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Story Publication logo September 1, 2013

Getting People to Brush Daily in Nepal Is Harder Than You Think


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For 10 years, Laura Spero has provided badly needed dental care for 18,000 Nepalis, with the...

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The Nepali village of Kaskikot below the Anapurna range. Image by Jon B. Healey/The Washington Post. Nepal, 2013.

It was pouring rain in the Nepali village of Kaskikot, which was bad news for Laura Spero and the ceremony she had planned.

Mid-April was far too early for monsoon weather, but one thing the 33-year-old had learned since she began traveling regularly between Bethesda and Nepal 11 years ago was that nothing in Nepal happens on schedule.

Kaskikot is a village of roughly 12,000 on a mountainside beneath the Himalayan Annapurna range. Almost everyone is a member of a subsistence farming family; they eat what they grow, and daily life is difficult. Water must be hauled, buffalos milked and kitchen fires built so that when the power goes out — which it does daily — rice can still be cooked. People have little energy to trek 30 minutes to attend ceremonies at the local health post. Especially in the rain.

Spero's ceremony was supposed to be a crowning achievement for Eva Nepal, the nonprofit group she founded in 2007 to provide the village with desperately needed oral health care. Today, for the first time, the health post would absorb responsibility for operating and funding the dental clinic. At least, it was supposed to. But the head clinician, Kamal Bhandari, who had been appointed by the national government in Kathmandu and goes by the title "health post in charge," had made it clear he wanted nothing to do with Eva Nepal or Spero. "I will not touch your dental instruments with my two hands," he had said. "Ever."

Perhaps Bhandari believed his authority was being threatened, and worse, by a foreigner. Or maybe it was because Spero would not pay him an extra salary once the handover took place.

Whatever the reason, Eva Nepal's program director, Nabaraj Sharma, had assured Spero that "not even a letter from the king" would make Bhandari change his mind. Clearly, because Nepal's last king had been deposed in 2006. But if villagers came to the ceremony in force to show support, then Bhandari might be swayed.

And if nobody showed up?

"It's quite possible that Kamal will ream me out," Spero said the night before the ceremony. "Or maybe Kamal will sign the handover papers and then do absolutely nothing."

The next morning, an hour past starting time, the Eva Nepal staff waited in the damp concrete local government headquarters. They had hung a banner that read "Kaski Oral Health Care Project." Two elderly women arrived, followed by a couple of middle-aged men. A stray dog wandered in from the rain and slumped down in the doorway. There was no sign of the health post in charge.'

Though Spero officially launched Eva Nepal in 2007, she had been raising money for oral health care in Kaskikot since 2006. Nearly all this money has come from Bethesda's Greenwich Forest neighborhood, where Spero grew up. Her parents still live there, and each Thanksgiving, roughly 35 Bethesda families and 30 businesses participate in a race and fundraiser.

Ted Alden, 52, met Spero in 2007, when she knocked on his door to hand out literature about the race. Alden had long been fascinated with the Himalayas, but he was inspired by how Spero included his kids, then 7 and 9, in the event.

"Laura has a pizza party at her parents' house the night before the race, and the kids make all of the decorations for the starting line," he said. "She's busy trying to strengthen the community in Nepal, but really she's building and strengthening the neighborhood she grew up in."

Alden says it wasn't until recently that he truly came to understand the scope of Spero's humanitarian ambitions. "Maybe she's raising $10,000 a year, and that doesn't begin to cover the scale of what she's trying to do," he said.

Dale Rosenthal, another Greenwich Forest resident, said Spero had been an important role model for her kids. "She didn't want to be sitting around and doing nothing in the privilege of Bethesda," she said. "She saw what needed to be done and actually carried through with it. But the beauty is that it's so local. We're not just writing a check and dropping it in the mail."

This year, Spero has expanded her dental program. Now 13,000 more people in the villages of Lahachowk, Lwang Ghalel and Rivan have oral health coordinators leading daily brushing programs at school. There are also community education classes, regular dental clinics at the local health posts, and discounted rates offered to these villages at larger hospitals.

None of this could have been accomplished without Greenwich Forest. But people there don't realize how much Spero has struggled for these successes; they don't necessarily understand that money alone is not enough.

In recent years, aid has flooded to Nepal. Westerners drawn by the Himalayas' remote beauty, the birthplace of Buddha and an impoverished population are eager to spend their euros and dollars there. In 1990, 220 nongovernmental organizations were registered with Nepal's Social Welfare Council. Today, there are almost 40,000.

Some of this is short-term volunteerism, or "voluntourism." But "if you really want to help the country, then you train local people," said Erica Stone, president of the American Himalayan Foundation. This requires a long-term commitment, one that doesn't ask the local population to house, feed and interpret for you.

David Citrin, professor of anthropology at the University of Washington, said voluntourists can often become unwitting pawns in local politics. "They help politicians look like they're doing good stuff," he said.

Spero's relationship with Kaskikot is itself an implicit stand against voluntourism. Long ago, she decided to implement a self-sustaining, community-based program there that could run without a Westerner at the helm. She is accountable to this vision, even if the village, as stubborn as it is beautiful, struggles to budge.

Laura Spero is broad-shouldered and strong, at once muscular and lean from her days swimming and rowing college crew and competing in national taekwondo competitions.

"Laura wanted to go to the edge of what she thought she could do," her mother, Nancy Chasen, said about her daughter's desire to travel to Nepal. She was eager to flee the "life of privileged Bethesda."

Spero grew up attending Georgetown Day School (full disclosure: we were in the same graduating class), and Chasen said she was looking for a place "where the rules weren't already set about what you were supposed to be and what constituted success."

But if Spero failed, her mother said, she didn't want anyone to see it happen. Chasen is a public interest lawyer and consumer advocate who worked with Ralph Nader. Spero's father, Don, is an entrepreneur who was previously on the U.S. Olympic rowing team. They had accomplished extraordinary things. Their daughter wanted the same for herself.

Spero first visited Nepal in 2001 on a three-week trip between her junior and senior year at Williams College in Massachusetts. Walking down a village road one day, she spotted a woman and her child in a doorway. Spero reached for her camera, then stopped herself. "It hit me that I'd come all the way there, but I wasn't really there," she said. "I wanted to stand where that woman was standing."

In 2002, Spero returned to Nepal for two months, but she still wasn't thinking long term. "I thought I'd come back to the U.S. and do something responsible," she said.

But she discovered that the Nepali organization she had paid to facilitate a volunteering project had not organized any work for her and, worse, had placed her in the home of Bhim Subedi, an influential school principal. Spero was in danger of becoming a voluntourist.

She persuaded Subedi to let her change homes. He suggested Radhika, a widow who lived in a two-room mud house with her grown daughters, Bishnu and Malika. This would mark the start of a long relationship.

In 2003, she returned to Nepal a third time, independent of the volunteering organization, and lived with Radhika for nine months. Spero helped with chores and learned Nepali. (Bishnu and Malika spoke little English, and Radhika spoke none.) She moved from sleeping on the attic floor to sharing a bed with Bishnu. Spero was now the woman standing in the doorway.

Not that she fit in — or planned to live there permanently. Spero was more of a local attraction: the tall white woman who could fix things. There was a perception among villagers that Americans — or their money — could solve life's daily frustrations. At the top of the list were toothaches. Many villagers came to Spero with horrible mouth pain, asking for medicine. The only dental tool at the health post was a rusty pair of pliers.

Spero learned that people expected their teeth to rot and fall out with age. They did own toothbrushes; they just didn't use them often. "All the pieces were there," she said. "The problem didn't seem like it would be so difficult to fix."

She had a lot to learn.

In 2004, the Nepali government drafted a National Oral Health Policy, which promised to bring dental hygiene to the country's 4,000 villages. That program is nearly identical to Spero's: daily brushing programs at school and regular clinics at village health posts. But nine years later, only a handful of villages offer any dental services.

Spero's small organization is essentially doing the government's work in a country where 58 percent of children and 69 percent of adults suffer from bacterial tooth decay. According to Shaili Pradhan, the chief oral health care focal point in Nepal's Department of Health Services, the country's high rate of heart disease and diabetes is likely linked to a lack of oral health care.

The National Oral Health Policy did introduce fluoridated toothpaste, especially important in a country without fluoridated water. But this doesn't do much good unless people use it. Rural Nepalis brush with a finger and ashes, salt or sand. Some use abrasive tooth powders that strip enamel from teeth. In some places, people chew datiwan, a stick with antiseptic properties. Then there's local lore about the dangers of dental care — deeply embedded myths that landed Spero in trouble when she started the dental program.

It was 2003. Spero had been living with Radhika for a few months and teaching English at a village school when a European couple arrived, looking to do humanitarian work. Spero had just begun to plan an oral hygiene program and had agreed to work with a fledgling organization headed by Subedi and other local leaders. Subedi hoped Spero could help launch his organization, and she, in turn, hoped Subedi's influence would help garner community support for hers.

The Europeans pledged Spero and Subedi 50,000 rupees, about $800, but then retracted, saying they didn't trust the organization run by the local leaders.

Subedi summoned Spero to a meeting of school administrators. They accused her of pocketing the money. "It took me many months to realize the compromising position that Bhim [Subedi] was in," she said. "He'd lost face, and I was going to suffer for it."

Not one to back down, Spero and her Nepali co-teacher, Govinda Paudel, invited dentists from Pokhara, a city in the valley far below Kaskikot, to run a clinic at the school, but this upset parents. Unbeknown to Spero, many rural Nepalis believed that tooth extraction could make you go blind, deaf or mentally ill. Worse, rumors began to spread that Spero was attempting to sell children's healthy teeth on the black market.

She and Paudel went from home to home and spoke personally with families, but the following week, a group of influential parents called Spero into another meeting and began berating her.

"I was trying to negotiate this very complex situation in a language I didn't speak very well," she said. "I just couldn't express myself." She burst into tears. This public emotional display — highly unusual in Nepal — floored everyone. The parents began to understand that Spero was truly committed to their children.

Today, the children at Subedi's school gather every morning to brush their teeth. They line up, toothbrushes in hand, as the school's oral health educator doles out toothpaste. Behind them stands a new multistory schoolhouse, which an international NGO constructed. In a corner of the yard, a much smaller building sits abandoned: a schoolhouse built by the Europeans.

The room itself is like a pressure cooker: two rambunctious boys, 5 and 7, two twin beds (the parents share one), a single dresser, stacks of pots and pans, and an electric range. Initially, Spero was shocked to see how Malika and her family lived. "The expectations in Nepal are very different than what we're used to," she said.

Within seconds of her arrival, the boys clobbered Spero, and the three toppled onto one of the beds. They giggled and screeched, begging Spero to play dhancuti. Spero took Aidan's small hands in her own and, balancing his stomach on her knees, lifted him. This is the Nepali version of "airplane," named after the seesaw-like wooden contraption used to pound rice.

It was clear how intertwined Spero had become with this family. Her relationship with Prem, who sits on Eva Nepal's board, is at once professional and intimate. She named both boys. She helps with the monthly rent, $32, and the kids' monthly private school tuition, about $20 total. She says this financial involvement deepened at pace with her personal relationships. As Spero sees it, she is simply supporting her own family.

The strengthening of her commitment truly started amid the European scandal. Thousands of miles from her home, and with the village's most powerful entities bearing down on her, Spero sought solace with her adoptive Nepali family. Before Malika married Prem, Radhika was a single mother raising two daughters in a culture where both sons and extended family are seen as vital. But Radhika, who married at 11, and whose husband was killed by lightning after Bishnu was born, had been abandoned by her in-laws.

As Radhika provided an emotional haven for Spero, Spero assumed responsibility for the family's physical and financial needs. In 2003, Radhika discovered she needed a hysterectomy. At this time, Malika was suffering through a difficult pregnancy in Pokhara, and Bishnu had been hoping to take a special course in the city for female trekking guides. With Radhika immobilized, Bishnu didn't think she'd be able to attend, but Spero knew the course was a way to help her adoptive Nepali sister earn a living outside the village. So she stepped in. Spero milked the buffalo, hauled water and carried 150 pounds of wheat on her back from the fields. She also helped cover the costs of the operation. "It was no longer about having a unique experience in the developing world," she said.

Meanwhile, Spero stopped filtering her water — "It just wasn't practical," she said — and was soon overrun with a severe parasitic infestation. It would take years and scores of medical interventions before she was healthy again, but, at the time, all she wanted was a mother's touch. One night, Radhika said, " 'Mom and daughter should sleep in this bed.' And she snuggled up behind me and put her arm around my stomach, and we just fell asleep."

In the village of Lwang Ghalel, kindergarten mothers gathered for their first oral hygiene class. They examined an oversize, cartoonish plastic mouth as Eva Nepal's new oral health educator discussed cavities and fillings. He explained that because children's mouths are still developing, removing infected teeth could create serious orthodontic problems. He stressed the importance of regular checkups and concluded with a spirited discussion about dental myths.

When an old man said he was perfectly content to have lost his teeth, the mothers shushed him. After the seminar, the kindergartners received checkups, and the ones who needed fillings or extractions were given slips requesting that their parents accompany them to the clinic.

The next day, the children lined up outside an empty classroom. Inside were two benches, one manned by Lwang's new dental tech and a second by a dentist from Pokhara. The children tolerated having their mouths poked and prodded. By the afternoon, 20 had been treated. Fifteen more needed work, but their parents hadn't shown up. Did the kids not give their parents the referral slips? Were the parents too busy? Spero wasn't sure how to proceed.

"In the U.S., that would be obvious," she would later explain. You don't give medical treatment to a child without parental consent. "But in Nepal, it's a more communal environment in terms of how children are raised." Spero worried that if kids with infections and cavities didn't get treatment that day, they might never return. After a long discussion with the Eva Nepal team and the school principal, Spero sent the kids in for treatment.

The procedures went smoothly until a little girl arrived with a decayed molar and an abscessed front tooth. The dentist pulled the front tooth, but he left the molar alone, concerned about future orthodontic problems.

Frightened and in pain, the girl began to cry. "It's scary," Spero said. "We're talking about a 6-year-old kid. So I went over three or four times and talked to her. I asked the teachers to sit with her and make sure she was all right." The girl went home. "I knew there was going to be trouble," Spero said.

Sure enough, half an hour later, the girl's mother showed up, enraged. "Why didn't you pull the back tooth?" she demanded of the dentist. "It's infected! But you pulled the front tooth, which was fine. Now my daughter could go blind!"

The dentist said this problem had been explained during the previous day's education session, which the mother hadn't attended. Eventually, the woman calmed down, satisfied that her daughter would be fine.

"At the end of the day, if you don't provide treatment, who suffers? The kid," Spero said. "It's a balancing act."

The health post in charge did finally show up for Spero's ceremony. Nearly two hours late, Kamal Bhandari took a seat on the dais beside the Eva Nepal employees, village elders and the other government-appointed officer in Kaskikot. This officer and Bhandari controlled the village budget.

All of these men sat in a row, facing a nearly empty room.

What proceeded was less of a celebratory event and more like an awkward high school debate. One by one, the Eva Nepal staff members told the five or so audience members why oral health care was important. Then they each turned to Bhandari and thanked him profusely.

Bhandari ignored all of this. Blaming national instability, he talked for nearly 10 minutes about how the village lacked money and manpower to implement the dental program. Previously, Bhandari's colleague had told the Eva Nepal team he wanted their program to continue, but on stage, he threw his support behind Bhandari.

When Spero was invited to speak, she stood up from her seat on the sidelines and faced the health post in charge. In near perfect Nepali, she played the game exactly as the others had, thanking Bhandari for his gracious support.

The debate now finished, Spero's staff handed a beribboned canister of dental tools to Bhandari, who did, in fact, take them with his two hands. He signed the official papers, which stated that the health post would now run and fund Eva Nepal's dental program.

Finally, the Eva Nepal staff received ceremonial blessings, white scarves and stylish backpacks embossed with the words "Kaski Oral Health Care Project." Then everyone stood around the freezing cold room eating snacks and drinking tea.

Back at Radhika's home, Spero, Prem and Eva Nepal's program director debriefed, huddling over steaming cups of milk tea. A cold drizzle fell, and thick fog pressed against the mud house. The group looked tired, but Prem turned to Spero with a mischievous grin. He whispered something.

"After the ceremony Prem overheard Kamal telling some people that he still wouldn't touch the dental tools. And then," Spero paused, barely able to contain herself, "Kamal complained that we didn't give him a backpack!"

All three laughed heartily.

Eva Nepal could fund the Kaskikot dental program and simply bypass Bhandari. But even if the program's expansion into new villages weren't already straining finances, Spero wouldn't agree to this. Each new village had agreed to take over the dental program after two years of support from Eva Nepal. If Spero made an exception, she'd lose credibility elsewhere. She'd be no better than a voluntourist.

Worse, she'd be demonstrating a lack of confidence in the villagers. To make Bhandari come around, the Eva Nepal team needed to rally the community to pressure the other government-appointed official to join their cause.

Before long, Spero would head back to the United States, where she has since relocated to Hartford, Conn., and makes her own modest living practicing a form of alternative medicine and the treatment that helped her get rid of the parasites. She visits Nepal for two or three months each year and stays in touch with Eva Nepal's program director through weekly Skype sessions and daily e-mails.

But as a woman who was both insider and outsider to villagers, Spero understands the limits of her power. She could never be their benefactor, their enforcer or their savior. She could be their champion and friend — and hope this was good enough.

View the companion slideshow by photographer John B. Healey on The Washington Post site.


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