Dr Bulela Vava – Interim National Chairperson of the Public Oral Health Forum, shares a first-hand account of the barriers disabled people face when accessing oral health care.
Health-e News/Image: Yeshiel Panchia/Health-e News
Dr Bulela Vava – Interim National Chairperson of the Public Oral Health Forum, shares a first-hand account of the barriers disabled people face when accessing oral health care. I am reminded how the right to health care services for people living with disabilities is not one enjoyed by all. Not too long ago, I consulted with Tshepo*, a teenage boy with cerebral palsy, and his mother. They had been referred to our centre for a consultation with the hope that Tshepo could be assessed and treated for a problem that had been plaguing him for a while. Tshepo, was suffering from a terrible toothache, which negatively affected his ability to eat and communicate well.
My assessment revealed rampant dental decay and localised dental abscesses in the mouth. It was clear that the only reasonable course of action would be to have all his teeth removed, but there was one major problem. Tshepo’s condition is characterised by limitations in his control of bodily movements and coordination, making it difficult to perform dental procedures in a typical dental setting. Additionally, Tshepo experienced anxiety from a previous encounter in a healthcare setting that included the use of ‘force’ to achieve a ‘successful’ procedural outcome.
Inadequate resources for people with disabilities
The only way the procedure could be performed would be to place Tshepo under general anaesthesia. The healthcare staff required for this procedure would be the anaesthetist, nurses, and dental practitioner. Regarding infrastructure and equipment, there would need to be a recovery room, a bed at a short-stay surgery ward and an appropriately equipped operating theatre.
However, only a dental practitioner was available, so Tshepo could not receive the appropriate treatment at this stage. Instead, a short-term solution involved prescribing medication to control the infection and alleviate his pain and then referring him to his local clinic for management and referral to another centre that could assist him with the procedure. Yet again, I found myself unable to help yet another person whose needs the ‘system’ had been unable to provide for.
With my extensive exposure to the South African public oral health service, I have yet to find oral health services structured so that they can respond to ALL people’s emergency oral health needs. Persons living with disabilities, especially intellectual disabilities, have, time and time again, demonstrated experiencing extreme challenges with accessing oral healthcare, which has been a systemic challenge that oral health professionals and the healthcare system have failed to address sustainably.
On the 18th of November, 2022, the World Health Organisation launched and published the Global Oral Health Status Report , which painted a grim picture of the status of global oral health. According to the report, more than 3.5 billion people globally are affected by oral disease, equating to nearly half of the world’s population, thus making oral diseases the most prevalent non-communicable disease globally. Oral diseases are on the rise due to an increase in the ageing population, a rise in oral health risk behaviours, and lifestyle and other factors. This is a result of decades of oral health neglect and non-action on oral disease by governments across the globe.
Too few dentists in public health
In South Africa, oral health services are provided in the private and public sectors. However, the private oral health sector remains inaccessible and unaffordable for most of the population, although it employs more than 70% of the country’s oral health workforce. More than 80% of the population depends on the public health sector for their healthcare needs, even though the same public health service has no more than 3000 dentists and far fewer numbers of dental therapists and oral hygienists to attend to the needs of an estimated 58 million people.
Now more than ever, the story of Tshepo and many others I could not help reminded me of the need to take action to foster disability-inclusive health systems and to take that action now. Oral diseases significantly impact the quality of life and general health of the people affected. Persons with disabilities are disproportionately affected by poor access to oral health services compared to those without disabilities and often suffer the worst health outcomes associated with oral disease.
Even so, oral health services have failed to adequately respond to the oral health needs of persons with disabilities and those of the general population. The are several challenges that adversely contribute to the current picture.
Public oral health not designed for special healthcare needs
Firstly, a lack of leadership and appropriate governance in oral health continues to be a major challenge. A significant majority of public oral health clinics cannot provide much-needed care for persons with special healthcare needs due to poor service planning and a lack of integration of oral health services in general health service programmes. General dental extractions are the order of the day in most facilities, with no emphasis on primary oral healthcare and prevention. Some colleagues have highlighted challenges with pleading the case with facility managers to prioritise oral healthcare services, e.g. experiencing difficulties to get theatre time and ward space for booked clients for dental procedures under general anaesthesia.
Secondly, there is a severe shortage of oral health practitioners in the public service, affecting access to and the quality of oral health services provided. Tshepo and his mother would not have needed to travel to another district on limited financial resources to make a trip that resulted in inadequate services for his immediate need had these services been available within their district.
Thirdly, the training of oral health practitioners does not adequately incorporate oral healthcare for persons with complex healthcare needs, especially those living with conditions like autism and cerebral palsy, amongst others. Consequently, the ‘independent practitioners’ tasked with serving ALL of society battle with the confidence to manage clients like Tshepo. At best, they are caught playing the “pill and refer” game that hardly results in the appropriate management and response to clients’ healthcare needs and instead could have telling implications for antibiotic surveillance and or the possible development of preventable antibiotic resistance in these particular clients.
Challenges around oral health and disability
Public oral health services may not be designed and organised in a manner that ensures the utmost accessibility and inclusivity. An example is the absence of training for healthcare workers and undergraduate students in basic South African Sign Language (now officially recognised as an official language of the Republic).
Several challenges are found at the intersection of oral health and disability, and they all need attention. No one should have to experience and overcome such extreme barriers to access urgent oral healthcare as Tshepo did. It is the society, the systems and the infrastructure that we design that place barriers that make it difficult and sometimes near impossible for differently-abled persons to enjoy their rights, including their right to health.
As we ‘wrap up’ National Disability Rights Awareness Month, it is important for those of us who serve on the side of privilege to reflect on how the status quo continues to push others to the margins. What kind of healthcare practitioner am I if I play no part in ensuring that those who need my assistance do so with the least barriers experienced? Public oral healthcare has to reform and demonstrate to the broader healthcare fraternity what is possible when you design and organise service delivery in a manner that prioritises the healthcare needs of ALL. It is time to advocate for and invest in building disability-inclusive health systems that include oral healthcare services today.