Tag Archives: rural dentistry

Around Town, Nepal Life, Oral Health Care Project, Work

A Piece of Christmas Cake

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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.

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Oral Health Care Project, Work

Apps and Bears: Summer CPD

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Welcome to…da da da…Summer Professional Development!

Bethy is here and we are off on our summer training. Since 2016 we’ve been able to do this every six months, each time covering a different topic of relevance to primary oral health care in a rural Nepal environment. Our past CPDs have covered things like infection control, treatment of older adults, school-based oral health care, treatment planning, and first aid.

This time we’re covering three topics during the week: data entry in the new-and-improved DentalHub app; using Silver Diamine Fluoride for prevention (usually we use this to treat already-decayed teeth); and complications that can occur with extraction. 

I could jump in to the technical details of the week, but I think you’ll have more fun with the photos. It is such a blast to get everyone together and enjoy the way the Jevaia family has expanded and professionalized. Our week included 3.5 classroom days and 3 days of fieldwork. The field setting has become an organized, smoothly run environment that is undramatic and pleasant to be in. On the last day, four technicians stayed late to do their “viva” session, or a live question-and-answer interview that’s done annually for our competency certification. It was such a pleasure to see how engaged everyone was with this chance to be in a live testing (and learning) environment with a community dentistry expert.

And with that…I bring you Jevaia Summer CPD, 2019!

 

Nepal Life, Oral Health Care Project, Work

Mothers Just Up the Road

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Our most recent clinic launched in the village of Deurali, where Hira runs a clinic at the Health Post every Wednesday. We were in Deurali a few weeks ago for a supervisory visit–or more specifically, a veteran technician K.P. was visiting Hira for mentor supervision, Rajendra our medical coordinator was supervising K.P.’s supervision, and I was there to see Rajendra supervising K.P. supervising Hira. So as you can see we’re doing our best to address any issues around lack of supervision and monitoring for primary care operators in rural Health Posts.

Hira’s been doing awesome in her clinic and already has a week of post-certification professional development under her belt, but we’re still working on building the patient flow in Deurali. This is no surprise; everywhere in the world, people are slow to seek dental care, especially for preventative and early-stage treatment. Rural Nepal is no different, and Health Post dental clinics don’t get much traffic unless paired with strong outreach and a referral system. We’re still getting rolling in Deurali, and this month the local Team Leader, Prashanna, organized an outreach gathering for a local Mother’s Group where his wife is an active member.

We piled in to a car at the office and arrived in Deurali mid-morning, having looped through the neighboring village of Rupakot to pick up Kamala, a talented clinic assistant who works in the Rupakot dental clinic and came to assist Hira for the day. Hira packed up a field kit from the Health Post, and we unloaded the supplies a short walk up the road at the Mother’s Group community building. This building was damaged in the 2015 earthquake, so we found ourselves in a completely normal half of a building with half a roof. The other half was open to both sky and the sweep of surrounding hills, not to mention that the road had recently been bulldozed and taken a chunk of the hillside with it, so the concrete floor dropped off precipitously, in mid-air, creating the effect of a film set on the edge of a cliff.

Behind the half-building, people began setting up a plastic chairs and stringing up a tarp for shade. Because it was the first adult outreach program in Deurali, our two education coordinators Bidhya and Shreedhar had come from the office to lead the workshop and model it for the local team leader Prashanna, who will soon become Deurali’s master of ceremonies for such events. Bidhya and Shreedhar are also new to our team, so this was their first adult outreach too, and they’d spent a good deal of time going through our teaching protocols and creating clever new materials to use. Hira and Kamala set up the treatment area to provide free screening, limited treatments of fluoride varnish and silver diamine fluoride, and referral tickets to the regular Wednesday clinic up the road.

People began to trickle in, take their seats, and chat. When the chairs were full, Prachanna and the primary health worker from the Health Post kicked off the morning. Then they handed the session off to Bidhya and Shreedhar, who inaugurated their roles on our team by doing a phenomenal job by engaging the crowd in an animated discussion. They covered everything from oral hygiene to junk-food-free schools to explanations of Hira’s available services in the Health Post.

I really love this example of Bidhya working what’s called “people-centeredness.” People-centeredness actually specific a term used by the World Health Organization as part of its quality-of-care framework. But what does it mean in practice? Health care that is attuned to lived experiences, that is easy to relate to, that is compatible with the physical and cultural environment. People may not leap out of bed to go get dental care, but they often have no problem talking at length about their teeth and the stories inside of them. What I saw watching Bidhya and Shreedhar work the crowd was not a lecture, but a dialogue not so different from the way that Aamaa and I sit around with Saraswoti and Saano Didi and Maya Bouju in the evenings, cataloguing the day and comparing notes about the world. There is a wealth of available wisdom already present in any community.

After the presentation, people waited as long as four hours for a screening in the half-of-a-community building. There was a 104 year old man, a woman with a difficult home life that made it challenging to arrange an initial screening at the Health Post, and a series of patients perfectly timed for interventions recently covered in our Professional Development Seminar on Aging. Watching as residents passed the time in plastic chairs, waiting their turn and talking about their teeth and other life topics, I pondered the fact that the Health Post, which offers the exact same services plus more, with the exact same provider, every week and ten minutes up the road, has struggled with patient flow. But the plastic chairs under the tarp was people-centered.

Hira screened about sixty residents before the wind picked up and began blowing rain in to the wallless clinic space. Before we repacked everything, she gave out forty referral tickets and delivered a swath of preventive fluoride treatments. I think she’ll keep busy in her clinic the next few weeks!

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Kaskikot, Kaskikot, Nepal Life, Oral Health Care Project, Work

Aging

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The second half of our winter professional development is focused on treatment of older adults. Even though a lot of treatment that dental technicians do is in schools, during the weekly dental clinic at the Health Post, they mostly get adult patients. And since most rural adults have had little or no dental care, and likely weren’t exposed to fluoride toothpastes or other preventative measures for their first few decades of life, some of the conditions that present in our rural clinics are pretty extreme. Besides that, tooth loss in older age is common enough that it’s more or less expected.

Of course, our technicians can refer older patients to higher care, and they do. But following up on referrals isn’t always that easy, especially for older folks with reduced mobility. Not to mention that rehabilitation of many mouths we see in elderly patients would require months of ongoing, expensive, complex treatment even in a state-of-the-art dental hospital–something that’s simply is not feasible for the majority population even in a first-world city. So here we are in rural Nepal working in primary care, which is about disease prevention and improving quality of life. But save for the occasional extraction, older adults are mostly left out of the process when it comes to primary oral health care: directly related to the ability to eat, sleep, and participate socially. If we can relieve pain and preserve teeth longer, that seems like a solid contribution.

With this in mind, we wanted to develop a professional development workshop on how the simple techniques that we’re already using – glass ionomer, silver diamine fluoride – can be used to help relieve the diseases experienced in older populations in Nepal. By “we” I mean Bethy since she’s the one obviously who did this because I write stories about teeth and she is a public health dentist. And even if you’re not a dentist or especially interested in cariology, I have to say that how this turned out is really pretty cool.

A few years ago, Bethy and Keri took photos of about 65 people who’d had restorations done in our clinics, and we used these as the basis for a quality-of-care assessment. It resulted in a few different things. One was adding some missing instruments. Another was noticing an apparent pattern among older adults where, around middle adulthood, adult teeth begin to wear rather than decay. It might be caused by anything from an acidic diet, to abrasive brushing with spices, to a lifestyle change like a new medication. The lower part of the tooth near the gums wears down and become loose, causing sensitivity and difficulty eating, and gradually, the teeth simply fall out. These are the adults who, right now, are getting no care at all besides the occasional extraction.  They were the focus of our training.

Our technicians practiced placing glass ionomer restorations on the root-surface lesions, near the gums, that so often lead to tooth loss in older adults. Bethy explained how an event in the life of a middle-aged adult, such as an illness, can cause a simple change like dry mouth that alters the whole environment and leads to deterioration of a previously resilient set of teeth over the next period of years.

I loved this workshop. For the first two hours, instead of looking at teeth, Bethy brought in pictures of older people and the clinical teams simply talked about aging. What makes people old? Are all old people the same? Do they have the same priorities and daily demands and ideas of self? What do we assume when we see someone who we think is “old”? How does a person’s identity factor in to how we work with them to improve their lives? What is our responsibility to someone’s dignity?

In preparing for the workshop, Bethy and I mined our respective photo archives for pictures of elderly people in Nepal and Cambodia. One by one their faces stared out at our group of clinicians, suddenly daring: Who do you think I am?

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In the beginning, most participants had a sort of default position that older people are weaker and less capable of handling dental treatment. But as we went through the photos for well over an hour, stories blossomed. In some cases, they were people whose backgrounds we knew- my neighbors in Kaskikot, steely women I’d photographed during our work after the earthquake in 2015, caretakers and weavers and shopkeepers who’d given interviews in Bethy’s surveys in Cambodia. Bethy used a clever framework called “Go-go, go-slow, no-go” to talk about what each of these people might be expecting or hoping for from a medical professional. I got to laugh about how Hadjur Aamaa has basically no teeth left and gets around pretty slow, but she’ll put one foot in front of the other to get to the house and then frets the entire day, every day, about the dishes or the peas that need to be shelled; it is absolutely vital to her human essence to be busy with something useful. By the end, our clinical teams were musing over what their patients might be thinking about, who they depended on, and who relied on them, what made them human and alive in the world. This was probably a go-slow patient, like Hadjur Aamaa; this one likely a go-go patient ready to sit there all day and get her teeth fixed; this patient probably wasn’t really about treatment, and mainly needed to have his discomfort acknowledged.

The next day, we returned to the same school in Kaskikot to treat patients age 45 and over. (We’re in rural Nepal, 45 is approaching the pre-elderly group…60 is safely considered “aged” and the point is to catch people BEFORE their teeth are gone.) It was exciting to see the same situations we’d learned about the previous day in the real lives of real people and to be able to offer simple treatments that have the potential to forestall tooth loss for years. The teams continued using the App, entering patient data digitally along side the paper forms.

While patients were waiting outside, the father in law of our local Channeler came by for a checkup. I’ve been to see our Channeler a few times – she lives down near Laushidunga, in the direction of Sada Shiva where I taught primary school for a year.  The story that’s told about the Channeler is that she suffered terribly from a kind of delirium for a period of time. She was treated in a hospital, but nothing helped. Then she began to channel spirits. She rebalanced. People travel from all over to see her; I’ve brought a handful of visitors there to connect with people they’ve lost.  Before Bishnu left for the U.S. in 2008, she went to see the Channeler to connect with her father. The Channeler’s husband has a bum knee, and once I gave him my knee brace from CVS, and he always greets me with an old familiarity when we meet in the road up in Deurali.

Anyway, at some point in the afternoon I couldn’t find our technician K.P., and I walked outside to find he was having his palm read in the waiting area. The Channeler’s father in law spent about an hour reading almost everyone’s palm for fifty rupees each. Everyone–our office staff, the field teams, the schoolteachers and other patients–exclaimed over the things he knew: who’s father had died young, who was still to be married, who was destined to successfully stay with one line of work for a long time (one of our clinic assistants! yay!). I didn’t get a turn because by the time I was ready – I’d had my 50 rupees in my pocket for like an hour – he’d had enough with palm reading. Palm reading was over.

Still, my most favorite patient of the day was a 93 year old woman who arrived alone. She was frail, used a walking stick, and barely spoke to anyone even to ask them to move out of the way as she plodded through clusters of people like Moses parting the sea. She wore a jaunty white knit cap that stuck up boisterously on her head. Her entire mouth was completely empty except for one jutting molar with an expanse of exposed root.

“How can we help you?” Hira, the Deurali technician, asked.

“This tooth hurts,” the woman said simply.

 

Hira treated the one tooth with silver diamine fluoride, a completely painless procedure that will hopefully preserve it a while longer and ease her suffering. Then the woman stood up, picked up her walking stick, parted the seas and went home without a word.

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Oral Health Care Project, Work

The App Frontier

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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. 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 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 striving for a medical technology to help to diagnose disease, we designed our App 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 evaluate aggregate data and identify specific needs in different area.  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 clinical teams to practice entering on the tablets, which were themselves acquired in a great feat of shopping conquery. As is becoming our usual training format, first technicians 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 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 field coordinators, about re-launching the school brushing program and creating a 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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Oral Health Care Project, Work

Gaurab the Bear

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Recently, Bethy was in Thailand and discovered that someone there has been making teddy bears with a full set of teeth.

In my life, this is a very interesting and exciting finding.

Bethy decided to order some teddy bears with teeth for health centers in Cambodia that are running an early childhood hood oral health program, and I figured I would bring a teddy bear over to Nepal. It was fairly simple. In brainstorming the idea, we got to thinking about the enormous contribution that Jevaia’s Education Field Officer Gaurab has made in our organization, beginning long before we had a name. Gaurab was our first Clinic Assistant in our first clinic in Kaskikot. He volunteered for years as a teenager in school seminars, teaching kids about about oral health. He became one of our field officers in 2015 and has walked literally countless miles, up and down hills, in the rain, after dark, and in just about every crazy situation possible to promote oral health in schools in Nepal.

We decided our first teddy bear with teeth should obviously be named Gaurab.

When I arrived recently in Cambodia, Gaurab the Bear had completed the first leg of his journey, from Thailand to Cambodia. He came with frens.

We were so excited to meet him!

We hung out in Cambodia for a while, and then Gaurab’s frens said goodbye

And we left for the airport.

We took a tuk tuk.

Gaurab seemed to like the airport

and he really blended in with all the other travelers.

Especially while waiting for his flight.

He settled in, clutching his ticket to Kathmandu

And we enjoyed perusing very expensive jewelry that isn’t really less expensive even though it’s Duty Free, in Kuala Lumpur.

Honestly we were pretty tired by the time we finally arrived in Kathmandu and Gaurab tried to be patient with the visa process but he was ready for a nap.

The next day, refreshed for our flight to Pokhara, we made some NEW Frens in the airport!

You can imagine Gaurab’s anticipation on the flight west…

And finally, upon arrival we were greeted by some real big fans.

Finally, after meeting the rest of the team, Muna and Rajendra,

 

 

 

 

 

 

 

Gaurab was united in the office with Gaurab!

Welcome to Nepal Gaurab!!

Kaskikot, Nepal Life, Oral Health Care Project, Work

Professional Ceiling Clouds

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For the year and a half, we’ve been extremely lucky to be able to provide bi-annual professional development for our dental technicians and clinic assistants.  It has quickly become one of my favorite parts of our project.  Jevaia dental clinics deliver the Basic Package of Oral Care, a collection of dental procedures that was designed in collaboration with the World Health Organization for limited-resources settings.  The BPOC was developed by Europeans, and it has mostly been used in developing world settings as aid or transient care.

Since we train local dental technicians to provide the BPOC in Health Posts instead of temporary camps or outreach programs, we’ve had the chance think about applying it as a sustained primary health care strategy–especially since we started working with Berkeley, Dr. Bethy and Dr. Keri and other collaborators in 2016.  I suppose that kind of thinking is one difference between aid, or any kind of temporary relief, and human rights, which entitles people to a consistent standard of health care.

Our past three professional development workshops have focused on the use of Silver Diamine Fluoride; infection control tailored to rural Health Posts; and treatment planning (one thing about a stable primary care provider is: they can actually plan!).  This summer, Dr. Bethy is teaching our professional development on school-based treatment planning, so we can shift to a more systematic school-based oral health care model with local dental technicians.

Dental technicians in JOHC already conduct monthly school seminars to do school-based screening and treatment for children and parents.  We call these “seminars” rather than “camps” because they are run by a local provider and they help connect people with the Health Post dental clinic. Unlike most “camps,” seminars don’t aim to treat as many teeth as possible in the shortest time, but to build relationships with the technician and raise public support for a government dental clinic and community outreach programs.

Our 2018 summer professional development was seven days long for veteran technicians and ten days for new technicians. It kicked of with technicians and assistants examining photos of real ART fillings (like the kind they do) organizing them in to acceptable and unacceptable outcomes. Then the clinicians had to use the photos to diagnose why the unacceptable treatments had partly or fully failed, which lead to a review of practice technique. It was really gratifying to see how this impacted everyone’s thinking a few days later, when we were back in a school placing fillings.

Since the BPOC was originally conceptualized as crisis management, a challenge of our project establishing a quality of care standard in a stable primary care setting. At this year’s workshop Bethy helped introduce a competency framework.  During the three days of classroom work, our new technicians supervised old technicians in a “simulation seminar” where they had to demonstrate each technique using the competency checklist.  When we moved to the three-day school setting with live patients, new technicians were supervised through ten of each procedure and had to pass the competency checklist ten times.  Veteran technicians performed one of each technique under a doctor’s supervision and we used the completed checklists to award “competency certifications” that are valid for 18 months.  We even created a framework for technicians to review their competency certification every 1-2 years.

 

 

 

 

 

 

 

Overall, the workshop was meant to guide our clinical teams toward a more rigorously informed, holistic approach to school-based health care, where JOHC technicians work as members of the primary care system rather than visitors. The training emphasized taking time to slow down and connect with patients rather than blowing through a line at the door.  Dentistry can be scary and rather than jumping straight at a kid’s teeth, the intake leaves time to comfort frightened children and to learn about their lifestyle habits and disease risk factors. In turn that information is used to provide more complete and well-informed care, instead of just treating as many teeth as possible. It seems obvious, especially for primary care practice, but in reality that’s not usually how dentistry is done in our setting (or often, in general, if we’re being honest). As part of this, the clinical teams spent a good amount of time reviewing cariology (the biology of oral disease) which unlike the practicalities of how to mix cement and apply it properly, informs which techniques should be used when.  In other words, without adding in more high-technology interventions, we are focusing on more effective deployment of the conventional BPOC.

For me as a non-clinician, it’s super interesting to see how these minimally-invasive techniques can be used not only for emergency management of foregone problems, but for early intervention and prevention of disease in the whole child.  In all children, actually.  This same package of care can be used in service to population level public health needs where resources are a practical limitation, and yet there has been little focus on applying it that way. My dream is that one day it will be rural technicians and assistants presenting to academics at conferences on how they’ve adapted and improved these innovations to benefit their communities in the real world.

An incredible thing happened on the third day of our practice seminar in Kaskikot.  The school we chose is next door to the Health Post.  The third day was reserved for parents so that technicians could apply the training concepts to adult patients.  I was waiting out in the stairwell when suddenly I saw a face I could never forget: Nisha, one of the students I taught for a year at Sada Shiva Primary when she was in fourth grade, a million years ago.  It was with Nisha and her classmates that Govinda dai and I ran our first ever school oral health program back in 2004.  At the end of that day, we took a photo of all of us in front of the Kaskikot Health Post, which at that time was just one simple building that today is fully dedicated to our Dental Clinic.  Nisha had come to our seminar because her daughter is a student at the school where we were running the training in 2018–with five dental technicians, seven assistants, and an international expert in public health dentistry as trainer.

 

 

 

 

 

 

Finally, the icing on our professional development cake was a world-class makeover for the Kaskikot Clinic.  My friend Maelle who lives in Pokhara started an organization called We Art One that paints murals and does art programs in schools.  We asked We Art One to turn our Kaskikot Dental Clinic in to something bright and welcoming.  They took it next level, putting this exuberant mural on the outside and literally building a ceiling mobile inside for patients to gaze at while lying in the chair. It’s made from hand-cut wooden clouds that Maelle painted.

I know not every rural Health Post in the world can have clouds and rainbows hanging from the ceiling.  But I think they all should and I think we should try. The only reason we need is that every patient in the world is a person.  Those of us with choices would never choose health care in an unfriendly, cold or unwelcoming environment, especially for medical treatment that can be scary like dentistry. I don’t know why we seem to believe in some kind of false economy that suggests it’s not realistic to afford that dignity to everyone.  This beautiful artwork was not expensive or difficult; it was just a decision.  It mattered more than doing something else for some other purpose.

So that was our summer.  Two new clinics and nine veterans are open for business, if anyone out there needs an appointment!  Come visit us soon!

2004:

2018:

 

 

 

 

 

 

 

Kaskikot, Oral Health Care Project

Confidence Under Construction

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For about a year now, the Government of Nepal has been undergoing a decentralization of power. The country has been divided in to five provinces and outfitted with new government employees at the state level. It’s an exciting moment for a project like ours, which is aimed at capacity building in the government health system. Right now entire tier of government in Nepal is literally undergoing construction for the first time.

In the mean time, a large number of essential items are not yet decided even as the new government is deploying its duties. The desks are purchased and people have been assigned to sit behind them – literally – but exactly what these people are responsible for and how their responsibilities are to be executed is still a work in progress. Many operational policies are still not in place, and decision-making power isn’t yet clearly defined between different levels of government. Basically, we are in a car that is being built while rolling down the highway. You’ve probably been there too, right? And I accept that many people would find this alarming.

These people, however, find it AWESOME.

This a great time to be a grassroots organization in Nepal that has been working on health care with previously less-empowered leaders in villages. Jevaia Foundation has accumulated a lot of specialized knowledge on a key primary health issue that few if any other organizations are working on in Nepal. We have policy ideas that we’ve already modeled in multiple health posts, and there are elected officials in lower levels of government with an interest in getting this model supported by the Ministry of Health. And right around the corner from us is the capital of Province #4, where policies, budgetary headings, and guidelines that will decide these matters are currently being created.

Our hope is that in coming months, we’ll be able to play a role in influencing some of the new health policy. Currently oral health care in Nepal is available almost exclusively in private practice. The ministry of health doesn’t even have a budget heading for oral health at the primary care level, and in the villages where we work, leaders have cobbled funds from other budget categories to run dental clinics in their Health Posts. In the new provincial system, we’re hoping to organize local officials and communities to demand the creation of oral health budgets from the Ministry of Health at the province level.  Cool, right?

So even though everything’s a bit weird here at the moment, a time of change and uncertainty is of course always, potentially, a time of heightened opportunity. It is certainly a million times better than an unyielding stasis, as anyone who has been in one of those surely knows.

Now let’s bring this all back down to the ground for a second, in my home village of Kaskikot, where the newly elected village leaders reopened the dental clinic we started…which had been closed for SIX YEARS. (Here’s the Washington Post story about our handover of the Kaskikot clinic in 2013.) The new Kaskikot clinic is fully integrated in to the Health Post and financed by the village government. Patients register in the main building and then take a registration ticket to the dental room. Data on patient flow and treatments provided is maintained just like all other primary care services delivered in the government Health Post. Our job is now confined to monitoring quality of care and technical support. It’s AMAZING.

In order to garner backing for this example and its variations in other villages, we’ve been hard at work over the last few weeks meeting people behind desks in the new province government, and then meeting with other people they suggest we meet with. It’s so refreshing to talk with these newly appointed officials and to brainstorm with folks outside government who, like us, have been chipping away at sticky issues for a long time and are trying to sort out what the new system means for these bigger goals. The confusion of the moment is offset by what feels to us like a sense of possibility and movement.  At the same time, it’s important that everyone carry on with a grand performance of confidence, even though nobody is sure what is going on. So, ok, we’re doing that.

For example, recently I thought to invite a couple folks we’d met up to Kaskikot to see the dental clinic one Sunday. They agreed to come. I immediately began worrying over how to make sure that they’d be there on a busy day. The Kaskikot clinic is generally seeing about 8-15 patients a day, which is getting close to full capacity…but it’s also the busy planting season, and it’s raining, and….and anyway, it would just be a bummer if we invited Important People to our clinic and there were not a lot of patients when they arrived.  Maintaining confidence under construction means pulling out all the stops.

Fortunately, the Kaskikot clinic runs on Sundays, and I spend Saturdays at home in Kaskikot. I decided to invest in some advertising. Here’s where we move this story from Important Offices to Aamaa’s Kitchen.

“We’re going to the clinic tomorrow morning,” I informed Didi and Aidan and Pascal over dinner. They were in Kaski last week for school vacation. Didi protested that she needed to leave early morning to cut grass for the buffalo because Aamaa’s leg has been sore. Also, she pointed out, What if it rains later in the day? I told her I was 100% certain that it never rains on Sundays and that, in conclusion, we were all to leave for dental exams at 9:30am sharp.

On Sunday morning I started my rounds early, at Saano Didi and Saraswoti’s houses. Nobody looked like they’d been planning on a dental checkup after breakfast. “C’mon guys, we’ll go together, it will be fun. Malika Didi is coming,” I begged. With dignity, of course. For the greater good.  Then, walking down the ridge toward Deurali, I ran in to Mahendra sauntering home.

“I need you to come to get a dental checkup today,” I said.

“A dental checkup?”

“At the health post. There are some important people coming to see it.”

“Ok Laura didi.”

“Really? You wouldn’t lie to me.”

“I wouldn’t lie to you Laura didi.”

“Hey and bring some of your friends,” I added, testing my luck. Mahendra has a posse of bros that move as a pack.

“Ok Laura didi.”

Mahendra and Saila

“Really?” It seemed suspicious.

“I’ll be there Laura didi.”

“Around 11,“ I said, and continued down the ridge.

I came to the yard of Saili Bouju, who’s married to our local shaman, Bauta Dai. Since I pass  their front yard every time I walk home from the main road, we check in pretty regularly. When I’d arrived on Friday, we had already made a plan to go to the dental clinic Sunday morning.

“Saili Bouju, we’re going for a dental checkup today, right?”

“Yes, yes Laura,” she assured me in her deep raspy voice.

“I’ll be by at 9:45,” I said. “With Malika didi.”

I continued up the walk to the the next two houses, where I made my pitch to Barat’s two sisters-in-law and their families over tea. Ambika Bouju happened to stop by as I was rinsing my teacup.

“Ambika Bouju, come for a dental checkup today.”

“Hey, I’ve been meaning to do that,” she replied, to my great happiness. “I need to take my son in.”

“Today’s the day! There are some Important People coming from Pokhara to see it. We need a crowd.”

“Ok, I’ll be there,” Ambika Bouju agreed.

Out at the main road I came upon Amadev bouju in her yard. She can’t hear very well. “Bouju, let’s go to the health post today,” I said. She smiled and nodded and said, “Sure, Laura.” She’s an overall positive person.

“Really?”

“Ok, ok,” Amadev Bouju said.

“To get your teeth checked.”

“Yep!”

I had a feeling we might not be talking about the same thing, so I hopped down in to the yard to discuss the matter at a shorter distance.  “COME TO THE HEALTH POST WITH ME TO GET A DENTAL EXAM,” I repeated.

“Oh! Dental exam? My teeth don’t hurt.”

“A checkup is important!” I proclaimed. Amadev Bouju rolled over fairly easily. She said she’d meet us at the clinic.

I made my way toward Butu bouju’s house.  Back in the day, when her daughters were younger, we used to have sleepovers and make chocolate chip pancakes over the fire.  Butu bouju was out in the yard and tried to impose more tea upon my already full-of-tea stomach. I was delighted to find out that she’d been thinking to bring her grandkids to the health post for a dental checkup at some point. “I’ll be by with Malika didi to pick you up,” I said, making sure that Didi would have no out now that I’d advertised her all over the village, and headed home.

“I’ve rounded up most of the people in Deurali,” I announced over breakfast. Didi replied that she was going to cut grass. I countered withthe importance of oral hygeine, and of my schemes, and how she loves me. And so on.

We set off mid-morning. Narayan and Amrit, who over to play with Aidan and Pascal, were rounded up and I shuttled the whole gaggle along the edge of the cornfield. They disappeared in to the tall stalks and I turned around to make sure that Didi was following close behind.

Somehow, by the time we got to Govinda Dai’s house, I was already alone again. Didi had peeled off to go retrieve Butu Bouju. Saili Bouju said she had a headache and would go another time, and only after much cajoling said that she’d meet us there in a little while, which I was pretty sure was a way of pacifying me and sending me on my way. When I passed Ambika Bouju’s house, she was nowhere to be found, and even though her daughter said she’d be up the road shortly, it seemed improbable. All four boys—Pascal, Aidan, Narayan and Amrit—had taken off ahead of me down the road while I was trying to recapture our patients, and by the time I reached Govinda’s house in Dophare they were nowhere in sight. I walked in to Govinda’s yard alone, not seven minutes after mission launch.

“Ok Dai, let’s go,” I resigned.  I’d been in this moment at least a thousand times before: everything looks static and bleak. There are no people. It is foggy or rainy or dark or something else that generally conveys that you are all alone. Well, something would work out, or it wouldn’t.

As Govinda dai readied his umbrella, I looked in the road and saw that Mahendra had appeared out of thin air, with a friend. They were carelessly posted by the side of the road, sullen and awesome as usual.

“I told you I was coming, Laura didi,” Mahendra said with casual authority. “You guys go ahead. We’ll be along.”

Near Maula, we caught up with Aidan and Narayan. “Where are Pascal and Amrit?” I asked. “THEY WENT HOME,” Aidan declared triumphantly, beaming. I sighed. Oh well. “I’m going to call your mom,” I said, and took out my phone to dial Didi, who was missing in action. “I HAVE MOMMY’S PHONE,” Aidan proclaimed ecstatically. “IF YOU CALL MOMMY IT WILL RING RIGHT HERE!”

I thought morosely that Didi and Butu Bouju most likely got to chatting and weren’t coming along.

We arrived at the Health Post in a thick fog. The previous night’s rain had left everything squishy and slick. Durga, the clinic assistant, was just getting through the morning disinfection and setup process. The technician Dipendra was nowhere to be found. It was 10:40 and our visitors where scheduled to arrive at 11.

10:50. Dipendra rolled up on his bike.

10:53. Pascal and Amrit came tumbling out of the fog through the gate to the Health Post complex. They tore across the lawn, jumped over the wall, and went back out in to the road to play by the pond until called for their exams.

10:57. Didi materialized from the fog at the gate. Behind her, Butu Bouju was walking and chatting with her grandkids, like spirits emerging out of a cloud. I blinked. There was Saili Bouju behind them.

11:10. A line of non-recruited folks had taken tickets and were awaiting appointments. The bench outside was full, not just with my neighbors, but with the natural flow of weekly patients.

11:15. Ambika Bouju arrived with her son.

11:20. Mahendra and his bros sauntered in to the yard.

11:30. Our two visitors showed up to find a full clinic with a long line of adults, children and elderly patients sitting out a roughly 40 minute wait. Inside the clinic room, Dipendra demonstrated the treatment planning form that was developed during our last professional development in December. I pointed out our infection control protocol on the wall and other features of the clinic protocol that we’ve added to the Health Post setting, like floor coverings, dress, tray numbers and documentation.

We retreated to the local government building next door to talk about our next steps at the province level. By the time we came back outside to get in a car back to Pokhara, it was about 12:00, and the line outside the clinic has grown even further.

“Saili Bouju!” I call across the lawn.

“I told you I was coming!” Saili Bouju shouted back.

*

(p.s. I have no idea what’s going on with my weird knome-hairdo in this photo)

Around Town, Nepal Life, Oral Health Care Project, Work

Politics and Poets

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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?”