Do Good, Better: Making a Difference in Global Oral Health

ABSTRACT

Short-term mission trips have long served as a way for oral health professionals to “give back,” using their abilities to address the heavy global burden of oral disease, a burden that disproportionately affects populations in low- and middle-income countries. These international volunteer programs may bring needed care to the communities they serve but can create challenges in ethical engagement, sustainability, and effectiveness. Currently, momentum is shifting away from the “clinical care elsewhere” model, where community context, relationship building, monitoring, and sustainability can be lacking, and moving toward approaches that focus on community collaboration, leadership, education, and advocacy. This paper aims to help clinicians evaluate their current and future short-term volunteer work through a new paradigm.

KEYWORDS:

• Global oral health
• dentistry
• mission trips
• global health ethics
• volunteerism
• STEGH
• short-term experiences in global health
• capacity

Global health is an attitude. It is a way of looking at the world. It is about the universal nature of our human predicament. It is a statement about our commitment to health as a fundamental quality of liberty and equity.

(Richard Horton, editor of The Lancet, quoted by Farmer et al., 2013: xv).¹

Introduction

The stark reality of the global burden of oral disease is that more than half of the world’s population suffers from an active disease that adversely affects overall health and quality of life.² Indeed, dental caries is largely preventable and yet it is the most prevalent non-communicable disease worldwide.³ Furthermore, populations in low- and middle-income economy countries (LMICs) are highly unlikely to receive any dental treatment.⁴ Disparate population-to-provider ratios are not the sole cause of inequity in access to care for people living in LMICs; the picture is much more nuanced and includes factors such as health literacy, costs of seeking care, uneven workforce distribution, cultural values and prioritizations, and upstream political and socio-economic drivers of health.⁵ This inequitable access to care continues to widen the gap of health disparity.²

Participation in oral health care “mission trips” to address this inequity is a popular trend. An online search for organizations that offer volunteer positions to dentists and other oral healthcare providers instantly yields numerous options. The extreme level of unmet need, along with plentiful service opportunities locally and internationally, inspire many oral health professionals to volunteer in low-resource countries or communities. To ensure that their actions are rewarding, impactful, and ethical, volunteers ought to become familiar with today’s paradigm of global oral health. This paper aims to help clinicians evaluate their current and future short-term volunteer work through a new perspective – one that may evoke mixed feelings, as self-reflection often does, but that can lead to a greater understanding of how to optimize the impact of their work.

Traditional Approaches

A common and admirable attribute among dentists is a desire to “give back.” For some, there is a deep sense of gratitude for having been taught skills to alleviate pain, cure an infection, or restore a smile, and to do that for people who have no other option feels rewarding. Many professionals choose to share their abilities with local communities, but others feel a distinct call to engage globally.

Traditional approaches have centered on short-term visits of one or several weeks for the delivery of clinical care. These short-term experiences in global health, or “STEGHs,” involve field experiences in a new setting and seek to serve vulnerable populations in places that frequently lack existing healthcare infrastructure. Activities often focus on clinical care delivery, but they might include research, teaching, or other outreach work and are usually sponsored by NGOs, universities, or governments.⁶ In addition to providing a feeling of fulfillment, possible benefits of participation include professional development and exposure to care provision in a new environment, among others.⁷ Most clinicians seeking work in global oral health cannot fully embed in a country or culture for extended periods. Yearly seasonal trips or STEGHs are particularly attractive because they require only limited time away from practices back home and can offer volunteers opportunities to visit for a short time to provide care, sometimes in an area of the world they want to see and where there is unmet need. Some STEGHs are marketed specifically to dental students and residents as a way to experience care delivery while being immersed in a new culture.

Judith Lasker estimates that as many as 200,000 Americans volunteer annually in global health,⁶ and volunteer work by US health professionals has an estimated value of $37 billion annually.⁸ Impact, however, is not well documented. There is little peer-reviewed evidence in dental literature that evaluates the ability of short-burst, direct-service provision models to provide a positive long-term benefit to the community. It should be noted that when done well, these activities provide much-needed relief for those who receive care. On the other hand, these activities often fail to address health disparities or global inequities, and when done poorly can carry a risk of harm to those whom we wish to serve.^4,6,7 Today, broader questions of ethics and efficacy are at the forefront of global health discourse.

STEGHs face a number of challenges.^4,6,7,9 Volunteers may be unaccustomed to the social context (language and customs) and geographic climate in which they want to serve.⁴ Given the short timeframe of STEGHs, comparatively few persons can receive treatment, and a desire to help as many as possible within these limits may lead to compromising quality of care. In addition, STEGH activities sometimes focus on pain relief without provision for follow-up or comprehensive care.⁴ Volunteers who are inexperienced with the constraints of the low-resource setting can feel pressured to practice outside of their scope, or in substandard ways due to a lack of equipment or materials. Also, while seasonal travel and sponsored STEGHs enable dentists to bring technology, resources, and medical supplies that are often unavailable locally, the impact of this model remains undetermined.^4,7

To avoid these pitfalls, volunteers are urged to consider developing a knowledge of the cultural context in which they will work and prepare to address language barriers prior to engaging. By establishing collaborative relationships, open and honest communication is more likely to flow. Following the gold standard model of comprehensive care, volunteers are encouraged to consider what local arrangements will be available for post-trip continuity of care for follow-up, emergent, preventive, or restorative services once the trip finishes. In addition, volunteers may want to consider how equipment, materials, and even waste will be managed after the trip is completed. It can be helpful to reflect on the following: Do participants leave equipment or take it home? Can local providers procure the materials that were used, for sustainability? What about waste management of lead foils, or dental amalgam, or plastics?

A variety of concerns exist at the systems level as well. As mentioned above, the lack of impact evidence stems in part from the fact that, unlike global health research, no monitoring body oversees short-term service work or provides any standard set of guidelines.^4,7 Some intervention activities do not follow evidence-based protocols.^4,10 Organizations that are disconnected from the health systems of the host nations risk perpetuating an unsustainable dependence on donors, rather than strengthening local capacity for integrated and sustained local care for the population. Furthermore, the presence of providers who may be offering higher-level care compared to that offered by local providers not only competes for limited resources but also undermines the value of local systems.^10,11

The desire of oral health professionals to volunteer, coupled with the massive levels of unmet need, drive ethicists and global health thinkers to confront these challenges and more. The authors perceive that there is a momentous global health paradigm shift underway that steers us toward better sustainable engagement.³ We have an increasing body of evidence to guide us in making more ethical, power-balanced choices in our global health work. For those who choose to go abroad for a short amount of time or participate in these experiences, which can offer incredible value, the activities can be thoughtfully organized. Momentum is shifting away from the “clinical care elsewhere” model where community context, relationship building, monitoring, and sustainability can be lacking, and moving toward approaches that focus on community, leadership, education, and advocacy.¹² The past few years have seen exciting and substantial achievements in this arena.^13–16

Recent Achievements and Global Oral Health Today

Recent policy and advocacy activity provides an opportunity to reevaluate how we’re engaging in this field as a profession. Being able to articulate the essence of ‘global oral health’ is the first critically important step. The recommended definition follows:

Global Oral Health aims for optimal oral health for all people and elimination of global health inequities through health promotion, disease prevention, and appropriate oral care approaches that consider common determinants and solutions and acknowledge oral health a part of overall health.¹⁷

Key points to note from this action-oriented definition are 1) the notion of busting the oral health silo and integrating oral health into primary care approaches that address non-communicable diseases (NCDs), and 2) the clear nudge away from procedure-focused interventions to those targeting health promotion and equity.

In 2021, the FDI World Dental Federation released Vision 2030: Delivering Optimal Oral Health for All, identifying drivers, challenges, and opportunities for ensuring optimal oral health with evidence-based and integrated approaches.^12,18 The report was built around three pillars that aim to integrate essential oral health services into general health care for more collaborative and effective prevention and management of oral diseases. The realization of FDI’s vision relies heavily on the education and training of oral health professionals in public health concepts to enable us to better respond with impactful, population-wide interventions. Vision 2030 urges professionals to serve in education, leadership, and advocacy roles in oral health care.

Also in 2021, the World Health Organization (WHO), in a significant moment, formally recognized oral disease as a non-communicable disease alongside cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes, noting that they all share common risk factors (such as sugar consumption and tobacco and alcohol use).¹⁹ The WHO also released its Global Oral Health Status Report noting alarming levels of oral disease globally and calling for urgent action. More recently, the WHO released its Draft Global Oral Health Action Plan (2023–2030) complete with guiding principles and specific strategic objectives that relate to health governance, health promotion, health care, and health research.²⁰ It’s important to note that most countries that host STEGHs strive to align their national plans according to WHO recommendations; therefore, volunteers who organize and participate with STEGHs should be aware of global strategies and work within the scope and vision of national plans.

In acknowledging the exponential growth and popularity of short-term healthcare trips, recalling that many STEGHs run without standards or accountability, and recognizing the need for ethical, sustainable, and practical approaches, the Brocher Declaration was developed by the Advocacy for Global Health Partnerships. It outlines six foundational principles to guide STEGHs toward appropriate practices and offers volunteer dentists a framework by which they can evaluate potential programs with which to be affiliated (Table 1).^21,22

Table 1. Principles of the Brocher Declaration.¹⁵

Mutual partnership with bidirectional input and learning Empowered host country and community-defined needs and activities Sustainable programs and capacity strengthening Compliance with applicable laws, ethical standards, and code of conduct Humility, cultural sensitivity, and respect for all involved Accountability for actions

The Brocher Declaration offers six guiding principles for ethical practice as global health actors embark on STEGHs.

Concepts featured in the guidelines strongly emphasize the empowerment of host countries through the establishment of mutual partnerships and the implementation of contextually driven, sustainable programs. These offer foundational guidelines for ethical and impactful practices as we seek to provide oral health for all.

The FDI, WHO, and the Brocher Declaration encourage us to avoid perpetuating a traditional power imbalance, reflect on the ethical nature of our proposed engagement, and approach service opportunities with a mind-set of “learning” rather than “helping.” This leads us to ask if the organization with whom we want to partner is structuring activities along ethical guidelines.

Key Ethical Principles

Ethically approaching global health engagement requires much more than well-intentioned volunteers taking specialized skills and equipment to distant locations. Exploration of several ethical principles can help prevent unintended consequences that may result in harm. The most relevant principles to consider are autonomy, beneficence, and justice.

The principle of autonomy requires that regardless of language barriers, we as clinicians properly discuss treatment options and gain consent, allowing all patients to make their own care decisions. Autonomy also dictates that the host community take the lead in defining the programs we engage in and the needs to be addressed.

Beneficence, our call to “do good,” dictates that we strive for sustainability and continuity. In a global health setting, this means having an awareness of the social determinants of health while collaborating on solutions that focus on prevention and capacity-strengthening. It calls for fostering a sense of mutuality in learning and respect for local health professionals. The principle of beneficence also invites us to consider our own motives in participation. Is our desire more about resume-building or improving our self-image, rather than being of service? The other side of the coin is non-maleficence, our commitment to “doing no harm,” which requires that we perform regular evaluations of programs for impact and improvement. It also calls for appropriately recruiting, preparing, and supervising volunteers who may travel with us. Non-maleficence demands that we are mindful not to disrupt or disempower any existing efforts to address the oral health needs of a community but instead seek collaboration and enhancement. Non-maleficence demands that we ensure adequate arrangements for follow-up care whenever possible.

Justice is the principle in our ethical code that states we must treat all patients equally. In global health settings, justice requires treating patients with the same standards that we would at home. It means not working outside of our scope or asking others to perform treatment they are not properly trained or licensed to do. Justice aims to enhance the health of all people, keeping in mind the most effective and appropriate use of a community’s dental care resources. Justice recognizes a need for bringing care to areas where there is none but also requires respect for governance and for legal and ethical standards.

How, then, do we do this? How can we engage in global oral health in an ethical and effective way? What does this look like?

Doing Good, Better

The authors have observed that when dental professionals volunteer in global health activities, they witness firsthand some of the many challenges faced in low-resource settings. They see that barriers to care differ greatly from setting to setting and solutions to addressing these barriers are equally varied. They start to appreciate the complexity of making a lasting difference. While the urgent care they deliver is much appreciated by the individuals who receive it, its effect is limited. A common feeling of many at the end of a short-term outreach is that “there is so much more to be done.”

The good news for those with a keen desire to engage in global health is that there are other, non-clinical ways we can use our considerable skills and expertise to create an enduring and contextually-appropriate impact on a community. Consider teaching, collaborating in technical training, and supporting research and public health initiatives. Holding a clinical degree is not a pre-requisite to pursuing a career in global health, as the heart (and challenge) of global health work is addressing the root causes of health disparities, which are often the conditions in which people live and work.

For clinicians who are considering working with an organization with an established collaborative presence in a community, it’s important to conduct due diligence on the organization before getting involved. We offer the following questions for reflection to support the thoughtful selection of where and how to participate: What is the organization’s stated mission? In addition to treating patients, are they actively working to enhance the local provider capacity? Do they explicitly state a commitment to program sustainability? Do they have an established monitoring and evaluation program? Are they accountable to an advisory board with specific goals for performance, quality, and impact, and do community leaders serve on that board?

Some of us may observe a significant, unaddressed need somewhere and feel called to organize help. In that case, our work starts with community input. The very first steps are listening, observing, and building trust. We offer the following questions for reflection and as a guide for activities: What are the challenges facing the community? What is the socio-cultural and political context and what is the day-to-day reality? What are local laws and customs that we must follow? How can our presence support addressing community needs? What do we hope to learn from the community? How can we partner with local providers to create an impact that lasts long after our trip is over? If there are no local providers, how can we work with local or national governments to explore building or strengthening education programs?

The answers to these questions are complex and nuanced and will take time to discover, but the tools, references, and examples provided in this paper can help guide our work. And as always, a practice of constant self-reflection and acknowledgment of our own internal biases is essential. When we commit to seeking opportunities for ethically delivered, contextually relevant, and locally driven clinical care; to prioritizing collaboration and intervention sustainability; to enhancing local systems and providers; and to focusing on prevention, we can support the enduring improvement of community oral health outcomes (Table 2).^{3,6,11,12,23,24}

Table 2. Global health resources for dental professionals.

ADA Principles of Ethics & Code of Professional Conduct^Citation16 The Global Health Starter Kit^Citation17 Hoping to Help, Judith Lasker^Citation6 FDI Vision 2030^Citation12 Revitalizing dental school missions^Citation11 Oral Health Atlas^Citation3

Preparing for any global health work requires research and reflection. There is now a substantial body of evidenced-based literature available that outlines best practices, and dental providers wishing to “do the work before they do the work,” can readily find preparatory resources. The following list is by no means exhaustive, but offers a handful of useful and informative references.

Conclusion

Oral disease does not exist in a silo; it is the consequence of multiple social, economic, and political forces, and the methods to address it should be both timely (providing urgently needed care to individuals) and sustained (enhancing local capacity to meet those needs). Our profession has a long tradition of stepping up to meet clinical needs worldwide, and exciting landmark shifts in policy and advocacy present an opportunity for us to engage in global oral health even more effectively and beneficially. In the long run, practices such as focusing on prevention, partnering with local stakeholders, and advancing local technical capacities and skills prove more powerful and sustainable tools against dental disease than elevators and forceps alone.

Disclosure Statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.

Notes on contributors

Donna Hackley

Donna Hackley, DMD, MA, MPH, is pediatric dentist and Assistant Professor in Oral Health Policy and Epidemiology and Global and Community Health at the Harvard School of Dental Medicine. She holds a masters in Peace and Conflict Studies/Organizational Leadership Track and a masters in public health, UC Berkeley, Interdisciplinary/Global Health track. With more than 15 years of experience in private practice, Dr. Hackley’s global projects center on educating an interdisciplinary workforce, identifying the burden of oral disease, and strengthening health systems to improve health. As PI for the Human Resources for Health Rwanda project, she led the team that supported the development, launch, and accreditation of the first and only dental school in the country. She also served as Co-PI for the first National Oral Health Survey in Rwanda. Dr. Hackley serves as Department Head of Oral Health at the University of Global Health Equity, Rwanda, where she co-developed and directed of a novel clerkship on oral health for physicians. Dr. Hackley strives to promote contextually relevant, sustainable, and inclusive development and to leverage her practical experiences to inform operations and policy.

Christy Colburn

Christy Colburn, MA, is Associate Director of Development and Alumni Relations at the UCLA School of Dentistry. She is a veteran of academic public/global health programs with extensive experience in advising, student recruitment and engagement, and program management. Most recently, Christy worked for the Global Health Program at UCLA’s David Geffen School of Medicine, where she focused on communications, global partnership management, and donor development. Prior to joining UCLA, Christy directed Harvard University’s Undergraduate Program in Global Health. In this role, she managed both an academic degree program and a summer experiential learning program for the Harvard Global Health Institute. Christy worked with faculty across the university to develop global health curricula and increase student and faculty engagement. In collaboration with the Harvard School of Dental Medicine (HSDM), she became lead author on the first module of a competency-based global health curriculum for dental students. Christy also worked on a mixed-methods maternal mortality research study at the Harvard T.H. Chan School of Public Health, advised international students at MIT, and provided technical support for the World Health Organization in Geneva. Christy has spent time living abroad in Switzerland, Luxembourg, and the Czech Republic and volunteering in Haiti and Honduras.

Jean Creasey

Jean Creasey DDS, UCSF D 01’, is an Assistant Professor and serves as course director of the Ethics and Professionalism program at California Northstate University, College of Dental Medicine. She practiced as a community health dental hygienist for 10 years prior to earning her DDS degree and then practiced general dentistry in rural Northern California for 20 years. She regularly visits southwestern Uganda where she collaborates in teaching oral health assessments and prevention at the Uganda Nursing School Bwindi and Bwindi Community Hospital. She has also engaged in research on understanding the East African traditional medicine practice of removing unerupted canine tooth buds from infants known as infant oral mutilation (IOM). Additionally, she has worked in global outreach activities through the Global Dental Ambassador teaching program in Sicily and Morocco, the NYU School of Dentistry in Ecuador and Rotary International in Mexico. She lectures regularly to dental and dental hygiene students on the ethics of global health volunteering.