Story by Fernanda Pires, Michigan News | Photos by Austin Thomason, Michigan Photography
Before the global pandemic reached Kenya, 30 University of Michigan students immersed themselves in the east African country in a learning and service journey.
MERU, KENYA—The joyful chaos of the elementary school playground buoys the children along on their unusual mission. Some University of Michigan dental students have come to their school and asked them to help carry the classroom furniture outside.
Before long, the playground is transformed into a pop-up dental clinic. School benches are now dental chairs. Masks, gloves, polishes, rinses, floss, adhesives and cotton rolls are set on the teachers’ tables. Each clinician and assistant sits on a wooden chair.
Their work done, the children wait to find out what happens next. Once everyone is settled in, the U-M dental students break into three groups.
The dental students are part of a larger team of U-M faculty and students in dentistry, medicine, pharmacy and engineering who work together on programs to improve health care and overall community health around Meru, in central Kenya.
One group of dental students, the runners, together with the local teachers, coordinates the Kenyan students in lines by grade and age and enters their information into an electronic health record they have developed. The goal is to track the children’s oral health over the years.
Another group gives oral hygiene instructions to older students, teaching them how to use toothpaste and brush their teeth. This way, they can mentor younger peers and parents at home to practice better oral health.
Caroline Wanjiri, who is in the eighth grade, is participating in the U-M training for a second time. She “loves” learning from the dental students, she said, and enjoys the responsibility.
“Later, I teach my friends the importance of taking care of their teeth and how to prevent some diseases, like cavities,” she said. “I tell them to stop eating sweet things, eating so many candies. When they’re given money, not to go to the shops and buy only sweets. They can buy fruits and other healthier food. I also encourage them to go and teach their parents and neighbors.”
The third set of dental students examines the patients. They work in pairs and screen every single child, about 200 per day. They mark all decayed, missing, filled and present teeth. Based on that data, the U-M students provide the necessary treatment, if needed.
“If the child has decay in the baby teeth, students will place silver diamine fluoride in the decayed areas to kill the decay and arrest the lesion,” said Robert Eber, clinical professor of dentistry and a faculty leader of the project.
Eighth-grader Samuel Bundi wants to be a dentist. With eyes wide open, he tracks each of the clinicians’ movements.
“I like to see other people’s teeth when they smile. I like when they are clean and white,” he said. “Dentists help people with smudged teeth, give them medicine, so the teeth get strong and they can chew some meat and maize.”
U-M clinicians appreciate the students’ enthusiasm for learning. Being closely followed by the attentive audience is not a bother. In fact, it’s “quite the contrary,” said dental student Dana Smith.
“I feel like I don’t even notice it that much,” she said. “I like it because some of them ask questions and they want to learn. A big part of this trip is teaching the older kids. We’re only here for one day, and then we go to a new school. So when we’re gone, the older kids can keep teaching the younger kids and their families and friends.”
Carlos González-Cabezas, U-M director of global initiatives in oral and craniofacial health, has led groups of dental students in Kenya since 2010. He said the program aims to educate Michigan students “at a higher level, to think in a global context, to understand the needs of all types of populations.”
“We are trying to prepare our students to work in different situations,” he said. “At the same time, they have an opportunity to learn how the disease is presented in different ways in different countries.”
Besides academic goals, González-Cabezas stresses the importance of the initiative for the local African community. Kenya faces a shortage of dentists nationwide. There are only about 1,000 dentists in the entire country, or one professional for every 50,000 Kenyans. The World Health Organization recommends one for every 7,000.
“And the dentists they have are mostly in Nairobi or in Mombasa, so the rest of the country is underserved,” González-Cabezas said. “We have also observed their dietary customs have changed. Now they eat a lot more sweets and drink more soda. That’s why they have an increasing rate of decay. This really is a tremendous problem because they still don’t have the habits of prevention that we have in developed countries.”
Agnes Kimathi, a nurse in Meru, couldn’t agree more. She says the children have little or no knowledge of dental care. Neither do most of their parents.
“They don’t think it is necessary to clean their teeth after meals and don’t encourage the children to do so,” she said. “This partnership is super important. It has helped reduce the number of school absences because of dental care. Before, many kids could not eat because of decay and pain. Now we have about 80% fewer complaints in these schools visited by the University of Michigan.”
Providing first dental consultations and dreaming high
While older students are comfortable and even enjoy the examinations, many younger patients are afraid when sitting in the dental chair for the first time.
Dental student Carla Jones helped a few scared little ones.
“Some just looked very nervous, very scared. Then as soon as we tried to get them to open their mouths, outbursts of screams and running away occurred,” she said. “The sad part is that I noticed some of the children who were screaming were the ones with the most need. You could see the black on their teeth, which is decay. And I think they were in pain.”
Despite some crying, the majority of young patients were very excited about the experience; some were intrigued about becoming dentists themselves.
Originally from Syria, dental hygiene student Said Al-Jazaeri also hopes to advance oral health infrastructure in the developing world. That is why he is making plans to attend dental school.
“I want to travel and be able to provide services similar to what we are doing here in Meru,” he said. “And even help to create a dental curriculum and also maybe start dental schools in different communities around the world.”
González-Cabezas and his dental students are part of a cross-disciplinary partnership with students and faculty from the U-M Medical and Pharmacy schools and College of Engineering working together for a decade to improve health care in and around the state of Meru.
Among the pioneers of the partnership is Daniel Clauw, professor of anesthesiology at Michigan Medicine. The fact that a two-week trip transforms so many people, he said, is the main reason this program endures.
“As a professor, I have tremendous opportunities to mentor scores of students and junior faculty, but nothing I can do that takes just two weeks approaches this type of impact on individuals,” he said. “I feel that it is important that we give students this opportunity to work globally and see that all humans have the same wants and needs, and that people who have little can still be quite happy and content.”
Debut for engineering students
Born and raised in Meru, Mutai Kinyua proudly shows off his coffee farm to a group of U-M engineering students. It is the first time professor Gregory Hulbert, who teaches courses for the International Programs in Engineering, has brought his students to Kenya. They design solutions that work across cultures.
Walking around the plantation with 4,000 trees—and located 1,300 meters above sea level—Kinyua explains he is working to keep his production 100% organic.
He intercrops coffee trees with macadamia trees, which provides an ideal amount of shade and improves soil nutrients. He also raises honey bees. Coffee flowers produce sugary, high-quality nectar, and bees improve coffee berry ripening, size and uniformity with their cross-pollination.
“I have several strategies to keep my organic production while maintaining productivity,” Kinyua said. “My biggest challenge is improving efficiency and quality in coffee picking and sorting. Ideas?”
The engineering students are learning about ethnographic methods, different ethnographic scales, ethnographic observations and ethnographic interviewing.
“After talking to their clients, like Kinyua, I want my students to brainstorm a potential product or service that works in that country, considering the local cultural and economic aspects,” Hulbert said.
His students have a lot to learn from their local partners, he said.
“Kenyans have strong engineering minds to work with what they have and complete tasks under numerous limitations,” he said.
Computer engineering student Jaime Hare has traveled to the African continent for the first time. She is thinking differently already.
“Sometimes in the U.S., it gets a little too centered on what we think is cool and what would work,” she said. “I think there needs to be a bigger shift and focus to multidiscipline engineering and international engineering and things like that.”
For Hare, the visit to the coffee plantation was “interesting and eye-opening” since the Michigan students had heard about the coffee co-op in Kenya and how it affected the plantations.
“The team was really excited about how much information we recorded and how that enabled us to create design requirements that could actually help someone that we met in person,” she said.
After reviewing their observations and interviews, the U-M team made the following design recommendations for a new piece of harvesting equipment:
- The device must only pick fruit that is at least 90% red from stem to end to maintain integrity of coffee harvest and follow all regulations of the local government.
- It should be made out of at least 80% recycled material, including a mini solar panel on the top—to charge throughout the day.
- It should not damage the coffee bean plant by cutting off unnecessary parts of the plant and operates effectively between the temperatures of 11°C and 27°C.
- It should cost less than the amount paid for the work to be done by hand in a five-year period.
“These design requirements could hopefully help all the coffee plantations, while still being appropriate for the culture and engineering realities of Kenya,” Hare said. “The more independent sources we heard from, the better the team’s understanding of culture in Kenya and how designs would be used once they actually got on the ground in the country, and the better design requirements we could make.”
While in Meru, the engineering students also visited primary and secondary schools, hospitals and an orphanage, where they met prospective engineering student Kevin Mwendi. “Having the opportunity to meet and talk to the U-M students opened my mind and also inspired and guided me,” Mwendi said.
Pharmacy practice and breaking taboos on sex ed
They write the questions, anonymously, and place them in a plastic bag. Students from Bishop Lawi Imathiu Secondary School (BLISS) are enjoying a rare opportunity in a safe space to discuss sex and other topics that are taboo in Kenya.
“For generations, many of the parents have been raising their children without talking about sex,” said Moses Marete, BLISS principal. “Many are still ashamed, and feel uncomfortable talking about it. That is one of the main reasons we have a lot of pregnancy in our institutions.”
Pushing back against the cultural context, BLISS invited U-M professionals to provide sexual health education to all first-year students. Since 2010, obstetrician Amy Tremper and a group of medical and pharmacy students have provided teens the knowledge, confidence and space they need to learn.
Tremper wrote the teen-appropriate guide “Healthy and Happy in Kenya,” now used in their annual sessions and distributed to each participant.
Pharmacy student Sabrina Miller said it was extremely important for her to participate in the sexual education classes.
“Besides providing information and discussing topics that may have been ‘taboo,’ we wanted to empower the students to make the informed decisions for themselves,” she said.
Prior to pharmacy school, Miller worked at a federally qualified health clinic in Grand Rapids, Michigan, serving primarily refugees, undocumented people and other underserved populations.
“I loved building relationships with the patients, hearing their stories and learning from them,” she said. “This is what initially sparked my interest in this patient population and why I decided to come to Kenya. Having a deeper cultural understanding can make you a lot more impactful as a health provider.”
BLISS principal Marete said the discussions are helping remove myths about teen pregnancy and other issues regarding sexuality.
“Knowledge is power. It is critical for them to be able to understand themselves, and also to know how to take good care of themselves as they grow up,” Marete said.
In addition to providing sex ed classes, the five pharmacy students shadowed local physicians and pharmacists. They visited two hospitals, an HIV clinic and six chemist shop dispensaries.
This is the seventh year Vicki Ellingrod, U-M professor of pharmacy and associate dean for research and graduate education, has taken students to Meru, where they exchange ideas about the practice of pharmacy and structure of pharmacy education.
Students learn how pharmacy practice and implementation in Kenya differ considerably from the United States, including pharmacy education and the process of storing and dispensing medications.
“Although the education of pharmacists is different compared to the U.S., the pharmacists are now giving vaccines and working to incorporate clinical care into their sites,” Ellingrod said. “They are doing this through continuing education and are making these changes in response to the needs of their patients as hospital clinics are reaching capacity and cannot always provide these services.
“Despite not having electronic patient profiles, or any patient profiles, they are working to ensure the proper use of medications for every patient that comes into the pharmacy.”
The U-M students across the disciplines working in Meru expressed gratitude for the opportunity and hope for the future.
“My time in Kenya reinforced to me that we must first understand things in the proper context before making assumptions or suggesting solutions,” pharmacy student Miller said. “I also have an overwhelming feeling of gratitude for having been part of it. At the end of the day, we are all connected as humans and want similar things.”