Poverty All Over Again

Hard packed dirt floors, unfiltered well water, homemade outhouse bathrooms, showering clothed in front of family, washing clothes in the river, 15 people in a house, living off of $2/day, no electricity, no running water.

Extreme poverty.  I had seen seen it from afar.  Walking by beggars with signs and collection hats, driving past make-shift homeless camps, I’ve even served the occasional free holiday meals.  I’ve read about it in books and seen it in movies.  But I hadn’t seen daily life in extreme poverty up close.  Not until I moved here.

It took until I got to know people well enough to be invited into their homes to start understanding what it means to be 3rd world Nicaraguan poor.    Still now, with two and a half years of experiences, it’s difficult for me to wrap my brain around what poverty really means because while I can see, feel, and smell it, I don’t eat, breath, and sleep it.

I’m used to the rusting barbed-wire fences distinguishing one property line from the next; dilapidated houses with black tarp coverings nestled against the lush jungle; emaciated horses ripping the last tiny individual blades of sweet grass from the ground as the rainy season leaves them behind; cows and pigs wandering the roads with their necks trapped in triangular stick contraptions so they can’t walk through fences and destroy crops; chicken after chicken trying to cross the road at the most inopportune times; starving dogs searching endlessly for food; pigs comfortably lying in the muddy-puddled dirt roads; young boys steering ox carts loaded down with hay, papaya, wood, or food; enormous bulls nonchalantly moseying down the road, their balls knocking their knees with each step; outdoor dome shaped cracked clay ovens; hitch hiking young children excitedly piling in the back seat of my truck; bright white shirts and dark blue jeans connected to the laundry lines by their buttons; varying lengths of machetes attached to pant loops, bikes, motos, horses, or hands; jam-packed chicken buses with limited pockets of stale air; layers of yellow cut corn dehydrating in the fierce sun; spraying Baygon along the perimeter of the house to limit scorpions and snakes crossing through the cracks of the un-sealed houses; pulling up water from open top wells and pouring it through a sieve to remove debris before drinking it, silver-crowned or missing teeth; and it all feels normal.  This is 3rd world rural daily life.

And then I experience something that surprises me.   Something I haven’t seen before, or something I had previously overlooked.  My brain discombobulates, my ideas scatter everywhere, I can’t reorganize my thinking without my ideas first becoming a gigantic mess.  My thinking feels out of balance.

Days later, with my schema restructured and my awareness expanded, my understanding jumps to a whole new level.  I experience once again, with an ache in my stomach and a breath of utter relief, gratitude of an awesome magnitude.   I am reminded of one undeniable fact:  I am unbelievably fortunate, by no doing of my own, to have been born into a fantastic life full of opportunities and choices.

A Dentist Without Borders clinic is once such experience that got me thinking about poverty all over again, making me aware of yet one more layer of an impoverished life: dirty, brown, pitted, infected, smelly, rotten teeth.

My neighbor, Pili, arranged for a Dentists Without Borders brigade from Madrid, Spain, to provide free dental care for the local residents this past July.  She housed 17 dentists in her two bedroom townhouse and arranged for food, transportation, and financing to support the dentists for the 4 days they were here.

At her suggestion, I arranged a field trip to the dental clinic for the children at Eliana’s public farm school by confirming interest from the teachers and securing friends as drivers.

On Tuesday, the second day of the clinic, I took our maid for a cleaning and check-up.  The line was short and we waited less than 10 minutes before she was called.  With so few patients, the dentists had time to cater to each patient: cleaning, repairing, filling, and/or removing teeth as needed.

While waiting, I asked a volunteer what the dentists required in order to provide care to a group of school children.  I was told to bring written parental permission.  Luckily there was a parent-teacher meeting the following afternoon, so getting the word out would be easy.  I later spoke with the teacher who said she would request parents to send their children to school Thursday morning with signed permission slips.

Thursday morning came quickly and upon arrival at school, I discovered that less than a handful of students had permission notes.  The teacher and I spoke outside, wiping sweat from our brows in the 8 a.m. heat, discussing how to best proceed.  Two kids, overhearing our conversations, quietly slipped inside the classroom and composed two permissions slips for themselves.

I quickly realized that an illiterate parent population would not be able to write their own permission slips.  I felt obtuse for not realizing this in advance, but I had also trusted that the volunteers were familiar with our population and would have known that such a requirement would have been difficult to obtain.   I wondered why the dentists hadn’t suggested going about this in a specific way, such as recommending that I provide a written letter that the parents could simply sign.

The teacher and I began calling the parents of the kids who either wanted to go or claimed that their parents told them to go.  It was a slow process and I envisioned entire families arriving at the clinic as each minute passed by, lengthening our time in line.

After just two phone calls, we decided to drive to the clinic without permission, get in line, and call the parents once we were there.  If parents didn’t want their child to be seen, the child would just spend their morning playing on the most elaborate play structure they’ve ever played on, which would be an experience in and of itself.

We drove the 17 students and 1 teacher split between 3 cars.   The other students who didn’t want to go stayed behind with the two remaining teachers who had hoped to join us.

The clinic was hosted in the weight room gym of the Ford Family Foundation, just 20 minutes from school.  The waiting area consisted clusters of people spread throughout the basket ball court.   The dentists were sitting scattered about as well, sitting on the ground talking in small groups, or leaning against walls.  They had forgotten their keys to the gym and were waiting to be let in.

The clinic opened 45 minutes late.  We pulled folding chairs outside to create a line along the shaded baseline of the basketball court.  To enable the dentists to rotate between the students and adults so no one had to wait too long, we set up a second line of chairs perpendicular to the first, running half the length of the sideline.  The front of each line met at the partially covered 90 degree corner closest to the gym’s main door.

Just as the students sat down, the head dentist approached me and asked if I had a medical history and list of known allergies for each child.  That would be a big, “no.”  And so began our second round of phone calls.  Junior’s battery ran dead and the teacher and I both ran out of our prepaid minutes.  I drove to my mechanic’s house 5 minutes down the road to buy more minutes, returned to the students, and continued with the calls.  All parents gave permission for their children to receive treatment and we recorded the health information for all 17 children.

When the children were called into the gym for their visit, they first sat in a chair next to the door and were handed a plastic bucket with dental instruments.  They held their buckets on their laps as the triage dentist assessed the condition of the children’s teeth.  Students who received a passing grade were congratulated and returned to the basketball court.  With such long lines, there was no time to clean their teeth.  Students who had infected or rotten teeth that needed pulling or cavities were given a small report paper and instructed in which line of chairs to wait inside the clinic.   One section was for fillings, another for cleaning, and the third for pulling.  The children were not told the significance of the line they were in, or what services they would receive, until they were greeted by the treating dentist.  Some children went from one line to the next, to the next.

The students, ranging in age from 6 – 12, were incredibly brave.  Most walked the process solo, but a few faces revealed fright, especially as they watched others receiving treatment, panicking or squirming in their seats.  I checked in with some of them to see how they were doing, sat with those who needed it.   For those who wanted a friend or sibling, I located the requested companions and brought them inside.  The teacher remained in line in her seat.

Of the 18 people we took from Eliana’s school, most had cavities and several had teeth pulled, some more than one.

Most students entered the clinic willingly, however, I did have to bribe one student.  He repeatedly avoided the front door, playing quietly, staying out of the way.  His mom had told me personally that she wanted him to be seen so I was determined to convince him to walk through the doors.  Both his brothers had already passed with flying colors, but he was nervous, backing away from me and shaking his head.   I asked him if his teeth ever hurt him, to which he nodded.  I talked about the importance of his teeth being repaired now instead of allowing more time to pass while the teeth get worse and he has more pain.  He still wasn’t budging.  I promised to bring him homemade ice cream that night and he gave it serious consideration.  Just when I was sure he was going to shake his head to that too, he agreed to be seen.  It turned out he was nervous for good reason.  The little guy proceeded to have a couple of cavities filled and 3 rotten baby teeth pulled.

One of the girls walked out of the gym crying.  She wouldn’t talk.  Eliana sat with her arm around her, rubbing her back, stroking her hair, and protecting her from others who came to to see what was going on.  “She wants to be alone,” Eliana told her schoolmates.  This didn’t come automatically to Eliana.  She at first kept trying to find out what happened. I finally told Eliana that if she could not respect her friend’s privacy, she would have to move 5 seats away and sit by herself.  I then shooed away another girl who kept asking questions.  From there, Eliana took over guarding her friend from inquiries.  Eliana thinks her friend had a few of her front bottom teeth removed, because she saw inside just a little and she saw only the girl’s tongue.  But I can’t verify that.

At 11:15 a.m. more than half of kids had finished their visits and were playing on the play structure, so I called for the driver of the largest vehicle, a Land Cruiser with bench seats which could comfortably transport 12 kids, to pick up the first large group of kids back to school.  I planned to call my friend, Lindsey, to help me drive the rest once all had finished.

The Land Cruiser driver, an employee of a friend, mentioned to me at drop off that he had lost his phone, and to call his boss so he could be notified to pick up the kids.  It turns out he was not so easy to find.  After 20 minutes of trying to reach him, I went to plan B and called Lindsey.  By the time she arrived, just after 12:00 noon, everyone had been seen.  So the two of us debated if we could actually get all 18 people, 20 including ourselves, into both of our cars.

We discovered that, in Nicaragua at least, you can drive 20 people split between two standard-sized SUVs.  We drove home very slowly, stopping several times along the way to drop people off as we passed by their houses.

While driving home I had a small freak-out moment, thinking about the girl who had been crying, wondering exactly what happened and what would her parents would think.  I realized, at that moment, how much trust the parents put into the dentists to send their kids without being present.  I was naively thinking the kids would get their teeth cleaned and cavities filled.  It didn’t cross my mind they could have one tooth pulled, let alone two or three.

I can’t imagine sending Eliana to the dentist with the parents of schoolmates and having her come home with fewer teeth.  But I also can’t imagine her having one rotten tooth, let alone three, nor being so accustomed to teeth in such bad shape that I don’t question the need for a tooth to be pulled.

Could some of the teeth have been repaired and not pulled?  Did we do more harm than good?  Were they all baby teeth that were pulled?  I didn’t know.

The following day Lindsey spread the word throughout the local community that we would drive through the village to pick up anyone who wanted to be taken to be seen on the last day of the clinic.  Her husband and I picked up 2 car loads of adults and drove them to the clinic where we discovered that the dentists had shut down operations 3 hours early.  Our group was denied service.  Five people, who had already been turned away, sat on the chairs outside hoping they would be seen.  We called our friend, Pili, who said, “No, no, no.  Put the dentists on the phone.”

Two minutes later the dentists laid their materials out again, counted how many people were waiting, and issued numbers to each person.  No new patients were to be seen.  We asked for 3 extra numbers knowing Lindsey was on her way with 3 more women.

Interestingly, it was recommended to the mom of the young boy I bribed with ice cream, that a few of her teeth be pulled, and she denied the treatment.  She explained that they can only pull her teeth, they cannot provide replacements, so she preferred to wait until her vacation days to pay to have her teeth pulled and new ones made.  Her vacation has since come and passed, but she did not seek treatment, and so she remains with her rotten teeth which, as I understand, with time, will affect other teeth.

I had the opportunity to talk with the dentists later that night at Pili’s house.  I shared with them how shocking it was for me to see so many teeth pulled, and I asked how they know when it’s best to remove a tooth rather than to repair it, and if they ever pull teeth that could instead be repaired due to lack of resources or time.

I learned that when the clinics have only a few patients, the dentists can do full check-ups which can include cleaning, repairs, and restorations.  But when lines are long, they have to focus on the highest priority needs so they can work efficiently to give all the waiting patients a healthy mouth.  They pull rotting teeth so they do not infect adjacent teeth, even if in a different circumstance the teeth could be saved. They know the patients will not seek out follow-up care and the rotten teeth would then continue to rot and soon affect more teeth.

I left this experience with a whole new understanding of the importance maintaining healthy teeth.  I really had taken it for granted that most people know how to care for (and do care for) their teeth, and that they in turn have relatively healthy white teeth  they get to keep.  It continues to surprise me what I take for granted as what “we” know as basic survival skills, thinking it is what people around the world know.  But what I find equally amazing, is that I am similarly unskilled at basic jungle-life survival, having not had a lifetime of experience learning how to sustain myself living off the land in poverty.  It’s is fascinating to see first hand how personal experiences affect what we take for granted as basic knowledge, and how relative the term “ignorance” can be.