Zimbabwe meets Glasgow meets Malawi – an international odyssey in global oral health

I am delighted that this guest post has been written by Cleopatra Matanhire, a dentist from Zimbabwe who recently completed a Master’s degree in Global Health at the University of Glasgow.

For her research project, undertaken in part-fulfilment of her master’s degree, Cleopatra undertook a case study of the work underway by the Oral Health Policy Task Force, established by the Ministry of Health in Malawi.

Cleopatra was able to visit Malawi in October 2021, allowing her to attend a meeting of the Ministry of Health Technical Working Group when it considered the draft policy and to meet key personnel from the Ministry, the Dental Association of Malawi and the Kamuzu University of Health Sciences.

This account, based on a diary of Cleopatra’s visit to Malawi, gives a flavour of her experiences as as she visited the ‘Warm Heart of Africa’.

Monday 4 October 2021

After several weeks of the journey to Malawi being postponed, finally it materialises today, the 4th of October 2021. The story of how this happened emanates from a self-initiated introduction that I made to the University of Glasgow (U of G) dental team on my arrival in Glasgow for my MSc Global Health Studies. Even though I was enrolled in a different College, I had hoped to learn as much as I could about the accomplished and renowned work the U of G Dental School was doing in the world, especially in Africa. In my reading, I had come across the MalDent Project in Malawi and Bwiza Childsmile Initiative in Rwanda that U of G was involved in. Little did I know that I would end up doing my Master’s thesis on one of the projects.

Sometime in October 2020 I had a virtual meeting with Professor Jeremy Bagg and Professor Lorna Macpherson at Glasgow Dental School. I informed them of my willingness to learn as much as I could about their work, especially in dental public health. Instantly they asked what I planned to do my dissertation on, which was oral health policy related work, and our worlds aligned. One of the MalDent Project goals was to develop a national oral health policy for Malawi.

This was it, it ticked all the boxes, a dentistry related project, African context and if possible, on oral health policy. I had hit the jackpot!

What followed was months’ worth of preparation, reading, meetings and more familiarization with the MalDent Project. I settled on the title Developing Oral Health Policy in Africa: Case Study of Malawi. All of my project had to be done online as a result of the COVID 19 pandemic, but I sought to go visit Malawi physically and contextualise my research. Which is the purpose of this trip.

As I departed from Harare International Airport I wasn’t sure what to expect. One thing for certain though, I knew I would be intrigued by the journey as all things to do with developing oral health, especially in Africa, get me excited.  I was expectant to learn from the hard work the Malawi team had put in. I was fortunate to have been invited as a physical observer to the Oral Health Policy Taskforce meeting with the Technical Working Group (TWG) of the Malawi Ministry of Health, when Draft 11 of the policy was to be considered for sign off.  My journey would start in Lilongwe, where the TWG meeting was to take place and then I would proceed to Blantyre. A busy but interesting itinerary was laid out for me by the Malawian team.

Tuesday 5 October 2021

We hit the ground running. I would be in the company of Dr Peter Chimimba (MalDent Project lead in Malawi) and Dr James Mchenga (academic lead at the new dental school). Both James and Peter are Oral and Maxillofacial Surgeons (OMFS), in fact the only two OMFS in Malawi. On the schedule lined up for us in Lilongwe were a tour of Kamuzu Central Hospital, a visit to the Kamuzu University of Health Sciences (KUHeS) Lilongwe campus (formerly known as University of Malawi College of Medicine), a meeting with a Dental Association of Malawi representative and attendance at the Ministry of Health Technical Working Group meeting where the national oral health policy document was being discussed in depth. All this and more were achieved.

James Mchenga, myself, Peter Chimimba at KUHES Lilongwe Campus

The tour of Kamuzu Central Hospital was very interesting. The quality of services rendered by the currently available manpower is impressive.  Because for a long time there hasn’t been a dental school in Malawi, dental therapists’ scope of practice goes above and beyond the typical expectation. The therapists man rural health centres and district hospital facilities mostly on their own, undertaking maxillofacial procedures such as cyst enucleations and intermaxillary fixations.

Myself and Austin Mnthambala, Principal Dental Specialist at Kamuzu Central Hospital Dental Department

At Kamuzu Central Hospital I was impressed to see Registered General Nurses running the Dental Department’s infection control and equipment sterilization – I was informed they had been requested from the Central Sterile Supply Department (CSSD). This was particularly interesting as Malawi does not have qualified dental nurses or dental surgery assistants but had managed to plug the gap with an appropriate standard. I also had the privilege of meeting Mr Edgar Mthunzi, a dental therapist with further training in general anaesthetics. He was preparing for retirement, but I was rather impressed – never in my mind had I imagined that the local cases that were being conducted under GA were being undertaken with the anaesthetist having a dentistry background. This was a brilliant solution for the context and he had worked in this capacity for many years. In fact, the gentleman had worked with one of my colleagues from Zimbabwe during his training to qualify as an OMFS. I had to have a photo taken with him! I thought of our Dental Therapy students back home in Zimbabwe and how this would be a great example for career diversification and growth within the dentistry profession, if one is willing.

Mr Edgar Mthunzi and myself

During the trip, James and Peter would share with me their career journey and life stories which were so interesting. Later, that day we met with Dr Wiston Mukiwa, who I had been privileged to interview on-line for my master’s research project. Wiston has been practising for more than four decades. He had the privilege of serving as Principal Secretary in the Ministry of Health and Chief Dental Surgeon of Malawi earlier in his career. I spent the afternoon in the company of the three, as they narrated the journey of Dentistry as a profession in Malawi, from when there were only three dental practitioners to the present day. I was in awe of the accomplishments they had made, including the involvement of private practitioners in the development of the new National Oral Health Policy. The biggest takeaway from the afternoon discussions was that you only need a few dedicated, committed people to do the job. We agreed to work on strengthening collaborations as Regional dental associations and dental schools.

James Mchenga, myself, Wiston Mukiwa & Peter Chimimba

Wednesday 6 October 2021

Today the Ministry of Health meeting was held. Two new policy documents were being discussed – the National Oral Health Policy and the Emergency and Critical Care Strategy. Though we were physically at the Crossroads Hotel in Lilongwe, most of the participants logged in virtually on the Zoom platform. At the meeting I got an opportunity to meet Dr Jones Masiye (Deputy Director Clinical Services – NCDIs and Mental Health) from the Ministry of Health and Dr Martha Chipanda (the newly appointed National Oral Health Coordinator). Dr Dube, the Chief of Health Services and a specialist paediatrician, brought the house to order and led with poise. In fact, what surprised me the most was how well versed she was with both policies and specialties, having clearly reviewed the draft documentation thoroughly. She had an intriguing depth of oral health intersectionality with other health disciplines, referencing relevant previous projects and documentation that had been run within the Ministry of Health, decades prior. She proved to have a wealth of knowledge and offered wise suggestions of what needed to be improved.

I couldn’t help but think, this is what we need in African countries – homegrown, innovative and contextually relevant solutions to the health challenges: eradication of the silo approach and integration of health services.

There were even discussions to incorporate oral health into emergency services. At the hospital the previous day it had been indicated that most of the surgical cases were Road Traffic Accidents (especially with motorbikes being on the rise as public transportation in Malawi), followed by tumours.

With James, Jones, Peter and Martha at the Crossroads Hotel for the TWG meeting
James, Jones and Peter during a break in proceedings at the TWG meeting

Thursday 7 October 2021

Today we travelled to Blantyre by road. James made a great tour guide, helping me discover more about Malawi. He even showed me the area where my mother’s paternal roots and heritage originate from, before migrating to Zimbabwe. This was really a life defining moment, as I always wanted to appreciate the land of my forefathers in Malawi, Ntcheu!

Coming home to Ntcheu- my mother’s paternal roots!

After a 5-hour road trip we arrived in Blantyre. No time was wasted as we went straight to the Queen Elizabeth Hospital. We toured the Dental Department and the rest of Queen Elizabeth Hospital. I had the privilege of seeing Mercy James Paediatric Hospital, a specialty facility that Madonna, in collaboration with various benefactors, built and named in honour of her daughter who she adopted from Malawi.

The Mercy James Centre for Paediatric Surgery and Intensive Care

In there were benefactors close to my global health academic journey: the Beit trust who had sponsored my postgraduate studies at the University of Glasgow and NHS Greater Glasgow and Clyde, who were a frequent find in our studies and whose staff we interacted with a lot.

The benefactors listed inside the Mercy James Centre

The highlight of the afternoon was James preparing his theatre list for the following day. I was present for all the case reviews. I was yet again impressed as dental therapy interns that had clerked the patients presented the patients, including differentials and provisional diagnosis, surgical and treatment management plans. What stood out was the early age of presentation of patients with benign and malignant tumors of the maxillofacial region – more than 4 of the cases were patients less than 24 years of age; some were even in their teens. A minority of the cases were trauma cases, the injuries having been sustained in road traffic accidents and assault cases. The staff helped me appreciate that the patients had travelled far and wide to be able to access these particular oral health services.

From the Hospital, we headed to Kamuzu University of Health Sciences Blantyre Campus. A quick tour of the institution helped me realise the outstanding work the Malawi and Glasgow team have been putting in equipping and establishing a world class dental training facility. Even though we had had an extremely busy and exhaustive day, it was productive and ended on an extremely high note!

Newly equipped Dental Department at Queen Elizabeth Hospital

Friday 8 October 2021

Friday commenced with a debriefing session with Peter and James at KUHES Blantyre Campus for the week’s activities and more. We ended our meet and said our goodbyes to each other and the other MalDent team members.

Annie Mwapasa (MalDent Administrator) and myself at KUHES Blantyre campus moments before departure.

Aboard the return flight from Blantyre to Lilongwe my official itinerary was complete, with everything done and dusted. It was time to carry out in-depth personal reflections of my visit.

My reflections …

Though it is clear Malawi’s oral health workforce is inadequate, it is highly specialized. In Blantyre at Queen Elizabeth Central Hospital I spent the afternoon yesterday with Dr Mchenga and his team of dental therapy interns attending to the theatre list for the following day. The knowledge the interns had of OMFS was the standard of BDS finalists / interns. They even gave provisional diagnoses and treatment plans.

Prior to that I had been informed that due to the similar challenge of the Oral Healthcare Worker shortage, Dental Therapists are equipped in districts to perform minor surgical procedures such as inter-maxillary fixation, enucleations and the like.

For me, there is an emerging story to be told here. I reflect on home and realise that contrary to Malawi we have a large oral health workforce, but it is now concentrated in the urban areas, whilst the remote parts of the country are unserved.  Most recently the BDS program has been restructured to become longer and internship for foreign trained dentists extended. The African region faces a clear shortage of practitioners, but the regulatory authorities continue to tighten training policies and increase the timeline to produce a Practitioner. It made me think, what is the motivation for these decisions? Are the decision makers informed of the situation on the ground? Do they consult oral health experts prior to imposing these decisions? Do they consider the plight of the candidates who take up the training who now have to invest 8-10 years of their time into undergraduate degree training without pay? At present, there already is a massive exodus of health practitioners. Where will we stand in a decade from now on oral health service delivery? In the meantime, the oral disease burden increases and lives are at risk.

Lessons from the visit to Malawi

Oral Healthcare Worker shortage is no excuse for not delivering services.  Existent health workforce can be capacitated within the required field. Dental Surgery Assistants are non-existent in Malawi, but Central Hospital Dental Departments have RGNs from CSSDs manning infection control, disinfection and sterilization. Meeting a dental therapist who had pursued further training in anesthetics and worked in house with the OMFS was another revelation – a career path for a dental therapist that I had never thought of.

We need to think again about workforce models, because the traditional norms in developed countries do not work for low- and middle-income countries. In reality, there is now a realisation that they don’t work well for developed countries either, particularly as the need to address sustainability and planetary health has become an urgent imperative. There is an opportunity for countries like Malawi and Zimbabwe to develop and lead the way on new ways of working. I am excited to be part of it!

Dental students’ first taste of refurbished dental clinic at Queen Elizabeth Hospital, Blantyre

After a short break on the MalDent blog, we are delighted to be back with a guest post from Chifundo Banda, one of the pioneer cohort of Bachelor of Dental Surgery students at Kamuzu University of Health Sciences (KUHeS).

However, by way of preamble I would like to congratulate Drs James Mchenga and Peter Chimimba on the work they have been doing with colleagues to improve the clinical facilities available at the Dental Department of the Queen Elizabeth Hospital in Blantyre.

These improvements have included installation of some new dental chairs:

and the installation of a digital pan-oral radiography unit:

These enhancements to the infrastructure will be a great benefit to patients as well as to staff and future students and were part of the experience gained by Chifundo and his classmates when they visited recently.

I hope you enjoy Chifundo’s reflection!

My name is Chifundo Banda, a second year Dentistry student at the Kamuzu University of Health Sciences. I totally had no idea of what a Dental Department at a Central hospital looks like. On the 27th of October 2021, I had the privilege to visit the Dental department at Queen Elizabeth Central Hospital in Blantyre, Malawi. I was very eager to see and experience how the setup is like and how it operates. Everyone was excited and we were smartly dressed in our white lab coats, we really looked like Dentists. We were warmly welcomed by our Academic lead, Dr. J. Mchenga. We made a mistake by not arriving on time, and this was our first lesson that as Dentists we should always keep time. We also learnt that we should not just sit anywhere else because we do not know who was previously sitting there to minimize the risk of infection spread.

Our first room to go in is where extractions are done. The room is spacious with about 4 extraction units and it is well ventilated. I realized that the instruments that are used for extractions are kept in silver trays that are fully covered and each is classified according to its use. When one wants to get an instrument, they had to use forceps to minimize contamination. There was also a waste disposal bin and another one for sharps. We were lucky to see a little girl having her tooth extracted by one of the dental therapists. From there, we went to a room where surgeries like oral and maxillofacial surgery are performed.  It is the best room that we ever visited; the paintings, equipment and ventilation made it look good. There were two Dental chairs fully equipped and each had a separate radiograph machine mounted on the wall that could easily be used to examine a patient while sited on the chair. It is a convenient room to work in with a patient. The drainage system itself was very perfect.  There was a mobile suction machine ready for use in case the one mounted on the chair gets out of use. We were lucky that we had our first hands on experience by sitting on the dental chair, and using some of the things that are on it. While we were still there, we saw a boy with a swelling, probably a tumour on the left mandible who was with his guardians. Our academic lead, welcomed them warmly and they were helped. Every one of us realized that there is more to Dentistry than just teeth.

Our next station was the Dental laboratory for the hospital. I was wondering of what would we would find in the lab. To my surprise, I really confirmed that Dentistry is an art too. This is the lab where we make false teeth (crowns, bridges, veneers) and jaw impressions on our own. Materials like acrylics and plaster of Paris are used, I really liked the lab since I love art. We then entered another room that is under refurbishment. This is the one that will be used for paediatric dentistry when it is complete. Our academic lead told us that he wanted it be painted with beautiful drawings since children like them. We loved the idea.

Pertaining the issue of infection prevention, we were shown another room where all used dental instruments are sterilized using an autoclave and other cleaning machines. In order for a Dentist to make a good diagnosis, there is a need to use supporting equipment like radiographs. It is therefore a privilege that our department has a radiology room since if we depended on that for the whole hospital it would take long to get the results. We were amazed to learn that as part of our training we learn radiology so that we are able to interpret the results on our own. We also entered another room where all other Dental procedures like orthodontics, periodontics and prosthodontics are done. It was also fully equipped, I really felt that I was in a clinic.

Finally, at the entrance there is a plasma that is supposed to convey Dental related education to the people who come to the clinic but that was not the case. It is the therefore our responsibility as Dentists-in-training to come up with something to show up to the community. It was really a wonderful experience that I have ever had in my life and am looking forward to the completion of my degree so that I serve mankind.

As Chifundo and his colleagues look forward to the clinical dentistry components of their BDS course from next February onwards, it is not only the technical aspects of the profession they need to understand, but also the social and environmental context in which they will be serving their fellow Malawians. This latter aspect is a very strong component of all healthcare courses at KUHeS and for that reason students spend time living with a family in a rural area for several days to understand and see at first hand how the social determinants of health play a key role in disease prevention and access to care. This module is called ‘Learning by Living’ and will provide great benefit to dental students as part of their learning to be dentists who are not only ‘globally competent’ but also ‘locally relevant’.

Chifundo and his colleagues have recently completed the ‘Learning by Living’ module as part of their BDS 2 programme of study and we look forward in due course to their reflections on the experience.

Dr James Mchenga with the BDS 2 class, preparing to depart for the ‘Living by Learning’ module in Mangochi

It’s a century – the hundredth post on the MalDent Project blog!

During a recent discussion with Nigel and Vicky Milne, co-founders of the charity Smileawi, I mentioned that we were coming up to the hundredth post on our blog. Vicky suggested that I focus on the many collaborations that we have established and the multiple sources of support that underpin the project as a way of reflecting on where we are and where we are heading. It was an excellent suggestion and I’ve taken up the challenge. Where appropriate I have added web-links to earlier posts and included some photos of key events.

First and foremost, the MalDent Project is a partnership between the Kamuzu University of Health Sciences and the University of Glasgow, which is now well established and based upon trust and mutual respect. The progress made by this partnership since 2017 has been made possible through generous funding from the Scottish Government Malawi Development Programme. The photo below illustrates the beginning of this tripartite basis for the MalDent Project which occurred during a working lunch in Malawi in September 2017 between myself, Dr Mwapatsa Mipando and Mr Ian Nicol from Scottish Government International Development.

A working lunch which proved to be the start of the MalDent Project journey

Two other organisations that have provided very valuable support are the Corra Foundation and the Scotland Malawi Partnership. Chrissie Hirst provided exceptional support with the log-frame development for the MalDent Project and to my colleagues at Smileawi with their Scottish Government grant relating to task shifting of emergency dentistry in Malawi.

Chrissie at the Corra Foundation providing log frame support!

The Scotland Malawi Partnership has helped us to publicise the MalDent Project and been responsible for introducing us to a number of our current collaborators, which has been a tremendous support for our efforts.

An opportunity to talk about the Maldent Project at a Scotland Malawi Partnership Health Forum at Edinburgh City Chambers

The NHS Scotland Global Citizenship Programme has also been a valuable resource and we have established a MalDent Project web domain on its main website.

One of the earliest supporters of the MalDent Project was the Royal College of Physicians & Surgeons of Glasgow (RCPSG), through its Global Health Group chaired at the time by Mr Mike McKirdy. My initial scoping visit to Malawi in September 2017 was partly funded by the College and when a delegation from Malawi visited in March 2018, the College generously hosted a dinner for our visitors. The HOPE Foundation of the RCPSG has also provided funding in support of our work to refurbish the Dental Department at Kamuzu Central Hospital.

Great Scottish hospitality for our Malawian guests in the Livingstone Room (very appropriately!) at the RCPSG

Another early and continuing supporter has been the journalist and author Susan Dalgety who I met with her husband in Malawi whilst she was living in the country for six months to research her wonderful book, The Spirit of Malawi.

With Susan and her husband Nigel Guy after a great discussion over coffee in Blantyre

Not only did Susan mention the Maldent Project in her book, which was a tremendous thrill, but also covered us on several occasions in a weekly column she writes for The Scotsman newspaper, which gave us a great boost.

The university sector plays a major role in the MalDent Project. The challenges posed by poor oral health and delivery of dental care in Malawi were initially brought to the attention of the University of Glasgow in 2016 by the Principal of the University of Malawi College of Medicine (now Kamuzu University of Health Sciences), Dr Mwapatsa Mipando. This was the beginning of the partnership from which the MalDent Project arose. We have benefitted greatly from the high level partnership between the two universities.

Partnership working and collaboration – here at the University of Glasgow with Professor John Briggs, then Clerk of Senate and Dean for Africa

This partnership has also resulted in a very exciting biomedical research programme based around a new state of the art laboratory known as the Blantyre Blantyre Research Facility. The MalDent Project team is very grateful to colleagues involved in the Blantyre Blantyre laboratory development for advice, encouragement and support.

Alex Mackay and Paul Garside of the Blantyre Blantyre Project with Ben Macpherson MSP and I at a Scotland Malawi Partnership AGM – all great supporters of the MalDent Project

Discussions in the Marketplace at one of the the Scotland Malawi Partnership Annual General Meetings led to an invitation to speak about the MalDent Project at the Rotary Club of Ayr. Professor Bob Kalin from Strathclyde University was in the audience that evening and that meeting in turn triggered a very valuable study with Bob’s team on fluoride levels in groundwater in Malawi and dental fluorosis that has recently been published.

The University of Dundee has involvement with the Maldent Project on several fronts. Its Centre for Medical Education (CME) has been working with the Kamuzu University of Health Sciences for several years and when we invited a delegation of colleagues from Malawi to visit Glasgow Dental School in March 2018, we arranged a visit to to the CME which was hosted by Dr Neil Merrylees.

We also engage frequently with colleagues at Dundee Dental School, particularly Professor Peter Mossey, who introduced us to the FDI (International Dental Federation), resulting in the MalDent Project being used as an exemplar in its recent 2030 Vision document, and Mr Andrew Paterson who is a Trustee of the charity Bridge2Aid (see later). Very recently Olivia Welch, a Dundee dental student, completed a dissertation for her intercalated BMSc in International Health based on a study of the design work currently underway for the new dental teaching facility / student hub on the Blantyre campus of KUHeS, which is also funded through the MalDent Project (see below).

Collaboration across universities and with local partners was key to success of the curriculum development for the new BDS course. Two curriculum conferences were held involving KUHeS, the University of Glasgow, the University of North Carolina and Wits University. Professor Simon Nemutandani, Dean of the Dental School at Wits, provided valuable support to the local team in Malawi and played a pivotal role at the Second BDS Curriculum Conference in November 2018. The curriculum conferences were also attended by representatives of the Dental Association of Malawi, Medical Council of Malawi and the National Council for Higher Education to ensure that the relevant official and regulatory bodies were involved from the outset.

Wits University is also hosting the four Assistant Lecturers as they undertake Masters degrees in a range of dental specialties before returning to their teaching roles at KUHeS.

Delegates from multiple organisations at the Second BDS Curriculum Conference in Mangochi, November 2018

Chance encounters which have brought great opportunity have been a feature of the MalDent Project. It was one such encounter at a gathering in a Glasgow coffee shop for discussions with Professor Phil Cotton, Vice-Chancellor of the University of Rwanda, that resulted in my introduction to Professor Chris Platt, Mackintosh Professor of Architecture at Glasgow School of Art. Chris had been working on plans for student hostels in Rwanda and when I explained that we had funding to design a dental teaching facility in Malawi the conversation rapidly became very animated – it was fantastic. By chance, Dr Mwapatsa Mipando, then Principal of the University of Malawi College of Medicine, was due in Glasgow shortly afterwards and a meeting was hastily arranged.

Happy faces after a very positive discussion

It was agreed that Chris would lead a design workshop with key stakeholders in Blantyre, which would also provide opportunity to view potential sites on the campus. Two senior architecture students from the Glasgow School of Art agreed to join us to help organise the event – Breffni O’Brien and Ciara Durkin.

It was a whirlwind few days but very successful. We had invited the Head of Architecture, Ike Phiri, and some of his students from the University of Malawi Polytechnic to join the workshop and we visited their department the day before to brief them on the project, which provided a great piece of experiential learning for the students. Also in attendance were architects Patrick Calisse and Peter Creaser from MOD Architects, a local practice with previous experience of building on the Blantyre campus.

This very successful workshop provided sufficient information to establish an initial project brief and schedule of accommodation to incorporate in a procurement process to appoint a design team. Following a formal process through the University of Glasgow Procurement Office, a consortium led by John McAslan + Partners was appointed. The consortium included Studio KAP, Buro Happold, Quant Consult Associates and David Narro Associates. The design process is well underway and a bid by KUHeS led by Dr Mwapatsa Mipando to the World Bank for $5.2m towards the capital cost of the project was recently agreed and has been approved by the Malawi Parliament.

At the interface of education and clinical service, NHS Education for Scotland (NES) is a formal partner of the MalDent Project. There are two dental educational programmes, managed by NES, that are of particular value for both undergraduate and postgraduate dental education. The first of these is the suite of clinical guidance document produced by the Scottish Dental Clinical Effectiveness Programme (SDCEP). The second is the repository of learning materials, developed in partnership by academics and learning technologists in Scotland’s dental schools, known as Scottish Dental Education Online (SDEO). Both of these resources are freely available online to dental students, academic staff and other dental professionals in Malawi.

A number of Scotland’s NHS boards have supported the MalDent Project through donation of dental equipment, particularly dental chairs. These have included NHS Greater Glasgow & Clyde, NHS Lothian, NHS Highland and NHS Tayside. We have also benefited through donations from general dental practitioners.

Members of our great portering team at Glasgow Dental Hospital loading dental chairs donated by NHS Greater Glasgow & Clyde into our rented 7.5 tonne truck ready for transportation to Dentaid and then Lilongwe

Donation of medical equipment to low income countries is a complex area, riddled with potential pitfalls. In particular, the donated equipment must be in good working order and robust but it is also important to ensure that there is engineering expertise for installation in the recipient country and biomedical engineers available who can service and maintain the equipment in the long term. Unfortunately, such expertise is in short supply in many low-income countries such as Malawi. In order to address these issues, the MalDent Project has been very fortunate to number the charity Dentaid and the international dental supply company Henry Schein among its closest and most active partners. Both organisations are a key part of the chain of ‘donation – transportation – installation in country’, working with local engineers and tradesmen, in the refurbishment of the Dental Department at Kamuzu Central Hospital, which currently delivers training of dental therapists from the College of Health Sciences and, from February 2022, will also be used for pre-clinical and clinical teaching of BDS 3 students.

With colleagues from Dentaid and Henry Schein together with two carpenters from Kamuzu Central Hospital after a day of installing dental chairs and phantom head units

To address the longer term need for skilled dental equipment engineers in sub-Saharan Africa, the development of a module in dental equipment technology is currently underway to be offered as part of the Biomedical Engineering BEng degree at the Malawi University of Science and Technology (MUST). This is a partnership within the MalDent Project between MUST, KUHeS, Henry Schein, Dentaid and a large American dental supply company DCI.

The charity sector continues to play a major role in the Maldent Project. In addition to Dentaid, the two dental charities Smileawi and Bridge2Aid are key players, with all three of these organisations bringing different skills and experiences to the MalDent Project work streams. Furthermore, there is great cooperation and communication between all the parties

A joint meeting at Dentaid HQ with colleagues from Dentaid, Bridge2Aid, Smileawi and Henry Schein, discussing a variety of work streams linked to the MalDent Project

Bridge2Aid introduced me to the programme of task-shifting of emergency dentistry to Clinical Officers in Tanzania, that they have been running for over 15 years. It was a model that was clearly applicable in Malawi and in collaboration with the Dental Association of Malawi and Smileawi, with full support of the Ministry of Health, Bridge2Aid planned a pilot course for Malawi in June 2020. Unfortunately the COVID-19 pandemic resulted in postponement but as soon as conditions allow, the pilot will proceed.

Bridge2Aid and the Dental Association of Malawi participating in a Smileawi CPD Conference for dental therapists, to explain and discuss the plans for the task-shifting initiative.

Smileawi instigated the pilot child oral health survey which they undertook in June 2019 with a group of senior dental students from Glasgow and Dundee Dental Schools. This study turned into the largest child oral health survey ever undertaken in Malawi and has provided valuable learning for the national child oral health survey planned for 2022 in which Nigel and Vicky Milne have already agreed to participate.

Smileawi and senior dental students under supervision performing dental examinations during the pilot oral health survey

Very recently, with Scottish Government funding through the Small Grants Scheme, Smileawi has collaborated with Bridge2Aid, the Dental Association of Malawi and ProDental CPD to produce twelve on-line training modules for dental therapists in Malawi. Twenty six therapists in the North have been provided with tablet computers and pre-purchased data bundles and are completing the full course, for which they are awarded CPD. The therapists have provided comprehensive feedback on the course content and therapists in other districts are now keen to participate.

Dental therapists celebrating beside Lake Malawi after receiving their CPD certificates from Martha Chipanda, the recently appointed Oral Health Coordinator at the Ministry of Health. The presentation ceremony was shown on Malawian TV.

The close involvement and constant support of the Dental Association of Malawi, particularly from its Secretary Dr Wiston Mukiwa, has opened many doors for the Maldent Project and continues to be a vital partner.

Another key partner from the charity sector is the Borrow Foundation, which is providing significant funding for the work on prevention of dental caries in children. Ronald Manjomo, our PhD student at KUHeS, receives a bursary and the funding will also help to support the forthcoming national child oral health survey.

Lorna Macpherson and I with Nigel Borrow and Margaret Woodward, following a meeting to discuss how the Borrow Foundation could support the MalDent Project

Many of the activities underway in conjunction with charities are closely aligned with priorities that have been identified in the ongoing work to develop a national Oral Health Policy. This package of work is led by the Malawi Government Ministry of Health and commenced with a two day workshop in Lilongwe in February 2020.

Delegates attending the National Oral Health Policy Workshop in Lilongwe, February 2020

Subsequently an Oral Health Policy Task Force was established with representation from the Ministry of Health, Ministry of Education, Science and Technology, Office of the President and Cabinet, Dental Association of Malawi, Medical Council of Malawi, WHO Africa, KUHeS and the University of Glasgow.

The close involvement of Dr Yuka Makino, WHO Technical Officer for Oral Health in Africa, has been especially valuable in the policy work to date and has provided an excellent interface with oral health activities in other sub-Saharan African countries.

Discussions with Dr Yuka Makino in preparation for the National Oral Health Policy Workshop

The policy and implementation plan are due for official launch in late Summer this year. In addition to providing a route-map for oral health improvement activities in Malawi, we hope that much of the content will be generalisable to neighbouring countries with whom we are developing links, including Rwanda, Zambia and Zimbabwe.

This blog post has concentrated on highlighting the input of more than 50 organisations to the work of the MalDent Project. In addition, there are many other individuals and small groups who make a highly significant contribution. The on-line Christmas Concert put together by Glasgow Dental School’s Big Smile Big Band to raise money for Smileawi and the contribution to the recently established MalDent Student Aid charity by my class mates at our 40th Reunion are just two examples. Others such as Deirdre Kelliher who looks after the grant management and Annie Mwapasa our Project Administrator in Malawi work with total commitment and dedication on the project. Many thanks to them all.

I’d like to finish with a photo of the three men whose vision and hard work lit the blue touch paper to ignite the MalDent Project and who have then continued to provide the support needed to maintain progress, despite multiple challenges such as COVID-19.

Dr Peter Chimimba, Dr Mwapatsa Mipando and Prof Nyengo Mkandawire at the launch of the BDS degree programme in August 2019

They deserve the last word as we look forward to the next 100 posts!

Sustainable building design in low income countries – a Dundee dental student’s perspective

I’m delighted today to publish a guest post from Olivia Welch, a dental student at the University of Dundee.

At the end of her second year of study on the Bachelor of Dental Surgery degree course at the University of Dundee, Olivia decided to undertake an intercalated BMSc degree in International Health. I was introduced to Olivia by two of my colleagues from Dundee, Neil Merrylees and Peter Mossey, both of whom were aware of the MalDent Project and thought that it may provide an opportunity for Olivia to select a relevant topic for her dissertation. After a wide-ranging discussion, a subject area was chosen and in this post, Olivia describes her experience.

This time last year I was on a Zoom call with Professor Bagg, marking the beginning of my involvement with the MalDent Project. Having just decided to take a year out of dental school to study for a BMSc in International Health, I was searching for a topic to focus my dissertation on.

The collaboration between Malawi and Scotland to design a state-of-the-art facility in a country recognised as “low-resource” captured my interest, and the enthusiasm and ambition of those driving the project was infectious. As a result, I undertook a research project focussing on the factors affecting the design team’s decision-making process in their efforts to make the Malawian dental school a highly sustainable building – environmentally, economically, and socially.

My eyes were opened to challenges faced by architects unique to this region, such as how to safely store captured rainwater in a malaria-endemic country, where standing water poses a hazard to public health. My research revealed that difficulty sourcing environmentally responsible materials and tradesmen experienced in building with such materials in the local area were one of the main obstacles the design team had to overcome. In addition, this project was backdropped by the COVID-19 pandemic, the restrictions of which forced the team to hold virtual meetings to begin designing the dental school after just one site visit.

Attending an on-line meeting with members of the design team and MalDent Project

Conversely, it was inspiring to see the creativity the circumstantial limitations of this project inspired. Indeed, as mused by one of the architects of the dental school, constraints are a vital component in nurturing creativity in the design process. For instance, the demand for a building with low running costs combined with a lack of local expertise in maintaining advanced air-conditioning systems led to the incorporation of passive design in the building, which takes advantage of the climate and clever use of shading and ventilation to maintain a comfortable temperature range in the building with little to no mechanical intervention, a highly sustainable solution.

Carrying out this research project allowed me to step out of the prescriptive learning format of my dental degree and nurture skills beyond “drilling and filling” by providing me with my first experience carrying out formal interviews. On clinics, we employ the ‘golden minute’ whereby, if you allow the patient, most of the relevant information will emerge, so long as they are not interrupted. It may sound simple, but this is a difficult practice to exercise because humans are not naturally comfortable with silences. After carrying out seven interviews each lasting an hour, I have no doubt this practice will improve my patient consultations when I return to clinics in September.

This experience would not have been possible without the support of those kind enough to volunteer their time and knowledge to this project, and I was genuinely touched by the willingness of the design team to be involved. The next step for me is endeavouring to get my dissertation findings published: I recently met with Professor Bagg, Professor Platt and my project supervisor Dr Fioratou, to brainstorm ideas and as always, I came away from the discussion inspired by our discussion about aspects of my dissertation I could possibly focus on.

A meeting to discuss publication of dissertation findings with Dr Fioratou, Professor Platt and Professor Bagg

To see the ambition of providing Malawi with its first dental program coming to fruition has been inspirational to witness at this early stage in my dental career and has taught me this: anything can be achieved, it just takes belief to make the first step, the rest will fall into place as there is a wealth of talented and benevolent people out there willing and able to help make it happen. I wish everyone involved the very best of luck and I look forward to visiting the completed building in Malawi someday soon!

Posing with my final dissertation

To conclude this post, I would like to congratulate Olivia on achieving a First Class Honours classification for her intercalated BMSc after a year of very hard work and commitment on her part. Good luck when you re-join your BDS colleagues next session and we look forward to keeping you updated on progress with the building.

Finally, grateful thanks are due to Professor Chris Platt, Chair of Architecture, Mackintosh School of Architecture, Glasgow School of Art and to Mr Paul East, Associate, John McAslan + Partners, for their support. Thanks also to those who agreed to be interviewed by Olivia as part of her data gathering, both in Malawi and the UK.

Supporting the Oral Health Policy – a new appointment, CPD approval, and linking with the Ministry of Education

As regular visitors to our blog will know, one of the main work streams of the MalDent Project is the development of an Oral Health Policy for Malawi, together with an Implementation Plan. Work on drafting the policy is nearing completion in preparation for a planned launch in August. Three recent developments map perfectly onto the policy objectives.

First, the Ministry of Health has recently appointed Dr Martha Chipanda as Malawi’s National Oral Health Coordinator. Martha has been involved with the MalDent Project from the outset in 2017, when she was part of the team that drafted the curriculum for the newly established BDS programme at the Kamuzu University of Health Sciences (formerly the University of Malawi College of Medicine). At that point Martha was a dental surgeon at the Kamuzu Central Hospital in Lilongwe, but more recently she has moved to her current position as a dental surgeon at Mzuzu Central Hospital. Martha will continue to deliver clinical service in Mzuzu in addition to the duties of her new role in the Ministry of Health.

Martha (centre) at the Ministry of Health in Lilongwe following a meeting in 2018 relating to a task-shifting proposal from Bridge2Aid in support of emergency dentistry provision

Secondly, after a significant amount of work by its Secretary, Dr Wiston Mukiwa, the Dental Association of Malawi has been officially approved by the Medical Council of Malawi as a provider of CPD.

Wiston receiving thanks and a gift from Andrew Paterson of Bridge2Aid after he had spoken at a Smileawi CPD meeting in Mzuzu in 2019

The Dental Association has received the relevant certification, dated 22 June 2021 and valid for a period of five years:

Like Martha, Wiston has been involved with the MalDent Project from its inception and is now a part-time Lecturer on the new BDS programme. His role as Secretary of the Dental Association of Malawi has been a real asset to many of our activities since 2017, particularly in our communications with the Ministry of Health. It is fitting that the first educational materials to be supported with official CPD credits for dental therapists are the learning modules launched on 31st March this year following the Scottish Government – funded collaboration between the Dental Association of Malawi, Smileawi, Bridge2Aid and ProDentalCPD.

Thirdly, a major emphasis within the new Oral Health Policy will be on prevention of dental disease in children. Ronald Manjomo, our PhD student at Kamuzu University of Health Sciences, is making great progress with his ongoing review of systematic reviews of dental caries prevention in children and case studies from around the world. Professor David Conway, from the University of Glasgow Dental School Community Oral Health Research Group, has joined the supervisory team and is providing excellent additional guidance and support for Ronald.

All smiles at a recent PhD meeting with Ronald

Linked to Ronald’s work is the planned national Child Oral Health Survey, scheduled for 2022. A critical initial step has been to establish contact with the Malawi Government Ministry of Education. Following discussions with our Oral Health Policy Task Force colleagues in the Ministry of Health, we arranged a meeting with Albert Saka (Chief School Health Nutrition HIV and AIDS Officer) which took place on 22 June 2021.

Peter Chimimba, Albert Saka, Lorna Macpherson and I at the conclusion of our meeting

Albert was extremely positive about the planned survey and together with his team has agreed to guide and support us through the processes that are required to gain the necessary permissions and to establish appropriate communication channels with the schools and teachers.

These three areas of progress will all help to support implementation of the national Oral Health Policy scheduled for sign-off and launch this Summer.

The ‘MalDent Student Aid’ charity is launched

Following approval of the BDS curriculum by the University of Malawi College of Medicine in March 2019, I had a number of conversations with Malawian colleagues to identify ways in which we could provide support for the students who would be joining this fledgling programme. An obvious possibility which came to mind was the acquisition of relevant dental textbooks for the Blantyre campus library. However, I was advised that the combined costs of University fees, accommodation and food prove financially challenging for some of the students in higher education and that a more valuable route of support would be to establish a mechanism for funding a bursary scheme for those who were struggling to cover their costs.

It was then explained that for medical students there already existed a programme called ‘Medic to Medic‘, administered by the University, which provided means-tested financial support for those needing some additional money for daily living. Thus was born the concept of ‘Dentist to Dentist‘, to provide a similar bursary scheme for dental students.

We have established a new charity called ‘Maldent Student Aid’ (Registered Charity No.: SC050001) which will raise money here in the UK to provide a source of funds for the ‘Dentist to Dentist’ financial aid scheme, administered by the Kamuzu University of Health Sciences (formerly the University of Malawi College of Medicine). As I did for our MalDent Project visual identity, I turned again to my brother Simon to design the logo for our new charity:

Our first donation

I was a dental student in Edinburgh between 1975 and 1979, and at the end of 2019 we had our 40th Reunion at the Apex Hotel in Edinburgh. Big thanks are due to classmates Shirley Hopkins and Yvonne Millar who undertook all the organisation and ensured that we had a great time. The relevance of this event is that I had mentioned to another former classmate, Alastair Bryden, that I was going to be establishing a small charity to support Malawian dental students. Unknown to me, he had shared this information with Shirley and Yvonne who in turn gained agreement from all my classmates that the evening’s raffle proceeds should provide the first donation to the charity. I was really touched by their thoughtfulness and generosity.

After dinner, I was invited to speak for a few minutes about the MalDent Project:

Shortly afterwards the raffle was drawn and realised a total of £500 – all of which my generous class-mates have donated to MalDent Student Aid. This was truly ‘Dentist to Dentist‘ and I hope a good omen for the future success of the concept. So a massive ‘thank you’ to all my great friends and colleagues in the Edinburgh University BDS Class of ’79!

Keeping in touch and supporting our cause

We have established a web-site for our charity at http://www.maldentstudentaid.org, which explains our purpose and vision:

The web-site includes a link to this blog to ensure that supporters are kept up to date with the broader MalDent Project, but we will also update it with news and views as the charity develops. There is also a facility for making one-off or regular donations via CAF Donate for those who would like to support our cause.

Ultimately our ambition is to widen access to the new BDS programme in Malawi for those requiring some additional financial support with their studies, so that in due course they can join our MalDent Project mission of achieving ‘Oral health for all’.

Establishing a charity is not as straightforward as I had originally thought and there are a number of colleagues that I would like to thank:

Ewen Dyer and Jayne Clifford at Martin Aitken and Co. were extremely helpful with preparing and submitting the application for charitable status from the Office of the Scottish Charity Regulator. I am very grateful for their advice and support.

Petrina Sweeney, Alex Mackay and Niall Rogerson, three of my University of Glasgow colleagues, have joined me as Trustees of the charity and I look forward to working closely with them as we build a sustainable future for MalDent Student Aid.

Finally, a massive thanks to all my Malawian friends who have encouraged me to establish this partnership between MalDent Student Aid and the Kamuzu University of Health Sciences ‘Dentist to Dentist‘ programme. It’s taken a while but we got there in the end!

World Health Assembly approval of Oral Health Resolution coincides with great progress on finalising Malawi’s National Oral Health Policy

For those of us engaged in global oral health initiatives, the Oral Health Resolution that was proposed by the WHO in January 2021 marked a very important moment and was mentioned in an earlier blog post. Many of the recommended actions resonated strongly with the direction of travel being followed by the Malawi Government Oral Health Policy Task Force.

On 27th May 2021, at the Seventy-fourth World Health Assembly (WHA), the Oral Health Resolution was approved. Delegates asked WHO to develop a strategy on tackling oral diseases and to translate the global strategy into an action plan for oral health. You can read more of the detail here.

It was especially fitting for the MalDent Project that the Malawi Government was invited to make a statement at the WHA, which read as follows:

MALAWI-STATMENT-ON-NCDS-ORAL-WHA-73

By coincidence, a close to final draft of Malawi’s forthcoming Oral Health Policy was being reviewed by Task Force members and other Government stakeholders at a workshop in Mangochi on 27th-29th May 2021, with the aim of producing a final, polished document ready for presentation to the Ministry of Health Technical Working Group. The workshop delegates are pictured below:

The Oral Health Policy Workshop delegates

The photo shows (left to right):

Dr James Mchenga ( Academic Lead, KUHeS Dental School)

Dr Michael Udedi (Assistant Director – Clinical Services for Mental Health and Substance Abuse at MOH)

Miss Annie Mwapasa (Administrator, MalDent Project at KUHeS Dental School)

Mr Brian Chaima (Principal Economist, Real Sector Policy Analysis Section, Ministry of Economic Planning and Development)

Miss Yacinta Phiri, in front of Brian (Economist, Planning and Policy Department, MOH)

Dr. Martha Chipanda (Head of Dental Department, Mzuzu Central Hospital)

Mr. Noel Kasomekera, behind Martha (Technical Assistant-NCD Unit at MOH)

Mr. Daniel Ntengula (Economist, Planning and Policy Department, MOH)

Ms. Gloria Kadangwe, behind Daniel (Administrative Assistant for Dean of Medicine at KUHeS)

Dr. Wiston Mukiwa (Clinical Lecturer at KUHeS Dental School and Secretary at DAM)

Dr. Peter Chimimba (Team lead and Coordinator of MalDent Project at KUHeS Dental School)

Dr. Jones Kaponda Masiye ( Deputy Director Clinical Services – NCD at MOH)

The team at the meeting worked hard to finesse the draft Oral Health Policy (Version 8) that had been produced by the Oral Health Policy Task Force and which had been informed by the Concept Paper, Narrative Review and Situation Analysis previously reviewed and approved by the Ministry of Health Technical Working Group. This last push allowed a final polishing to ensure that the version of the Oral Health Policy that would be presented to the Technical Working Group would satisfy all the relevant editorial and formatting requirements of the Malawi Government.

The hard work was interspersed with occasional refreshment breaks!

Fresh air and relaxation outdoors

The next stage will be a review of the final draft by all members of the Oral Health Policy Task Force before consideration by the Ministry of Health Technical Working Group and eventual sign-off by the Secretary for Health and the Minister of Health.

Annex 1 of the Oral Health Policy will be the Implementation Plan, which is followed by Annex 2, the Monitoring and Evaluation Plan. As with any policy, it is the implementation which is both the most important element but also the most challenging. However, if the energy and commitment of the Task Force to date are anything to go by, the momentum will continue as Malawi pushes forward with its oral health improvement agenda, in line with the WHO Oral Health Resolution.

Letter from Wits University – great progress for young Malawian dental academics

One of the major challenges facing any newly established undergraduate dental surgery programme is identification of the teaching faculty. In this regard, the new BDS course in Malawi has been very fortunate to have recruited Dr James Mchenga as the founding academic head and Drs Jessie Mlotha-Namarika and Wiston Mukiwa as experienced clinical lecturers.

There remains, however, a need to identify young dentists who are keen to pursue academic careers and to become the dental teachers and researchers of the future. Consequently it has been very exciting to see the appointment of four Assistant Lecturers onto the staff team. They are currently all attending masters degree programmes at Wits University in Johannesburg and this post has been written with their cooperation, as a means of introducing them formally to readers of the MalDent blog.

Wits University, Johannesburg, South Africa

The School of Oral Health Sciences at Wits University is based in the Charlotte Maxeke Johannesburg Academic Hospital and is a joint member of the Faculty of Health Sciences and the Gauteng Department of Health. In addition to its 5 year undergraduate Bachelor of Dental Science and 3 year Bachelor of Oral Health Sciences courses, the School runs a range of Masters and PhD programmes.

Throughout the preparations for establishing and delivering a BDS programme in Malawi, the School of Oral Health Sciences at Wits University has been a very important source of advice and support, particularly in respect of the curriculum development. Professor Simon Nemutandani, the Dean of the Wits School of Oral Health Sciences, was a very significant player during the second curriculum conference we held in November 2018 and also provided valuable help to the local team both before and after that conference.

Professor Simon Nemutandani (centre) in conversation with Professor Dixie Banda (left) and Dr Peter Chimimba (right) during the second BDS Curriculum Conference at Mangochi in November 2018

So, without further ado it is a pleasure to introduce the four Assistant Lecturers who are now working hard on their studies at Wits University.

Dr Mirriam Chipinga is studying towards a masters degree in Orthodontics and Dr Tasneem Chikwatu is pursuing her masters in Restorative Dentistry. Mirriam and Tasneem both arrived in Johannesburg ahead of their two colleagues.

Mirriam and Tasneem sent the following message:

After all the challenges we had in Malawi with our visa applications, we finally were able to travel to South Africa for our studies. We got here on February 5, but we moved to a new place after a month. We settled very well although we had some pressure trying to balance between settling in and studies because we got here two days before commencement of our studies and we started processing our moving to a new place almost right away.

The other challenge was that it was our first time having to study online (we still are, due to the Covid-19 pandemic) but it’s all good now, we have gotten used to it.

Things are going on well so far. Our studies are being conducted online. We are learning not only our course of study at a deeper level, but new ways of studying. For example, the way our programme has been planned (changes made to adapt to the current Covid situation) has taught us to be creative and proactive which we believe will make things easier for us if implemented when we get back home in Malawi.

We do not go out except for morning jogs and sometimes for grocery shopping, so we are mostly indoors. We just finished block 3 classes on Friday, and have started with assessments.” 

Mirriam and Tasneem out to do the shopping

Next, we can introduce Dr Nathan Lungu, who is studying for a masters degree in Oral Surgery:

Nathan at work on his laptop compute

Nathan sent the following message:

“First I would to take this opportunity to thank the management of Malawi College of Medicine and the MalDent Project for offering me a full scholarship to study Masters of Science in Oral Surgery at Witwatersrand University in South Africa, so that I can have more knowledge to impart to the Bachelor of Dentistry students after I graduate.

Currently I am in my first year; this is the third month since schools were opened on 8th February. So far so good, lessons are going on well. My knowledge is being increased day by day as I attend the class sessions and study. I hope by the end of my Masters I will have more knowledge in dentistry than the time I came here at the University of Witwatersrand.

Of course challenges are there; without challenges there is no life. The most challenge I have encountered is due to the coronavirus pandemic, whereby lessons are done virtually without face to face contact, hence we don’t engage much with our lecturers.”

Finally, we introduce Dr Don Chiwaya, who is studying for a masters degree in Community Dentistry:

Don at his desk

Don sent the following message:

“I arrived on 26 February 2021 having delayed for almost a month due to a positive Covid 19 test. I was so anxious as I could not know when I will depart for school. I did the test several times and when it finally came negative I was so happy as I did not want to miss again this academic year. On arrival, I did registration, and fortunately it was extended, I believe to give an opportunity to people like me.

Don attending registration on the main campus

Dr Tasneem Chikwatu and Dr Miriam Chipinga oriented me on how to go about life in Johannesburg – many thanks to them.

Don enjoying a visit to Pretoria’s Union Buildings, with Nelson Mandela’s statue in the background

Finally now I am settling in well attending to classes and assessments. Due to the pandemic most of our work is done online and we are ever in doors. What I miss most is the physical interaction with my colleagues as I believe we would share and learn better experiences on oral health issues across Africa and maybe even across the world. But as for now will go with this ‘new normal’ as we wait for the return of the ‘NORMAL’

Nelson Mandela spoke on many occasions about the importance of education to individuals and countries. He once said:

“Education is the most powerful weapon which you can use to change the world.”

On another occasion he said:

“Young people must take it upon themselves to ensure that they receive the highest education possible so that they can represent us well in the future as future leaders.”

Mirriam, Tasneem, Nathan and Don have all accepted the opportunity they have been given to further their education to enhance the teaching they will deliver to future generations of dental students in Malawi and to become future leaders of their profession in the country. As the Malawi Government Ministry of Health prepares to launch its new Oral Health Policy and Implementation Plan later this year, the timing could not be be more appropriate for investment in developing keen young clinical academics to play their role in Malawi’s exciting oral health improvement agenda.

Back on the road – this time with thanks to NHS Lothian

One element of the MalDent Project which has been significantly affected by the COVID-19 pandemic is Phase 2 of the refurbishment of the Dental Department at Kamuzu Central Hospital in Lilongwe. Back in 2019 we had purchased a shipping container which had been delivered to Dentaid’s premises and was being filled with donated and serviced dental equipment. The plan had been to send the container by ship in early 2020 and for the team from Dentaid and Henry Schein Dental to undertake the installation of the equipment in June 2020. Sadly the pandemic meant a cancellation of that plan and the container is still at Dentaid’s HQ!

In December 2019, I had been approached by Caroline Haywood, who is the Assistant Service Manager for Oral Health Services at NHS Lothian. She was working on a dental chair replacement programme and Professor Angus Walls, the Clinical Director, suggested that Caroline contact me to see whether we would be interested in a donation of the four chairs that were to be removed in March / April 2020. I sent photos of these A-dec chairs to Stuart Bassham at Dentaid who agreed that they would be eminently suitable for Lilongwe. You can guess what happened – we were thwarted by the COVID-19 travel restrictions. Undeterred, however, Caroline persuaded her colleagues to store the chairs for us until restrictions were lifted.

The silver lining was that three further dental chairs were replaced as part of the programme in early May 2021, so on Friday 14th May we planned to collect all seven chairs for delivery to Dentaid.

A long time family friend, Stan Harvey, agreed to come along with me. This was to be his second dental chair delivery, having accompanied me to Southampton on a previous mission. Stan is a fully qualified professional HGV driver and a fantastic companion to have along on jobs like this.

At 1pm we picked up the van from Leslie Commercials, who always provide a very friendly, courteous and efficient service. We headed straight through to Edinburgh Dental Institute in Lauriston Place and were admitted to the goods entrance to load up. Paul, our fantastic Head Porter at Glasgow Dental Hospital, had lent me a skateboard trolley to help us move the chairs. It was heavy and awkward work – every part of a dental chair seems to swivel as soon as pressure is applied! However, the loading was completed in just over an hour.

I was delighted that Caroline was able to come across and meet us as we had been exchanging mails for many months. I suspect that she hadn’t realised she would be part of the loading team, together with George MacDonald, the Facilities Manager, Stan and myself, but she joined in willingly! I am very grateful to Caroline and to Angus Walls for the chair donation and for the extended period of storage.

Stan and Caroline all smiles after the challenges of loading the van

I should add a word of explanation on our destination. Until a few days before we left, we had assumed we would be heading to Dentaid’s base in Southampton. However, Stuart Bassham contacted me early in the week to explain that for logistical reasons we should deliver the consignment to Mission & Relief Logistics in Aylesford, near Maidstone in Kent. Whilst it would have been very nice to catch up in person with Stuart, there was a ‘Plan B’ reunion since my brother Simon lives in Ashford, which is only about 17 miles away from Maidstone. Accordingly we arranged that Simon would come across to help with unloading and then we’d convene at the nearby Maidstone Services on the M20 for coffee, cake and a chat.

After leaving Edinburgh we drove South to the Great Barr Premier Inn just off Junction 7 of the M6 for an overnight stay. This is a stopping off point that’s worth remembering for future deliveries of chairs. In addition to a very friendly welcome at the hotel reception, we spotted both a fish and chip shop and an Indian restaurant next door together with a petrol station opposite – not an inflated motorway services price in sight!

Van and team fully rested after our overnight stop at the Premier Inn – ready for the 6.30am departure

We set off early the next morning, stopping for some breakfast en route, and reached Mission & Relief Logistics Ltd just before 10am. We were greeted by Michael Harrison, who runs the company, and his relative Louis, both of whom had a great sense of humour and ‘can do’ approach. I explained that loading the van had been quite an effort and I that I had some concerns about the offloading – I should not have worried.

Stan promptly reversed the van very expertly through the warehouse entrance …

… and we set about initially removing smaller components before tackling the chairs themselves:

Michael was straight onto the job in hand

What transformed the unloading was the availability of a manual hydraulic forklift:

Hydraulics can make all the difference!

Shortly after we began unloading, Simon arrived …

The Brothers Bagg!

…. and with all of us engaged …

… we had the van emptied in about 40 minutes.

Forty minutes from full to empty – ready for the drive back home

The load was all safely secured in a large container at the back of the warehouse. In due course Michael will deliver the chairs to Stuart at Dentaid where they will receive the full servicing, checks and repairs as necessary before joining the container bound for Lilongwe. However, for now it was time to bid farewell to Michael and Louis and head for coffee and cake.

Job done!

After a really enjoyable catch-up with Simon we hit the road for the return drive up to Glasgow. The traffic was remarkably light and we were back in Glasgow just before 8.30pm: another small piece of Scotland – Malawi partnership working complete.

Our trusty steed enjoys a sunny Sunday rest back in Glasgow

Acknowledgements

Many thanks are due to Caroline Haywood, Angus Walls and NHS Lothian for donating the dental chairs – we will keep you informed of progress.

It was a real pleasure to meet Michael and Louis at Mission & Relief Logistics Ltd – good humour and ingenuity are a great combination!

Thanks to Simon for helping with the offloading and for directing us to the coffee and cake.

Last, but by no means least, big thanks are due to Stan for being such good company on the trip and for great support with the heavy lifting and driving (particularly in reverse!).

Planning gets underway for Malawi’s first national child oral health survey

The MalDent Project has at its core a philosophy of prevention of oral and dental disease. This under-pinning mantra of ‘prevention, prevention, prevention’ which was coined at the National Oral Health Policy Workshop, is emerging strongly in the ongoing work of the Oral Health Policy Task Force. Prevention of dental caries in children will be central to Malawi’s Oral Health Policy and Ronald Manjomo’s PhD project is focusing on this area.

It will be very important to be able to measure the impact of any interventions that are introduced as part of a programme to prevent dental caries in children. However, in order to do so it is essential to establish the baseline level of disease. At present, this is unknown but work is now underway to design and plan a national child oral health survey. This component of the MalDent Project benefits from funding granted by the Borrow Foundation in addition to our core funding from Scottish Government.

A multi-disciplinary team has been established to deliver this survey and the first meeting was held on Friday 23rd April:

The oral health survey team members meet for the first time

The team includes representation from the Malawi Government Ministry of Health, University of Malawi College of Medicine, WHO Africa, Strathclyde University, University of Glasgow, Smileawi and the UK Community Dental Service.

Following general introductions, Nigel and Vicky Milne gave a presentation about the pilot child oral health survey that they had completed with Glasgow and Dundee University elective students in 2019.

Nigel and Vicky Milne illustrate the collaborators in their pilot child oral health survey in 2019

They took us through the various stages of the process …

… including illustrations of their interactions with teachers and pupils …

… and of the dental examinations being undertaken…

The data generated have now been submitted to the African Journal of Public Health and we are awaiting responses from the referees.

One of the most important aspects of the pilot study was to identify specific challenges of undertaking oral health surveys in Malawian schools. A number of lessons were learned, particularly in relation to collecting socio-demographic data from the children and this will help to inform the definitive study design.

One of the other aspects of the Smileawi pilot study related to fluoride content of local water supplies and the prevalence of dental fluorosis among the children examined. This work was undertaken in collaboration with Strathclyde University and provided fascinating data which have now been published in the journal Water:

A copy of the paper can be accessed here.

Professor Bob Kalin, who heads the group at Strathclyde University with which we collaborated, gave a fantastic summary of the joint work and of the wide variation in fluoride concentration of groundwaters in different geographic areas of Malawi. He also described the amazing technology that this group uses to map the boreholes with extensive information on each individual water source. His knowledge and experience will be of great value to our team moving forward.

Bob Kalin showed examples of the on-line detailed data capture systems used by his team

We continue to collaborate closely with Dr Yuka Makino, the WHO Technical Officer for Oral Health in Africa. We are delighted that Yuka has agreed to be part of our team and she gave a presentation on the oral health indicators which the WHO recommends for Africa. We will ensure that the survey design we use maps onto the principles espoused by WHO.

Yuka Makino described the WHO Africa approach to oral health surveys

This first meeting, which introduced the team members to one another and began to lay down the foundations of the survey, will be the first of many. Our intention, COVID-19 permitting, is to complete the planning and ethical approval application this calendar year, with a view to undertaking the survey in the first half of 2022.