Professional Ceiling Clouds

 

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:

 

 

 

 

 

 

 

The Milk Truck

We spent a very long time waiting for the milk truck to pick us up.  As part of Optional Class, I’ve found people to come up from the city and tell the kids about their jobs: a librarian, a radio jokey, and someone from the photo shop.  Today, we were headed to Pokhara to visit the places they work.

While we waited for our ride, the kids sat on the grass, leaning on each other, practicing the song that Govinda and I wrote about the solar system.  We make them sing it every day – Venus has poisonous air, there’s a big storm on Jupiter, la la – so the tune has more or less become the Optional Class Anthem.  The radio jockey had invited our students to sing the solar system song on air during our visit, and the quartet selected for that job was practicing next to a few other students who we’d chosen to read their poetry on the radio.  The early morning hour was one of quiet satisfaction for Govinda and me, watching our kids with their heads bent over the books they’ve made, feeling important.

The milk truck finally came, and we all crammed in to the back: Govinda, Laximi, and eighteen kids, and me.P1060843  The inside was a military-style canvas box with two benches and railings on the ceiling to provide handholds.  With a lurch we set off, bouncing down the dirt road toward the city.

To keep out the dust from the road, we had all the canvas flaps down over the back and side windows.  I looked around at all the little faces squashed into our sealed box, and was struck with the sudden feeling that nothing, no words or photos or documentaries, would ever be able to recreate that stuffed space.  At the end of the day, we will be exactly that: a giggling ring of faces pressed together inside our container, moving along a dirt road towards something, out into a world which sees us as if from above, tiny on the crumpled earth.  The instant reels in my mind from its birds eye view, and I look from the inside out, where we are now, and fall on the moment with a surrendering crush of love.

Because the outside is moving, moving, always crawling along the road, but the inside—the inside is still, aside from the bouncing.  With the windows covered we couldn’t see the road going by, or the place we’d come from, or where we were headed.  And when I considered that we would eventually arrive, and get out, and be outside too, I felt the weight of a universe crammed into a milk truck.  This is our now: the gravity of all the past and future collapsed into a present that will pass and forever be gone.  It seems almost impossible, amazing, to be here now.  In a milk truck, with these kids.

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Lookout point (and clouds!)

Help from Elves

A flat rock about the size of a medium pizza, I figured, would work nicely.  I arrived at Sada Shiva half an hour early carrying my stone.

Last week, we installed a water hose that is propped up on a stick where the schoolyard drops off and slopes downhill.  It’s a great setup, except that in order to use the waterspout, you have to stand on the hill, which is gradually eroding under the constant stream of water splashing out of the pipe.  I had decided to improve things by wedging a rock into the hill, so that at least one small pair of feet could find purchase on the muddy slope.

Setting my bag down outside class three, I climbed over the edge of the yard and scooted down to where I could crouch below the water spout.  Using another rock, I began chipping away at the hill.  It was peaceful in the deserted yard.

“MISS!”

I looked up to see Sunil and Hari looking down at me.

“ARE YOU BUILDING A WATER TAP?”  They always talk in capital letters.

“Yes,” I said, although it seemed generous of the boys to elevate my stone to a “tap.”  Without further discussion, Sunil and Hari disappeared.  I began chipping again.

“MISS!!”

Overhead, Sunil and Hari were leaning over the edge of the yard, holding two wide, flat rocks.

“MISS!!!”  Krishna came galloping up behind them with a third rock.

I looked down at the small stone I was using to whittle away an indent in the hill.  Things were not going according to plan.  When I looked up all three boys had left their three stones and gone off again.

“MISS!!!!” Madu and Ganga arrived. More rocks.

Five minutes later, students were coming out of the woods, like elves, by the dozens.  Their stones piled up at the edge of the yard.  I was impeached, moved aside, and replaced by Ganga and Madu, who began wedging the stones into the hillside where I had been standing.  Rita-Madam arrived and squatted at the top of the slope, looking down at us.  Her ponytail rolled around to the front of her shoulder.

Thik, thik,” she murmured.  Good, good.

More rocks marched out of the woods.  Ganga and Madu shouted up to Hari, who passed them down.  It was not eight minutes before the students had built a neat ledge where the water splatted onto a flat rock, sending up fine celebratory drops that leapt into the grass.  Just to show off, they’d created a few steps leading down to the tap from the yard.  There were still five minutes to spare before morning line.

That, I thought, is what I meant.

Thik, thik,” Rita Madam said.

We climbed back up to the yard and they scrambled into place for morning exercises.  Govinda arrived and initiated the daily yard routine.  I went into the office, where everybody had taken up their normal posts: by the table, with the comic book, quietly off to the side.  Rita Madam rang the bell, and the day began.

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Pictures of Schools

all 710I had heard that there was a small school in the woods, facing south, far below the road that cut through Kaskikot along the mountain ridge.  On a late fall morning in 2002 I went looking for it.

I followed a descending path of broad stones as far as the village mill, and from there I turned onto a winding footpath that halted and dropped and navigated roots in the ground and in some places seemed to disappear entirely.  Soon I heard no sounds except the whir of the trees and the suggestive rustle of an occasional monkey in the tall grass.  I passed a spring and a temple.  I came around a bend.  And then, demurely, as if waiting for a visitor, a stone wall appeared in a clearing up ahead.

I approached the building and emerged from the hushed woods into its open yard, a bald mound of dry dirt looking out over forests and terraced fields.  The view extended all the way down to the valley floor, but the school ground still felt hidden among the trees.  There were two piled stone buildings with wooden shutters and doors, most of which were missing panels, the gaps blocky and conspicuous like missing teeth in the open-jawed windows.  I peeked in to some of the classrooms and saw benches sitting mid-wobble on the dirt floor, facing blackboards whose still-fading scribbles bespoke prior lessons.  These objects regarded each other diplomatically, as if ready for anything but expecting nothing soon.

When I’d left the United States, I hadn’t decided where I was going to end up.  China was a leading Sada Shiva (Class 3?) - Version 3contender.  I was offered a position in a school with 2000 students. My mother didn’t want me to go to Nepal—there was an insurgency happening.  I didn’t know anything about any of these places.  I didn’t speak Chinese, for example.  I spoke French.  I was a terrible candidate to do any reasoning on the topic.  One day, in Bhutan, I was sitting still doing nothing except worrying about where I was going next, when, with as little ceremony as a tenant entering his flat, a picture of a small classroom floated in to my mind and landed there.

To this day I can’t explain why, but I knew that classroom was in Nepal.  I was going to Nepal.

I wound my way back through the forest, past the spring and the temple and the mill, and up a different set of ascending broad stones, I emerged again onto the wide bus road along the ridge.  Directly across from me a man was sitting in front of his house on a low wall.  He was wearing simple brown pants and a V-neck sweater over a long sleeved shirt, and chatting with a round-bellied man dressed in the clothing of a Brahmin priest.

The two men called me over and asked when I had arrived in Kaskikot and what I would be doing there.  I told them I had just been to a small school in the woods, whose name I had forgotten, but where I was hoping to teach.  As it turned out, both of these men were teachers at that school, which was called Sada Shiva Primary.

The man in the V-neck sweater introduced himself as Govinda Prasad Paudel, the English teacher.  For the next two and a half months Govinda and I walked the wooded path back from school together every day.  During that time our friendship was formed, and instead of calling each other by name, we began to follow the Nepali tradition of addressing one another by a familial relation.  I called him daai, or “older brother,” and he called me bahini.

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