Liz onsite in Musoma, February 2013

“In early February, together with my nurse, Tracey,
I spent two weeks in northern Tanzania with Bridge2Aid (B2A). I imagine most of you are aware, but for those who aren’t, B2A is a charity that aims to train local Clinical Officers (3 years medical training) to be able to carry out basic dental treatment in remote clinics and to know when to refer patients to the nearest hospital.

This was our seventh trip and, having travelled up to Mwanza, on the shores of Lake Victoria, we separated into two groups, Tracey being based in Bukoba, whilst my team were based in Musoma, North-East of Mwanza, towards the border with Kenya.

Whilst we were away my husband kept a blog (www.parascosa.com/Tanzania.htm), documenting our adventures, and I know that many of you have been reading it; my thanks to everyone for their support and interest.

When I arrive back people usually ask me whether I am pleased to be returning to ‘normality’. This begs the obvious question: what is normality ? Normality to the people that we treat is:

• walking for 5 hours to the clinic;
• waiting, often in great pain, for four years for dental treatment;
• having 1 dentist for every 400,000 people (2,000:1 in the UK);
• having no running water or electricity;
• being grateful when we hand out our used water bottles at the end of the day.

When we first went out it was a great adventure into the unknown and we were surprised by what we experienced; now we realise that it is just ‘business as usual’ for the people whom we treat and for the Clinical Officers whom we train and who care so deeply for their community. The patients never cease to amaze me as they simply wait in the sun for hours to be treated and stoically put up with the pain. As we drive back to base in the evening it is inspiring to watch people come together around cooking pots to meet and share food. I often find myself wondering whether our far-flung families and separate living are really signs of ‘progress’ ?

This year I again returned home feeling somewhat guilty, that the two weeks away had acted as a sort of tonic and that I have got more out of the experience than I put in. I would encourage anyone who is pondering whether they should become involved in any charity – not just African-oriented ones – to seize the opportunity and take the plunge; you will be surprised how rewarding it can be. At the end of this year’s clinic I gave my shoes – a pair of old trainers that I used for gardening – to a young girl who had been watching us. I was amazed to find that this meant that she can now attend school as she needs a pair of shoes to walk to school and the school require children to wear shoes. You, too, will find a way to make a difference.

The obvious question: are we going back ? The answer is again a big YES and, once again, we will be holding a quiz in the autumn (Saturday, 28 September) to help raise money to fund the next visit. B2A is expanding its work into neighbouring Rwanda and so next time we may have new experiences to write about.

-       Liz Stringer, Dentist

What would you do if, for whatever reason, good or bad, you suddenly only had until noon at work every day?

That’s the question posed by a great podcast I listened to recently. If you only had a few hours a day to get the high priority parts of your job done, how would you respond?

The question is an interesting one for me because for the past 10 weeks, that’s pretty much where I have been.

In mid-March I came down with a virus. Nothing too dramatic, just headaches, lethargy, shortness of breath. I spent most of the week on the sofa. I then developed a chest infection, and after the antibiotics finished, expected to get better.

Armed with my best attitude, I marched into the office the following Monday morning after 2 weeks off, declared myself fit and well… and was back in bed by lunchtime.

Since then I’ve been on an incredibly slow recovery. Making the best of the first 3-4 hours of the day to work in short bursts, then resting till mid-afternoon and flopping down again in the evening. For a driven perfectionist achiever like me it has been incredibly frustrating. Thankfully I have a very understanding wife, family, and team.

The interesting thing though, is that only having a few hours available each day has made me VERY focussed.

A lot of the ‘good’ things to do, that I might have spent time on have gone out of the window, in favour of the really high priority aspects of my job description.

So how has only having a few hours a day available to work affected my general level of productivity?

Not much.

That’s right – I am almost as productive, and on track with my objectives, working 4-5 hours a day, as I was before when I was able to work 9-10 hours a day.

Because activity does not equal achievement.

Which begs the question – What was I doing with the extra time?!

A caveat -

• I have a distinct set of responsibilities which aren’t very ‘operational’.
• I have an amazing team
• I have a great (part time) PA

But I do think this principle has some great truths for all of us. I highly recommend you listen to the podcast, look at the infographic he describes, and have a think about you can implement the recommended steps.

Finally, as I continue to recover (and unfortunately I have gone back a couple of steps this week, but I’ll bounce), the big question I am asking is:

What would things be like if I used the work hours that I don’t currently have, to do more of the ‘great’ at the expense of the ‘good’?

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.

Let’s compare:

• 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.

“One week from now, we embark on another exciting milestone in the development of the work of Bridge2Aid.

In March of this year, in partnership with the Tanzanian Government, Bridge2Aid successfully ran the first Phase 2 course (click here to read my previous blog on Phase 2) when we trained four District Dental Officers (DDO) as trainers of Clinical Officers in Oral Urgent Treatment (OUT).  During this ‘Phase 2A’ the DDOs were trained and then closely supervised as they, in turn, provided training for five Clinical Officers (CO) in OUT.  The programme was a huge success and the DDOs and COs performed at a really high standard.

On May 20^th we begin Phase 2B when five new Clinical Officers will be trained by the group of four DDOs who took part in Phase 2A, but this time, with far less direct guidance from the Bridge2Aid team.  The course is designed to give answers to the following questions

• How well have the four DDOs retained the information and skills learned in course A?
• Can this team of DDOs train COs to a good standard, with minimal support from the Bridge2Aid team?
• Are the DDOs competent to be able to independently train Clinical Officers in the future, without Bridge2Aid organising a programme to facilitate this (Phase 3)?

It’s a step into the unknown.

We have our hopes, and our targets, but in the end this is up to the Tanzanian District Dental Officers themselves.

It’s a little scary…..a time of handing over some of the control to others. But most importantly, it’s a very exciting time which could launch us into a significant period of growth.

Here’s to a successful programme!”

- Paul

Ps.  Follow the Phase 2 programme on Facebook from May 20-29

“Today I had lunch with a man that I have great respect and admiration for. He may or may not know it, but he provides me with the inspiration to continue what we are doing. I’m not going to name him but he knows who he is. I want to say thank you for taking the time to talk and offer help and guidance in what I know is always a busy time for you. You and your team will always have my respect and support. Kilimanjaro 2014 here we come!

To the people who know who I am, I don’t need to introduce myself. To those that don’t, I will stay with no name, no face and no big profile to go behind what I am doing. I am but 1 humble person that was moved one ordinary day by four brave and inspirational men and decided to make a difference.

The one thing to remember from anything about this article is this: who I am isn’t important. The important part is the amazing people that help our patients. It is also the people they treat that are important.

In a nutshell, we arrange dental consultations and possible treatment for injured ex service personnel. They come to us via various routes; Help for Heroes, recommendation from treated patients, social media and at least 3 other charitable teams we have worked with. We have patients with treatments from routine check ups and hygiene appointments to full mouth rehabs involving implants and oral surgery, and by the end of our first 12 months we had treated over 20 patients.

So how are we able to provide these people treatment? We don’t raise money, there isn’t a big pot of money that was given to us to use AND the patients do not pay.

We are 100% reliable on the amazing dentists that have signed up to what we are aiming to do. They are dentists from all areas of the country, different backgrounds, different practices, who all give their time and clinical skills in return for knowing that they are helping these patients as part of their recovery and confidence rebuilding. Each of them has got involved for their reasons, from ex-forces dentists, having friends and or family members in active service or simply because they know how much they can help change a person’s life, want to give back and say thank you.

Whatever their reason, they can see our vision and are one of the types of people to whom actions do speak far louder than words.

At this point I could name all the dentists and practices that have got involved and treated patients but as I have limited words left I can’t. They know who they are and to those people I can only say THANK YOU.

To those who want to know more and get involved please do so – you are always welcome in our team.

Find us: Facebook.com/smile4heroes | www.smile4heroes.co.uk | @smile4heroes

As many Bridge2Aid volunteers will identify with, treating patients such as we do can turn your perspective of life upside down. They will inspire you, you will change their confidence & give them a reason to smile on their toughest days. Can you handle that without any payment? If that isn’t you, or you don’t share our vision we understand, but I will throw you a challenge and that is to do something for no reward that challenges or changes people’s lives.

Try it. You might just like it!”

No matter where

No matter where you are there are always people who want to make a difference.

No matter where you are there are always people who are indifferent.

No matter where you are there are always people who care.

No matter where you are there are always those people who can’t see the beyond their own horizons.

No matter where you are there are always those who can dream beyond themselves for the sake of others.

No matter where you are there are always those who don’t.

No matter where you are there are always those who have to have the resources to make an impact.

No matter where you are there are always those who haven’t.

Thankfully, those that want, do, can, have and will; outnumber the rest!

- Ian

The following post was originally written in 2011, and has been updated. 2 years on, I remain as convinced and passionately committed as ever that the overriding priority for oral health in developing countries is not simply providing equipment or more dentists, but giving safe, sustainable access to basic pain relief and simple oral health education. Here’s why:

On a balmy summer’s evening in 2003, in return for a curry, I made the mistake of driving Ian Wilson to speak about Oral Health in Developing Countries – an evening that changed my direction in life completely.

On that night I was blown away as I learned about the impact of oral pain on the quality of life for people living in developing nations.  The extent of the problem was huge.

Today I find myself the chief executive of a dental charity.  Over the past 7+ years since Jo and I moved to Tanzania, I have tried to learn a bit about teeth and specifically how oral pain impacts people living in countries like Tanzania.

Over the coming weeks, interspersed with other ramblings, I plan to blog about this.  Don’t expect academic papers or in depth clinical discussion. This will be my honest perspectives based on the last few years of living and working in this wonderful country.

____________________________________________

For those of you who are new to this, here’s the deal:

Most countries in the world don’t have enough dentists.

The problem is, people living in them  suffer the same levels of tooth decay and pain as we do in the west.  Tanzania for example, has about 440 dentally trained personnel – dentists, therapists, assistant dental officers etc, – mostly located in the cities, caring  for a population of 40 million people.

But at least 75% of people live a long way from the cities. The vast majority of them won’t have any access to a dentist who can help them when they have dental pain. And most of them will experience pain in any given year.

So it’s not about teeth – it’s about people in pain, and what we can do about it?

How about just increasing the number of dentists – that would work?

Or would it?

Even if we could bring about an instant increase in the numbers of trained dentists – the economy couldn’t support them.

Dentistry is an expensive part of healthcare to implement – equipment costs a lot of money, and is hard to maintain. What is more, most of what dentists use in the UK is superfluous to meet far more basic needs. In countries like Tanzania, there isn’t enough money available to fund health care, let alone graduate level dentistry in the small towns, villages and hamlets where most people live.

Getting dentists to live where most of the problems exist is also nigh on impossible. Dental graduates simply expect a certain standard of living. You can imagine the congratulatory letter from the Ministry of Health -

‘Congratulations on gaining your BDS! After many years of school and 5 years of dental school, your assignment is to work in a remote district town with sporadic running water, frequent power cuts, no tarmac roads, no good schools for your children, and no restaurants or places to hang out with your friends. Oh, and you’re the only dentist for 400,000 people.’

So although more dentists are needed, focusing on that alone won’t address the problem. It’s going to take many years for economies to grow to the point of sustaining this level of provision.

In the meantime people suffer.

My opinion, based on what I’ve seen and learned in East Africa, is that in this generation at least, for places like the one where I live, what is needed is not simply more dentists – but instead to train the army of healthcare professionals already present in rural areas to help people in pain.

Someone who has got toothache and has been in pain for months – or even years – simply wants to know;

Can you get me out of pain?

and

How did I get into pain in the first place?

That’s why our Bridge2Aid Dental Training Programme (served largely by our DVP volunteers) is built around answering these two questions – training local health workers in emergency dentistry to relieve pain in their communities, and educating rural populations about the causes of tooth decay. By training those health workers already deployed by the government to provide a simple, safe emergency dental service, the impact on the prevalence of pain is very high.

I also believe that we should keep building capacity.  Let’s keep training dentists! But we must be pragmatic – the pace of development is slow, and it will take many years before economies and infrastructures in this part of the world have grown to the point where the oral health care system can put a dentist within reach of every remote community.

And let’s keep it simple. Expensive dental equipment will break down and become unusable. I have lost count of the number of District Hospitals I have visited that have redundant and decaying equipment bought at great cost. Why not equip dentally qualified personnel with something more basic and appropriate to the level of treatment they will pragmatically be providing?

Waiting to implement a developed world model  in places where it is not yet appropriate isn’t good enough. People are in pain, we need to do something about it – now.

- Mark

Well I tried to imagine it and found it horrifying. Therefore, I decided that I had to do something about it. I am sure that many of you reading this are aware of the good work that Bridge2Aid do in East Africa by providing dental access on the ground. They do so by focussing on sustainability and empowering the local people so that they can improve their own lives for the long term. Very much from the ‘If you give a man a fish you feed him for a day, if you teach him to fish, you can feed him for a lifetime’ school of thought.

One of the key parts of becoming a Unity Partner is that we sponsor the training of a local healthcare worker – or Clinical Officers as they’re known. This Clinical Officer will then go on to work in their local community treating thousands of people who would otherwise have no access to dental care, providing vital relief from pain. A worthwhile cause.

However, I am not bringing this up to tell you how wonderful my team is (although if Bridge2Aid get some more support, then so much the better). I now take the view that those of us who are successful in our chosen fields have a duty to give something back. This is a quite accepted view in the USA but perhaps in the UK we have been reticent to put ourselves forward to help with charitable causes because either we don’t want to attract attention to ourselves, or perhaps we feel that the state has a duty to do this. Perhaps it does, but it isn’t going to happen anytime soon so we have to do something about it ourselves.

And let us not forget, that as well as massive benefits that we can deliver to the world and the people around us, giving something back is of benefit to us and our businesses too. How so?

• Mental wellbeing – I am not being flippant. The slightly selfish pleasure of knowing that we are doing something to help others is good for our mental (and possibly physical) health too.
• Team Building. I have to say that the team at Luke Barnett are delighted to with the Bridge 2 Aid project and it gives us something to concentrate on away from the daily work around the bench.
• Differentiation. It can be a tough world out there for all independent businesses at the moment. I feel that by supporting the Unity Partnership, we are offering another reason to do business with us aside from the excellent work that we deliver. Business is important but it isn’t everything. Having said that, I do feel we have a competitive advantage as a Unity Partner.

We should all take a step back and see where we can change lives. What cause you choose is up to you. I just feel that you should be doing something.

If you and your practice feel that you can make a difference, and want to find out more about Bridge2Aid and their work then please contact Kerry@bridge2aid.org or call 0845 8509877.

- Luke Barnett

Dr Kiaran Weil is a dentist from Darwen, near Blackburn.  She has been involved in 7 dental training programmes, is part of the site clinical lead team and heads up the UK training day for people coming out on our Dental Volunteer Programme.

“You may have heard Bridge2Aid quote the proverb ‘give a man a fish and you feed him for a day. Teach a man to fish and you feed him for a lifetime’.  Our DVP training programmes are based on our belief that if we just use our skills to treat people in rural Tanzania, we can only have a small impact, but if we train others to offer emergency dental treatment, we can have a far greater impact.

So what if instead of ‘teaching a man to fish’ we ‘teach a man to teach others how to fish’?

What impact can we have by teaching and empowering Tanzanians to teach emergency dentistry to others?

This is what phase 2 is all about.

At the beginning of March 2013 we successfully ran the first Phase 2 training programme in Misungwi district, about an hour’s drive from Mwanza.  Up to this point, our training programmes have utilised the skills of mostly UK dentists and dental nurses to train clinical officers, but this training has limitations.  In order for the training of clinical officers in Tanzania to be truly sustainable in the long term, we have to find a way to hand over responsibility for all aspects of the training and supervision to the government health system.  Phase 2 is a stepping stone towards this hand over.

Here’s how the phase 2 programme works in brief.

Four district dental officers (DDO) are selected to come on a training course where they are given 2 days of theory training on how to teach.  Under direct Bridge2Aid supervision, these DDOs train clinical officers in tooth extraction and oral health education on a nine day training programme.  During the programme both the standard of the clinical officers and the quality of teaching provided by the DDOs is assessed and improved.  Following the programme, ideally all clinical officers pass the course and receive basic dental instrument kits.

The nine day training programme is then repeated a couple of months later with the same DDOs, who are still supervised by Bridge2Aid but with far less direction needed.  This second programme allows us to assess if the DDOs have retained the knowledge and skills from the first programme.  Again clinical officers and are trained by the DDOs.  At the end of this programme, clinical officers that pass receive their instrument kits, and the DDOs on the programme (if they have performed to a high standard) are certified by Bridge2Aid and the government as ‘certified trainers’.

Following phase 2, the DDOs are then expected to each train 6 more clinical officers each within their own districts over the next 2 years , still supported by Bridge2Aid but with far less direct contact.  It is up to the districts to take the initiative and make the training happen.

A few weeks ago, Dr Kiaran Weil travelled out to Mwanza to work with me on the programme.  Together we provided training in how to teach and assess those we are teaching.  We supervised four DDOs – Dr Kalongoji, Dr Joseph, Dr Sasi and Dr Nyanda, who provided excellent training for 5 clinical officers.  It was interesting and quite humbling to see how much better some aspects of the training could be when delivered in Swahili.  We should never underestimate the importance of good communication in passing on dental skills! The nursing role was undertaken by Mariam Alphonce, one of our nurses at Hope Dental Centre, who worked brilliantly as a sole nurse to keep the clinic running efficiently.

I’m delighted to report that all five clinical officers passed comfortably and will be receiving the instrument kits soon.  The DDOs all reached a high standard by the end of the course and we look forward to the second part of phase 2 in May with confidence.

What impact is this going to have in the long term?  Up until now, the number of clinical officers trained has been growing steadily.  Phase 2 and the subsequent phase 3 will allow for exponential growth in the number of clinical officers trained.  In 2012 we successfully trained just over 50 clinical officers.  By 2015 we plan to train 176 clinical officers in one year, about 50% of this number coming through the programmes.  This level of growth will result in about 600 trained clinical officers by the end of 2015 providing emergency dental treatment in rural areas.  There are currently 440 dentists, assistant dental officers and dental therapists in Tanzania.  Our training will have increased the number of those able to provide a tooth extraction service by almost 150% within three years.

I think that’s pretty exciting.

But there’s a long way to go.

And we still need your help – now not just for DVP (phase 1), but also dentists and nurses who are willing to be trainers of trainers as part of phase 2. Interested? Then please contact our visits team: visits@bridge2aid.org.”

-          Paul

Over the past few days, I’ve been preparing a funding proposal for one of our donors to see if they would like to help fund our plan for the next three years.   There’ll be a post on that plan soon (along with Ian I’m currently talking with our partners and stakeholders about it before we go public).

As part of the funding document I had to update our achievements to date. I found it really encouraging to see just how much the B2A family has achieved since 2005:

- The total number of successfully trained Health Care Workers (HCWs) to date (2005-Feb 2013) is 222 (these are HCWs that passed).

- 243 trained in total since 2005 – presenting a pass rate of 91%.

- To date (2005 – Feb 2013) 2,220,000 people in rural areas of Tanzania (Lake Zone and Central Zones – 27% of the rural population in those areas) have been provided with access to Emergency Dental Care (EDC).

- Total number of patients treated for free during our training programmes to date (since 2005) is estimated to be around 17,263.

- We have now operated training on 29 occasions, using 41 teams since 2005.

- We have increased the number of people trained to provide EDC in Tanzania by 50% since 2004 (by adding the 222 HCWs trained in EDC by B2A to the existing 440 dentally qualified personnel).

The reality is that although the B2A family has done an amazing job with our impact over the past eight years, we have never been content to sit on that achievement. Because we see the impact of untreated dental disease on an almost daily basis, we are driven to reach as many people as possible through our training programme.

To grow, two of the fundamentals we need are volunteers and money.

Thankfully our volunteer numbers continue to keep pace with our growth. That is testament to the quality and impact of the programme, the standard of delivery that our amazing team continues to meet, and the almost evangelistic nature of our volunteers when they return to the UK.

In these economic times it is a tough thing for a charity to grow. Particularly when there is so much competition for funds from other causes. And so funding always remains an issue. Using funds well is crucial, but inevitably to deliver more, we need more.

My firm conviction is that the strength of the B2A family, combined with the demonstrable impact we are having, along with the generosity of the dental trade and profession will mean we can continue to achieve a great deal. Real impact for real people with real needs.

So. Volunteer, donate or fundraise?

Whatever you can do, I hope you will visit the B2A website and get involved.

- Mark