a torrential briefing for the Chief District Officer on housing.

He turned out to be the guy in charge of shelter coordination in Lamjung.

And this is how Aamod and I got an up-to-the-minute report on transitional housing in Lamjung District. It was PURE LUCK. If it hadn’t taken us 2.5 hours longer than planned to get to Lamjung, we would have missed this entire interaction. The man’s name was Pradeep Khanal, and we are going to be best friends.

Pradeep (and indeed, much of our afternoon in Lamjung) countered all the negative stereotypes of Nepal’s apathetic, dysfunctional bureaucracy. He provided us a list of the six big agencies doing shelter in Lamjung, updated at a meeting just that morning, and directed us to villages not yet adopted by the large iNGOs doing housing. We looked at drawings of government shelter models and I was surprised to realize I could quickly tell which had advantages and why; which were too resource-heavy or laborious to construct except as a permanent house.

This surprised me as much as when I watched a Hindi film with the boys last winter, and discovered I understand a good bit of Hindi. With no background in construction, the only reason I could interpret all this information from housing drawings is because I’ve lived in a rural house for 12 years, and done things like wood collecting and carrying heavy loads up long distances. Looking at these models, I had a pretty realistic sense of how the proposed spaces would be used daily, of what would be involved in constructing them, and how the result and effort required would compare to a permanent house.

See, you just never know when your niche specialty is going to turn out to be JUST THE THING, right?

We also learned that just that day the government had finalized shelter kits (or Shelter Kids, as the documents charmingly call them) which include tin, nails etc., for each family that needs to rebuild. The government will provide the raw materials, and let people figure out how to use them.

I asked if the government will still provide these kits in places where NGOs had taken on housing projects. They said no – no reason to duplicate money and materials.

Aamod and I scoured a list of districts, numbers of damaged houses, and a huge map on the wall of Lamjung district. We can only afford 100 – 200 housing structures; was there any place where that was the right number? The CDO asked us to please consider offering at least 300 houses, to properly cover a single village.

Suddenly something occurred to me. It was actually completely obvious.

When we do dental care, one of the most difficult parts of our job is motivating the government to collaborate on investment. But this government is already investing. Why would we steal their thunder? If we can simply fill in around the government, we can use our resources to supplement and improve their plan instead of replicating it. What’s more, one of the major lessons from Haiti was that the NGO industry that usurped the government was a giant debacle, essentially displacing governance to outsiders and leaving public systems powerless.

“Sir,” I asked the District Health Officer, “how are you going to deliver these rebuilding kits?”

He said the district government would bring housing kits to the village governments for distribution. I can tell you right now that we’ll be reading stories about how housing kits didn’t reach people who needed them. You know how easy it is to carry hundreds of bundles of tin and nails around in the hills of Lamjung and Gorkha? And what’s more, the government is under pressure to show transparency, so distribution of government aid is already being hampered by a requirement that people have identity cards. Which obviously, have mostly been buried under rubble.

“I was wondering,” I said, “If we were to provide manpower for distribution and building, would the government still be able to provide materials?”

The DHO turned to the CDO sitting behind the desk.

“She’s wondering if we can provide materials in their working areas, if they help with distribution and building.” Is it possible nobody else has asked this question?

“Sure, of course,” said the CDO. As if this wasn’t a miracle. If it was that easy with dental clinics…

Aamod and I practically bounced back out to the taxi. There are countless advantages to channeling the resources of the government to an efficient, people-centered result, over acting independently. One is supporting the government, which, for all its problems, is in charge of the welfare of its people. And instead of buying tin sheets and nails, we can use our relief fund to think about quality of life. Instead of roofs, we can think about walls. Instead of crisis shelter, we can learn about design that can be transferred over time to permanent housing.

Also, we have communities in our own working areas in Kaski and Parbat, where the government currently has no plans to offer housing kits, asking for tents. Instead of using funds on tents, we can reallocate the money saved in Lamjung to mimic the housing kits in our villages, see how people use them, and learn how to supplement supplies and design ideas.

On the way home we talked for 3 hours nonstop about ideas that seemed accessible now: creating day-labor employment, paired-village building, little things that could be easily discounted or added to make all the difference. Out the window, the hills rolled by in reverse, and night fell.

“I was thinking,” I said from the back seat, “about this idea of a safe box for valuables. What do you think?”