Whilst the MalDent Project is focused on Malawi, the challenges of untreated oral disease are faced by many other African countries.
The charity Bridge2Aid (bridge2aid.org) has been working in rural Tanzania for the past 14 years. Unlike many dental volunteer programmes, Bridge2Aid (B2A) concentrates on training of local rural clinical officers (Medical Officers) in the provision of emergency dental treatment. Since 2004, these training programmes have provided access to care for over 5 million people in Tanzania. This sustainable training model provides rural clinical officers, who know the environment, with the essential skills they require to improve the lives of people in their local communities, long after the volunteers have left. It is a model that is potentially applicable in other rural African environments and is of undoubted relevance to the MalDent Project.
A friend and colleague, Andrew Paterson, has been a dental volunteer with B2A for many years. Earlier this year Andrew introduced me to Shaenna Loughnane, the Chief Executive of B2A. Shaenna very kindly invited me to visit one of the B2A training programmes in September 2018 and I am extremely grateful for the opportunity that this provided. Coincidentally it was a two-week programme for which Andrew was the Clinical Lead and I was delighted to accept the invitation. As a result I arrived in Mwanza, via Dubai and Dar Es Salaam, on the evening of 17 September with Shaenna and two other visitors to the programme, Arun Mehra, CEO of Samera Business Advisors, who is one of the B2A Trustees, and Lucy Mander from Dental Design, a Corporate Friend of B2A.
After a good night’s sleep and breakfast we headed off on the Tuesday morning to visit the Hope Dental Centre in Mwanza. This dental centre was originally established as a social enterprise to provide high quality dental care for fee-paying patients, with the profits being fed into the charitable activities of B2A. Recently it has moved into superb new premises in the Rock City Shopping Centre in Mwanza and is now managed by a Tanzanian NGO known as eh4all (eh4all.co.tz) (Education and Health for All).
Next we drove to the B2A office in Mwanza:
Here we transferred to a Toyota Land Cruiser safari vehicle and loaded up a significant number of dental instruments that had been generously donated by Henry Schein and brought across by Shaenna in her luggage. These instruments were for inclusion in the kits of instruments that would be donated to those rural clinical officers who completed the training programme successfully.
Sorting out the instruments Our trusty safari car
At 11.55am we set out with our driver Chacha. The 4.5-hour drive to Chato took us through many villages, the mining town of Geita and some beautiful countryside:
Typical villages en route to Chato
Bicycles and motorcycles were the predominant modes of transport – many loaded with unbelievable quantities of wood, charcoal, bananas, water and other sundry items such as bed mattresses! The road was very undulating with many hills and those on cycles had to work very hard to move their goods:
The journey included a ferry crossing over Lake Victoria, with lovely views in all directions.
Loading up About to dock
On arrival in Chato we checked into the JS Hotel, which was literally next door to the family home of the President of Tanzania – in fact he owns the hotel! Shortly after we arrived, the team of dental volunteers arrived back from their working day at the site, which was about a 45-minute drive away. We all had dinner together followed by a game of Jenga, which soon ensured that we all knew one another very well!
It was up early for breakfast on the Wednesday to join the volunteers on the bus to head out to the clinical site and observe the day’s activities.
The ‘road’ was 27km of un-metalled rutted track and certainly not terrain for which a bus was designed, but our experienced driver negotiated it expertly.
We passed by many remote villages. Men, women and children were busy in the fields with hand implements. The sight of a bus predominantly full of muzungu (white people) was clearly a very unaccustomed spectacle for many of these local residents and there was much enthusiastic waving.
Typical village scenes
We also met some excited cattle en route who were certainly not used to meeting a bus in the morning!
Eventually the bus pulled up at Kachwamba Health Centre, one of the sites that B2A was using for the dental treatment and training sessions. It was a new campus of buildings but they were only partially completed. Already a queue of patients was waiting as we alighted from the bus and headed into the one area of the site that had glazed windows, was lockable, and which had been converted into the dental clinical area.
It was impressive to see how quickly the well-rehearsed routines all swung into action. The dentists, who had each been paired up with one of the rural clinical officers for the day, checked over their workstations.
The dental nurses busied themselves in the instrument decontamination area, whilst Innocent and Emmanuel, both of whom are Tanzanian staff of B2A, began to organize the waiting patients in the adjoining building, which was a partly completed hospital ward, with a roof to protect those waiting from the sun, but no windows.
The patients were each assigned a number to identify them when called for treatment. One hundred and twenty patients were booked for the day with a potential to add an additional ten patients if unexpected emergencies arrived. The progress of the consultations was logged on a paper chart outside the clinical area:
Morning, midday and evening – the waiting patients are all eventually treated.
During the course, the rural clinical officers received training on oral health promotion messages and each had to deliver a talk for the waiting patients, to the satisfaction of one of the volunteers. First thing that morning we listened to rural clinical officer Edwin delivering his second oral health promotion talk, supported by visual props provided by B2A. He did a fantastic job, providing important messages to the assembled patients, which will have been news to all of them. Emmanuel translated into English for the volunteer, to allow an assessment of the messages that were being delivered by Edwin in Swahili.
Meanwhile, the other five rural clinical officers had started to examine patients under the watchful eyes of the B2A dentists. They took the histories and agreed with their paired dentists on appropriate treatment plans. On most occasions the decision was to undertake one or more extractions. The rural clinical officers would administer the local anaesthetic, test for numbness, undertake the extractions and provide post-operative instructions, again under the supervision of the dentist. As they were now nearing the end of the training period, the rural clinical officers were becoming very proficient and the amount of input required from the dentists was minimal.
A key person, who had been involved from the earliest planning stages of the visit to Chato months earlier, was the local District Dental Officer (DDO) – one of only two trained dental staff for a population of 365,000. The DDO, ‘Doctor David’ Ngata, had graduated in dentistry from Muhimbili University, Dar-es-Salaam, Tanzania in 2014. He worked closely with Andrew, the Site Clinical Lead, in dealing with very difficult extraction cases that were unsuitable for the rural clinical officers and also participated in the assessment of each officer as the training course progressed, to ensure that he was happy with the standard reached. A key element of the training was to ensure the rural clinical officers recognised the limits of their competence and identified those cases that needed to be referred to the DDO.
The lunch break took place at 1pm. The food was produced locally in the neighbouring village and delivered by four ladies who served us with a delicious selection of local dishes in a nearby building.
Immediately after lunch the rural clinical officers received one of a series of tutorials, this time on use of antibiotics in managing dental infections and the importance of antibiotic stewardship, which I was privileged to deliver. This was an important message, since prior to the training they had received on extractions their only option for management of dental infections had been recourse to antibiotics. Since surgical drainage via extraction reduces the need for this inappropriate prescribing, the rural clinical officers had been provided with a new skill of great relevance to antibiotic stewardship.
After the tutorial it was straight back to the clinical area to complete the day’s patients:
As an oral microbiologist with a particular interest in infection control, I need to reflect on the instrument decontamination process that had been established to support the clinical work. First, remember that this health centre has no supply of electricity, so forget autoclaves and washer disinfectors.
Secondly, consider the volume of patients undergoing treatment – seven chairs being operated simultaneously by the teams of rural clinical officers, their trainers and the DDO.
Question: how do you apply the principles of instrument decontamination in that environment? Well, B2A has the answer.
All of the instrument decontamination is undertaken in a separate room – the Local Decontamination Unit (LDU), – operated by three dental nurses working as a team. This area is clearly divided into ‘dirty’ and ‘clean’ zones.
Instruments are all managed within trays, each with a disposable liner. In the clinical area, trays containing used instruments are placed on the floor and rapidly collected by one of the nurses for return to the LDU. All instruments are cleaned in detergent with a soft brush, rinsed, checked and then sterilised in pressure cookers over gas operated burners. They are cooled in sterile water, dried and returned to the pool of instruments for use.
This is a process that has been approved by the World Health Organisation and as someone who has spent a lot of time working in this field, I was very impressed with the application of all the correct principles of modern instrument decontamination in a very challenging environment.
There was much interest from the local children in all that was going on in the health centre. When there was a slight pause in activity in the sterilisation area, volunteers fascinated the children by blowing bubbles – something they’d never seen before and really loved.
By the end of the day, 132 patients had been seen and treated. After tidying up ready for the next morning, the team headed back in the bus along the rutted track to the hotel for the daily de-brief. This was a particularly important meeting because the following day was the last morning of training and the six rural clinical officers had by now completed all of their assessments. Both Andrew and Doctor David gave their verdicts and sought input from the other volunteers who had been involved in training the rural clinical officers over the preceding two weeks. It was agreed that all had passed the assessments, were safe, and would receive their certificates the following day. In addition they would each be presented with a dental kit, which included a set of dental instruments and a pressure cooker for sterilisation purposes.
When the training programme concluded on the Thursday, the teams had treated a total of 1021 patients. The rural clinical officers received their certificates and will now be able to deliver emergency dental care to residents in many rural areas of Chato District and within the local prison service which to date enjoyed no such access.
The team arrived back to the Midland Hotel in Mwanza at 7.30pm and, after a quick freshen up, joined together for an end-of-programme dinner. Andrew paid tribute to all members of the team and passed on ‘thank you’ cards before receiving a vote of thanks himself from Shaenna. The evening finished with drinks in the bar and some very emotional farewells as the team members had a variety of disparate travel arrangements the following morning.
What are my abiding memories of this amazing visit?
First, the desperate need for oral health education and access to dental treatment in these remote and rural areas of Tanzania. Many had walked long distances to attend and in addition to adults there were many children brought along by parents for treatment. The resilience and stoicism of many of these young children facing extractions under local anaesthesia was astonishing, but often aided by the outstanding support of the dental nurses. The poverty is grinding for these largely farming peoples, a fact highlighted by the overwhelming gratefulness expressed by one patient who was funded to the equivalent of £10 by B2A to allow a hospital referral for a complex surgical extraction of a carious wisdom tooth. A trivial amount of money to us means the earth to these delightful people who have next to nothing.
Secondly, the effectiveness of the training model developed by B2A, which combines delivery of much needed dental treatment with up-skilling of local rural clinical officers to embrace a sustainable legacy of the time spent in-country. It was a tour de force, by an extraordinary team of volunteers, expertly led and highly organised on the ground.
So what about MalDent? Whilst the establishment of a Dental School at the College of Medicine is a key thrust of the project, the ultimate purpose is to establish an oral health infrastructure in Malawi which provides access to care in the hard to reach rural areas as well as in the centres of population. It will take at least six years from the initial BDS intake in 2019 before the first cohort of Malawian dental graduates emerges. The current shortage of dental work-force in the rural areas, despite ongoing training of dental therapists, suggests that up-skilling of local rural clinical officers could provide a very valuable interim resource as part of a strategic approach to short term delivery of the oral health component of the Essential Health Package defined by the Ministry of Health in its Health Sector Strategic Plan II (2017-2022). There is a conversation to be had …!
In closing, I would like to acknowledge the tremendous hospitality and generosity of spirit extended to myself, Arun and Lucy as visitors to the programme. Andrew Paterson, Kirsty Jones, John Milne, David Wood, Amit Patel, Gurrinder Atwal and Jack Shreeve, the dentists in the team, all shared their experiences at length, both in the clinic and in the evenings. Similarly, the fantastic dental nurse team of Holly Shreeve, Lavada Conyers-Laster and Julie Wright, who worked so hard in the LDU, stocking the units and supporting many children through their treatments, gave us honest insight into their experiences. The two legends of the B2A Tanzanian team, Innocent Bikere and Emmanuel Mwenere, kept everything running smoothly and always with a smile. Finally, thanks to Magreth Madiga, Edwin John, Japhet Yohama, Elias Petro, Lucas Mwanoata and Michael Joseph, who also embraced our presence and who now represent the latest in the long-line of up-skilled clinical officers supporting oral and dental health in rural Tanzania, thanks to the outstanding work of B2A.
If you would like to support the work of Bridge2Aid or just learn more about its activities, please visit the organisation’s web-site at: bridge2aid.org