The App Frontier.

This winter our professional development has two parts. Part one is learning to use a new App we’ve been developing with a local startup called Wiseyak. Part two will focus on treatment of older adults in a rural setting. 
Our still-to-be named App is designed for use with the Basic Package of Oral Care in Health Posts (or potentially any primary care center in a rural, limited-resource setting). Bethy and I have been meeting with the developer, Ravi, for a few months, discussing how an App can be most beneficial our environment, where public health needs are paramount.  What exactly is the role of technology in a Health Post in rural Nepal? Should it help with smart diagnostics? Facilitate “telemedicine” where midlevel providers in remote areas consult with doctors (a hot area of tech innovation that I feel some feelings about)?
We weren’t trying for either of these. I felt strongly that the greatest need in our rural clinics isn’t producing technical magic between provider and patient. For one thing, the logistics are scratchy: most Health Posts can’t rely on a stable cellular connection, much less fast WiFi. But the main reason is that dental technicians should have good training and expertise equivalent to their responsibilities. Why invest in an app instead of improving the skills and abilities of the operator? 
Instead, our App is simply designed to provide excellent documentation. Good digital record keeping offers a wealth of valuable opportunities.  It can help us track specific conditions at population level (in case you’re into dentistry, which I’m kind of not, that would be things like decay on first permanent molars in schoolchildren). Rather than medical technology to help to diagnose disease, it’s designed to facilitate documentation of treatment plans over multiple visits and make it easy for technicians to follow-up with patients in their villages. The App should also be able to spit out referral lists to higher care and provide urban centers with referred patients and contact information. And last but not least, as a health surveillance tool, it will allow us to scan aggregate data and identify specific needs in different areas–and because we are using a community-based and rights-based design, the issues we’re tracking are those that can be addressed with skills that the technicians provide right there in the primary care system (again, in case you’re in to dentistry, that would be things like silver diamine fluoride, ART and sealants).
So in a sense, our App is a much as social justice technology as a medical or public health technology.
It was kind of a thrill to kick off our training on the App yesterday. Bethy gave a great orientation and had meticulously prepared case studies and patient ledgers for the clinicians to practice entering in to the tablets that we acquired in a great feat of shopping conquery. As is becoming our usual training format, first clinical teams practiced applying the concepts using case photos, which they used to go through the diagnostic process, write the treatment note on paper, and then in this case transfer the note it on to the app. In the afternoon, real patients joined us and the teams worked at super slow speed with lots of time for questions, consultation, and App usage.

The next day, we went to Kaskikot to treat students at a primary school and field test the digital data entry process. Gaurab the Bear joined us and he was an enormous hit. I took some close up photos of young children with severe levels of disease in their mouths, and the next day, the teachers spent a few hours meeting with Bidhya and Shreedhar, our filed coordinators, about re-launching the school brushing program and junk food free school.

We left with a sizable list of adjustments to be made to the App, but it was incredibly gratifying to see how quickly everyone took to using the tablets. We’re aiming to use parallel paper and digital systems for about six months before – hopefully – switching over.

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Better Questions

 

After getting our first study with UCSF-Berkeley students under our belt last winter, this year I had the chance to work more closely with the lead student, Tanya, to help design a qualitative research project I’ve been wishing someone would do for a long time: conduct focus groups in rural areas to explore people’s lived experiences of their health care.

The reason I was hoping that Tanya would use her fellowship for qualitative research is that there seems to be a lack of rigorous investigation of health practices from the perspective of populations like those we work with in Nepal. In a talk I gave at UCSF last spring, I suggested that research agendas tend to be set by institutions that are far removed from marginalized communities, even when those communities are the target of the research (a phenomenon that is, in fact, its own area of critical analysis in human rights literature – no points to me for coming up with that).

Focus group prep with students and JOHC field staff

The result is that too often, resources are directed at research that serves the researchers instead of the development of better health care structures in places like Nepal. Worse still, whether or not we realize it, academics sitting in California or Ohio or Connecticut designing research questions about people in Rupakot, Nepal, are inevitably influenced by implicit biases about rural, non-western, non-white poor people. The result is an overage of studies on things like shamanism and use of medicinal chewing branches, and a lack of documentation on what drives people to practice inadequate oral hygiene even though, in point of fact, modern hygiene products like those in your own bathroom are widely available in rural Nepal and people already know how they should be used. This bias in research then translates to poorly conceived interventions such as distribution of free dental care products and lessons on personal hygiene, even though that’s not addressing the causes of disease. From a human rights standpoint, this result is demeaning.  And the overall dynamic preserves research institutions from the voices of marginalized communities and a responsibility to legitimize non-academic perspectives.

This year Tanya and I worked together to design focus group questions that would lead to conversation among rural residents about their actual beliefs and practices around health care. In Jevaia we’ve seen through years of trial and error that understanding people’s perceptions of their resources is as important as what those resources are. The focus groups will look at how much residents feel oral disease matters and why, and try to break down the choices that villagers make about both daily hygiene and seeking of treatment services. Knowing how little up-to-date research of this kind exists in Nepal, I am really hopeful that Tanya’s study will provide a foundation for more relevant, application-oriented quantitative research in the future.

So here you have it – our focus groups! The first was actually a presentation of last year’s study to the villages where last year’s students collected the surveys, in Puranchaur and Hanspaur. Then we had a lengthy and very informative discussion with leaders and teachers from those areas about the meaning of the study results.

The second and third focus groups were in two areas where our project has completed the two year seed cycle and the clinics and school programs are continuing in the handover phase.  We did two parallel focus groups in each location, and our Jevaia field staff took roles as facilitators and note takers, which is was a great professional development experience for them (and me!).

Bharat Pokhari

Salyan

 

 

 

 

 

 

 

 

The fourth pair of focus groups was in an area where our program will soon be launching, in the district of Parbat.  Finally, the last was in an area we’ve never worked in before, called Dhital, during our promotional camp.  By this time, our facilitator Sujata and I were really in the groove…

Note taking at the Dhital focus group facilitated by Sujata

In each of these, I took a job as an official note-taker, which gave me an awesome opportunity to listen in closely to what participants had to say. I learned that there is a very high level of awareness that sweets and junk food cause oral disease, and also that parents largely feel helpless to control their children’s junk food intake. I heard some things I expected, such as that basically everyone already knows you are supposed to clean your mouth twice daily, and that products to do this are available and affordable, but that for some reason, people don’t do it anyway. Some of the groups began to get in to nuanced discussions of why that is which were totally fascinating.

Important for us, many groups talked about treatment-seeking behavior. There was categorical agreement that this only happens when there is pain that is impacting someone’s ability to function. People felt that traveling to a city was a significant burden and that proximity of services was a major determinant of what kind of treatment they would seek. There was a widespread awareness that dentistry is a vaguely dangerous and poorly regulated practice, and that you can never be certain that a provider is qualified.

A few of the groups I was in veered in to more practical brainstorming once the official “focus group” discussion was over. These conversations ranged from funding their local clinics to requesting clarification around beliefs raised in the focus group (for example, dangers of blindness from dental care). One group even asked for a proper brushing lesson, so our Sarangkot Clinic Assistant Renuka, who was acting as a note taker, got up and gave an excellent demonstration right there in the focus group!

All around, this was a GREAT learning experience for all of us, and I hope it will produce some pretty solid qualitative data on health beliefs and practices in these areas.  Super proud of our whole team, especially Muna, Gaurab and Rajendra in the office, who organized an insanely complex tapestry of logistics to to make this happen.

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Welcome Back, Universities!

 

TADA! The Berkeley-UCSF-UP gang has arrived, and today we had our all-team orientation to the upcoming week. Look how many of us there are!! I can’t tell you how much I love this. Some of the field staff joining us this week are from villages where our program has been closed down for a year or two and is soon to be restarting, and I haven’t seen them in a while. Seeing them walk through the door with smiles and hugs was glorious. There is nothing like watching our team leaders and technicians and clinic assistants trickling in to a hotel in Lakeside from three districts, and then sitting interspersed with international students as the expert parties on rural oral health promotion in Nepal. Just the fact of seeing all these people in one place makes my heart soar.

We’ll be running five concurrent projects this week:

  1. Four-day Clinical Training for JOHC technicians and clinic assistants with Dr. Bethy
  2. Oral health focus groups in rural areas
  3. Observations of schools and shopkeepers in rural areas to assess nutrition habits
  4. An oral-health status survey conducted by a British student joining us from Barts and the London School of Medicine and Dentistry
  5. A promotional camp where students will do a survey on maternal and child health and nutrition, and technicians will treat patients to demonstrate our rural dentistry model and finish off winter clinical training

At our orientation, Dr. Karen shared the results of last year’s study, and I presented our program model to the visiting students. We played games to get to know each other and went over the plan for the week. In the afternoon, we divided in to groups according to project stream, and the technicians began their first half-day of clinical training with Dr. Bethy.

And, the shirts fit. PHEW!

Nepal Smiles 2.0

 

I’ve just arrived in Nepal for our second research and training collaboration with students and faculty from Berkeley, UCSF and the University of Puthisastra in Cambodia. Last year, this was a blast, brought me amazing new friends, and created my first chances to present our work internationally in California, India and Cambodia. This year we have a big group of sixteen people descending in to our Pokhara valley to five overlapping projects over the course of a week.

Getting ready for this research collaboration is, and was last year, somewhat like putting on a Broadway show. In the office we currently have just three full time staff, and they are responsible for getting all of the necessary government permissions in place, mobilizing unofficial social leaders whose support we need in rural areas, recruiting hundreds of participants for focus groups and surveys, securing transportation to remote villages (the entire group fills two buses), organizing food in rural areas where we can only eat at people’s homes, and not least of all, coordinating with our nearly 20 field staff to make sure everyone shows up from their respective villages for a week. On top of that, we need to design and print 40 logoed shirts, get hundreds of survey printouts, and translate multiple documents between languages. Our amazing office team of Muna, Gaurab and Rajendra manage to steamroll through all of this while keeping our regular work afloat across ten villages.

My role is to keep the different project streams sorted and to bridge between our foreign visitors and the reality of the ground situation in Nepal. I have an excel file featuring no less than ten tabs, tracking everything from hotel rooms to project leaders and bios to budgets. This is because, let’s say we need to buy 40 printed sweatshirts. That seems simple (nope), except that we have people ranging in size from Soba, our Team Leader in Sindure who is about the volume of a pencil holder, to me at 5’8” and a dozen foreign students of various heights and widths. So figuring out what sizes to order and then finding someone who can give us such a large quantity of them and print them on time is an entire spreadsheet. Everything gets more hectic when you are multiplying gaps in planning by 40, dropping them in the gap between two languages, and adding in the overall entropy of the Nepal environment. Do you know what happens when you show up with three dozen people for a project at an empty community building at the top of a hill and you didn’t think to plan ahead how many chairs you might need there? Or, let’s just say you don’t have enough pens?

Chaos, my friends. Chaos happens.

Appreciate my spreadsheet

Appreciate my spreadsheet

I will write about the different project streams of this year’s collaborations in upcoming posts. But they include focus groups, observations of schools and shopkeepers, a survey on maternal and child oral health and nutrition, an oral health status survey being conducted by a British student who has also joined us, and last but not least, an ENTIRE WEEK OF TECHNICIAN TRAINING which I am so excited about I can hardly handle it.

For now, here we are just after I arrived in the office yesterday. I sat down to debrief with the team and doled out Amercian candy and Race to the Rock tshirts. Within a short time, my two favorite creatures came busting through the door and started stuffing all of the office candy in to both their faces and their pockets. Before the performance begins this week, it was lovely to land here in our red-carpeted office and find this cheerful team, to listen and observe as they jammed about how hard they’ve worked to support each other with this complex preparation, and to see the pride they are taking in seeing things come together. It is a wonderful feeling to see our tiny but mighty team take on a cohesive identity as host to visitors, and I especially enjoyed the trill that these three were getting out of how much more they know about doing this than they did last year.  We are all on a steep and exciting learning curve as we introduce the world to the efforts we’ve been making here over these years.

Ok ok ok ok…bring it on!

*

Between the Corn and the Millet

I try to imagine Aamaa’s life as it was back then, when the water springs in Kaskikot weren’t concrete taps but delicate pools that stirred up silt if you took from them too quickly. As a girl and young wife of 13, she sometimes had to sleep overnight in line while other women had their turns gently lifting the water jug by jug. By the time Aamaa was 22, she was a widow with two young girls of her own, and it would still be years before a bus came to Kaskikot, or a door was put on the entrance to her one-room house.

There have been many impossibles in Aamaa’s life. She raised two educated daughters who could split wood and carry twice their weight by grade school. The civil war started, but it was elsewhere, in other villages. The electric mill came; the bus came; the tourists came; other people converted their houses to homestays and restaurants. Aamaa’s house is off the road in a cul-de-sac of mountainside that nobody wanders past by accident. Even after some foreigners bought the patch of land on the hill behind the house and built a fancy hotel there, passers-by from Korea and Israel and Japan and Australia hiked past with their eyes straight ahead on the sprawling white peaks, rarely looking down to notice Aamaa and Didi and Bishnu there in the sunny yard, drying grain.

The likelihood that I would wander through the door one day has always seemed both insane and inevitable.  And over the last fifteen years, I’ve mostly thought of my life opposite Bishnu’s.  We were the two girls born at the polar ends of the universe, the ones who looked at each other and thought, what if I were her?  She’s been in the U.S. for eight and a half years now, while I spend significantly more time in Nepal than she does.

Aamaa was always more like the soil: everywhere, earthy, constant, essential.  She has all the nutrients and produces all the food and water and shelter.  Aamaa keeps the house alive, the field and gardens fertile from cycle to cycle, the fire crackling.  No matter how many people show up, Aamaa feeds us all. And no matter how many people go away, no matter how empty this house gets or how many of her birthdays pass, she keeps the water jugs full and the seeds sorted in dusty bottles. Aamaa has spent five decades in this village.

I had no idea Bishnu had applied for Aamaa to get a tourist visa to the U.S. to see Bishnu graduate from her Master’s program in information technology. Nobody told me that Prem and Didi took Aamaa to Kathmandu for the very first time last May to go to the U.S. Embassy, or that on the way there, Aamaa didn’t eat any cooked food because she couldn’t be sure who had prepared it. A few weeks later, I answered my cell phone in the parking lot at Walmart, and Bishnu announced that Aamaa had been given a five-year multiple entry tourist visa to America.

“What?” I said.

“For my graduation!” Bishnu explained ecstatically. She hasn’t seen her mom since 2013.

This explanation failed to explain all the questions I couldn’t think of.  Obviously the idea of having Aamaa make this trip has floated through my brain millions of times, but it was the ultimate what if ever.  The craziest version of everything.  Part of me thought that maybe this was all kind of a whim – a thing that might happen next year, or something. But Aamaa had sold the buffalo within a week.

On my way to Nepal in June, I tried to imagine having Aamaa with me on the way back. First I tried to digest the most obvious and superficial matters. For example, how would I explain the enormous statue of a teddy bear bent over with an apparent stomachache dramatically bottom lit in the Doha airport?

I can’t even explain that to you.

When I arrived in Kaski, everybody’s greetings had adjusted to the most up-to-the-minute state of affairs. “Laura! You’re here! How long are you staying? So, you’re taking Aamaa back with you, eh?”

Only Aamaa and I seemed cautious and uncertain with our excitement. The whole thing is so surreal that even the discussion feels like an entirely new and foreign continent. For fifteen years Aamaa and I have had what is now a very well established routine: I come to Kaskikot, we eat together in the kitchen, we go plant things with neighbors and churn milk and carry water from the tap, I fix up some things that need fixing in the house, we gossip about family here in Nepal and all the far away people not in Nepal. Aamaa knows them all – my whole extended family and a good number of my friends who have been to visit – largely through stories. But she’s the stable point, not just for us, but for herself also.

“So we’re going to America, huh?” Aamaa says as we are sitting on the porch, as if testing out the statement.

“Sure seems like it, right?”

We stare out at the tall curly corn stalks, crowding out the grassy millet that’s planted between them.

“What is the name of your District?”

“Pascal, do you know how many states there are in the U.S.?” I ask, and he doesn’t know, so I explain again about Virginia and Maryland and Connecticut and North Carolina.

We discuss departure dates because I have to change plane tickets that currently have me going home from Cambodia, where I’m visiting Bethy in August; Amaa knows Dr. Bethy, because she’s been here too. We mull over how long Aamaa’s trip to America should be. A month would probably be good – she might be bored after a month?

“I’ll go after cutting down the corn, and I’ll come back to cut down the millet,” Aamaa suggests with sudden firmness.

That seems good, I agree.  That is more orderly – maybe because we can see the corn.

Long silences. What, exactly, should we should be planning?

“Bishnu suggested I should get some kurta salwaars made,” Aamaa says. “I guess you aren’t really allowed to wear a sari in the U.S.”

“You’re allowed Aamaa. But a kurta salwaar might be more comfortable.”

“Ok we’ll plan a day to do that in Pokhara,” Aamaa states. “I guess we have to leave time to have it stitched and everything, right? We should go soon.”

“It only takes a couple days, but we can go soon.”

“Nah, you should just pick something out and I’ll meet you at the tailor,” Aamaa adjusts. “I don’t know anything about picking fabric.” Honestly, in sixty years, Aamaa has never walked in to one of Nepal’s fabric shops and picked out material for an outfit, which is how literally everybody in Nepal gets their clothes.

“No no no,” I insist, “I think you should definitely get to do the fabric choosing. Pick your own color, something you like.” I have to talk her in to it.

A few weeks later Aamaa takes the bus to Pokhara and waits for Pascal and I to come meet her at a chautara in Chiple Dunga. She can find her way to Didi’s house, but for the most part she prefers assistance to get around the city. Between the three of us, Pascal is the only one who can properly read in Nepali. We set off up the road to go to the fabric shop.

Laura chiama, let’s have some ice cream,” Pascal suggests wisely, because I am the sucker who will pretty reliably buy us all ice cream. As we pay, Aamaa has sat down on the low wall at the foot of the store, which is not a seating area, and Pascal and I go with it. I hand Aamaa her first ice cream cone.

“Do I eat this bottom part, the biscuit?” Aamaa asks.

“Yes, but don’t eat the paper,” Pascal instructs.

“I’m not going to eat the paper,” Aamaa says.

I can’t even remotely transpose any of this to Connecticut. I ask a passer-by to take our picture, and as you can imagine, she looks at the three of us – the Aamaa who has very obviously just beamed in from the village, the entirely incongruous American, and this regular Nepali boy being raised in the city – and gets a huge grin as she takes our picture. What could our story possibly be?

We set off again. Aamaa has brought along a broken umbrella from the house. “Laura, where’s a place that we can fix this umbrella?” she asks. I blink, there must be an answer to that, but I’ve never thought about an umbrella-fixing place.

“We should probably just replace it,” I say, feeling guilty for my wastefulness and mental laziness. I don’t have the energy to try to figure out where the umbrella fixer might be and there’s really no excuse for it.

As we wander to the center of town I’m distracted and disoriented because everything is inside out. When I first came here I couldn’t say a word or do a single thing for myself, and in Kaski, Aamaa runs everything.  We get a few kilometers off her turf and suddenly she is the foreigner and I’m the one who knows what we’re doing. She has also brought with her a heavy bag of cucumbers and other items for Didi and Bhinaju and the boys, and she’s carrying it on her shoulder, the way people do in the village where nothing is flat.  Pascal is twelve and he goes sprinting out in to traffic as we cross the street and I pay him no heed whatsoever because I’m dodging people to keep eye on Aamaa, having no calibration for how much I do or don’t need to hover over her in traffic. We probably haven’t walked through the city together more than two or three times in a decade and a half, and never just us – not once.

We arrive at the fabric shop.

There are hundreds of colors and textures of cloth to choose from. Aamaa looks hopeful that I will take over. As a young man begins removing options from the shelf she bends over them. He throws one on top of another and another and another and another. Her hands settle on a jubilant orange outfit.

“I like this one,” she suggests. She looks at me as though asking if that one is a good one to like.

Within ten minutes, Aamaa and Pascal and I are pawing through dozens of kurta salwaars, trading opinions on what Aamaa should wear in America. She picks two, and we take them to the tailor, who takes out his tape measure. He’s going to make something just for her, in her size and shape, to wear between the corn and the millet.

“I think you should do short sleeves,” I say. “Definitely short sleeves.”

“I don’t know – I think they should be a bit longer. To the elbow,” Aamaa says. The tailor agrees – maybe longer sleeves for an Aamaa. No way, I say, short sleeves look best on a kurta and it will still be hot in September. Aamaa studies her arms for a minute, apparently imagining them in a very standard piece of clothing she’s never had.

“Yeah. That’s how I want them,” she concludes. “To the elbow.”

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Hittin’ the Big Stage

The chain of events that led to the UCSF Global Oral Health Symposium included, somewhere in the middle, a very serendipitous conversation about baskets.  But let’s start at the beginning.

Two years ago, when our work was going through a big transition and I was trying to identify exactly what it was about in the long-term, I happened to meet Tula Ram Sijali. He leads a research organization based in Pokhara and was a trove of knowledge about the broader health care system in Nepal, including well beyond our focus area of oral health. When we changed our name to Jevaia Foundation shortly afterwards, I asked Tula Ram to join an informal advisory group.

A few months later, Tula Ram introduced me to his boss, Michael, who was in Pokhara overseeing a project. We’d been hearing about Michael for about a year: he was a public health researcher at Berkeley who was the principal investigator on a few studies in Nepal. At the time, I was pulling my hair out trying to set up a research partnership with a university. So when Tula Ram brought Michael to our office on one of Michael’s visits to town, Aamod and I prepared ourselves to meet a bigwig academic from the prestigious halls of Berkeley. Michael turned up wearing sandals, easygoing and friendly, and sat on the roof drinking tea with us and talking about how much we all love Nepal.

We told Michael about our work in oral health (ok fine, I gave him a thinly clad pitch for Berkeley to start doing research on oral health in Nepal) and Michael told us that he waslaunching a new project.  He’d been shocked to see women in rural Nepal carrying heavy loads twice their own size, slung from their heads by ropes, and wanted to study the impact of this on their bodies.  But seriously, had I seen this? It looked brutal! Michael had already purchased a basket and rope and brought it back to an ergonomics lab at Berkeley.

Listen, I said, you really need to know me.

Also, if there’s a basket study happening, I need it in my life.

As you can see, we hit it off quite well.

When Michael got back to Berkeley, he introduced me by email to the head of Global Oral Health Programs at UCSF. Who turned out to be…my classmate Ben Chaffee from Williams College. Now he’s Dr. Ben Chaffee and he introduced me to Dr. Karen Sokal in the Joint Medical Program at UCSF and Berkeley, and Karen was responsible for organizing our university research collaboration last winter. The rest is history.

Mean time, to return to the punch line of this story, Dr. Chaffee invited me to be a keynote speaker at UCSF’s annual oral health symposium in March. This year’s theme was to be “global perspectives on the health care delivery team.” I would be the second of two keynote speakers.  The first was by Dr. David Nash, who I’d heard of and met the evening before the event.  He’s a congenial doctor from Kentucky working to advance the role of dental therapists in the U.S., a comparable effort to what we are doing in Nepal, although our version takes some decidedly unconventional turns.

All of this brings me to the podium in front of over a hundred academics at one of the best medical schools in the country, barely a year after Tula Ram introduced us to Michael, and just two short years after I was feeling rather lost about our long-term goals.

I spent weeks preparing my talk, but I also understood there was only one presentation I could give. As soon as Dr. Chaffee invited me to present, I said so. Mainstream professionals don’t always warm up to our work because it challenges established definitions of expertise and seeks to reorganize institutions that many people are invested in. Put simply: if you spent eight years going to dental school and getting a PhD, you might not clap your hands at the idea of community health workers in rural Nepal taking a two week training and then opening dental clinics. And I can understand why.  However, that’s also the only thing I can talk about.

There’s also the reality that the Academy, like other structures central to the development of medical systems, is oriented around various credentials that I don’t have. While the other speakers were medical professionals and researchers, I have a Master of Fine Arts in creative writing. I can really only claim to be a storyteller.  But Dr. Chaffee assured me that it would be a welcoming, progressive audience, and of course it was a huge honor to be invited. So off I went.

Most of the time, being a little bit of a weirdo outsider is basically just awkward. But every once and a while, it’s completely exhilarating. The response to my presentation, Rural Oral Health Care in Nepal: A Rights-Based Approach, was, from my point of view, comparable to arriving at a party wearing stilts and discovering that everyone had been, without entirely realizing it, just hoping somebody would show up on stilts. The talk can be viewed here beginning at 54:30. I barely had time to eat a strawberry at the reception because so many people wanted to ask me questions. I was invited to co-lead a workshop called “Delivering Improvements in Oral Health in Low Resource Settings” at a conference in Delhi next October.

But it was also so much fun. There were the photographs of our technicians, team leaders, teachers, and the kids in our school programs, a collection of images I’ve essentially memorized, projected on a large screen before a brand new audience.  As I said in my discussion, these are communities that do not get a voice in the ivory tower. What I realized was that it was the perfect moment to be a storyteller. To be able to talk about something that you do partly because you think it’s a good idea, but mostly because you love the people.  Anyone can disagree with a thing, but how can anyone disagree with people?  I saw how much eagerness there is for something surprising, human, and manifest.  I felt like what I had to say was not tolerated but welcomed.  Maybe that shouldn’t have felt as odd as it did.  But I’ve spent so many years plugging away in Nepal that it was a bit of a shock to watch the story unfold here in California, and realize how…much of it there is.  I think I was the most surprised person there.

And at the same time, I guess wasn’t.

I also got to reunite with Michael, who provided an update on the evolving basket-carrying study.  Dr. Karen and many of the students from last winter attended the symposium, and Bethy was in town for a conference that began the next day. She and Karen and I had coffee together after the talk, and then I lay on a bench in the sun, collecting my thoughts. My heart filled with gratitude.  I had the feeling that over a decade of work had come lightly to rest on a bench under the sunny San Francisco sky, and for just a second, this whole journey made sense. There have been so many false starts, disappointments, rejections and failures.  Here was one of those rare instances of rest.  We’d landed on something.

Then, I got up to wander the city for a few hours.  You can’t just sit there, or the magic evaporates.  Besides, it was a lovely afternoon, and surely there were gems on the sidewalks.

*

 

Over the Mountain and Up to the Clinic

 

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 camp-layout-2high-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 img_4484Health 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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Welcome Research Teams!

 

The troops have descended.  I woke up and headed down to the pair of hotels that are housing our mob.  One one side of the street is a group of twelve people from UC Berkley, UCSF, UConn and UP in Cambodia.  The group includes three dentists, a pediatrician, and a gaggle of dental and undergrad students.  Across the road is almost our entire JOHC field staff: 6 technicians, 5 clinic assistants, and 5 team leaders covering nine villages.  I stopped in both hotels to make sure breakfast was happening and then went down to our training hall about 10 minutes before we were scheduled to start.  Naturally, I found that the hotel staff had just begun to clean the hall, and that this process involved spraying copious amounts of air freshner in to a room with large, closed windows.  I requested a halt to the air fresher and opened the windows, which looked pleasantly out over the lake.

It was crazy watching everyone filter in to the training hall.  I know all our technicians pretty well, but the team leaders and clinic assistants I don’t see often besides in photos.  I’m only in Nepal for 4-8 weeks at a time and there’s no way to get to every site during every visit, so sometimes I won’t see field teams for over a year.  And the technicians collaborate with each other at big school programs, but the rest of the field teams don’t get many chances to see each other after their initial training, and even then, usually only in the cohorts they started with.  Then, on the other side of the equation, I’ve spent a lot of time on email and skype with all the people from the universities, but the only person I’d met in person Dr. Keri from UConn.  Now here was everybody, all together, in a very air-freshened room, sitting down in actual chairs.

We immediately encountered a projector obstacle.  Namely, the projector was not working.  Dr. Karen got everyone occupied with an introductory activity while I frantically tried to deal with the projector, which eventually led to a hotel guy running down the street with admirable good-will (he might have been fleeing from the crazy American going WHY? WHY ISNT IT WORKING WHYYYYY?) to have someone swap out a cable, while 40 people were distracted on a scavenger hunt looking for other people who had never had a cavity or who inappropriately eat sweets for breakfast.

The projector obstacle went through a number of other iterations that I’ll skip; eventually, it worked.  Aamod and I gave a presentation on our JOHC model and human-rights health care for the visiting research teams.  It was really fun to see our field staff get excited when photos of their clinics or programs came up on the screen.  Then Madhurima and Karen presented on the relationship between nutrition and oral health, which was super interesting and will make great material for our teams to incorporate in to their school education programs.

After lunch we split in to two groups.  Our team leaders went with Madhurima and Dr. Karen to learn how to conduct surveys tomorrow.  I am pretty sure from the one photo I took and the minute I spent watching that this involved a lot of everyone trying to figure out what everyone else was saying, which I’m sure will work out just fine.  They’ll be assisting the UCal group with a study of oral health practices and nutrition, and we set up some of the screenings in Puranchaur where we operate, and then in one of our non-working areas, Hansapur, to see if there are any differences between these two areas in oral health knowledge or practices.

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While that was going on, our technicians and clinic assistants had an amazing training with Dr. Keri, a pediatric dentist at UConn, and Dr. Bethy from New Zealand, who is doing her PhD in Cambodia.  They had an in-depth orientation on pain diagnosis, and then learned techniques for fluoride varnish and silver diamine fluoride, a substance which is used to arrest carries with no invasive techniques or anesthetic.  During the upcoming screenings this week, our technicians will begin using these techniques under supervision, in addition to the fillings and extractions they already do.

So while this was all happening, we encountered a fleece jacket situation.  I realize you feel that there are many reasons to believe we had overcome all components of the fleece jacket situation.  I understand how you feel.  I really do.

But by late afternoon, we still had no jackets.  Also, obviously, there was a random shutdown of travel in the middle of the day in one part of the city, so the Man In Charge of the Fleece Jackets couldn’t get to his printing factory.  Because, these things happen.  They really do.

Therefore, I kept leaving the pain diagnosis training to make calls about fleece jackets.  Finally Muna looked at me and declared, “We will get the fleece jackets.”

Me: “But–”

Muna: “Go upstairs.”

Me: “By–”

Muna: “We will get them.”

Oh Muna, bless your heart.  Back to pain diagnosis.

Muna and Gaurab got the jackets, using the magic and unknown powers of being not me.

Five PM.  Photo op!  Selfies.  Also staff hug.  We survived training day!


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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!!