A Piece of Christmas Cake

 

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.

*

 

 

 

 

 

Cash on Delivery

 

As the start of our winter Professional Development session approaches, it’s time for me to bite the bullet and shell out a bunch of cash for a pile of tablets for an App we’re developing. Teaching clinical teams how to use the app will be the focus of the first part of our upcoming workshop.

The problem is the tablet-acquiring part is…a bit intimidating. At home, I’d search options on the internet and then probably order a few different options, which would arrive at the door with an option for 30-day free returns. But I will shamelessly admit that when it comes to Nepal, I have no idea how to do this. I know how to do stuff that involves baskets, ropes, and misplaced stretches of mud…but I do not know how to do a normal officey thing I am in charge of, such as acquire some expensive pieces of unfamiliar technology.

I asked Muna, our Program Manager Who Literally Fixes Anything, how and where one buys a pile of tablets in Nepal. We were hoping for something with a little flexibility on standard retail price, since we’d be needing 5-7 of them to start.

Muna, did I mention she Literally Fixes Anything, told me about a site called Daraz.com where I could order things on the internet to my house. Or our office. I was floored. Internet ordering is a thing in Nepal? Where the heck have I been? Muna explained to me excitedly that they literally bring it TO YOUR DOOR.  Right to your very own door! And then, you pay for it there. If you don’t want it, you return it with the courier.

“The courier?”

“A person brings it.”

“You order it on the internet and a person brings it? But how do they find you?” I was pretty sure this wasn’t happening through the regular mail system.

“They call.”

I just want to point out that, while a postal service certainly exists in Nepal, most houses don’t have street addresses, and a minimum of streets go by name (that anyone uses or that command street signs), and a large percentage of the houses and streets that do exist were only recently built, and in the majority of the country there are a minimum of streets altogether.

“Are you sure this works?”

“I use it all the time,” Muna said, becoming excited again by the phenomenon of internet ordering. “It’s cash on delivery.”

We looked on daraz.com and ordered five $280 tablets to Ravi’s office in Kathmandu. I arrived in Kathmandu a day later, a week before our training was to start, intending to return with both our trainer (Bethy) and the highly necessary tablets. By this time Daraz.com had called Muna, and Muna began relaying messages between the company, Ravi, and me. At first everything seemed fine. Then Daraz explained that they had the five tablets, but needed to get them out to a store where the courier would pick them up and bring them to Ravi’s office. Or my hotel. Or wherever we asked them to come on the day that they would call us, some time soon, having secured the assets through the official processes.

“Are these going to get here on time?” I asked Muna. She knows things. Admittedly we’d ordered the tablets at the last minute, and even on-time things are almost never fast things. And I seriously doubt that Daraz often receives orders for a heap of five tablets at once.

“Let’s see?”

While the tablets whereabouts remained uncertain, Bethy did arrive as planned from Cambodia.  We spent an afternoon with Ravi to map out our training plan for next week. By Sunday, I was starting to worry. I started calling around in Kathmandu to see about buying some tablets from a show floor, something that in my mind was randomly assigned as a more feasible activity in Kathmandu than Pokhara.  We ended up locating a completely obvious strip of cell technology stores around the corner from New Road. I called Muna and told her we were going on an expedition to find the tablets ourselves.

“If I find them, we can cancel the order, right?” I asked her.

“I called to ask, and they said that when the courier shows up, we just say we don’t want them.”

My mouth opened and closed for a few seconds. “It’s seventeen hundred dollars of merchandise!”

“I know, it doesn’t make any sense, but that’s what they said.”

Just to be clear, I’m not telling this story as a lesson in how things don’t work in Nepal. To the contrary, this is exactly how things work in Nepal. The internet company wasn’t trying to give us the run around, they were just trying to figure out how to find a guy who could get his hands on the pile of pricey tablets we wanted and get them to our guy in a short period of time. Without street names. In a cash economy.

Bethy and I set off to New Road to begin the in-person search. If I’d been more savvy, I’d have known from the start that we should have gone to New Road: as we rounded a corner, there before us, like Oz, was a fairlyand of Samsung and Oppo and Huwaei stores packed together for a block and a half. We walked in and out of them pricing out different tablets, including the one we’d possibly or possibly not ordered online, and when we thought we’d settled on a winner, we wandered in to one last alley for a final try.

There we met Ravi #2, who presented us with our final and ultimately champion tablet, a simpler and smaller version than everything else we’d located. At about 40% of the price.

“I’m a movie star,” Ravi #2 said.

He is. Look him up.

“Here’s a video of me,” Ravi #2 said offhandedly, handing us his phone, his Bieber coif spilling over his brow glamorously but without obstructing his vision. We bent our heads over the small screen, which showed our tablet salesman serenading a beautiful woman on a bridge.

“I’m not the singer,” Ravi #2 admitted. “Just the actor.”

I withdrew a heap of cash from the ATM and forked it over. While five separate people bustled about unpacking our tablets in order to fill out warranty cards, add screen covers, and repack them, we waited and chatted with Movie Star Ravi. He reclined on his stool, a physically not possible thing that only Nepali movies stars can do.

“Do you know my pal Mahesh? He’s a movie star also,” I volunteered.

Why yes, Ravi #2 did know Mahesh, the brother of our field officer Gaurab (the human). Gaurab and Mahesh are both from Kaskikot and I’ve known Mahesh since he was a kid, and even produced a radio story about his robot-making career before he was a movie star with Ravi #2. His father Thakur was one of the founders of Jevaia Oral Health Care back when it was Kaski Oral Health Care, a bazillion years ago.

“Small world,” I said. “You should consider a further discount, considering that Mahesh’s family is closely involved with the very worthy project that these tablets are for.”

“Sorry,” Ravi the Movie Star said. “But here’s my number. Call if you have any problems with the tablets and I’ll get them fixed right away.”

We needed tablet covers.

Ravi the Movie Star didn’t have any tablet covers, but he gave us the name of a shop in another part of the city about a mile away. Obediently I put it in my GPS and Bethy and I set off at a fast clip, racing against the gathering dusk, the new tablets in my bag. In no time the main thoroughfare of Cell Phone Oz had narrowed, then faded away behind us and deposited us in to the heart of Kathmandu’s old, cloistered Newar alleys. Ornate wooden windows leaned precariously in over our heads, while vendors presided over every vegetable and shoe and devotional item imaginable, and as we dashed alternately through crowds and crowded passageways it seemed unlikely that we were headed closer to tablet covers. Night fell, and the cobbled paths and squares became lit by yellow squares falling out of spice stalls, flickering lamps dotting the pavement where vendors had spread out their treasures. We sped through, dodging colored blobs in our path like marbles rolling through a game.

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Out the mouth of a maze we arrived, suddenly, at the destination on Ravi the Movie Star had directed us to, and Lo and behold, there before us was a shop with exactly the name he had provided.

It sold a lot of stuff, but none of the stuff was tablet covers.

We turned around and went back in to the din. We wove about, passing up vacuum cleaners and suitcases and incense and frilly skirts. Surely, somebody, somewhere among all these objects, had some simple tablet co—-

And there it was. Bending off the laid stone path and its hoard of pounding feet was a harshly lit corridor of electronic gadgetry shops that contained four bazillion types of cell paraphernalia. At the end of it, positioned in such a way that suggested anybody arriving must surely be doing so at the end of a great pilgrimage, was a casual shop crammed with phone covers. A woman sat among them as if, obviously, we had been on the way and due to arrive at some point, whenever.  Inexplicably, she had only one type of tablet cover, in one size, and it was a size that fit our efficient little mini-tablets.

“We’ll take five,” I said.

We packed them up, shoved them in our now very full backpacks, and set off on the last part of our expedition through Bishal Bazaar and Ason, butter lamps burning what seemed like everywhere in the lively chill.

“Muna,” I said over the phone a little later, “I’ve secured our tablets. We can cancel the online order.”

“Where did you find them?” she asked.

…You know…streets?

*

The Primacy of Snack Time

 

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

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

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

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

*

 

 

Dance Parties, Sticky Notes and 1000 Goves

SO FAR SO GOOD!  We arrived at the office today to find that the internet wasn’t working, and I discovered that I’d left the house last night with one of my flip flops and one of Prem’s, and there was no time to swap them out today, so I’m still wearing till two different shoes.  Basically, our final preparations for the arrival of our Cal / UConn / UP Research Team included:

1. A beginning of the day de-stressing office dance party.

2. A discussion about the value, or lack thereof, of name tags.  Everybody else in the office thought I was nuts to insist we pick some up, because apparently sticky name tags are not a thing in Nepal.  I spent about five minutes trying to describe a sticky name tag and then advocate for its value in life, only to have everyone get very excited when Muna ran in to her office and then came out triumphantly with a sticky note, which she planted on my shoulder to the raving approval of the rest of the staff.  I countered that, aside from the fact that a sticky note is not a name tag, this made me look like an inventory item, and stuck it to Muna’s face to prove my point.

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3. Rearranging the dowry couches gifted to us by our landlord, and cleaning the office.  Ready for visitors!

Ready for visitors

5. Reviewing the schedule, completing our welcome packet, confirming hotel reservations and a training hall and a bus, organizing the inventory so it looks like a wax library, picking up everyone at the airport and sorting supplies in the hotel!  Want to know the best part?

Dr. Sokal brought NAME TAGS!!!  Basically, I won, and that’s what counts.

Welcome to Nepal!!

 

 

 

 

Beautiful Things

We are building houses of many kinds around here, one of which is our own. In between trips out to Lamjung, I’ve been slowly setting up our new office. We’re moving from a one-room office to a four-room office, and anybody who knows me will know that I can labor for weeks or months over small decisions, and filling up a new space requires an infinite amount of decision-making. It took me three weeks to choose carpet, and then the people who came to lay down the carpet did a really bad job, cutting jagged lines and making a mess of it. I had the store send them back and then stood there while they cut everything in straight lines. As they left we were chatting, and I asked them not to take it too hard. Americans, you know?

If I’m honest, my obsession over our new office setup isn’t just about an neurotic issue with straight lines. These walls are going to be ours for some time to come, I hope, and a home where we chase a vision of some kind. And after over a decade of sharing spaces – from dressers to offices – there is a part of me that feels the slightly daunting emptiness and possibility of this unfinished office. The prospect that it will be a space I designed, and that when we walk in, it will feel like it has something of me in it. I realize this is pretty indulgent, but the compulsion is real. 

Anyone who’s ever worked with a contractor knows that anyone in any country can obsess endlessly over both important and insignificant issues of build, and contractors can correspondingly obsess not enough over these things. But I do feel confident saying that Nepal takes certain aspects of haphazard interior design to a new level. The kind of care people put in to their planting, or their outfits when taking a photo, or cooking, or weaving mats, just doesn’t get put in to home decoration. Modern housing in Nepal is quite compatible with leaky faucets and doors that don’t quite fit their frames and paint assortments of ecstatic colors that overlap lazily from one feature to the next. So for better or worse, I’ve begun to lord over each poor unlucky soul who comes here to put something together, just to make sure our work space doesn’t become an accumulation of unloved creations.

IMG_5081So it’s not exactly going fast, but it’s going.

One funny quirk of our new space is this sink outside the bathroom, which is just hanging out in full view of the rest of the office. Someone suggested that I get a local bamboo artisan to create a simple screen to put here, so that people coming out of the bathroom would have some privacy while using the sink.

So last week I asked Shiva to go to Mahendrapul with me and stop in at one of the bamboo furniture places. He pulled his bike over at the first one we happened to see, where there was a young man Umesh.

Off all the things we need to set up in the office, the bathroom screen isn’t the one I was most concerned about. But when I set about explaining what we needed, Umesh and I began to examine various chairs and tables and hangers he had in his store of handmade bamboo furniture, organizing designs I liked. He was extremely attentive and enthusiastic, and as our conversation went on, he couldn’t help himself from admitting that he’d opened his shop just two weeks ago, after fifteen years of working for someone else.

“I told them, I can make anything,” he said, looking like he’d kind of been bursting to tell somebody this. “My hands are full of skills. I said, ‘Why are you keeping me down here?’ And I left and opened this shop.”

Being the choosy perfectionist that I am, I could easily have told Umesh thank you very much and moved on to the next place so he could get his business going with a less high-maintenance customer. He quoted me $90 for the screen – as expensive as one of our desks, three times as much as the chairs he sells. Way to raise the bar, my friend.

Instead, I went with him to our office so he could look at the space itself. And after all the discussing we’d done, I waved my hands and said, “Ok, the main thing is it has to be opaque from here to here. Other than that, do whatever you think will look nice. Make it your own style. By Umesh.”

“I’m going to make you a beautiful screen,” Umesh proclaimed. “This is a very new idea – it will be first of its kind in Nepal.”

Four days later he called to tell me it was ready. He put in in a taxi at his own cost and brought it to our office, and when I arrived to meet him, he was already standing in the road with the screen next to him, trying to hold his smile in.

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This bamboo screen is no doubt my single favorite thing in our new office. It is absolutely gorgeous and in the U.S. would sell for a few hundred dollars. It has the charming quality of being made from bamboo during a period of months where I’ve been, oddly enough, spending inordinate amounts of time in the hot sun encouraging and supporting the creation of bamboo homes in post-earthquake Nepal. But most importantly, it was created with a great deal of pride and love. One side is bent a little, the natural curvature of the bamboo, a perfect imperfection. What started off as a temporary wall to enclose a bathroom became this magnificent piece of artwork.  And as we were all discussing later, you should have some things that you keep around just because they are beautiful.

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Before Umesh left, he couldn’t help admitting another thing, which was that, actually, I’d been his very first customer. I said he was our very first artisian in our first professional office, and that I expected his career was going to go quite well.

“I’m never going to forget you,” he said as he left.   And I said, “I’m pretty sure I won’t forget you either.”

.      .      .

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