As you can imagine in my job, I get to chat to a lot of dentists, and over the past few years, I have got to know quite a few of them.
They come in all shapes and sizes, from all political persuasions and backgrounds. Some are outgoing, and some introverted but all (thankfully) are pretty good with their hands! One thing I’ve found that almost all of them have in common is the process they go through in getting to understand what we do at Bridge2Aid.
Until they understand what we do, most dentists believe that the best way to help people through using their skills in a developing country, is to do the same thing as they do at home when they get here. Just use the same approach – same equipment, same treatments, same resources, just in a different environment.
As an intervention this sounds plausible, until you dig a bit deeper into the practical realities one typically finds in the East African countries we work in.
Of course Oral Health is recognised as a fundamental contributor to general health by all governments. Oral health problems continue to affect most people throughout the world, and as all sufferers will know, toothache has the ability to seriously affect well being, quality of life and ability to work. Most governments allocate budgets for oral health services, but in many developing countries these budgets are very limited. For example, the NHS dental budget for the UK would outstrip the ENTIRE health care budget of many developing countries. Where they spend these resources in traditional ways (i.e. by having fully equipped dentists based in towns and cities), the services are not always directed to those most in need (who live in villages). This leads to situations in which large segments of the population have limited or no access to even basic oral health care, and when they have problems, they will continue to suffer for days, week and months in agonising pain, with no hope of accessing the centralised services.
As the World Health Organisation recognised, this situation calls for the establishment of oral health as a priority and for the implementation of the essential components of oral health care – extraction of decayed teeth, simple fillings and oral health education – that are affordable, within the prevailing health infrastructures of deprived communities.
In short, the provision of western dentistry in a developing world context, that will reach the majority of the population, is extremely problematic.
It is like having a £30K budget for transport for a family of 10, and choosing to spend the money on an Audi TT instead of a Ford Transit minibus.
- The Audi TT goes fast
- It has lots of cosmetic ‘bells and whistles’ that make it more desirable
- It has a high level of performance
- There’s a lot more status with being seen in it compared to the bus
- But – it has limited capacity, breaks down more easily in harsh environments, isn’t as robust and only a few people enjoy the benefits. The lucky ones arrive in style, but most of the family will be left behind, forced to walk.
The mini bus will cost the same amount of money
- It’s not fast
- It’s not as pretty, or comfortable
- But it will last longer, and it has the capacity to transport the whole family – no one gets left behind.
In my view, with the layman’s knowledge I’ve gathered over the past 10 years living and working in East Africa, the provision of Oral Health services is very much the same.
If we focus the majority of our budget on a high level of care which costs lots of money and is concentrated in areas where not many people can get to, then most people will miss out on any service at all, and in practice this means millions of people suffering in pain.
This is why the Basic Package of Oral Care was designed by the WHO. What it says in a nutshell is that the provision of oral health care in developing countries should focus on basic services that everyone can access – Oral Urgent Treatment (extractions) and Atraumatic Restorative Treatment (simple fillings that don’t need a drill or suction, or power). Along with education and the availability of affordable fluoride toothpaste, this is the pragmatic approach when limited resources are available.
So given this situation, where do we focus our efforts to impact as many people as possible, whether we be charities designing a strategy or volunteers that want to make a lasting difference?
Before I go on, I’d like to say I applaud the efforts of various charities and individuals who do good work in developing countries. But a fundamental question remains; how many people will you be able to impact if you focus on delivering western dentistry in a developing world context?
If you follow the Audi TT model you’ll use the same or similar complex equipment, provide similar levels of treatments and practice ‘western’ dentistry. From what I’ve seen, and what I have grown to understand, you’ll have a short term impact on a relatively small number of people who live near established facilities.
If you choose the Ford Transit minibus approach, you’ll focus on meeting the more basic needs of the majority. You’ll treat people who live in remote areas, and more importantly, build capacity by training in the rural health care system to enable ongoing treatment after you have left. By doing this, more people will get your help (both immediately and in the long term). Yes – you’ll be addressing more basic needs, but people will be out of pain – the most fundamental need. You may not have done the same things in the same style as you will be used to, but you’ll have carried out work that will really help.
The reality is that a single person with no kids can afford to operate an Audi TT. Someone with a large family cannot – unless they want to leave half the family behind.
So – what we are talking about is not an alternative to dentistry; it is the alternative to NO dentistry.
That is why at Bridge2Aid, we focus on training local health workers so that they can provide basic services, and make access to pain relief and education available to many, many people.
It’s not as pretty, but it’s the pragmatic thing to do. Everyone is included, no one is left behind.