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Peeling back the onion: An outsider's observations

2017; Medknow; Volume: 8; Issue: 1 Linguagem: Inglês

10.4103/ccd.ccd_226_17

0976-237X

David Okuji,

Dental Health and Care Utilization

I recently had the honor and pleasure to participate as a speaker at a conference in Punjab state and met with the leaders and members of the Indian Dental Association (IDA), Amritsar branch, and the administrators, faculty members, and students of dental colleges from the Punjab Government Dental College and Hospital, Amritsar, Sri Guru Ram Das Institute of Dental Sciences and Research, Government Dental College, Patiala, Dashmesh Dental Institute, Faridkot, National Dental College, Dera Bassi, Christian Dental College, Ludhiana, BJS Dental College, Ludhiana, and Maharishi Markandeshwar University, Mullana. At this same conference, Professor S.G. Damle, our esteemed editor of this prestigious and internationally renowned online publication, was honored as the chief guest and gave a moving oration which inspired the dental students to become leaders for the betterment of society. In alignment with Dr. Damle's call to action for bettering society, my participation as a speaker was part of a team of dentist-volunteers with the Global Dental Ambassadors group.[1] The dentist-volunteers share the mission to participate in academic and self-subsidize cultural exchanges among oral health professionals and institutions around the globe. I told the audience that this was my first visit to India and shared my observation that India is "like an onion" because I only had knowledge of the outer skin of onion from the stories of India, as told by my U.S-based colleagues of Indian ancestry. From these stories, my understanding of the onion skin was that India is geographically large, culturally diverse, and hugely populated. Of course, "onions are considered as a basic ingredient or the fundamental of Indian cooking,"[2] so it is fitting for me to continue with the "onion" metaphor. As I prepared for my trip to India, I peeled off the first layer beneath the "onion" skin and learned about the oral health infrastructure in India compared to the United States. With over 1.2 million people, India has a population which is four times greater than the U.S.[3] However, with approximately 120,000 dentists, India has fewer dentists to serve its large population, compared to the 195,000 dentists in the U.S., with the ratio of population per dentist much higher in India.[45] India's 310 dental schools are graduating nearly 31,000 dentists annually, compared to the 5500 dentists graduating each year from the 66 U.S. dental schools.[678] Hence, the first layer of the onion taught me that there was an overall shortage of dentists in India to serve its burgeoning population. As I peeled back more of the "onion," I learned that the majority of new graduates from Indian dental schools prefer to practice in the cities and not the rural areas, with only 75% of dentists located in urban areas which contain 25% of the population.[69] Similarly, this is a trend found in the U.S. as well.[10] As I delved deeper into the "onion," I found that the caries prevalence for children under age 5 years old is 39.9% in India and 28.0% in the U.S.[1112] Again, we find that there are similarities for both India and the U.S. with the burden of disease for early childhood caries and the mal-distribution of dentists. The overwhelming conclusion is that neither India nor the U.S. will be able to drill their way out of the burden of early childhood caries. Going deeper into the "onion," I found that in 2012, Dr. Raman Bedi, our esteemed colleague at King's College, London, conducted a survey of nearly 1200 Indian dentists to learn how the Indian diaspora might better support India. The results of the survey highlighted three key concerns expressed by the respondents. The dentists overwhelmingly concurred that (1) there should be a "national and or state community program to provide dental care for the underserved and health education to improve dental health literacy," (2) improvements are required "in dental education at both the undergraduate and postgraduate level," and (3) in general, "the population does not value oral health."[13] According to Gambhir et al., "most of the people in India do not have access to basic oral health care" and "patients are not covered under any type of insurance and generally pay out of their pockets to get treatment from both public and private dentists."[14] Comparatively in the U.S., 90% of children are beneficiaries of government or commercial insurance, with 10% un-insured.[15] Still not yet at the center of the "onion" and after speaking with many of the dental students who attended the conference, I learned that the students were very knowledgeable and well versed in the dental and medical literature. I also learned that they were very concerned about their future as dentists in India. They shared that they are worried about finding jobs and being able to care for those in need. They also asked about pathways to the U.S. Deeper in the "onion," I spoke with faculty members and IDA members who informed me that the practice of dentistry in India differs from that in the U.S. due to (1) the large number of dentists who are women and (2) the prevailing practice model that dentists tend to retain patients within their practices for specialty care by minimizing the referral of patients outside of the practice. "The most enlightening finding was the overwhelming and unanimous response by all of the conference participants, when asked to raise their hands if they believed that it was important that oral health care be equitable for all people. The entire audience raised its hands proudly and vigorously and, thus validating to me that the group was strongly committed to make society better. In closing, I wish to again thank Professor Damle for helping me understand the depths of the "onion" through the sharing of his inspired message for world betterment. I am confident that all of us, as global citizen-dentists, will continue to work together toward this goal."