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Barriers to the promotion of dental health in developing countries
0271-7123 XI 060X17-0XS02(K)O Perpmon Pro\ Lrd
BARRIERS
TO THE PROMOTION OF DENTAL DEVELOPING COUNTRIES
HEALTH
IN
M. H. HOBDELL and A. SHEIHAM The London
Hospital
Medical
College.
London.
England
AbstractPHealth in developmg countries is poor. Historically the trend towards ill health was initiated with the advent of slave trade and accelerated later by the colonial expansion of Europe. Dental health is no exceptton to this. There are many oral conditions which are functions of the poverty and undernutrition which are currently prevalent in developing countries. There are few human or physical resources available to meet these health needs. In most developing countries the dentist to population ratios are of the order of one dentist to 100,000 people or worse. In establishing dental health services in developmg countries. there is a danger that attempts will be made to establish the same patterns of organization and to use the same technologies as those used in industrial nations. Because such organizations and technologies are often specific to certain social, political and economic situations their direct transfer for use under totally different circumstances frequently meets with failure. This caveat is particularly critical since there are clear differences between industrialized and developing countries in their patterns of dental disease.
cern in developed nations is with high technology medicine, whereas in developing nations it is with primary health care. The second assumption follows from the first. Given the relationship between development and support of health activities, then transplanting health activities (the science and technology of medicine, that is) from one nation to another without regard to relative levels of development is likely to be unsuccessful-at least in achieving improvements in health. This does not mean that the transfer of all technology is impossible but only that it must be appropriate to the circumstances into which it is transferred. It must be recognized that science and technology cannot be considered politically or socially neutral. They are both the products and tools of society and are therefore frequently quite specific in their applicability. Given the first assumption (that of a relationship between the level of development of a country and the type of health activities that it supports), there is a need to define more precisely what is meant by high technology medicine and primary health care in order to develop the argument’more fully. By high technology medicine we mean not only the sophisticated equipment and complex life support systems (i.e. heart/lung machines or dialysis units) but also the many potent and complex pharmacologic agents developed by the international drug companies. Many of the complicated medical and surgical interventions carried out in the large hospitals of Europe and North America would be impossible without these drugs. Because of the unbridled proliferation of the pharmaceuticals the World Health Organization has developed a list of essential drugs considered basic for any country attempting to provide primary health care. The 1978 WHO Conference defined primary health care as “essential health care based on practical. scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community
INTRODUCTION
Two trends in public health thinking have become more apparent in the past decade. The first is an increasing awareness of and importance of the concept of Primary Health Care (PHC). The second is the recognition of the relative failure of ‘modern’ medicine to do much to reduce the premature loss of life caused by such chronic degenerative diseases as ischemic heart disease and cancer-regardless of the amount of money spent or the sophistication of the technology used. There are enormous differences between primary health care (with its emphasis on access to a basic list of drugs and techniques) and the complex technology involved in organ transplants and other similar interventions. However, all health activities can be arrayed on the basis of two criteria: the frequency with which they are needed and the degree of technological expertise involved. In this way it can be seen that primary health care, embracing those activities at one end of the scale and high technology medicine, embracing those at the other are not unrelated but are part of a continuum of health activities the component parts of which are generally directed towards gaining and maintaining health. In this article we will show the importance of this link between the two ends as one of the determinants affecting dental public health policy in developing countries. In this respect there are two major points to note about the continuum: first. that reference to primary health care is most frequently made in discussions relating to the health problems of the rural and periurban poor in developing countries [l]. Secondly, reference to high technology medicine is most frequently made in discussions relating to the health problems of urban industrialized populations in developed nations [2]. Two assumptions follow from this. The first and most obvious is that there is a relationship between the level of development of a nation and the health activities which that nation supports. Thus. the con817
M. l-l.
818
HOBDELL
and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination” [3]. Although high technology medicine may not be available to all in industrialized nations, basic primary health care is available to most. However, in industrialized societies many people still die prematurely from chronic diseases such as coronary heart disease and cancer. The failure of high technology medicine is illustrated by the persistence of high mortality rates for chronic diseases. Responses to this failure have usually been of two types. One form has been an appeal to make high technology medicine more widely available by constructing more hospital facilities and increasing the speed with which patients are treated in existing facilities. An additional aspect of this approach has been to encourage the development of an even higher level of technology. Such approaches all emphasize the technological aspects of a solution. The second general response to the failure of high technology medicine has focused on prevention in the form of either primary or secondary preventive programmes. Prevention at the highest levels of policy making is conceptualized in as ima8inat~ve and broadly based a manner as possible. These current conceptualizations in * tbtic health are relevant to any discussion of the problem of achieving and maintaining dental health in developing countries, since dental health is an integral part of general health. The achievement and maintenance of both general and dental health within any population requires that one understands that the science and technology of medicine and dentistry must be integrated with the economic and political forces which dominate the development of societies. One of the cornerstones of the PHC approach for achieving health for all by the year 2000 is the development and use of appropriate technologies. in this paper we attempt to analyze the dental health problems of developing countries. We then will examine the determinants of and effects of public health policies in resolving these problems.
THE BACKGROUND IN DEVELOPING
TO HEALTH
PROBLEMS
COUNTRIES-EXAMPLES
FROM
AFRICA
The relationship between health. illness and development has been well documented [4,5]. Nonethefess. it is appropriate to provide a few examples here. Essentially the argument rests on the relationship between environment. lifestyle and health. This relationship is well accepted in many developed industrialized nations and indeed constitutes the basis of many public health and industrial medical practices Frequently, however, in developing countries the ways in which environment, lifestyle and health have been radically altered by such processes as wars, the slave trade and colonial expansion have been ignored. The development of the slave trade provides one of the best known human examples. initially started first by the Portuguese and Spanish, it assumed a commer-
and A. SHEIHAM
ciaf basis for Britain in 1562 [6] with the departure of the first slave ship from London for West Africa and then the West Indies. This began the infamous slave triangle: slaves from West Africa were taken to the West Indies as cheap inexhaustible labor to produce first sugar, then cotton and tobacco. These products were shipped to Britain, where they were processed. consumed, or turned into manufactured goods. Some goods were shipped back to Africa to be used for the purchase of more slaves. This process gradually permitted the accumulation of wealth and the encouragement of the developed of more and more machines. The industrial revolution of Britain and Western Europe gathered pace carried on the backs of African slaves and European industrial workers. The ever increasing demand for more raw materials of other kinds gradually diminished the importance of sugar. cotton and tobacco from the West Indies and with it, the slave trade. Africa itself became the center of interest for Western Europe’s industrialists-not only for its metals but also for rubber. sisal. caju. and its apparently inexhaustible supply of cheap labor. At the same time it continued to provide a large potential market for manufactured goods. If the slave trade gave birth to. or at the least spurred on. the industrial revolution and capitalism in Europe, the industrial revolution gave rise to colonial expansion and advanced capitalism. Each phase resulted in many changes. Kingdoms and social systems were destroyed. Families were uprooted, members separated and many killed. In the period from 1530 to 1830. as many as 15 mihion people were inducted into slavery. During this time. several million died in the hunt for captives and some 10-139,; died during transportation [7]. The social, economic and health impact of all this can only be guessed. Probably those to suffer most. if indirectly, were the most vulnerable: children. mothers and the old. Turschen [S] examined the effect of the colonial plantation economy and its inherent need for migrant labor in Tanzania. She showed that one of the effects of the men going away to plantations for about a year ata time was to reduce considerably the nutritional value of the food available to the families left behind. The subsistence peasant economy was severely disrupted as a result of the reduced labor force to open up new land. The effects of colonial penetration on the African economy and health are graphically illustrated by the recently translated work of Nzufa, Potekhim and Zusmanovich [93. Perhaps one of the most horrific reports is that of the development of the rubber plantations in the Congo basin. which reduced the population from an estimated 3&40 million people in the 1890s to 8.5 million by the mid 1920s. Direct killing played a part but was clearly not the main factor --infectious diseases. introduced from Europe and under-nutrition did the rest. Colonial domination of African states was usually achieved through force and warfare. War was largely responsibIe for the spreading of diseases previously known in Africa. Rinder pest. for example. was brought to sub-Saharan Africa in 1864 and reached epidemic proportions soon after in the wild game and domestic cattle of West Africa. Its spread to East Africa occurred in 1889 when diseased cattle were brought from India as provision for the Italian Army
Dental health in developing countries on its campaign in Eritrea. An epidemic occurred in 1890-1891 in East Africa killing nearly all the cattle. The resultant loss of cattle (the basis of pastoral economies and an important source of protein for many semi-pastorial groups) precipitated an exodus of people from the region and created a famine in which endemic disease became epidemic. Thorn trees replaced grassland and bush crept over formerly cultivated fields. creating an environment favorable to the tsetse fly. This ecological change has proved difficult to reverse [8]. An interesting result of such health problems. not only in Africa. but in many developing countries which lie in tropical and subtropical regions. has been the labelling of many of the diseases which are prevalent there as tropical diseases. However, such high levels of disease and ill health have not been historically the norm for such areas [S]. Health in Africa today is not only the result of many cumulative factors such as the slave trade and war. but of many other events such as colonial land policy. forms of taxation and their effects on patterns of trade and agriculture which have resulted in the establishment of various forms of monoculture [S] and migrant labor [IO]. Typical developing countries experience extremes of rich and poor. landed, landless and hyper-fragmented small holders, overcrowded cities. inadequate academic education. limited non-existant health services and a stagnant economy. A pressing concern in such countries is to raise agricultural production to provide a surplus without further polarization and fragmentation. Implementation is largely political rather than a technical task. Although in colonial times state control resided in London, Paris, Brussels, Berlin and Rome, today it rests in the independent African States. Unfortunately, history has bequeathed a difficult legacy to these states. They have been left with little in the way of developed industrial resources for their own use and few educated and trained workers to man those that do exist. Those few established industrial organizations are concerned almost exclusively with the extraction of raw materials or the production of large quantities of agricultural products such as palm oil. cotton. or sisal. Many of these industries are controlled by multi-national firms who rarely process the products of the mines and plantations in the country of origin, Production of processed raw materials in excess of European and North American demand are exported back to Africa and other developing countries. An excellent example is that of sugar. The European Economic Community (EEC) is now an exporter of refined sucrose (and other processed foods such as dried milk) to developing countries. Frequently the old-style colonialism has been replaced by control exerted by large multinational corporations. Such trading practices can materially affect health and in respect of sugar consumption and dental health provide a specific illustration. There has been a steady rise in world sugar production and sugar consumption. In many developing countries consumption is rising rapidly [ll, 121. A levelling off of consumption has, however. occurred in the U.S.A.. Britain. and other high sugar-consuming industrialized societies.
x19
The mouth or oral cavity has not been immune from these various types of influences. Two diseases illustrate the point. Cancrum oris (gangrene of the face and jaw) is a condition seen almost exclusively in chronically under-nourished children whose resistance to infection has been lowered further by some acute generalized infectious disease such as measles. In the late 19th century, Cancrum oris was not an uncommon condition in children living ,in the industrial slums of Europe [13]. As living conditions improved in Europe and declined in the colonies in Africa. the condition decreased in Europe and increased in Africa. It is important to note that Cancrum oris is by no means limited to Africa and is found in all populations with poor sanitation. unsanitary water supplies and chronic undernutrition. The disease is often fatal. particularly since it often occurs concomittantly with generalized acute infectious diseases [ 143. Disfigurement and the subsequent need for major reconstructive and cosmetic surgery place a great drain on the already over-taxed health resources of any developing country. Another major disease is oral tuberculosis. described in modern European textbooks of oral pathology as a rare disease found mainly in elderly patients who have suffered pulmonary tuberculosis for many years [IS]. In developing countries it is far from rare. and frequently afflicts the young. Tuberculosis is wellrecognized as a disease which is a function of the interaction of poverty, overcrowding and undernutrition. These are two examples of major oral diseases caused by adverse environmental factors-nutrition. housing and sanitation. They are major only in the sense that they are life-threatening and make disproportionate demands on health resources in relation to their prevalence in developing countries. They are by no means encountered as frequently as dental caries and periodontal disease.
DENTAL
CARIES
PERIODONTAL
(DENTAL DISEASE
IN DEVELOPED
AND
DECAY)
(GUM
AND
DISEASE)
DEVELOPING
COUNTRIES
Dental caries and periodontal diseases are the most common oral diseases in the world. In developed nations they affect almost everyone. Indeed, dental caries has been called ‘the last great epidemic’. Dental caries became a significant health problem toward the end of the 19th century. Its prevalence world-wide is uneven. It is relatively rare in a few countries and rampant in others. In England and Wales 95”” of 12 year olds have dental caries in 5.2 teeth per child [ 161. In Rurutu (French Polynesia) 41:” of II-year-olds exhibit caries in 0.5 teeth [ 171. Major variations in disease attack rates also occur within single countries and populations. Within French Polynesia the severity of dental caries has been found to vary from 0.5 teeth in Rurutu to 6.8 teeth in Huahine [17]. When the data are examined the pattern which emerges is that the more highly developed nations of the world are affected most by dental caries while the developing countries are affected to a lesser degree [18]. If the
820
M. H. HOBDELL and A. SHEIHAM
data are examined in greater detail, several important trends can be observed: 1. The prevalence of dental caries is high to a very high degree in indust~alized countries and is usually very low in developing countries. 2. There is an increasing prevalence and severity of dental caries in developing countries [19-211. The most rapid increases are occurring in the urbanized. higher socio-economic groups [19] but rates of increase are very small in the rural populations. The increases in prevalence and severity in developing countries must be contrasted with the decreases which are occurring in a number of developed countries. Indeed, decreases of as much as 30% in the number of decayed, missing and filled teeth in the past 10 years have now been reported [22]. In addition to these differences between patterns of dental caries in developed and developing countries, there are a number of other significant differences. The sites of caries attack are predominantly in pits and fissures in developing countries, whereas in developed countries the smooth surfaces are more commonly affected. In most industrialized areas of the world the pattern of caries attack is similar in the deciduous and in the shan’t teeth. However, in many developing countries, caries is much more severe in the deciduous teeth [23]. In developed countries the dental caries attack is most intense during adolescence and decreases in adults with a small increase occurring in persons over 60 years. In developing countries dental caries is most severe in the very young and the mature adult. The increase in caries in mature adults is due to caries attacking the roots of teeth which have been affected by periodontal disease. For populations in both developed and developing nations, certain factors influence the prevalence, incidence and rate of progression of dental caries. The initiation of caries in susceptible populations is early, usually occurring within 18 months after tooth erup tion. However, the progression of the carious lesion is usually very slow and may require almost two years to progress through the outer enamel layer to the dentine. Some lesions do not progress at all [24]. Others may remineralize and reverse the process. In populations consuming little refined sugars, with fluoride-rich water, or fluoride supplements, the rate of progression of dental caries is substantially slower than in the high sugar consuming populations [ZS]. Periodontal diseases (diseases of the soft tissues and supporting structures of the teeth) were common in ancient times. The acute form of the disease, acute ulcerative gingivitis, is relatively uncommon, but the chronic forms are highly prevalent. Chronic periodontal disease occurs in over 90:& of people; the prevalence is slightly lower in developed than in developing countries. As with dental caries, the severity of the disease varies considerably between and within populations. Populations in developing countries, living in rural areas, the poorly educated, and the lower socio-economic status groups have more severe periodontal disease than those in developed, urban areas with high educational and high socio-economic status. The most important factor affecting the severity and rate of progression of chronic periodontal disease is oral cleanliness. The standards
of oral cleanliness are poorer in populations in developing than in developed countries. Therefore, it is not surprising that the rates of progression of periodontal disease are more rapid in developing than in deveioped countries. Periodontal disease is the most common cause of tooth loss in all countries. But in developing countries where the rate of caries is low and periodontal disease high. periodontal disease causes the loss of more teeth per person than in developed countries. However. overall in most developing countries the rate of tooth loss is slower than in developed countries. But in those developing countries with relatively h&h rates of dental caries and a high severity of periodontal disease, there is a similar pattern of tooth loss to that found in developed countries [27]. The loss of all the teeth (edentulousness) is relatively uncommon in developing countries because of the shorter life expectancy, the lower rates of dental caries and a tack of dentists or others to extract teeth. The acute form of periodontal disease. acute ulcerative gingivitis, is common in children under the age of 6 years in developing countries. By contrast, it is seldom reported in young children in developed countries. Apart from the pain and suffering of the disease, there is the added danger that it may progress to Cancrum oris in some children, or at least cause the premature loss of some teeth and alveolar bone [ZSJ. Oral cancer is relatively uncommon in developed countries. In developing countries (and in particular, some Asian countries) oral cancer is the most common of all cancers [29J. Burkitt’s iymphoma is an im~rtant cause of death due to maIignancies in children in developing countries. Its occurrence has been linked with concomittant infection with EB virus and chronic malarial attacks. Although this finding is still controversial, if it is substantiated, it will provide yet another example of the effects of the environment on health. Clearly, the increases in dental caries and the high levels of periodontal disease in developing countries add considerably to the total disease burden. SOCIAL, SHAPING
POLITICAL
AND
DENTAL
HEALTH
TECHNOLOGIES
ECONOMIC
FORCES
STRATEGIES
AND
IN DEVELOPING
COL’NTRIES
Dental disease constitutes a major public health problem in developing countries. The public health approach to these problems differs from that in developed nations in several ways as regard to planning and policy. In most developing countries there are significant differences in the population, its age structure and geographic distribution from those observed in developed nations. In many developing countries 25”,, of the population is under 5 years of age whereas I or 29; are over 40. In developed countries (for example, Britain) the population age groups only begin to ‘taper 08’ in size after the age of 55 years. Similarly. the geographic distribution is different but changing quite rapidly. With the attraction of the cities, in developing countries. urban populations are growing at the expense of the predominantly rural populations. The second consideration involves diet. With
Denml
health m developmg
in population distribution and life style there are often changes in diet. There usually occurs a decrease in fibre content with an increase in sugar content. as well as alterations in the total quantity of food eaten. It is conceivable that a landless peri-urban family will be worse off nutritionally than they were as subsistence peasant farmers. Mention has already been made of the increased selling of refined sugar to developing countries. This is clearly a matter of importance in dental health assessment and planning. Existing patterns of disease provided a specific orientation to both the preventive and curative aspects of any dental health services and therefore act as determinants of policy. To what extent these disease patterns can provide an orientation to health policy will depend to a greater or lesser extent on who is recording such data and from what population groups the data are being collected. Of primary concern are questions about who makes dental health policy and who implements it. Decisions about these will depend on the prevailing political philosophy, levels of production and wealth. They will also depend on whether there exists a specific group of people who see themselves and are seen by the policy makers, as being responsible for the planning of the dental health services. An additional and critical determinant of dental health policy and strategy development is the available number of personnel for implementation, or who can be trained to carry out. the policy and strategies adopted. This number is severely limited in many cases by factors such as high illiteracy rates in most developing countries. The abilities of these dental health workers are themselves. in turn, restricted by the availability of appropriate dental health knowledge and also the availability of the physical resources necessary. It, of course, must be recognized that many of the constraints operate in both developing and developed countries. However, they acquire a greater signilicance in areas where specialized knowledge and material is scarce and there is no tradition of any centrally organized dental health service. These factors profoundly affect the transfer of dental knowledge and technology as well as the growth of professionalization with its effect on public dental health policy development. changes
THE TRANSFER
OF DENTAL
KNOWLEDGE
The effective transfer of knowledge is not a one-way process from developed to developing countries. However. in dentistry. it has tended to be from developed to developing countries with respect to models of dental education and their related clinical techniques involving curative and preventive care. In many developing countries several approaches have been taken to developing a pool of professional manpower. In those countries where independence has been achieved, groups of the best educated young people have been sent to the former colonizing country for dental education. Upon their returning (if indeed they have returned) these young professionals begin to press for the establishment of a modern dental school in their own countries. They are usually
countries
821
designed and built exactly like those of the country in which they themselves were trained. The curriculum. teaching methods. clinical techniques and equipment and materials are also transferred without modification. Teachers from the ex-colonial country are frequently employed to assist in starting up the new school. An offshoot of this is an emphasis on the need to ‘maintain the standard of the old country’. This has often been most apparent in those schools which have been started prior to independence [30]. One major reason behind the adoption of an already developed curriculum has been the perceived need for comparability in standards of dental education which would permit graduates to travel to the colonial country for additional graduate or post-graduate education. or to work. An example of that is the controlling body for dental education in Britain, the General Dental Council, which also controls the general form of the curriculum in a number of former colonies for these very reasons. In the first part of this paper we have described the theoretical basis for objection to such direct transfers of knowledge and technology. The relevancy of the dental curricula of industrialized nations would seem to be limited to comparable situations where the population experiences a high caries rate and is accustomed to routinely seeking dental treatment for restorations, extractions, prosthetic services, etc. Such a system requires a high dentist to propulation ratio and convenient locations or transportation mechanisms to get the patient to the dentist. High level technology and money are needed to provide and maintain the relevant equipment and materials. Most of this is unavailable in developing countries. with perhaps the exception of the oil producing states. There are unfortunate results from the direct transfer of traditional industrialized dental curricula and technology. Graduates from these schools may return to the industrialized societies where their newly acquired skills have more relevance instead of remaining in their developing countries. This may also confine their practice to the treatment of the urban middle classes. The urban middle classes are wealthier, have more access to refined sucrose, a diet similar to that of many developed countries, and consequently a similar dental disease pattern [19,31]. Therefore, it is not surprising that dentists trained in the industrialized model feel more comfortable when confronted with these types of clinical problems than when confronted with the oral health problems of rural people. involving large deposits of calculus. little caries and moderate to high levels of chronic periodontal disease. However, by concentrating their attentions on the problems of what is, after all, a relatively small urban elite in most developing countries, the new dentists themselves become identified with and frequently absorb the aspirations and attitudes of this elite. With increased numbers of graduates. pressures are exerted to create other institutions similar or identical to those found in the former colonizing country. An institution quick to develop is a dental association whose prime function is usually to guard “the standards of practice”. This is usually accomplished In several ways. An image is adopted of a ‘learned society’ that propagates and gives legitimacy to the
822
M. H. HOBDELLand A. SHEIHAM
latest technological developments. It also exerts the control or limitation of those who may carry out dental procedures. Control usually takes the form of defining dental professionals as only those persons who have successfully competed dental school and license examinations. In a few instances, certain dental auxiliaries may be licensed to practice. Such limitation can have a great impact (particularly where there may be only one trained dentist or auxiliary dental health worker for every 500,000 to 1,000,000 people as is frequently the case in developing countries). With these restrictions, relatively few people will have access to even emergency dental health services .or learn of appropriate preventive activities which they could use to help themselves. The problem is often further exacerbated by the lack of control over the geographic distribution of the few dental health workers that do exist. As already noted, there are powerful forces that cause them to concentrate in urban areas where they have access to higher level dental technology and where there is an urban elite who can remunerate them more fully for their services. It must be added that a professional organization of the learned society type is more easily organized if a fair number of members are conveniently located geographically. The second major result of the limitation and control of practice in developing countries is that it suppresses both the beneficial as well as the harmful aspects of indigenous or traditional dental practice. In many developing countries, there exists a well developed second level of dental providers-the traditional dentists. In many instances they are involved in other traditional health activities as well. Such individuals have a number of advantages over their more formally trained colleagues. They are. for instance. often well accepted by the local population; they understand the local traditions and attitudes to health; and they are usually situated in accessible places. By banning these workers, the majority of people may be denied access to essential primary health care services. Also, as the banning can never be totally effective, those who do use the services of the traditional dentists may feel that they are getting second best. The licensed workers, of all types, automatically gain in stature and in so doing, may become further distanced from the people whom they have, at least nominally, been trained to serve. Dental public health policy aimed at incorporating the traditional dental health workers in a national dental health service would appear to be more effective in treating the majority of the population; provided, of course, that it is linked with a program of basic training to increase appropriate skills and so discourage harmful or ineffective measures. THE TRANSFER OF DENTAL TECHNOLOGY Traditionally the curricula of most European and North American dental schools have focused on the technical aspects of curative dentistry. It is not surprising, in the light of what has been discussed in the previous section, that dental technology occupies a central position in the curricula of most dental schools in developing countries. For these reasons it is also seen as a major issue by many of those respon-
sible for dental public health in developing countries. The concern is usually with the technical aspects of equipment and materials. Only recently has the concern been with the appropriateness of the clinical technology itself. There are, of course, good reasons why attention has focused on equipment and materials. Basic dentistry, unlike medicine. requires an armamentarium of relatively expensive and sophisticated equipment, It is one thing to provide a dentist in a modern airconditioned dental surgery in a large urban center with all the high technology of modern dental cutting and filling instruments and materials. It is quite another to transport even the essential hand instruments and anaesthetic solution to a remote rural area in a developing country. This is partly because transportation is often difficult and even then there is often a lack of general supporting services such as electricity and clean water. Equipment suitable for use in the highly controlled environment of a West German or North American dental practice is usually unsuitable in a rural health post in a developing country. This is yet further inducement for dentists to stay in the urban centres. Even when money or aid is available for the purchase of dental equipment and supplies, there is little opportunity for those in developing countries to know what is available or how satisfactory it is in the field, before placing an order. Obtaining a share of the available resources is particularly difficult when it occurs in competition with agricultural equipment and fertilizers or vaccines, for example. Virtually no dental equipment or materials are manufactured in developing countries so that foreign exchange is imperative. All too often, money for dental equipment and materials comes as part of an ‘aid’ package tied to a specific country’s manufacturers. Needless to say. such conditions further limit the choices of equipment and materials. Another important reason why the technological aspects receive so much attention compared to the preventive and politico-economic aspects of dentistry. is that the primary dental training of many of those now responsible for building up the dental health services of developing countries was completed at a time before the dramatic expansion of preventive techniques and programs which occurred in the early 1970s in industrialized countries [32]. Many of the preventive techniques that have been developed are for use in the one to one, person to person situation that exists commonly in European and North American dental practices. Where mass programs have been developed [33] much of the technology has never been tested under the difficult field conditions and tropical climates of developing countries. A simple lack of cups, for example. may effectively prevent the development of fluoride mouth rinsing programs. Much of the pioneering work carried out in Latin America. e.g. Venezuela [34] depends on the existence of a well developed infra-structure which is by no means common in all developing countries. SUMMARY
AND
CONCLUSION
In summary we have looked at some of the differences in dental health problems facing developing and
Dental
health
in developmg
countries and examined the effects that they may have on the development and implementation of dental public health policies in developing countries. In particular. we have examined the possible effects of the transfer of dental knowledge and technology and their contributions with respect to the institutionalization of an urban professional elite whose interests often may be in conflict with the objectives of the development of primary dental health care for the mass of the rural population. This professional group is often supported by central government policy, and for a variety of reasons it tends to serve the minority. relatively wealthy urban middle class. This leaves the mass of peri-urban and rural people to develop and use alternative dental health services un-aided and often in defiance of central and local government. Such a situation is similar to the problems faced by the urban poor in some developed nations [35]. Alternative services have often taken the form of simple emergency services, the relief of pain. tooth extraction, or the prescription of various medications. Clearly where ineffectual or harmful practices have developed. control is necessary. A more imaginative approach to the use of traditional dental health workers in national dental health services is recommended. This is important because the services that they provide are often more accessible and economically and socially acceptable. There is an urgent need to review the dental curricula to developing to maximize
countries from industheir appropriateness
in meeting the dental needs of the people of the developing country. Only when oral health policy is integrated with all aspects of general health policy involving an awareness of the pertinent economic. social and cultural factors. can it be successful.
823
status of populations:
developed
being ‘exported’ trialized nations and effectiveness
countries an historlcal
perspective.
J. puhl.
Hlrh Depr. 38, 272. 1978.
food consumption patterpz .-. In . .. (Edited by kechsigal M.). pp. 16-33. CRC Press. Cleveland. 1973. pp. 13. 3ailey H. Clinical Surgery ,for Dental Prucririonert 54. Lewis, London. 1937. 14. smslie R. D. Cancrum oris. Dent. Prucrn. denr. Rec. 13. 1’.
=ekkariness
M. World
Mun. Food und Nurririon
181, 1963.
IS.
ihaskar S. N. Synopsis of Or-u/ Purhologv. pp. 572. tiosby. St Louis. 1973. 16. fodd J. E. Children’s Denrul He&h in Englund und Wules, 1973. Her Malesty’s Stationery Office. London. !975. 17. Speake J. D.. Cutress T. W. and Ball M. E. The prevalence of dental caries and the concentration of fluoride in the enamel of children in the South Pacific. A’. 2. Dem. J. 75, 94, 1979.
18 Barnes
D. E. Epidemiology
Periodonr.
of dental
disease.
J. c/in.
4, 80, 1977.
factors in dental caries 19 Enwonwu C. 0. Socioeconomic prevalence and frequency in Nigerians. Curies Re.s. 8, 1.55. 1974. 20 Olsson B. Dental health situation in privileged children in Addis Ababa. Ethiopia. Commun. Denr. owl Epidem. 7, 37, 1979.
21
22 23
24
25
Hobdell M. H. and Cabral J. R. Dental caries and gingivitis experience in 6 and 12 year old school children in four provinces of the People’s Republic of Mozambique (1978). Trap. Dent. J. 3, 111.1980. Palmer J. D. Dental health in children-an improving picture? Br. Denr. J. 149, 48. 1980. Russell A. L. World epidemiology and oral health. In Enrironmenrul Vuriahles in Orul Diseuse. pp. 21. Amer. Assoc. Adv. of Science, Washington, 1966. Zamir T.. Fisher D., Fishel D. and Sharav Y. A longitudinal radiographic study of the rate of spread of human approximal dental caries. Archs ortrl Biol. 21. 523. 1916. Harris R. The biology of the children of Hopewood House. Bowral. W. Observations on dental caries experience: proximal lesions. Ausr. Denr. J. 8, 521. 1963.
26. Loe H.. Anerud A.. Boysen H. and Smith M. The natural history of periodontal disease in man. J. Periodonr. REFERENCES 1. World Report Health World 2. Lalonde
3. 4.
3. 6.
Health Orgamzation. Primur!~ H&r/l Cure. of the International Conference on Primary Care. Alma-Ata. USSR. 6-12 September 1978. Health Organization. Geneva. 1978. M. A. ,Tl~a Per.yx~cri~r on rhe Hetrlrh of Cunutliun.A M’or-b.rnu Docunlrrlr. op. 82. Ministrv of Health. Ottawa. Canada. 1974. ’ . World Health Organization. op. cir.. p, 3. 1978. Navarro V. The underdevelopment of health or the health of underdevelopmenr: an analysis of the distributton of human health resources in Latm America. Inr. J. Hlrh Srrc. 4. 5. 1974. Doyal L. with Pennell L. 7hr Polirrcul Econon1.r of Hwlrh. pp. 96 137. Pluto Press. London 1979. Dakldson B. B/uc,k .Morhrr. 2nd edn. p. 67. Pelican Books. Harmondsworth. 1980.
7. Ibid 8. Turschen M. It’omrn. For)11 ‘VI
Res. 13, 550, 1978.
27. Ministry
of Health.
Surrey, oj IY7kApril
28.
29. 30. 31
Adults /Y??.
Malaysia. in
Peninsulur
Denrul Epidemioloqicul Mulrr~k, Sepremher
Dicetak Oleh Ibrahlm Bm Joheri. Kuala Lumpur. 1978. Sheiham A. An epidemiological survey of acute ulcerative gingivitis in Nigerians. Arch, oral Biol. 11, 937. 1966. Pindborg J. J. Epidemiological studies of oral cancer. Inr. Denr. J. 27, 172. 1977. Ruheni M. The Furure Leaders. p. 22. Hememann. London. 1973. Hobdell M. H. Dental caries prevalence and esumated
sugar
consumption-a
comparison
between
the
People‘s Republic of Mozambique and The United Kingdom. Trap. Denr. J. 4. 45. 1981. 32 Sll\ersin J. B.. Coombs J. A. and Drolette M. Achievements of the Seventies: self-applied fluorides. J. puhl. HM Dent. 40, 248. 1980. E. Achievements of the Seventies: com33 Newbrun munity and school fluoridation. J. pub/. Hlrh Denr. 40, 234. 1980.
34 Gillespie G. M. Dental care delivery in Venezuela. In Inrrrmlrio,nr/ Denrtr/ Cure Delirerj, Sj,srems (Edited b> Ingle J. 1. and Blair P.), pp. 69-78. Ballinger. Cambridge. MA. 1978. of bar35 Frazier P. J. and Jenny J. Parents‘ descriptions riers faced and strategies used to obtain dental care. J. pub/. Hlrh Dem. 34, 22. 1974.
BARRIERS
TO THE PROMOTION OF DENTAL DEVELOPING COUNTRIES
HEALTH
IN
M. H. HOBDELL and A. SHEIHAM The London
Hospital
Medical
College.
London.
England
AbstractPHealth in developmg countries is poor. Historically the trend towards ill health was initiated with the advent of slave trade and accelerated later by the colonial expansion of Europe. Dental health is no exceptton to this. There are many oral conditions which are functions of the poverty and undernutrition which are currently prevalent in developing countries. There are few human or physical resources available to meet these health needs. In most developing countries the dentist to population ratios are of the order of one dentist to 100,000 people or worse. In establishing dental health services in developmg countries. there is a danger that attempts will be made to establish the same patterns of organization and to use the same technologies as those used in industrial nations. Because such organizations and technologies are often specific to certain social, political and economic situations their direct transfer for use under totally different circumstances frequently meets with failure. This caveat is particularly critical since there are clear differences between industrialized and developing countries in their patterns of dental disease.
cern in developed nations is with high technology medicine, whereas in developing nations it is with primary health care. The second assumption follows from the first. Given the relationship between development and support of health activities, then transplanting health activities (the science and technology of medicine, that is) from one nation to another without regard to relative levels of development is likely to be unsuccessful-at least in achieving improvements in health. This does not mean that the transfer of all technology is impossible but only that it must be appropriate to the circumstances into which it is transferred. It must be recognized that science and technology cannot be considered politically or socially neutral. They are both the products and tools of society and are therefore frequently quite specific in their applicability. Given the first assumption (that of a relationship between the level of development of a country and the type of health activities that it supports), there is a need to define more precisely what is meant by high technology medicine and primary health care in order to develop the argument’more fully. By high technology medicine we mean not only the sophisticated equipment and complex life support systems (i.e. heart/lung machines or dialysis units) but also the many potent and complex pharmacologic agents developed by the international drug companies. Many of the complicated medical and surgical interventions carried out in the large hospitals of Europe and North America would be impossible without these drugs. Because of the unbridled proliferation of the pharmaceuticals the World Health Organization has developed a list of essential drugs considered basic for any country attempting to provide primary health care. The 1978 WHO Conference defined primary health care as “essential health care based on practical. scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community
INTRODUCTION
Two trends in public health thinking have become more apparent in the past decade. The first is an increasing awareness of and importance of the concept of Primary Health Care (PHC). The second is the recognition of the relative failure of ‘modern’ medicine to do much to reduce the premature loss of life caused by such chronic degenerative diseases as ischemic heart disease and cancer-regardless of the amount of money spent or the sophistication of the technology used. There are enormous differences between primary health care (with its emphasis on access to a basic list of drugs and techniques) and the complex technology involved in organ transplants and other similar interventions. However, all health activities can be arrayed on the basis of two criteria: the frequency with which they are needed and the degree of technological expertise involved. In this way it can be seen that primary health care, embracing those activities at one end of the scale and high technology medicine, embracing those at the other are not unrelated but are part of a continuum of health activities the component parts of which are generally directed towards gaining and maintaining health. In this article we will show the importance of this link between the two ends as one of the determinants affecting dental public health policy in developing countries. In this respect there are two major points to note about the continuum: first. that reference to primary health care is most frequently made in discussions relating to the health problems of the rural and periurban poor in developing countries [l]. Secondly, reference to high technology medicine is most frequently made in discussions relating to the health problems of urban industrialized populations in developed nations [2]. Two assumptions follow from this. The first and most obvious is that there is a relationship between the level of development of a nation and the health activities which that nation supports. Thus. the con817
M. l-l.
818
HOBDELL
and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination” [3]. Although high technology medicine may not be available to all in industrialized nations, basic primary health care is available to most. However, in industrialized societies many people still die prematurely from chronic diseases such as coronary heart disease and cancer. The failure of high technology medicine is illustrated by the persistence of high mortality rates for chronic diseases. Responses to this failure have usually been of two types. One form has been an appeal to make high technology medicine more widely available by constructing more hospital facilities and increasing the speed with which patients are treated in existing facilities. An additional aspect of this approach has been to encourage the development of an even higher level of technology. Such approaches all emphasize the technological aspects of a solution. The second general response to the failure of high technology medicine has focused on prevention in the form of either primary or secondary preventive programmes. Prevention at the highest levels of policy making is conceptualized in as ima8inat~ve and broadly based a manner as possible. These current conceptualizations in * tbtic health are relevant to any discussion of the problem of achieving and maintaining dental health in developing countries, since dental health is an integral part of general health. The achievement and maintenance of both general and dental health within any population requires that one understands that the science and technology of medicine and dentistry must be integrated with the economic and political forces which dominate the development of societies. One of the cornerstones of the PHC approach for achieving health for all by the year 2000 is the development and use of appropriate technologies. in this paper we attempt to analyze the dental health problems of developing countries. We then will examine the determinants of and effects of public health policies in resolving these problems.
THE BACKGROUND IN DEVELOPING
TO HEALTH
PROBLEMS
COUNTRIES-EXAMPLES
FROM
AFRICA
The relationship between health. illness and development has been well documented [4,5]. Nonethefess. it is appropriate to provide a few examples here. Essentially the argument rests on the relationship between environment. lifestyle and health. This relationship is well accepted in many developed industrialized nations and indeed constitutes the basis of many public health and industrial medical practices Frequently, however, in developing countries the ways in which environment, lifestyle and health have been radically altered by such processes as wars, the slave trade and colonial expansion have been ignored. The development of the slave trade provides one of the best known human examples. initially started first by the Portuguese and Spanish, it assumed a commer-
and A. SHEIHAM
ciaf basis for Britain in 1562 [6] with the departure of the first slave ship from London for West Africa and then the West Indies. This began the infamous slave triangle: slaves from West Africa were taken to the West Indies as cheap inexhaustible labor to produce first sugar, then cotton and tobacco. These products were shipped to Britain, where they were processed. consumed, or turned into manufactured goods. Some goods were shipped back to Africa to be used for the purchase of more slaves. This process gradually permitted the accumulation of wealth and the encouragement of the developed of more and more machines. The industrial revolution of Britain and Western Europe gathered pace carried on the backs of African slaves and European industrial workers. The ever increasing demand for more raw materials of other kinds gradually diminished the importance of sugar. cotton and tobacco from the West Indies and with it, the slave trade. Africa itself became the center of interest for Western Europe’s industrialists-not only for its metals but also for rubber. sisal. caju. and its apparently inexhaustible supply of cheap labor. At the same time it continued to provide a large potential market for manufactured goods. If the slave trade gave birth to. or at the least spurred on. the industrial revolution and capitalism in Europe, the industrial revolution gave rise to colonial expansion and advanced capitalism. Each phase resulted in many changes. Kingdoms and social systems were destroyed. Families were uprooted, members separated and many killed. In the period from 1530 to 1830. as many as 15 mihion people were inducted into slavery. During this time. several million died in the hunt for captives and some 10-139,; died during transportation [7]. The social, economic and health impact of all this can only be guessed. Probably those to suffer most. if indirectly, were the most vulnerable: children. mothers and the old. Turschen [S] examined the effect of the colonial plantation economy and its inherent need for migrant labor in Tanzania. She showed that one of the effects of the men going away to plantations for about a year ata time was to reduce considerably the nutritional value of the food available to the families left behind. The subsistence peasant economy was severely disrupted as a result of the reduced labor force to open up new land. The effects of colonial penetration on the African economy and health are graphically illustrated by the recently translated work of Nzufa, Potekhim and Zusmanovich [93. Perhaps one of the most horrific reports is that of the development of the rubber plantations in the Congo basin. which reduced the population from an estimated 3&40 million people in the 1890s to 8.5 million by the mid 1920s. Direct killing played a part but was clearly not the main factor --infectious diseases. introduced from Europe and under-nutrition did the rest. Colonial domination of African states was usually achieved through force and warfare. War was largely responsibIe for the spreading of diseases previously known in Africa. Rinder pest. for example. was brought to sub-Saharan Africa in 1864 and reached epidemic proportions soon after in the wild game and domestic cattle of West Africa. Its spread to East Africa occurred in 1889 when diseased cattle were brought from India as provision for the Italian Army
Dental health in developing countries on its campaign in Eritrea. An epidemic occurred in 1890-1891 in East Africa killing nearly all the cattle. The resultant loss of cattle (the basis of pastoral economies and an important source of protein for many semi-pastorial groups) precipitated an exodus of people from the region and created a famine in which endemic disease became epidemic. Thorn trees replaced grassland and bush crept over formerly cultivated fields. creating an environment favorable to the tsetse fly. This ecological change has proved difficult to reverse [8]. An interesting result of such health problems. not only in Africa. but in many developing countries which lie in tropical and subtropical regions. has been the labelling of many of the diseases which are prevalent there as tropical diseases. However, such high levels of disease and ill health have not been historically the norm for such areas [S]. Health in Africa today is not only the result of many cumulative factors such as the slave trade and war. but of many other events such as colonial land policy. forms of taxation and their effects on patterns of trade and agriculture which have resulted in the establishment of various forms of monoculture [S] and migrant labor [IO]. Typical developing countries experience extremes of rich and poor. landed, landless and hyper-fragmented small holders, overcrowded cities. inadequate academic education. limited non-existant health services and a stagnant economy. A pressing concern in such countries is to raise agricultural production to provide a surplus without further polarization and fragmentation. Implementation is largely political rather than a technical task. Although in colonial times state control resided in London, Paris, Brussels, Berlin and Rome, today it rests in the independent African States. Unfortunately, history has bequeathed a difficult legacy to these states. They have been left with little in the way of developed industrial resources for their own use and few educated and trained workers to man those that do exist. Those few established industrial organizations are concerned almost exclusively with the extraction of raw materials or the production of large quantities of agricultural products such as palm oil. cotton. or sisal. Many of these industries are controlled by multi-national firms who rarely process the products of the mines and plantations in the country of origin, Production of processed raw materials in excess of European and North American demand are exported back to Africa and other developing countries. An excellent example is that of sugar. The European Economic Community (EEC) is now an exporter of refined sucrose (and other processed foods such as dried milk) to developing countries. Frequently the old-style colonialism has been replaced by control exerted by large multinational corporations. Such trading practices can materially affect health and in respect of sugar consumption and dental health provide a specific illustration. There has been a steady rise in world sugar production and sugar consumption. In many developing countries consumption is rising rapidly [ll, 121. A levelling off of consumption has, however. occurred in the U.S.A.. Britain. and other high sugar-consuming industrialized societies.
x19
The mouth or oral cavity has not been immune from these various types of influences. Two diseases illustrate the point. Cancrum oris (gangrene of the face and jaw) is a condition seen almost exclusively in chronically under-nourished children whose resistance to infection has been lowered further by some acute generalized infectious disease such as measles. In the late 19th century, Cancrum oris was not an uncommon condition in children living ,in the industrial slums of Europe [13]. As living conditions improved in Europe and declined in the colonies in Africa. the condition decreased in Europe and increased in Africa. It is important to note that Cancrum oris is by no means limited to Africa and is found in all populations with poor sanitation. unsanitary water supplies and chronic undernutrition. The disease is often fatal. particularly since it often occurs concomittantly with generalized acute infectious diseases [ 143. Disfigurement and the subsequent need for major reconstructive and cosmetic surgery place a great drain on the already over-taxed health resources of any developing country. Another major disease is oral tuberculosis. described in modern European textbooks of oral pathology as a rare disease found mainly in elderly patients who have suffered pulmonary tuberculosis for many years [IS]. In developing countries it is far from rare. and frequently afflicts the young. Tuberculosis is wellrecognized as a disease which is a function of the interaction of poverty, overcrowding and undernutrition. These are two examples of major oral diseases caused by adverse environmental factors-nutrition. housing and sanitation. They are major only in the sense that they are life-threatening and make disproportionate demands on health resources in relation to their prevalence in developing countries. They are by no means encountered as frequently as dental caries and periodontal disease.
DENTAL
CARIES
PERIODONTAL
(DENTAL DISEASE
IN DEVELOPED
AND
DECAY)
(GUM
AND
DISEASE)
DEVELOPING
COUNTRIES
Dental caries and periodontal diseases are the most common oral diseases in the world. In developed nations they affect almost everyone. Indeed, dental caries has been called ‘the last great epidemic’. Dental caries became a significant health problem toward the end of the 19th century. Its prevalence world-wide is uneven. It is relatively rare in a few countries and rampant in others. In England and Wales 95”” of 12 year olds have dental caries in 5.2 teeth per child [ 161. In Rurutu (French Polynesia) 41:” of II-year-olds exhibit caries in 0.5 teeth [ 171. Major variations in disease attack rates also occur within single countries and populations. Within French Polynesia the severity of dental caries has been found to vary from 0.5 teeth in Rurutu to 6.8 teeth in Huahine [17]. When the data are examined the pattern which emerges is that the more highly developed nations of the world are affected most by dental caries while the developing countries are affected to a lesser degree [18]. If the
820
M. H. HOBDELL and A. SHEIHAM
data are examined in greater detail, several important trends can be observed: 1. The prevalence of dental caries is high to a very high degree in indust~alized countries and is usually very low in developing countries. 2. There is an increasing prevalence and severity of dental caries in developing countries [19-211. The most rapid increases are occurring in the urbanized. higher socio-economic groups [19] but rates of increase are very small in the rural populations. The increases in prevalence and severity in developing countries must be contrasted with the decreases which are occurring in a number of developed countries. Indeed, decreases of as much as 30% in the number of decayed, missing and filled teeth in the past 10 years have now been reported [22]. In addition to these differences between patterns of dental caries in developed and developing countries, there are a number of other significant differences. The sites of caries attack are predominantly in pits and fissures in developing countries, whereas in developed countries the smooth surfaces are more commonly affected. In most industrialized areas of the world the pattern of caries attack is similar in the deciduous and in the shan’t teeth. However, in many developing countries, caries is much more severe in the deciduous teeth [23]. In developed countries the dental caries attack is most intense during adolescence and decreases in adults with a small increase occurring in persons over 60 years. In developing countries dental caries is most severe in the very young and the mature adult. The increase in caries in mature adults is due to caries attacking the roots of teeth which have been affected by periodontal disease. For populations in both developed and developing nations, certain factors influence the prevalence, incidence and rate of progression of dental caries. The initiation of caries in susceptible populations is early, usually occurring within 18 months after tooth erup tion. However, the progression of the carious lesion is usually very slow and may require almost two years to progress through the outer enamel layer to the dentine. Some lesions do not progress at all [24]. Others may remineralize and reverse the process. In populations consuming little refined sugars, with fluoride-rich water, or fluoride supplements, the rate of progression of dental caries is substantially slower than in the high sugar consuming populations [ZS]. Periodontal diseases (diseases of the soft tissues and supporting structures of the teeth) were common in ancient times. The acute form of the disease, acute ulcerative gingivitis, is relatively uncommon, but the chronic forms are highly prevalent. Chronic periodontal disease occurs in over 90:& of people; the prevalence is slightly lower in developed than in developing countries. As with dental caries, the severity of the disease varies considerably between and within populations. Populations in developing countries, living in rural areas, the poorly educated, and the lower socio-economic status groups have more severe periodontal disease than those in developed, urban areas with high educational and high socio-economic status. The most important factor affecting the severity and rate of progression of chronic periodontal disease is oral cleanliness. The standards
of oral cleanliness are poorer in populations in developing than in developed countries. Therefore, it is not surprising that the rates of progression of periodontal disease are more rapid in developing than in deveioped countries. Periodontal disease is the most common cause of tooth loss in all countries. But in developing countries where the rate of caries is low and periodontal disease high. periodontal disease causes the loss of more teeth per person than in developed countries. However. overall in most developing countries the rate of tooth loss is slower than in developed countries. But in those developing countries with relatively h&h rates of dental caries and a high severity of periodontal disease, there is a similar pattern of tooth loss to that found in developed countries [27]. The loss of all the teeth (edentulousness) is relatively uncommon in developing countries because of the shorter life expectancy, the lower rates of dental caries and a tack of dentists or others to extract teeth. The acute form of periodontal disease. acute ulcerative gingivitis, is common in children under the age of 6 years in developing countries. By contrast, it is seldom reported in young children in developed countries. Apart from the pain and suffering of the disease, there is the added danger that it may progress to Cancrum oris in some children, or at least cause the premature loss of some teeth and alveolar bone [ZSJ. Oral cancer is relatively uncommon in developed countries. In developing countries (and in particular, some Asian countries) oral cancer is the most common of all cancers [29J. Burkitt’s iymphoma is an im~rtant cause of death due to maIignancies in children in developing countries. Its occurrence has been linked with concomittant infection with EB virus and chronic malarial attacks. Although this finding is still controversial, if it is substantiated, it will provide yet another example of the effects of the environment on health. Clearly, the increases in dental caries and the high levels of periodontal disease in developing countries add considerably to the total disease burden. SOCIAL, SHAPING
POLITICAL
AND
DENTAL
HEALTH
TECHNOLOGIES
ECONOMIC
FORCES
STRATEGIES
AND
IN DEVELOPING
COL’NTRIES
Dental disease constitutes a major public health problem in developing countries. The public health approach to these problems differs from that in developed nations in several ways as regard to planning and policy. In most developing countries there are significant differences in the population, its age structure and geographic distribution from those observed in developed nations. In many developing countries 25”,, of the population is under 5 years of age whereas I or 29; are over 40. In developed countries (for example, Britain) the population age groups only begin to ‘taper 08’ in size after the age of 55 years. Similarly. the geographic distribution is different but changing quite rapidly. With the attraction of the cities, in developing countries. urban populations are growing at the expense of the predominantly rural populations. The second consideration involves diet. With
Denml
health m developmg
in population distribution and life style there are often changes in diet. There usually occurs a decrease in fibre content with an increase in sugar content. as well as alterations in the total quantity of food eaten. It is conceivable that a landless peri-urban family will be worse off nutritionally than they were as subsistence peasant farmers. Mention has already been made of the increased selling of refined sugar to developing countries. This is clearly a matter of importance in dental health assessment and planning. Existing patterns of disease provided a specific orientation to both the preventive and curative aspects of any dental health services and therefore act as determinants of policy. To what extent these disease patterns can provide an orientation to health policy will depend to a greater or lesser extent on who is recording such data and from what population groups the data are being collected. Of primary concern are questions about who makes dental health policy and who implements it. Decisions about these will depend on the prevailing political philosophy, levels of production and wealth. They will also depend on whether there exists a specific group of people who see themselves and are seen by the policy makers, as being responsible for the planning of the dental health services. An additional and critical determinant of dental health policy and strategy development is the available number of personnel for implementation, or who can be trained to carry out. the policy and strategies adopted. This number is severely limited in many cases by factors such as high illiteracy rates in most developing countries. The abilities of these dental health workers are themselves. in turn, restricted by the availability of appropriate dental health knowledge and also the availability of the physical resources necessary. It, of course, must be recognized that many of the constraints operate in both developing and developed countries. However, they acquire a greater signilicance in areas where specialized knowledge and material is scarce and there is no tradition of any centrally organized dental health service. These factors profoundly affect the transfer of dental knowledge and technology as well as the growth of professionalization with its effect on public dental health policy development. changes
THE TRANSFER
OF DENTAL
KNOWLEDGE
The effective transfer of knowledge is not a one-way process from developed to developing countries. However. in dentistry. it has tended to be from developed to developing countries with respect to models of dental education and their related clinical techniques involving curative and preventive care. In many developing countries several approaches have been taken to developing a pool of professional manpower. In those countries where independence has been achieved, groups of the best educated young people have been sent to the former colonizing country for dental education. Upon their returning (if indeed they have returned) these young professionals begin to press for the establishment of a modern dental school in their own countries. They are usually
countries
821
designed and built exactly like those of the country in which they themselves were trained. The curriculum. teaching methods. clinical techniques and equipment and materials are also transferred without modification. Teachers from the ex-colonial country are frequently employed to assist in starting up the new school. An offshoot of this is an emphasis on the need to ‘maintain the standard of the old country’. This has often been most apparent in those schools which have been started prior to independence [30]. One major reason behind the adoption of an already developed curriculum has been the perceived need for comparability in standards of dental education which would permit graduates to travel to the colonial country for additional graduate or post-graduate education. or to work. An example of that is the controlling body for dental education in Britain, the General Dental Council, which also controls the general form of the curriculum in a number of former colonies for these very reasons. In the first part of this paper we have described the theoretical basis for objection to such direct transfers of knowledge and technology. The relevancy of the dental curricula of industrialized nations would seem to be limited to comparable situations where the population experiences a high caries rate and is accustomed to routinely seeking dental treatment for restorations, extractions, prosthetic services, etc. Such a system requires a high dentist to propulation ratio and convenient locations or transportation mechanisms to get the patient to the dentist. High level technology and money are needed to provide and maintain the relevant equipment and materials. Most of this is unavailable in developing countries. with perhaps the exception of the oil producing states. There are unfortunate results from the direct transfer of traditional industrialized dental curricula and technology. Graduates from these schools may return to the industrialized societies where their newly acquired skills have more relevance instead of remaining in their developing countries. This may also confine their practice to the treatment of the urban middle classes. The urban middle classes are wealthier, have more access to refined sucrose, a diet similar to that of many developed countries, and consequently a similar dental disease pattern [19,31]. Therefore, it is not surprising that dentists trained in the industrialized model feel more comfortable when confronted with these types of clinical problems than when confronted with the oral health problems of rural people. involving large deposits of calculus. little caries and moderate to high levels of chronic periodontal disease. However, by concentrating their attentions on the problems of what is, after all, a relatively small urban elite in most developing countries, the new dentists themselves become identified with and frequently absorb the aspirations and attitudes of this elite. With increased numbers of graduates. pressures are exerted to create other institutions similar or identical to those found in the former colonizing country. An institution quick to develop is a dental association whose prime function is usually to guard “the standards of practice”. This is usually accomplished In several ways. An image is adopted of a ‘learned society’ that propagates and gives legitimacy to the
822
M. H. HOBDELLand A. SHEIHAM
latest technological developments. It also exerts the control or limitation of those who may carry out dental procedures. Control usually takes the form of defining dental professionals as only those persons who have successfully competed dental school and license examinations. In a few instances, certain dental auxiliaries may be licensed to practice. Such limitation can have a great impact (particularly where there may be only one trained dentist or auxiliary dental health worker for every 500,000 to 1,000,000 people as is frequently the case in developing countries). With these restrictions, relatively few people will have access to even emergency dental health services .or learn of appropriate preventive activities which they could use to help themselves. The problem is often further exacerbated by the lack of control over the geographic distribution of the few dental health workers that do exist. As already noted, there are powerful forces that cause them to concentrate in urban areas where they have access to higher level dental technology and where there is an urban elite who can remunerate them more fully for their services. It must be added that a professional organization of the learned society type is more easily organized if a fair number of members are conveniently located geographically. The second major result of the limitation and control of practice in developing countries is that it suppresses both the beneficial as well as the harmful aspects of indigenous or traditional dental practice. In many developing countries, there exists a well developed second level of dental providers-the traditional dentists. In many instances they are involved in other traditional health activities as well. Such individuals have a number of advantages over their more formally trained colleagues. They are. for instance. often well accepted by the local population; they understand the local traditions and attitudes to health; and they are usually situated in accessible places. By banning these workers, the majority of people may be denied access to essential primary health care services. Also, as the banning can never be totally effective, those who do use the services of the traditional dentists may feel that they are getting second best. The licensed workers, of all types, automatically gain in stature and in so doing, may become further distanced from the people whom they have, at least nominally, been trained to serve. Dental public health policy aimed at incorporating the traditional dental health workers in a national dental health service would appear to be more effective in treating the majority of the population; provided, of course, that it is linked with a program of basic training to increase appropriate skills and so discourage harmful or ineffective measures. THE TRANSFER OF DENTAL TECHNOLOGY Traditionally the curricula of most European and North American dental schools have focused on the technical aspects of curative dentistry. It is not surprising, in the light of what has been discussed in the previous section, that dental technology occupies a central position in the curricula of most dental schools in developing countries. For these reasons it is also seen as a major issue by many of those respon-
sible for dental public health in developing countries. The concern is usually with the technical aspects of equipment and materials. Only recently has the concern been with the appropriateness of the clinical technology itself. There are, of course, good reasons why attention has focused on equipment and materials. Basic dentistry, unlike medicine. requires an armamentarium of relatively expensive and sophisticated equipment, It is one thing to provide a dentist in a modern airconditioned dental surgery in a large urban center with all the high technology of modern dental cutting and filling instruments and materials. It is quite another to transport even the essential hand instruments and anaesthetic solution to a remote rural area in a developing country. This is partly because transportation is often difficult and even then there is often a lack of general supporting services such as electricity and clean water. Equipment suitable for use in the highly controlled environment of a West German or North American dental practice is usually unsuitable in a rural health post in a developing country. This is yet further inducement for dentists to stay in the urban centres. Even when money or aid is available for the purchase of dental equipment and supplies, there is little opportunity for those in developing countries to know what is available or how satisfactory it is in the field, before placing an order. Obtaining a share of the available resources is particularly difficult when it occurs in competition with agricultural equipment and fertilizers or vaccines, for example. Virtually no dental equipment or materials are manufactured in developing countries so that foreign exchange is imperative. All too often, money for dental equipment and materials comes as part of an ‘aid’ package tied to a specific country’s manufacturers. Needless to say. such conditions further limit the choices of equipment and materials. Another important reason why the technological aspects receive so much attention compared to the preventive and politico-economic aspects of dentistry. is that the primary dental training of many of those now responsible for building up the dental health services of developing countries was completed at a time before the dramatic expansion of preventive techniques and programs which occurred in the early 1970s in industrialized countries [32]. Many of the preventive techniques that have been developed are for use in the one to one, person to person situation that exists commonly in European and North American dental practices. Where mass programs have been developed [33] much of the technology has never been tested under the difficult field conditions and tropical climates of developing countries. A simple lack of cups, for example. may effectively prevent the development of fluoride mouth rinsing programs. Much of the pioneering work carried out in Latin America. e.g. Venezuela [34] depends on the existence of a well developed infra-structure which is by no means common in all developing countries. SUMMARY
AND
CONCLUSION
In summary we have looked at some of the differences in dental health problems facing developing and
Dental
health
in developmg
countries and examined the effects that they may have on the development and implementation of dental public health policies in developing countries. In particular. we have examined the possible effects of the transfer of dental knowledge and technology and their contributions with respect to the institutionalization of an urban professional elite whose interests often may be in conflict with the objectives of the development of primary dental health care for the mass of the rural population. This professional group is often supported by central government policy, and for a variety of reasons it tends to serve the minority. relatively wealthy urban middle class. This leaves the mass of peri-urban and rural people to develop and use alternative dental health services un-aided and often in defiance of central and local government. Such a situation is similar to the problems faced by the urban poor in some developed nations [35]. Alternative services have often taken the form of simple emergency services, the relief of pain. tooth extraction, or the prescription of various medications. Clearly where ineffectual or harmful practices have developed. control is necessary. A more imaginative approach to the use of traditional dental health workers in national dental health services is recommended. This is important because the services that they provide are often more accessible and economically and socially acceptable. There is an urgent need to review the dental curricula to developing to maximize
countries from industheir appropriateness
in meeting the dental needs of the people of the developing country. Only when oral health policy is integrated with all aspects of general health policy involving an awareness of the pertinent economic. social and cultural factors. can it be successful.
823
status of populations:
developed
being ‘exported’ trialized nations and effectiveness
countries an historlcal
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21
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