Notes for a Smile

Bolivia Study Abroad by Cindy Larson, RDH

I’ve never traveled to South America or a Third World country before. My only experiences outside the United States were to Canada and Israel. So I didn’t know exactly what to expect on this trip to Bolivia but I was excited to learn and help. I should have known more Spanish though!

My first impression of Bolivia was of a more relaxed culture—polite, warm, less rushed. We experienced wonderful hospitality with food, entertainment and conversation. All of our needs were attended to and I came to love and expect the warm greetings with hugs and kisses on the cheeks. But communication and collaboration were also an issue—they didn’t seem to communicate what was going to happen or realize how what they did or didn’t do affected outcomes. While being less rushed was at times refreshing it could also be frustrating because no one seemed to honor time commitments and if you weren’t productive, it was accepted. Examples: Flight cancellations, dentist not showing up to open clinic in Mora Chata. Duality of values was a theme too–they requested new money but exchanged bills, many references were made to religious icons but few people practiced their faith, timeliness and commitments were not important to them but they became upset if we were late or didn’t keep promises, the focus was on family but they often sacrificed the family welfare for a party.

A prime reason Bolivia is not as advanced is due to a level of education which is not as available or progressive. Therefore the people don’t understand how things could be done differently. The public seems to accept their present circumstances and without outside influence, most things will probably remain unchanged. The Internet may bring about change in this area more quickly by connecting at a global level. My impression was that the Internet was primarily used as a marketing and social networking tool at this time however.

Examples: Lack of fluoride, a diet high in carbs (lots of Coke, candy and sweetened foods), poor infection control (no gloves in ICU)

The political system also plays a role in Bolivia’s lack of progress. Once the land of the Incas and then Spanish conquerors, they have never had a stable government—there have been 192 different regimes over the country’s existence since 1809. Outside influences (Caesar Chavez’s Communistic leanings, the demand for cocaine, corporations like Coca Cola et cetera) as well as corrupt influences within the country are an issue. Bribery is an accepted way of getting things done. There isn’t much internal economic growth either even though the country is mineral rich. It’s hard to find any concerted effort to provide any solutions in this area—outside corporations and a few within the country are allowed free rein to capitalize while the masses remain in poverty. President Evo Morales’s enabling strategy is to give positions within the government to indigenous people ,who often do not have the skills or education to succeed. It’s hard to have hope in a system like this.

I also noticed discrimination of women and the poorer, indigenous population. While this is beginning to change, especially with the election of an indigenous President who brings more opportunities for his people, overcoming cultural norms is always difficult. Machismo is still alive and well in the country–women are often objectified, and expected to take care of men and children and yet there are a number of women entering the professions. Just as we found with our own sexual revolution, it is hard to do it all! It is difficult for the women studying at Smiles Forever to get jobs after graduating as dental hygienists. Of the 37 current graduates, only 4 have jobs within the profession. They often are single mothers without support from their families and they have the huge job of breaking into a field no one has been aware of and then dealing with the dual discrimination of being indigenous and women. Several of the women have realized the importance to banding together and networking by forming a Dental Hygiene Association. Their biggest challenge will be to persevere with patience! I naively thought a model for dental hygiene, which has worked so well in this country, would also be successful in Bolivia. But they have many obstacles to tackle and I feel they really need a dental hygiene therapist model to serve the population the best. I think the most important way we can help them to succeed in this area is to continue to share our knowledge and experience and let them develop their own systems.

One of the highlights of the trip was applying the preventive agent silver diamine fluoride on the children’s teeth. Our hope was to stop the rampant decay process but it was also rewarding to share this information with the dental community in Bolivia. There is not nearly as much of a preventive approach in healthcare in Bolivia. Just like in years past in the USA, healthcare providers take a paternalistic approach where treatment is valued over the education and expectation that the patient has responsibility for their own health. Smiles Forever seems to be stuck in this approach too. Marketing has had it’s influence in Bolivia too—patients value white teeth and often choose to drink Coke rather than water. Until we realize our mission is not just to give treatment but support education and practices that empower people to become healthier on their own, we will fail to decrease disease in Bolivia and entities like Smiles Forever cannot be financially sustained without massive infusion of outside money.

This was an interesting and inspiring trip! I’m glad I had the opportunity to go with SCC where the focus was on learning—I can always have fun but learning is of utmost value to me. I also believe we learn so much more when we are immersed in a culture because we gain from our experience with different perspectives in other settings. I learned that while Bolivia has many struggles because of it’s lack of adequate infrastructure and focus on problem solving, we could learn much from the people who truly live in the present.

Bi Thai

It has been a privilege to be a part of the study abroad program to Bolivia this summer. The trip gave me an opportunity to learn more about the people and culture of Bolivia. I also learned to adapt myself to an environment that is unlike my home in Seattle. Everywhere we went, from the small town of Morichata high up in the Andes mountains to the small city of Cochabamba, people were friendly to us.  The students and staff at the Smiles Forever clinic were welcoming and helpful. They were as interested in knowing about us as we are about them. Many children we met at the orphanage, burn center, and in schools are inquisitive, fun, and endearing. Fears about the ability to communicate with the Bolivian people due to lack of knowledge in Spanish were relieved because many locals were patient in our attempt to communicate in their language. We were also glad to discover that Bolivia is a safe country where a group of foreigners may travel without fears of danger. Although Bolivia is the poorest country in South America, we felt comfortable in the three weeks there.

Bolivia, we experienced a culture that is very different than that of the United States. One difference is time. Here in the US, many people are expected to be punctual to their appointments. In Bolivia, time is flexible and the people are not as strict about time as we are. To our dismay, many appointments and air plane schedules were not on time. If an appointment is made, one has to be prepared to be half an hour early or up to an hour late. This was very frustrating for many American students who are used to being timely. To keep our sanity, we accepted the cultural difference in time and try to to not get stressed out when people and appointments are late. Being in Bolivia taught me patience. I adopted an open attitude and accepted the local culture without judgement based on my own culture in the US.The community service enhanced my academic learning by encouraging me to gain more knowledge about social issues in dental hygiene such as patient education and access to care. Although the United States and Bolivia have many cultural differences, the poor people in both countries all face the same problems with dental care. Many poor peoplecannot afford to go to the dentist for preventative care. The children in Bolivia showed me that dental care is a universal need among the poor in the world. Seeing very young children with multiple tooth decay and infections is disheartening. We need to provide more oral hygiene education and increase access to dental care to all the poor people of the world.

Sarah Lyons

SCC DENHY Special Topics 293

We arrived in Cochabamba, Bolivia exhausted and excited to begin our journey in this country. Prepared with bags full of floss and toothpaste, Cheyanne Osborne and myself had the opportunity to accompany seven other women on a summer study abroad trip that would change our lives.

Our first day in Cochabamba, Bolivia greeted us with the challenge of educating the Smiles Forever students about basic oral hygie­­­­­ne, extra oral and intra oral cancer screening exams, patient positioning, and use of the mouth mirror. It was a great exercise for me to reinforce what I have spent many months learning and perfecting. I felt like I had so much experience in comparison to these girls and it made me think of how silly we must have looked in our first weeks of clinic. We were able to do hands on work and use the show, tell, do method with the students. Cheyanne demonstrated the use of the mirror on me and had her student partner do the same. The students were so hesitant to put their hands in our oral cavity, as it was one of their first experiences doing this. We assured them it was safe and we were willing, and eventually we started to make headway in clinic. We spent much of this time learning how to communicate with the Smiles Forever students and using broken Spanish and English to do so. I was amazed by the eagerness of the students to learn, even though it was difficult to understand. This language barrier followed us through out Bolivia, but we got better, and more resourceful as time progressed.

My biggest challenge in Bolivia was feeling overwhelmed. I have been on mission trips before. I have built many houses for faceless people. Here, I was delivering care to actual people. I was serving humans with feelings and fears. I was completely overwhelmed by my first patient. She was an indigenous woman, who had never been to the dentist, not even one time. She reached out to Smiles Forever for care because members of her family had done so. She got into my chair and I attempted to start scaling with their dull, old instruments. I felt like I wasn’t making any progress and it was over my head. I had never seen a calculus bridge like this before, not even in pictures. I had never seen inflammation to this extent. I attempted as well as I could for about thirty minutes and eventually sought out help. Rosie Bellert, the director of our program took over for me. She began working, slowly removing huge chunks of calculus and doing what I could not for this patient. Clinic time expired and we rescheduled the patient for that afternoon, but only a small portion of need was met with this patient. There was a lot more to accomplish. This is the moment that I will carry with me throughout school, throughout practice, and throughout life. I instantly felt a desire and a need to be in service. I was so affected by her eyes, her fear, and her need. Rosie told me that this feeling would happen. I shrugged it off…I had been on missions. I had traveled the world. I didn’t realize the difference in service when you directly deliver care to a patient. This is the moment that changed my life.

We spent time in several different locations in Bolivia. We worked at an orphanage, a burn unit, and a rural village in Morochata, Bolivia. We did the same procedures in each location, but each location affected us in a different way. Cheyanne and I actually had the opportunity to go to the orphanage together, and I am so glad we went together because we needed each other this day.

Madre de Dios is a home for girls between the ages of 8 and 18 that are in unfortunate circumstances and do not have a home anywhere else. They also have daycare on site for younger children. Here, they are fortunate enough to have a dental clinic that is overseen by Doctora Patty. There is a lot of need at this site. During our time there Cheyanne and I placed sealants and scaled on four young girls. We hardly scratched the surface of what needed to be done. Although I felt this way, Doctora Patty was so thankful for our help. She expressed how overwhelmed she gets and how little funding and help they get. At one point, Cheyanne was working on debriding her patient and her lips were cracking and bleeding, when she asked for lip lubricant, Doctora told us that it was not something they could afford in this clinic, and they do without it. It reminded me that the little thing that we expect to have and take for granted, are not common amenities there.

Working in the burn center in Cochabamba was a fragile and delicate craft. These children have been through a great deal of pain due to their burns and have had terrible experiences with doctors. We came to work at the burn center with our masks and gloves, and the children that were once loving and sweet were afraid and timid. Smiles Forever is working hard to create a positive presence there so that the children will be more willing to receive care in the future. The clinic we set up in the center was small and archaic, but is served its purpose. By the end of the clinic we were taking photos with the children, and letting them try on our masks and gloves. It seemed as if their fear had subsided for the moment, and that is what we wanted to achieve. In the rural town of Morochata fear of dentistry is also prevalent, but the pain these children were feeling overpowered their fear of dentists.

We drove to Morochata in the wee hours of the morning in September eager to start work in the village. When we arrived we set up clinic in the school in the center of town. Here, a handful of dental providers supplied care to 398 students. We had a silver fluoride application clinic, as well as an extraction unit. This school provided a center for multiple schools to meet so they could be provided care. All day we worked, educating, applying, extracting. It was an exhausting day. My mind and heart was tired by the end of our clinic. The Smiles Forever students took each class, one at a time, and talked about the importance of brushing and flossing, and nutrition. From here, the students went into the school restrooms to practice their newly learned brushing skills and to debride their surfaces for silver fluoride application. Here, silver fluoride was applied and if extractions were needed, they were sent on to the extraction unit. Most students had at least 2 extractions to be done that day, some up to seven. Some children were eager to get into the chair and have their teeth removed, some were terrified, but in pain. Reluctantly, they watched others go through extractions and come out with puffy cheeks. Eventually, we had compliance and were able to help those in pain. Our last extraction of the day is the one that stands out most in my mind. It was for a young girl that had watched all day. She stood back with her papers, but did not come forward for care. While we were cleaning up at the days end she finally asked for her extractions to be done. The Bolivian doctors were done, but Dr. Fred from Seattle gloved up. She sat in the chair with tears already running down her face, but she also complained of “duele,” or pain. After delivering an injection of Lidocaine, Dr. Fred began working on the two extractions needed. She was in tears. Cheyanne held her hand and comforted her, however, it was still a traumatic experience for her. Eventually, we completed the procedure, and she was given pain medication due to the level of discomfort she exhibited. We left with saddened hearts. We ate lunch at our hostel talked over our experiences and trying to discuss ideas for improving dental health in this area. We all felt overwhelmed by the need. This experience made the impression on me that we had made a large impact in a small area, but the reality is that there is so much more to do. That is why I feel a great loyalty to this area now.

There is a great need is Seattle, Yakima, and all over the United States. I do feel a commitment to my home, however the poorest people in the United States have a greater access to care than the people in these areas of Bolivia. The experience of giving a child their first toothbrush changed my perspective about health care. It alleviated my worries about finances and my future. It gave me an understanding that providing for the underserved is where my passion in dentistry lies. This study abroad experience was greater and more powerful than I could have hoped for. The three weeks that we spent in Bolivia only gave me a desire to spend more time in this country, and a dedication to community service. Dental hygiene school has prepared me with didactic and clinical skills, but this course has given me more knowledge about life and love than I could have read about in a book.

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