Oral diseases are a major public health problem in the African region where, despite encouraging “official” GDP percentages, the number of poor people increases inexorably due to a massive population growth. Like all diseases, they affect primarily the disadvantaged and socially marginalized populations, causing severe pain and suffering, impairing functionability and impacting quality of life.
 

As in many other countries in the world, chronic diseases and injuries are overtaking communicable diseases as the leading health problems. This rapidly changing global disease pattern is closely linked to changing lifestyles including diet rich in sugars, poor unbalanced diet and increased uncontrolled selfmedication. These lifestyle factors also significantly impact oral health, and oral diseases qualify as major public health problems owing to their high prevalence and incidence in all African regions.

 

Traditional treatment of oral diseases is known to be extremely costly in industrialized countries and is neither affordable nor accessible in most low and middle-income countries of Africa and oral diseasemanagement is not part of health budgets available.

 

Africa has been my second university (1). It cannot be described in few words but must be experienced to understand it. Non-Africans have no idea of the diversity, the wealth of knowledge, the school of patience and all other fundamental human qualities you grab from this continent known as the “land mother” of humanity. Earth of Africa, hostile sometimes, generous nevertheless, rich in wisdom and in skills but threatened (plundered) by the greed of the modern man. The run after easy money, lead by mediocrity and misfortune, is killing our mother’s smile. Our “modern” civilisation puts this jewel in danger. On the sinking Titanic, instead of fighting to get a better cabin it is time to sit under the meeting palaver tree and think how to survive the disaster to come. What is the place for dentistry among the endless needs in elementary health care priorities submerging the continent?

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The problems affecting improvement of dental health in Africa have to be identified and described from an holistic point of view, and to help solving these problems, we must accept to name them and set up a strategy to motivate dentists, offering the dental staff a better quality of life for the benefit of the population and public health.

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(1) I graduated as a dentist in 1974. I made my first professional experience during the 1974/1975 war in Vietnam where I practiced nomad dentistry in orphanages, refugee camps and leprosies. As a dentist in the French Navy, I worked in Djibouti, Mayotte and I visited other African harbours. In 1978, freshly married, my wife and I decided to go to Zaire. We decided to go there the same weekend of the battle of Kolwezi. My wife was 8-months pregnant, and we had the opportunity to travel around Africa for 6 months. Then we decided to live in Kinshasa for 10 years. After 40 years, my heart always beats for Africa and two of our sons run a company dedicated to dentistry in Africa.

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What is the "real Africa" ?

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Flooding the article with figures and biased statistics will not help

the reader to build up to itself an opinion. As everyone knows:

“Statistics are to the economist  what the lamp post is to a

drunk person, he uses it more for support than illumination.”

 

If numbers are needed, several website are useful as:

http://perspective.usherbrooke.ca/ where you can collect quite

“accurate” figures. Among them, it is strange to compare the

evolution between 1960 and today of the GDP of South Korea

with the GDP of most of the African countries. Today South Korea

is a wealthy, well-organized, modern industrialized country while

the GDP of many African countries show a flat EEG. This is a worrying but tragic reality explained by Bernard Lugan (2) as follows:   

 

“The image of Africa is deformed by percentages of disembodied or artificial GDP percentages, "experts" and media lie to Africa when they claim that Africa is growing and that a "middle class" was born there. Unfortunately, not only the continent does not develop, but, in the South of Sahara, it is stepping back in an economy of trading posts. In the XVIIIth century, slave drivers ruled the continent; in 2015, the slave drivers are oil, gas and mining companies. As before, this economy benefits only a small part of the local population when the majority struggles to survive.”

 

This description, dry and rough, reflects regrettably more the reality than the figures appearing since few
years in the international economic media. Africa is diverse and non easily understandable. The following description deserves to be read entirely (3).

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The real Africa is hidden beneath a veneer of poverty and hunger and death, a cancerous mass on the face of the world that the rest of the world name homogenous “Africa”. The real Africa is submerged underneath corruption and greed, underneath tyranny and an ostentatious elite, underneath the faces of the people they cannot feed. The real Africa is buried beneath shantytowns rife with dirt and diseases, where children are forced to grow up much too quickly to survive… The real Africa is concealed under a no-man’s land of desert, bare and dry and unable to sustain green and healthy life.

…Africa is also the land of spontaneous smile, the heart of different peoples, different languages, different cultures; different identities that all call this land their home… The real Africa can be smelt the minute you step off a plane onto African soil and feel the air calling you, beckoning you home. The real Africa is the chaos and the calm side by side as honking cars zoom past on streets that run parallel to cows grazing peacefully in a field. This is the real Africa, the one you never show. This is the place I call home. (Unknown author)

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(2) https://en.wikipedia.org/wiki/Bernard_Lugan
(3) https://melfunktion.files.wordpress.com/2013/05/the-real-africa.jpg

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Impacting factors on which the dental profession has no power

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Among the most obvious pictures, the following representations of Africa help to give a clear idea of a worrying reality.

 

When we see Africa on a Mercator projection (4), it always looks as big as Greenland. In fact Africa is 15 times the size of Greenland or the size of USA + China + India + Japan + Europe + Mexico. (5)

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But if you represent Africa vs the world in term of “dentists working”, Africa almost does not exist. In addition to this, the entire population is sprayed all over the continent with strange higher concentration of population on the Mediterranean coast, in the Delta of Niger and in landlocked countries like Ethiopia, Uganda, Rwanda and Burundi.

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 The total population, equivalent to the population of India is sprayed on a 10 time larger area and with similar socio-economical problems increase with the number of countries. 57 different countries with boundaries artificially drawn by former colonial rulers, managed (plundered) by oligarchs, worried about protecting their privileges and where all the democratic experiments have led to murderous and destructive conflicts. The rare infrastructures inherited from the colonies collapse. The increasing drift from the land towards overcrowded chaos of the mining camps and growing slums making them more lawless, generating rampant banditry, gambling, prostitution and violence.

 

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This chaotic drift from the land to the unhealthy and unhygienic cities

stresses the already worrisome sa nitary crises (6). Health issues,

usually linked to parasitism and unsafe water are today aggravated by

nutritional deficiencies and malnutrition increasing the risk of acquired

immune deficiency syndrome (AIDS) and also all the new NCD

(Non Conventional Diseases) growing inexorably among a population

stressed by wars and conflicts.

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In front of this accumulation of sanitary crisis, obesity, diabetes,

cardio-vascular diseases appear now and the dental profession is

unable to reach the position they deserve as a medical speciality.

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What is the room left for dentistry? – The brewers have developed

a juicy and performing network allowing 95% of the African population

to have access to soft drinks and meanwhile less than 10% has access

to primary dental care. This sad comment illustrates the lack of means

awarded to the financing of the health system. Between Ebola crisis

and Oral Health issues, public health representatives allocates scarce

allowances and focus mostly on water related diseases, malaria and

immunization programs.

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The very few dental facilities worthy of the name exist in every major town. They are linked within a few hours to European capitals where wealthy dentists regularly collect their everyday needs, as they don’t have to care about costs since their patients are often expatriates, diplomats or international officials. Some others are managed by NGO and charity organisations sponsored by generous donators from outside the country who keep sending outdated non-repairable equipments. In the meantime, most of the dentists working in public health facilities struggle to survive and where the few motivated dentists practice with limited means. Many of these facilities are located in suburbs where water and electricity are available only few hours a week (7), invaded by insolvent people to whom they prescribe painkillers or antibiotics. The happy few have the tooth pulled when they can pay the needle and anaesthetic. And when aesthetic problems occur, only wealthy Africans can afford travelling to higher dentistry standards abroad.

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Who cares? That is how more children die annually from complications of dental caries than from any other disease. This could be cured very easily on large scale if public health authorities would consider dental decay, a major issue impacting general health far beyond believes as important as measles or malaria instead only a cosmetic one. The only difference is that oral diseases kill slowly and silently.

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A special mention has to be given to Noma.

 

The only article you can find on NIH website on Noma was first published in 1995 with the aim to unify existing information and to promote wider knowledge and awareness among the population. What has been achieved since 1995? Only very few European NGO are struggling to repair the few surviving children. Today you can find over 1000 publications on Ebola creating fear and anxiety in our “modern countries” and calls for controversial vaccines and none on noma.   

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(4) https://en.wikipedia.org/wiki/Mercator_projection(5) World mapper. http://www.worldmapper.org

(5) World mapper. http://www.worldmapper.org

(6) It is difficult to understand and not politically correct to investigate into this Ebola outbreak. Millions of US$ have been allocated to VHFC (Viral Hemhorragic Fever Consortium) and other Researchers from many institutions including Harvard University, Tulane University, The Scripps Research Institute, Irrua Specialist Teaching Hospital, and Kenema (Sierra Leone) Government Hospital to develop assays, vaccines and other. Visit: http://vhfc.org/

(7) Production of 28 Gigawatts in Sub-Saharan Africa = Production of Argentina or Spain Poor Reliability Entreprises experience power outages on average 56 days per year7 Costing 2 to 3 times more in Africa compared to world. « 2/3 of African population does not have access to electricity »

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Impacting factors on which the dental profession has a relative power

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  The national dental associations have to get better organized. Dentistry must

 be recognized as a major medical speciality. Teaching must be adapted to the

socio-economic realities of the continent. Due to the absence of insurances, allow

public health dentists to collect the cost of material they use.

 

Invite the local industry as breweries, mining, oil companies, to sponsor dental

clinics open to general public where primary but efficient dental care will be

performed according to the state of the art.

 

Encourage as much as possible nutritional education, preventive care, hygiene

instruction, interceptive ART and Minimum invasive dentistry treatment with

copper cements and/or glass ionomers delivered by oral-health-co-workers,

avoiding too many mutilating teeth extractions never compensated.

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Set up a policy to import affordable, robust and reliable dental equipments. Rank dental facilities according to the level of treatments provided and provide equipment accordingly. Supervise the donations of materials and equipments, usually offered for good intention but often unsuitable as outdated, out of order and not repairable due to lack of spare parts.
 

Set up a banking system of loans suitable with the level of investment of the dentist's needs (8) (9).

 

Considering the low number of dentists in each country, economy of scale is almost impossible to realize.
Encourage dental associations to supervise and mutualise the importations of dental equipments and consumables. Enhance training of bio-engineers, dental nurses, dental lab technicians and all other necessary coworkers involved in dental clinics.

Stop smuggling of unsuitable material (equipment), offering poor quality and being even dangerous. Encourage procurement through fast, reliable cost effective channels through competent local representatives having the necessary confidence from manufacturers and distributors abroad.

Include training of maintenance, management, logistic, regulations, custom issues side by side with clinical studies. Training bio-engineers, oral-health-co-workers and managers is today probably more important than teaching implantology !   

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(8) No banking system adapted to middle class investors. In Europe and USA almost 80% of the middle class has access to credit
and less than 7% in Africa
(9) http://www.cairn-int.info/resume.php?ID_ARTICLE=E_AFCO_227_0153

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Behave as a beehive : No money, no honey, & vice versa

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  In Africa, if the high number of patients is a “gold mine” to train medical doctors, training dentists is much more complicated. This long, complex and costly training requires heavy and diverse equipments subject to importations. The products subject to strict pharmaceutical regulations and basic heavy and/or hazardous products with very low added value is a burden and nevertheless essential on a daily basis. This business got in hands of smugglers and “suitcase businessmen”, because they were able to avoid complicated bureaucratic procedures.

 
It is advisable to question the necessity to train only dental surgeons at the same level as their colleagues in the developed countries or if it is necessary to train dental therapists able to face the daily challenges of an outstanding poor population? This provoking dilemma deserves nevertheless to be questioned.

Training dental therapists to carry out primary dental care techniques allowing an immediate health improvement and decent income; offering them, through continuing education access to a full training is a challenge to be evaluated as training academically students who will never get the first cent to purchase a costly working tool and will end as a taxi driver due to lack of solvent patients and of a nonexistent insurance system.

Facing scarce allowance and an exploding demand, it could be wiser and more efficient to build dental therapists dedicated to primary dental care than more dentists for insolvent patients?
 

Whatever the choice is, both trainings have a heavy cost and everybody is deaf to calling for funds. Neither government nor professional institutions nor dental industry partners are ready to support this necessary path.
 

In this context, the Congolese national dental association (ANCD) launches the original idea to associate the image of the beehive to finance their continuing education program.
 

Beekeeping in Africa is a great opportunity to maintain population in rural area and to stop migrations to over-crowded towns. Beekeeping gives a regular and daily income to many families. Instead cutting trees to produce charcoal, farmers collect and sell honey. At the same time, bees pollinate trees helping reforestation and regeneration of soils.

From another point of view, beehive by-products as wax and propolis have an application in dentistry. Propolis added cements are being developed for their positive action against bacteria, creating Inside the tooth a "bacteria-free and friendly environment" helping healing of the pulp. And the last but not the least, honey is a wonderful substitute to refined sugar and supports better nutrition.

With the help of beekeepers, the ANCD is collecting wax to be exported to help financing the continuing education and simultaneously creates awareness among the population about the danger of sugar consumption.

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This initiative has to be encouraged and might allow the Congolese dentists to finance their education independently from greedy sponsors, expecting a quick return on investment.

   

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Conclusion

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   It is time to talk the truth to African dentists as they face a coming disaster from which they cannot escape. When the younger generation risks their lives, many in deadly boat trips to the so-called "European paradise" to escape hunger and death, skilled dentists have no future on their continent and migrate to USA or Europe for a better life. We have to dive deeply into the reality, change the paradigms, accept to name the problems and stop hiding behind curtains and closed eyes. 

 
Finding the staff and resources to manage all health issues is no small problem. As far as dentistry is concerned, the highest priority among the priorities is to develop a strategy to improve the dental education at different levels according to the needs.
 

The bush lovers exist, the skilled persons exist but they don’t meet. Many “African bush lovers” have experienced ways to improve dentistry and some succeeded locally, but most of them, without an holistic approach of African realities, failed as they do not get the needed financial support. How can we raise these necessary funds to help to fill the gap and change the dangerous downward spiral?
 

To play a symphony we need a conductor to guide the different instruments. Thanks to

Pr. Charles Pilipili, Vice Dean of the Faculty of medicine and School of dentistry at UCL in

Bruxelles who has been recently given the responsibility to organize the continuing education

program of the FDI in Africa. He brings the focus back to patient benefiting products as

urgent for dental caries management.

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Thanks to Dr Jacques Melet (Trust as a management tool for the profession) and

to Dr Nicola Minotti (Management of the dentinal interface) for their encouraging lectures

during IDEA Dakar. Thanks to Pr. Jo Frenken for his contribution to ART. They all deserve our

support and respect.
 

Another world is to be invented. A world where we shall have to work, produce, exchange

and consume differently, fostering the cooperation and the balance rather than

the competition and the exploitation.
 

This is our challenge and this can only be achieved by supporting the education and the continuing education.