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March 08, 2008

Dentistry on Nabugoye Hill

If anyone told me four months ago that I would be taking out teeth and caring about the future of dental health in Uganda, the land of Idi Amin and the Raid on Entebbe, I’d have told them they were crazy. I knew I was going to Kenya for Operation Smile, as a dentist on a team treating children with cleft palate, and sent in a deposit to go on a safari after that. But a string of events led me to Samson Wamani, Medical Director for the Abayudaya community in Uganda— and helped me realize there’s a huge difference between what is dental care here in the U.S., and what is available to fellow Jews of the Abayudaya. This was more important than seeing lions.

Learning about Uganda

There are books and websites about the Abayudaya, a group of near 800 Ugandans who trace their Jewish history to 1919, when a tribal leader, Semei Kakungulu, led his people to begin practicing Judaism. I sought to read as much as possible. One book by Richard Sobol at Michigan’s Grad Library has wonderful pictures and a CD of community members singing songs and prayers they sing during their Shabbat service, some in Hebrew, others in their native Lugandan. I loaded this CD on my iPod and listened to it constantly. There were also pictures of community members, young and old, living in a rural, rustic setting. Many of them live on Nabugoye Hill, outside the city of Mbale, Uganda’s third largest city with a population of 75,000 in the foothills of 12,000 foot Mount Elgon in the southeast corner of the country.

I emailed Samson back and forth for a couple of months, asking questions and finding out more. Samson grew up in the community and always wanted to be their first physician. He recently graduated from medical school in Kampala, and his tuition was partially supported by some individuals from Rochester, New York. Did the community need dental care? Did they need equipment or personnel? He told me there was no dentist in the community, and that there was only one in Mbale. Access to that dentist was difficult both because of the challenge of transport and the cost of care beyond reach of most community members many of whom are subsistence farmers. In the health clinic was a military field-style dental chair which several dentists from California brought a few years ago when visiting. They held a clinic for three days and each day a line of people waited to have a tooth extraction. This told me that it was likely that there were people with dental pain in this community.

Before leaving, I gathered supplies to treat patients in Uganda. I sent an email to dentists in the Detroit chapter of Alpha Omega Dental Fraternity, and people came forward and sent me anesthetic needles, extraction instruments, and offers of money. I purchased some supplies, including glutaraldehyde (cold sterilization solution) from a dental supply company. I “borrowed” anesthetic solution from the dental school.

Operation Smile in Kenya

I arrived in Kisumu, Kenya and spent ten days with Operation Smile. Kisumu is in western Kenya on the east side of Lake Victoria, and north and west of Kisumu is Uganda. The mission of Operation Smile is to provide repair of cleft lip and/or palates. Dentists check the teeth on everyone, remove any teeth that were problems and could affect the cleft repair, and make special prostheses called obturators to cover the cleft palate for those who could not have surgery. To be honest, except for the first couple days of screening, I wasn’t terribly busy. This is likely because the children’s teeth in general were in good shape, and only one child needed an obturator. But it was great to be a member of a team that was doing important work and changing lives. I worked with my fellow prosthodontist and new friend, Dr. Omondi. Omondi was from the area and of the Luo tribe, but had traveled to Nairobi and then London for his prosthodontic training. We enjoyed working together and have kept in touch, especially recently with the turmoil going on in Kenya post-election.

The Journey to Uganda

I had told Omondi of my need to get to the Ugandan border to meet Samson and he was truly helpful in finding a car and agreeing to drive me to Busia, the border town. I didn’t want to rush him, but I wanted to get to the Abayudaya community before dark to make it to Kabbalat Shabbat services. He got the car late, and we left late. We drove off, first through the busy Kisumu downtown, then out the main road, with potholes that made this Michigan resident feel very much at home!

When most Americans in northern states think of “crossing the border”, they think of driving their car up to the Canadian customs window and answering a few questions of the customs official. Busia is a busy border town that straddles both Kenya and Uganda as in Kisumu, there was commerce of various forms along the street and in the street. Omondi helped me through this maze and I obtained a visa for $50 at the Ugandan office. It was there that I finally met Samson; it was like meeting long lost relative ---while we had never met, we knew we had a strong bond.


On to Mbale

Samson had hired a driver and we headed up to Mbale along some dirt roads. As it got darker, I made my first observation about Uganda: drivers don’t turn on their headlights until they can’t see at all. My second observation about Uganda was that the power goes out rather frequently. After almost two hours, we neared Mbale.

North of town, we drove up a very difficult dirt road up Nabugoye Hill, the main area for the community (there are several areas, but this is where the high school, health clinic, internet café and the largest synagogue are). The drive was made more difficult due to road construction, which narrowed the dirt road to a one car-width access. When we reached the synagogue, Kabbalat Shabbat services were ending. We were able to say hello to many people, and enjoyed a kiddush and motzi with Israel, the community leader, Tehilah, his wife and the nurse at the health center, and their daughters. After talking for a bit, it was time to go. The driver had still been waiting, and it was time for me to go back to town to my hotel.

I stayed at the Mt. Elgon Hotel in Mbale which is a fine hotel, but something bothered me about it. It distanced me from the community I was visiting, both physically by six challenging kilometers, and also personally. The Abayudaya were in their village, while I returned to a fine hotel frequented in large part by whites. The Abayudaya are currently building a guesthouse on Nabagoye Hill. This will not only make it more convenient to visitors and create a better experience, but also bring much needed funds to the community to retain potential lodging funds. My first evening at the Mt. Elgon, the power went out three times.

Shabbat with the Abayudaya community

Shabbat morning I made it up to the Moses Synagogue on Nabagoya Hill via piki piki (motorcycle with a seat on the back). I probably should have said an additional prayer in thanks that I got there without injury. I will not miss piki pikis. I approached the small but airy building and was welcomed by all and introduced myself to so many people. There were chairs set up about five on each side of the aisle, with women sitting on the left and men on the right. In many ways the service was very familiar. We used the same siddur as in the U.S. (complete with bookplates from New Jersey) and many of the melodies for prayers sung in Hebrew were similar. Then I heard the congregants singing the psalms in Lugandan, the same psalms I had on my iPod. While there was exuberance and joy in so much of the singing I heard, there seemed to be a little extra with these psalms. I think that’s because the congregants know these songs are theirs. They are likely the only congregations singing these psalms in this way in all the world.

This Shabbat there was a Bat Mitzvah for two of the girls of the community. This was especially interesting for me, because in two weeks, I would be attending the Bat Mitzvah of my niece back in Massachusetts. The Abayudaya girls did well and the community was quite proud of them. Aaron, the assistant spiritual leader, praised them for the good work they had done studying and their beautiful voices. It is a small community, so the youth are valued greatly. The rest of Shabbat was spent talking to people and going on some walks. Samson showed us the guesthouse, which is almost finished, the foundation for the new health center, which needs more work, and the view of Mbale in the distance. We met some teenagers and hung out talking, and then had a small Havdalah service.


Setting up for dental care



The next day, I arrived at the clinic not really knowing what to expect. Having only dental extraction instruments meant, well, that the only treatment option was extraction. It seemed so strange to me, because in the US when a patient presents with a toothache, after the diagnosis the next step is to explain to the patient what’s going on and what the alternatives are for care. But in Uganda, all I could do was explain what was going on and that we needed to extract the tooth. It was very funny then to read the patient’s expression, which basically said, “Of course I knew I needed it extracted; that’s why I’m here!” I guess it’s akin to listening to a barber give a long explanation about how hair grows and why it needs to be cut before he actually cuts it.



I had set up a clinic to perform extractions, but violated a couple of basic rules. I was not able to take radiographs, which reveals potential problems and assists in preparation. But there was no x-ray machine, only people in pain. Also, I didn’t have any instruments normally used if an extraction turns “surgical.” For example, if a tooth fractures below the gumline, I would normally use a “power tool” to relieve some of the binding bone around the tooth. Without that tool, all I could do was just hope that no teeth broke below the gumline!

My luck held out pretty well. I was actually pretty surprised how easily all of the patients achieved local anesthesia (“got numb”). Was it because I had brought some really good anesthetic, or were they already so relaxed and calm that the anesthetic worked well? Or perhaps they’re just a very stoic group of people. There were older men and women of various ages who were certainly uncomplaining. A young man named Samuel, who was training as a health care assistant, functioned as my dental assistants and interpreter. The younger patients were a bit afraid of the needle but with a little coaxing and help from Samuel, they became stronger and let us work.

Sam is a very common name in both Kenya and Uganda. It gave me a little comfort and made me feel at home. I taught Samuel how to give post-extraction instructions and I wrote prescriptions so that Tehilah, the clinic nurse, would dispense some medications for post-extraction pain control. Our little dental clinic got quite busy. As soon as one patient exited the chair, there was a new patient sitting there. But Samuel often forgot to clear away the used instruments and the extracted tooth! I had to show him how to do this and clean the room before seating the next patient.



Now I laugh as I remember little children (and an occasional cow), curious about what was going on, peering through the open window behind the dental chair. But at the time I got a little annoyed and shooed them away to be sure the patient’s privacy was respected. Dentistry is not a spectator sport! Time seemed to fly by and I was getting very thirsty. It was 2 pm and we had been working non-stop. Tehilah took a look at me and could tell I was hungry and went and got me a bottle of water and a chapatti. That was probably the most delicious chapatti!

Some difficult cases

All did not go so smoothly. There was one patient with a wisdom tooth that had decay and gave me a good work-out! Another patient had a maxillary second premolar unfavorably positioned and decayed. There was no easy way to grab the tooth with the usual dental instruments. I advised the patient that it there was a possibility that I would not be able to take the tooth out and gave him the option of having me try or not. He wanted me to try, and I spent quite a bit of time on it and may have gotten some movement, but in the end the tooth was not going to come out. In retrospect, considering my doubts about being able to remove it, I probably shouldn’t have attempted it. And it’s not a great idea to take out a “funky” tooth without a radiograph. There very easily could have been a curve to the root, which I would need to know beforehand. Both of these cases helped me realize how necessary it would be to have the proper equipment for taking and developing radiographs of teeth.

Reflections on dental health in Uganda

My assessment of dental disease in the part of Uganda I visited is not based on a large study, but rather on observation of about 20 people. Interestingly, the areas of decay that I saw were all on back teeth where they contact. I don’t recall seeing any decayed front teeth. This is probably caused by two things. First, in the foothills of Mount Elgon, the water is naturally fluoridated and fluoride strengthens the enamel mineralization. Second, exposure to sweets is primarily from chewing on sugar cane with the back teeth. Here in the U.S., when I see a person with significant decay on the anterior teeth, I can almost bet that it’s caused by an addiction and constant exposure to sugared carbonated beverages (i.e. sipping on Mountain Dew or Coke all day). People just do not have the money to become addicted to sweets or soda pop. Another thing I did not see in Uganda that we see here in the U.S. is older adults on multiple medications, some of which decrease the production of saliva. Saliva plays an important role in the prevention of tooth decay, so people with less saliva seem to have more cavities. This was not a problem in Uganda.

In the United States, the dentist to population ratio is estimated at one dentist per 1700 people. In Africa, it is estimated to be one per 100,000 people. In the area of eastern Uganda, it is probably the same or perhaps a bit worse. In Mbale Town, there was one dentist who did only extractions. There had been another dentist who provided more comprehensive care, but he moved. In the surrounding smaller towns and villages, there were no dentists. Some of the regional hospitals or health centers have “dental assistants” who can perform basic services. Basic preventive services, and dentistry performed with the intent of conserving teeth, rather than extracting, is distant for many. There is hope, however. There is a new dental school at Makerere University in Kampala, and a growing sense that dental health is a public health concern.

What’s next? First, I think a more comprehensive sampling to assess the dental health of the population in different age groups will give a good sense of the community’s needs. Second, the new health center will hopefully be finished soon, and it would be appropriate to have a dental unit equipped to provide the full range of dental services. I plan to submit a grant requests to help support the purchase of dental equipment, instruments, and supplies. It would be of great benefit to have a unit to take radiographs if future dentists are to perform any care. Finally, good thought needs to go into how this clinic will be staffed. It could be staffed by dentists from abroad as volunteers visiting for short periods. Or, if there were community members interested in a career in dentistry, funds could be raised to help pay for their education. It may not be prudent to tie to such a scholarship to a commitment to work at the community health center full time. This may not be financially viable for the dentist nor a long-term solution.

I believe we all want for our fellow Jews in all lands good quality of life. Dental health is a part of this. As winter comes to Michigan, I hope to keep my friends and family in Africa in mind, and keep working full steam ahead. After all, great things can happen when a group of Sams get together.



Want to learn more?
Feel free to contact me, or visit one of the following websites:
1. The Abayudaya Community: http://www.abayudaya.or.ug/ (may not open if the power is out)
2. Kulanu, an organization which aids dispersed Jewish communities: http://www.kulanu.org
3. Institute for Jewish and Community Research, which is supporting the building of the new health center, http://www.jewishresearch.org/sc_projects_AJ.htm

Thanks to Sid Rosenzweig for his editing assistance.

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