Safaa Suliman sees dental care as an integral part of public health
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As a pediatric dentist and epidemiologist, Safaa Suliman knows that working with children is not just about restoring their teeth. It also involves dietary counseling and educating parents about the importance of preventive dental services. In this capacity, dental health is closely linked to public health, noted Suliman, a doctoral student in epidemiology at Columbia’s Mailman School of Public Health.
according to American Academy of Pediatric Dentistrypolicy, paediatricians should refer parents to paediatric dentists for first dental exams when infants are 6 to 12 months old. Collaborations such as these can help reduce some of the barriers to receiving dental care. In 2016, only about 42% of American children ages 0 to 17 visit a dentist every year.By 2020, this proportion has risen to 80.9%. Suliman attributes this success in part to better coordination between pediatricians and dentists.
“Oral health needs to be integrated with public health, because prevention should not be an individual issue,” Suliman believes. “Instead, the prevention of dental disease needs to be addressed at the state level.”
While leading oral health and hygiene initiatives at the Earth Institute Millennium Village ProjectSuliman tried to implement a similar cooperative strategy in Ethiopia.
Suleiman, originally from Sudan, made his first foray into public health after joining the Ministry of Health in the Sudanese capital Khartoum. Using her expertise as a general dentist, she helped establish the first statewide oral health school program in Khartoum and developed research guidelines for the ministry.
This experience sparked her interest in working with marginalized populations and implementing an ambitious national oral health plan. In 2009, she moved to New York to join Columbia University Master’s Degree Program in Public Health to gain a deeper understanding of the field. After graduating in 2011, she was soon accepted for a Ph.D. student at the University’s Department of Epidemiology. She then joined the Earth Institute (now Columbia Climate School) on a part-time basis in 2012 as Koraro’s Oral Health and Hygiene Program Director. Millennium Village Project Website in Ethiopia.
Joining forces with rural Ethiopian communities
Socioeconomics and lack of dental services are not the only reasons for the prevalence of oral disease in children and adults in rural Ethiopia. Cultural beliefs and harmful traditional practices also played a role. Some of these practices include gum tattoos, extraction of baby teeth and uvulectomy (a surgical procedure in which the uvula – the bell-shaped piece of meat that hangs from the roof of the mouth – is removed) in children. “Misinformation and mythology led villagers to believe that a sick child could be cured by removing the uvula or tooth bud during teething,” explained Suliman.
Shortly after arriving in Ethiopia in 2012, Suliman set out to explore how to tackle Collaro’s deep-rooted oral health problems.
Corallo is a remote village in the Tigray region of northern Ethiopia. To overcome the language barrier, Suliman recruited dental students from Addis Ababa University who were fluent in English and Tigrinya. Under Suliman’s direction, the team conducted extensive research including focus groups, surveys and dental exams at Koraro. These studies shed light on the causes of oral disease.
She observed that most of the villagers had no tooth decay. “I wasn’t shocked because they didn’t have access to sugar at the time. The problem was that they didn’t brush their teeth regularly, which caused a lot of inflammation and bleeding of the gums,” Suliman said. “When sugar is introduced into their diet, which I think is happening due to easier access to sodas and snacks, they also develop cavities.”
As a foreign researcher, she realizes that simply telling a community that their traditional practices are wrong and why they need to adopt new habits can be seen as an attack. “Don’t just tell them what to do, it’s important to first gain the trust of community gatekeepers and work with them. If they can be convinced that traditional practices are harmful, they will also convince others in the community,” Suliman added.
She first approached several local stakeholders in Collaro, such as nurses, midwives, farmers, youth organisations and development team members. In particular, Suliman worked closely with community health workers known as the Women’s Development Army. “They are smart and active mothers in the community. Their local policy makers hire them to spread the health message to other mothers,” Suliman said. “So I piggybacked on these women’s development armies that had been formed and trained them on how to discuss harmful traditional practices specific to these regions. Also, the importance of nutrition and oral hygiene with other mothers.”
in a 2019 Lancet Study, Suliman and colleagues detail what they gleaned from an initial focus group that included 96 community members in Corallo. They found that lack of awareness of oral health was more prevalent among older participants. Some people believe that worms cause tooth decay. Although young people are better informed, they are still unable to establish an adequate oral hygiene regimen due to the high cost of purchasing toothbrushes and toothpaste.
Using data from focus groups, Suliman launched a school oral health program in which she trains teachers on how to educate students about oral health and hygiene. The training also included having teachers supervise the brushing habits of younger students after they were provided with toothbrushes and toothpaste. The program runs throughout the academic year.
To test the program’s effectiveness, Suliman and her team randomly assigned Koraro’s schools to three interventions: In the first group, teachers educated students with the help of Suliman’s oral health and hygiene classes. In the second group, teachers not only educated the students, but also gave them free oral hygiene tools and monitored their brushing habits. A third group of students received neither the course nor the tool.
Not surprisingly, schools overseeing brushing and education performed well. The children’s gum inflammation subsided and their oral health improved dramatically in a short period of time. However, the group of students who only received lessons but no toothbrushes and supervision performed poorly, similar to the third group without the intervention. “Education alone will not work. There needs to be practical application of the skills taught in the classroom,” Suliman said.
The long road to overcoming lack of access to dental care
In 2017, the Ethiopian project came to an end. Suliman then had the opportunity to do a three-year pediatric dentistry internship at Boston University. At the end of 2021, she completed her residency and has now resumed her Ph.D. Program at Columbia University.
From her extensive fieldwork in Ethiopia and Senegal, Suliman observed that while low-income countries have made strides in providing health services to the masses, the average person living in any rural area still lacks access to dental care. During the project, there was only one dental therapist in rural Tigray – a health centre in the largest nearby town, a 45-minute drive from Corallo. “At the end of the program, he told me he was leaving the medical center,” Suliman said.
Villagers have to walk for hours to reach that health center. They will only visit in the event of a health emergency. In these rural areas, traditional practitioners in the village continue to pull teeth unhygienically, she added. “Although the villagers know this may be counterproductive to their health, their options are limited. Sadly, dentists cannot relocate to such remote areas. The only way out is to provide dental therapists with adequate resources to allow They stay in rural areas and serve their communities.”
Another persistent problem is that toothbrushes and toothpaste are still too expensive for Ethiopians living in rural areas. This makes it imperative for policymakers to subsidize these necessities so that marginalized communities can buy them in local stores.
“This is how everyone can use soap. Sanitation workers provide soap at low prices and educate the community on the importance of sanitation. Once it becomes affordable, members of the village start buying soap,” Suliman said. “Policy makers need to understand the importance of oral health and prioritize it.”
Over the years, Suliman has observed that oral health trends are the same everywhere. In high-income countries such as the United States, access to dental care depends on whether someone has insurance. “For low-income communities, it doesn’t matter if they live in New York or the village of Koraro in Ethiopia — access to dental care is a worldwide issue.”
