Spring 2018

12 Million People. 48 Dentists.

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John Morgan, a professor of public health and community service, (far right) at a survey site. Photo: courtesy of Donna Hackley

In the spring of 1994, the East African nation of Rwanda collapsed into one hundred days of bloodshed. Over the course of three months, somewhere between eight-hundred thousand and one million people were murdered as the country’s Hutu majority waged a genocide against the Tutsi minority ethnic group. The human cost was devastating, and Rwandan society, including its health-care system, was torn apart. Facilities and records were destroyed. Doctors, dentists, nurses, and others were killed or fled, and, for the next two years, no new health-care providers could be trained.

More than two decades later, Rwanda is still working to knit its society back together. Along with an ambitious restorative-justice effort to reconcile the victims and perpetrators of the genocide, and a host of economic and educational reforms, that has also meant rebuilding the health-care system.

In time, attention turned to oral-health care for the nation of twelve million people, but progress has been slow. In 1998, Rwanda began training dental therapists—approximately three hundred are now employed—but the scope of their practice is limited to preventive care and simple treatment. The pool of practicing dentists is even more limited. Rwanda has about a million more people than its former colonial ruler, Belgium, a country with an estimated eight thousand dentists. Rwanda, by comparison, has forty-eight registered with the government.

Because of the lack of dentistry professionals, anything more complex than a simple extraction usually means a referral to a district or provincial hospital, which could be as far as a four- or five-hour walk for patients. Most people in rural areas—about 80 percent of the population—don’t own cars, motorcycles, or bicycles, nor do they have the money to pay for a ride from someone who does. As a result, Rwanda’s thirty-six district hospitals saw more people complaining of tooth and gum disease than any other ailment in each of the last ten years.

And that was just what country officials knew. There was much they didn’t—and they had no way of finding it out. Although the Ministry of Health conducts a national survey every five years, it contains no questions about oral health. So before they could begin to chart a course for the future, Rwandan officials, academics, and dental professionals needed a clear-eyed look at the current state of oral health in the country. And that’s where a Tufts professor and his team of researchers came in.

During a trip to East Africa in 2013, John Morgan, a professor of public health and community service, met with members of the Rwandan dental surgeons and dental therapists associations. They presented him with a bold idea: a National Oral Health Survey of Rwanda, one that would record the oral-health status across all age groups and geographic regions. “They had been asking for this data for a while,” Morgan said, “but didn’t think they had the capacity on their own to develop and implement this study.” At the time, Morgan was in the country to explore oral-health needs at a cancer center supported by the Cummings Foundation, a nonprofit based in Woburn, Massachusetts, founded by Bill Cummings, A58, H06, and Joyce Cummings, H17. Understanding the urgency of the national assessment, Morgan took up the challenge, and the Cummings Foundation agreed to fund it.

Researchers Donna Hackley and John Morgan meet with data collectors on the project. Photo: courtesy of Donna Hackley

Capturing detailed health data to represent twelve million people—many of whom live in isolated rural areas without dependable electricity or well-maintained roads—was a daunting task, even for a public health researcher like Morgan, who has done extensive work in other areas of Africa. “It’s very hard to find a good baseline study in a lot of countries with developing economies, not just in Africa,” Morgan said. “Oral health never seems to get as much attention as some other diseases.”

The first-of-its-kind project would take three years of planning. It would require the cooperation of almost two dozen researchers, eight on-the-ground data collectors, and three universities. And it would turn out to be one of the largest field-research projects ever undertaken by Tufts School of Dental Medicine. The results, Morgan said, stand as “a wake-up call” for how much work remains before Rwanda fully tackles its oral-health dilemmas.

Rwanda is a landlocked country roughly the size of Massachusetts. Before Morgan’s research team visited in late 2016, the country’s small size led him to underestimate the difficulties they would face. Rwanda is mountainous—its name means “Land of a Thousand Hills”—with rugged terrain, and getting in and out of remote villages can be daunting. “I didn’t appreciate how hard it would be to get to some of these places,” Morgan said. At times, their vehicles barely made it over roads; sometimes they needed small boats to reach villages perched on islands.

The survey, which was developed by the dental schools at Tufts, Harvard, and the University of Rwanda, called for covering all five provinces of Rwanda, including rural areas, two small cities, and the capital city, Kigali. At each of fifteen sites, at least twenty-five people in five age groups would be screened for overall dental status.

A member of the research team practices before heading into the field. Photo: courtesy of Donna Hackley

To recruit the more than two thousand survey subjects they eventually recorded, Morgan turned to local volunteers. The Ministry of Health supervises community health workers in every village throughout Rwanda, who tend to issues such as newborn care or malaria prevention, and serve as a link between the rural population and health-care facilities. “They were phenomenal team members,” Morgan said. “They know every member of the community—how to contact them, the names of all the members of their family. They are really committed to improving health at the village level.”

During the survey, a cadre of Rwandan dental therapists collected information from study participants and performed dental chartings. Even though the areas sometimes lacked electricity or cell phone service, Morgan said the data-recording went remarkably smoothly, thanks to the Computer Assisted Personal Interview program developed by Tufts School of Medicine and the rigorous preparation of the survey beforehand, the cooperation of the local communities, and the resilience and dedication of the data collectors.

As the team traveled the country, a more troubling level of dental disease than it had expected quickly began to reveal itself. “There were many beautiful smiles,” said Donna Hackley, a member of the research team and instructor at Harvard School of Dental Medicine. “But when we looked inside, particularly past the incisors, there was plenty of decay and plenty of perio conditions.” (Hackley also trains faculty at the University of Rwanda’s School of Dentistry as part of the Rwandan government’s Human Resources for Health partnership.)

The results were striking. Although the literature suggests that dental caries is less prevalent in most African countries than in many industrialized nations, Morgan said, more than half of the Rwandan children and adults surveyed had untreated caries. He and his colleagues found that 70 percent of the people they reviewed had never been to an oral-health care provider—even though significant numbers reported dental pain or difficulty chewing. For the adults, more than half of those ages twenty to thirty-nine, and two-thirds of those over forty, reported difficulty doing their usual jobs because of their mouth, teeth, or dentures. Most people over forty reported difficulty chewing. Nearly two-thirds of all respondents reported painful aching in the mouth at some point during the past year, including 90 percent of those over age forty. And among those who had been to a dental professional, almost all—98 percent—said it was pain that drove them there. “Most everyone,” Morgan said, “had some type of dental problem or need.”

By the end of December 2016, Morgan’s team had finished the survey, a five-week sprint that he called “nothing short of miraculous.” In August 2017, Morgan and members of the team presented their findings to Rwanda’s Minister of Health, Diane Gashumba. “It confirmed the fact that oral disease is prevalent in the communities that we surveyed,” Morgan said. “A high percentage reported problems with quality of life [because of oral pain], especially as they got older.”

One of the many rough roads the team navigated. Photo: courtesy of Donna Hackley

More than half of the people in the survey said that cost was the main reason they could not get dental care. This despite that fact that nearly 80 percent of Rwandans surveyed have low-cost health insurance through a national program called Mutuelles de Sante, which includes dental services. So whether they meant the cost of treatment, or other, associated costs—such as transportation or lost wages—was unclear, Morgan said, and worthy of further investigation.

It’s now up to the Rwandan government to decide on solutions. But this baseline research did point to several challenges as Rwanda’s health ministry moves ahead. One challenge is cultural. A practice called ibyinyo, found largely in eastern Rwanda and neighboring countries, involves removing the cuspid tooth buds from babies or young children by traditional healers—raising the possibility of infection and other complications. The erupting teeth are often blamed as the cause of GI distress in youngsters. Nearly 7 percent of the children ages two to five showed evidence of ibyinyo, and 4 percent of children aged six to eleven.

Morgan’s research also points to the need of increasing the use of oral hygiene supplies such as toothbrushes and toothpaste, particularly in rural areas. Another challenge is related to infrastructure: Six percent of people showed evidence of fluorosis, mottling of the teeth from excess consumption of fluoride, possibly because of high fluoride levels in drinking water in the Western Province, where evidence of fluorosis was most prevalent.

All of this information will be put to use as Rwanda plots out its next moves. “Once you document the need, now you have evidence-based data for making policy, for deciding about training programs, for surveillance,” Hackley said. And, added Morgan, “The data can be used for advocacy at the community, district, provincial, and national levels.”

Until then, there is more reason for optimism. In 2013, the University of Rwanda opened a dental school, with assistance from schools at Harvard and the University of Maryland. And the first class of homegrown Rwandan dentists, fourteen of them, will graduate this fall. As a group, they refer to themselves as “the Pioneerz.”

Helene Ragovin, the editor of this magazine, can be reached at helene.ragovin@tufts.edu.

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