Where in the world have you been?

We've been to South Africa! In addition, we represented the American Dental Hygienists' Association and the People to People Citizen Ambassadors Program!

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People to People Ambassadors offer services to South Africa

by Margaret Lappan Green, RDH, MS, and Irene Mary Connolly, RDH, MS

We've been to South Africa! In addition, we represented the American Dental Hygienists' Association and the People to People Citizen Ambassadors Program! It doesn't get much better than that! Here is the short version of our fantastic journey extracted from the Journal of Professional Proceedings authored by our leaders, delegates, and guests. For the complete story, pictorial and narrative, please visit www.adha.org/news/people_to_people.htm.

A delegation of 37 individuals from 18 different states and one from Saudi Arabia endured a 17-hour flight to Johannesburg to embark upon a life-enriching, nine-day professional and cultural exchange with South Africa. Our group of ambassadors, consisting of 28 dental hygienists, one pedodontist, and eight guests were praised for their philanthropy, international goodwill, and embracing the common goal of improving the oral and total health of all people. Educational activities and meetings centered on dental hygiene and public health, while cultural experiences highlighted the history and beautiful sights of Johannesburg and Cape Town.

Delegates embraced an insider view of the dental care systems and intimately experienced the culture through their conduct of oral health projects in two villages. The journey heightened each delegate's appreciation and knowledge of the political and cultural diversity of South Africa, demographics, governmental operation, and historical progress of the "Rainbow Nation." Examining a history beginning with 3 BC up through the May 2009 election of President Jacob Zuna was intriguing and emotionally moving to realize the suffering, disparity, peaceful amnesty, and entrepreneurial spirit that have swept the persevering people of South Africa.

OHASA, formed in 1978

The first of the six professional meetings began with the leadership of Oral Hygienists' Association of South Africa (OHASA) addressing education, practices, and policies of the oral hygiene profession in South Africa. It is fair to say that we were surprised to learn that "oral hygienists" are employed in educational institutions, private practice, research, and public health, and have a considerable amount of autonomy in regulating the licensure and practice of dental hygiene.

As a result, more diversified fields of recognized practice and leadership authority have been created, even beyond those that exist in the United States. For example, licensed oral hygienists can complete an additional year of expanded functions, Level III Emergency care, plus one year of experience to become a dental therapist. This credentialed, independent practitioner can successfully compete directly with licensed dentists for basic restorative dentistry and other basic dental care, but cannot prescribe medications.

OHASA's assistance and support enabled the establishment of a Professional Board for Oral Hygiene in 1980. The board is composed of oral hygienists, dental therapists, and dental assistants. It is one of 12 boards under the Ministry of Health for South Africa and the Health Professions Council, and controls the standards of education, fees for practice, and is self-sufficient in funding.

The practice of oral hygiene has been governed by legislation since 1969. Their scope of practice was initially enacted in 1974 by the Minister of Health and Welfare in the Medical, Dental, and Supplementary Health Service Professions Act and in 2000 expanded to include extended functions. Since 2004, compulsory continuing professional development (CPD) of 50 CPDs in a 24-month period has been required for license renewal. OHASA is an official accrediting agency for CPDs. National regulations for oral hygienists provide for independent practice and a universal scope of practice across the nation for their 915 practitioners, which include 10 males.

Oral hygienists may be commissioned officers in the South African Military Health Service (SAMHS) beginning as a second lieutenant with opportunity to advance to lieutenant colonel. The commissioned oral hygienists initially examine all military personnel to classify and refer, according to health care needs, and direct and manage the annual "dental readiness" of all military personnel of the four branches of SAMHS, which includes the country's Navy, Army, National Defense Force, and Air Force (no Marines). The lieutenant colonel is also responsible for forensic identification records, oral health education training, exhibits, and dental outreach programs for all branches of the SAMHS and their dependents, and serves in an advisory role to the minister of health in South Africa.

University of Witwatersrand (Wits)

Our first visit to an educational institution took us to the well-known Wits where we visited with the faculty at the School of Oral Health Sciences and Department of Public Oral Health, located in a referral hospital in Johannesburg. At Wits, dental and oral hygiene students are afforded the unique opportunity to study collaboratively with the medical disciplines. Our tour of the Wits Oral Hygiene Clinic unveiled a very modern teaching facility. Among the many challenges to oral health, funding was the largest. Fluoridation of water became law in 2004 for all provinces, but due to the controversy and lack of funding it has yet to be enacted. Some access to care challenges include poverty, transportation, equipment, and lack of funds for equipment maintenance.

Currently, there are 785 oral hygienists in the private sector and 130 in the public health sector. This means that there is one oral hygienist to 400,000 people. Oral hygienists focus on oral health promotion and integrated oral health in school programs of oral exams with childhood immunizations, brushing, fluoride rinses, sealants, and ART and outreach programs. Many cases of HIV/AIDS are first diagnosed by the oral hygienist.

The first class of dental therapists (DT) graduated in 1977. Currently, a three-year bachelor of dental therapy degree is available at two universities. In 1980, rules permitted DTs to work in urban areas at public health clinics under the supervision of a dentist. In 1993, rules were changed to allow unsupervised practice after one year of being under supervision and permission to prescribe antibiotics and analgesics. There are 457 therapists in South Africa, with 25 new graduates annually. The Department of Health has proposed to increase the number of DT graduates from 25 to 600 a year.

Children's Memorial Institute

Our visit of the governmentally funded health care system and targeted populations served at the Memorial Institute for Child Health and Development and the Teddy Bear Clinic for Abused Children Dental Hospital (Wits) opened our eyes to their passionate dedication of ensuring abused and/or abandoned children are protected and rehabilitated. The free clinic treats indigent patients ranging from infancy to 16 years of age, and the "Teddy" staff works with the parents, imparting knowledge and skills to help put an end to child abuse and abandonment. This vital clinic also deals with troubled emotional and social issues of nonphysically diseased children throughout the area.

Another heartwarming experience was our visit with the "Big Shoes" nonprofit organization that provides medical and outreach care through pediatric clinics and children's homes, and specializes in early HIV diagnosis, preparing foster children for adoption, and placing of the unwanted children in homes when neither parent can financially care for them or they are serving jail time. Big Shoes also cares for children suffering with chronic TB, teaches English sign language to support those with hearing loss due to HIV, trains child and youth care workers from children's homes on basic child health care – especially HIV and antiretroviral treatment regimes – and provides training in the emergency and medical care of the abandoned newborn. Counseling is offered to parents and family as well as the dying children.

Approximately 17 new babies arrive each month; in Johannesburg, there is an average of one new abandoned baby a day left to die in back street terminations. There are two other branches: one in Durban where 75 children a month are screened for HIV. There is also a Cape Town location that has an advocacy forum dealing with children in prison. At the time of our exchange, the statistics reported HIV/AIDS in South Africa have the highest prevalence in the world, causing 1,000 deaths per day and one million orphans.

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While the professional delegation was meeting with their counterparts, the Ambassador guests visited the Orlando Children's Home, an institution that cares for abandoned and orphaned children from newborn to 21 years of age, sent by the children's court. With the government providing only 49% of operational funding, daycare services are provided to generate income. The guests presented many gifts of oral health and school supplies, clothing, books, and toys. The exceptionally friendly and well behaved children gifted the guests with a moving experience of singing a variety of songs in gratitude for their visit.

Philani Child Health and Nutrition Project

Appropriately, Philani in the Xhosa language means "to live and get healthy." Dr. Kerstin Lundgren, a Swedish dentist, founded the Khayelitsha clinic in 2007 as an outgrowth of an initiative started by her sister, a physician who saw the overwhelming need for oral health among the population. This project is truly a family affair in that Bert Lundgren, the husband of Dr. Lundgren, is the financial manager for the project.

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Children in Khayelitsha Township smile for the cameras during the screening.

Approximately 450,000 inhabitants live within the three townships. Six medical clinics serve the project where roughly 25% are infected with HIV/AIDS. Two oral hygienists are employed by the clinic to provide preventive services and community health education to children, parents/caretakers, and to the outreach workers. More than 80 outreach workers supplement the educational and diagnostic services of the oral hygienists and dentists by their daily visits to people residing within the village. The dental health needs are such that they have led, in many instances, to malnourishment. A recent examination of 200 children revealed the DMFT statistics and PUFA indices in Table 1 (the PUFA Index: P= pulp involvement; U= ulceration; F= fistulas; A= abscess). It was not uncommon to examine children with these serious problems.

As a result of the efforts of two Rotary Clubs in Sweden and Cape Town, funds were raised for two fully equipped dental rooms. Reverend Archbishop Desmond Tutu performed the inaugural blessing on Dec. 13, 2007. The holistic approach begins with children and introduces interventions as needed. This is a satellite clinic for the faculty of Dentistry at the University of the Western Cape. Arriving from Sweden in 2009, two oral hygiene students in the spring and four dental students in the summer delivered oral health care at the clinic.

It is the hope that the United States will collaborate with the Philani Clinic and the University to establish student externships in South Africa. Children with needs beyond the scope of Philani may be referred to the UWC Faculty of Dentistry for treatment (transportation is provided). Dr. Lundgren was enthusiastic about working with American professionals to create mutually beneficial opportunities through services of education, prevention, and therapy. We also enjoyed shopping in the village store for the beautiful and inexpensive handmade items crafted and staffed by the township's residents.

University of the Western Cape (UWC)

The faculty at UWC took time from their busy schedules to greet us and serve us tea and muffins in china cups and saucers, in the proper South African tradition. Natalie Gordon, an oral hygienist and head of the Department of Oral Hygiene, delivered a PowerPoint presentation explaining the merging of faculty at the UWC, which is located over three campuses.

In 2004, the UWC grew to incorporate Stellenbosch University's School of Oral Health Science and became the largest dental facility with the largest concentration of dental expertise on the African continent having three campuses: UMC, Mitchells Plain, and Tygerberg. The last few years have included merging of faculties to include more diversity.

Credentials offered are a diploma in oral hygiene, a two-year degree in oral health, a three-year bachelor's degree in oral hygiene, and a degree in master's of public health or education. UWC also offers a five-year degree in dentistry. The postgraduate studies include specialties, masters, and diplomas with a degree in dental therapy (three-year program) to come in the future. The program makes a significant contribution to their immediate communities. A national survey revealed Western Cape as the poorest province having the highest incidence of decay in the country with baby bottle caries being prevalent.

Excellent presentations sharpened the delegation's knowledge of UWC's educational vision, philosophy, curriculum, instructional methodologies, and challenges. The challenges included very little time for faculty to conduct research due to teaching commitments and the tremendous diversity of the students. The fact that the department is currently looking at training oral hygienists for independent practice certainly piqued our interest. The future is being addressed by a vision statement that includes the offering of a bachelor's degree in oral hygiene (only) and a postgraduate degree in oral hygiene.

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Group examiners man their posts during Mustadafin screenings. They removed their shoes out of respect for the Muslim tradition inside the mosque.

We observed students working in labs and clinics and found the available computer technology to be impressive. Instructions are given via computer, followed by students practicing on manikins. Instead of practicing on each other, the students' progress from manikins directly to the public. All instruments are provided by the school and all radiographs were digital. They said 80% of students make it from first year to second year. The dental hospital was on three floors, and they have about 100 dental students. Dental patients are screened first and then referred to the different clinics. The Health Professions Council accredited the institutions.

Mustadafin Foundation

The director's address on the history and mission of the Mustadafin Foundation described how the 1986 political unrest led to violence and faction fighting that had a devastating effect on the community of Crossroads, a township near Cape Town. The women and children were particularly affected, and the support of the foundation focuses on those groups and helping with disaster relief. Khayelitsha Township suffered through much of that violence. But that was the past, and the township, during our visit, welcomed us in song. Khayelitsha means "new home." "Mustadafin" is an Arabic word meaning deprived, destitute, and oppressed. The foundation was formed when a group of caring people wished to provide services. The organization's growth and sustainability come from the Muslim community that is dedicated to its success as a program to help those in need, especially the women and children, and to reach out to non-Muslims as well. Most of the donations come "in kind," as opposed to monetary, and include food, clothing, vehicles, and even the building that now is used as a mosque. It was said "we survive 'in kind.'"

Making a difference as Ambassadors

Our final day in Cape Town encompassed our community service project of oral health assessment screenings and education at two Early Childhood Development centers (ECD) served by the Mustadafin Foundation. Each delegate was provided, prior to departure to South Africa, a training manual, standardization guidelines, and tests to establish examiner calibration.

Our professional delegation was divided into two groups of examining teams and transported to two separate locations for conducting the screenings. As the children encircled the dental hygienists, demonstrating their wonderment, our digital cameras clicked into full speed and witnessed great pleasure and delight among the children as they viewed their beautiful images captured and vibrantly displayed on the camera screens. Soon, we had every child smiling widely and proudly displaying their teeth. This was an effective and efficient means of encouraging the children to participate.

Teams partnered with one performing the clinical exam and the other recording findings on the oral assessment form. The completed forms were then tabulated to present compiled data of prioritized oral health needs. As each screening was completed, the child received a sticker and was then ushered to another station for floss, toothbrush, paste, mouth mirrors, and instructions on use. A typodont puppet and other visual aids were used to relay oral care instruction and a Xhosa interpreter helped us communicate our educational messages. Nutritional education was included in the sessions with the children and parents/caretakers.

There was a long line of children wrapped around the building waiting to be screened. We witnessed older children turning to their younger siblings and immediately begin to show them how to brush as well. There was even a young girl who vowed "to become an oral hygienist when she grows up."

The total number of children screened was 400, and the compiled data was given to the Mustadafin organization to empower their efforts of securing philanthropic support to serve the unmet oral health needs identified by the 15 teams of examiners. The gratitude expressed for our service and donations was communicated with hugs, tear-filled eyes, and heart-warming comments of deep appreciation. We were also moved by their statement that "we were the first oral health support to come into their organization." Their motto states, "If every man helps his neighbor, then who will need help?" We only wished we could have stayed longer to continue our volunteerism of helping our brethren.

Marcia Butler, RDH, MPH, created the screening instrument for the Mustadafin ECD. Center 1 screened 291 people (274 children, 18 adults) and Center 2 screened 109 people (83 children, 24 adults).

Cultural experiences

Although too numerous to list, the delegation participated in many cultural and social activities. Some of these included museums depicting the political struggles of South Africa during its darkest days, highlighting the struggles, resistance, and eventual end to the apartheid form of government, the Origins Centre that combined technological exhibits and traditional techniques of display to tell the story of the origins of human beings and humanity now thought to originate in Africa, and Robben Island where Nelson Mandela was held as a political prisoner for 17 years.

Some of the natural beauty we witnessed were the beautiful jacaranda trees, Kirstenbosch National Botanical Gardens, Table Mountain, the Cape Peninsula, and Cape Point, along with the colorful Victoria and Alfred Waterfront in Cape Town harbor. We were welcomed with champagne, hors d'oeuvres, breath-taking floral arrangements, and first-class accommodations.

Before leaving each destination, we joined our South African colleagues for a farewell dinner. While dining in uniquely decorated restaurants serving succulent cuisine, we exchanged casual conversation sharing our similarities and professional concerns, and participated in the fun events of music, dance, and facial painting. Our national guide and delegate manager, Alan Petersen, delivered a farewell speech commending the entire delegation for its excellence in leadership, philanthropy, and outstanding contributions made to the people of South Africa in both in-kind gifts and exceptionally valuable oral health and educational services delivered at the two ECDs. Delegation leaders, Marge Green and Irene Connolly, presented the guides our gifts of collective appreciation and expressed gratitude for everyone's contributions to the outstanding success of the exchange. Baie dankie (thank you) to everyone who made our journey a lifetime treasure and for being fabulous Ambassadors for PTP and ADHA!

When reflecting on this journey to South Africa, we think about how terribly busy we were and how our days were jam-packed with professional and cultural activities. We recognize that we had an opportunity of a lifetime. In less than two weeks we experienced another culture, viewed breathtaking landscapes, flora, wonderful African animals, and developed new friendships. We were elated to be able to share our talents, professional services, and materials to those in great need.

Witnessing the South African health-care professionals give unselfishly to rectify what seemed to us insurmountable problems, in order to lift their country out of the circle of poverty, will have a lasting impression on all of us. United in voice and mission, we returned home to our blessed United States filled with hope that our exchange has built everlasting bridges of harmony and collegial collaboration.

As a footnote, we should add that on August 20-30, 2013, the International Federation of Dental Hygiene Meeting and Symposium will be hosted by OHASA and held in Cape Town, South Africa. Plan ahead to experience this wonderful opportunity!

Margaret Lappan Green, RDH, MS is a past president of ADHA (2006-07), periodontal practice clinician, and adjunct professor at the Gene W. Hirschfeld School of Dental Hygiene at Old Dominion University in Norfolk, Va. She was the leader of the PTP/ADHA Exchanges with Russia, Poland, South Africa, and Israel.

Irene Mary Connolly, RDH, MS, is an adjunct assistant professor and ADHA Student Chapter Advisor at the Gene W. Hirschfeld School of Dental Hygiene at Old Dominion University in Norfolk, Va., and a former member of the ADHA Board of Trustees. She was co-leader of PTP/ADHA Exchanges with Russia, Poland, and South Africa.

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