Improving Access to Oral Healthcare In Latin American Countries Through Task-Shifting

My name is Helen Yang, and I am from Troy, Michigan, but that is not where I was born. I was born in Northern China and moved to Montreal when I was in first grade. Then, from first grade to sixth grade, I went to a different school every single year. I think that shaped a little of who I am. I did my high school in Troy, Michigan. That’s where I identify myself as being from. For college, I went to Harvard College, where I studied History of Science, and Global Health and Health Policy. I am currently a second year dental student at the Harvard School of Dental Medicine. I am hoping to pursue a master’s in public health in the near future. I am very passionate about improving access to oral health care.

For the longest time, I had wanted to be a surgeon for as long as I can remember—I think back to ninth grade. I remember in tenth grade, I shadowed my first bariatric surgery. In eleventh grade, I was the president of my high school’s pre-medical club; it was pretty small. By twelfth grade, I had spent over 350 hours volunteering at a hospital. I think the fact that I wanted to be a doctor was really influenced by the people I looked up to back when I was in high school. Neither of my parents were doctors, but a lot of my friends’ parents were. In my English classes, we read about Paul Farmer and Jim Kim. I really admired the kind of broad-reaching work that they did.

In college, I went into Harvard College knowing that I was going to pursue medicine. I had turned down a couple of colleges where I had gotten into the medical and bachelor’s program. I thought that going into Harvard would give me a broader understanding of medicine, so I wasn’t so focused into getting medical school. At Harvard, I explored different activities. I didn’t want to just be a typical pre-med by doing research and volunteering. I wanted to explore journalism, so I comped the Harvard Crimson, where I ended up writing science articles for them. I wanted to do some community service, so I ended up mentoring a girl who was adopted from China, and I taught her Chinese. I was really active in a global health club on campus. Through all these activities, I got to explore medicine without, in my opinion, explicitly doing the medical stuff. When it came time to choose a concentration, I ended up choosing history of science because it allowed me to take some of the pre-medical requisite classes as well as really cool History of Science classes that caught my eye.

The first time I was exposed to dentistry (outside my dentist’s office) was in sophomore year of college. I was writing this article on this new research that came out linking obesity and gum disease. It was the first time I thought about how anything happening in the mouth affected the rest of the body. That was pretty intriguing to me. I ended up doing some independent research on my own after the article had come out. The more I learned, the more it seemed to me that diseases of the mouth really affected people’s quality of living. In a separate instance in this global health class that I was taking, taught by Professor Sue Goldie, I read a case study that was not part of the required curriculum, but I read it anyway. It was about how fluoridating salt in Jamaica was extremely cost-effective and was able to reduce the rate of cavities for ten cents a person.

All of these sorts of things ended up coming together over the course of those six months. I shadowed a dentist to check it out. I thought it was pretty cool. After doing some soul searching, I realized that the reason I wanted to be a surgeon was to have the set of transferrable or mobile skills that could really improve somebody’s quality of life in the span of a few hours. I realized that dentistry would allow me to do the same. I had been really struck by the fact that there was this huge need in dentistry. For all these reasons, I sort of made the change to pursue dentistry instead. It was a huge deal to me because I had been so set on becoming a surgeon for so long. When I told my parents, they didn’t really believe me. They said, “Okay, good. When are you going to sign up for the MCAT?” I said, “I’m not taking the MCAT. I’m going to take different tests. It’s going to be a different path for the same reasons. I’m going to be doing pretty much the same sorts of things. Instead, I have now chosen a slightly different field.”

Once I made that decision, around junior year, switching to a pre-dental path wasn’t extremely hard because the prereq courses were very similar. For my history of science concentration, instead of focusing more on the history of global health, which I was doing previously, I focused instead on the history of modern dentistry and its development as a profession. That was a really fascinating topic for me because it linked to me some themes in public health with these issues that dentistry is struggling with right now, such as issues dealing with low-level providers, third-party payers, and things like that. In senior year, I applied to dental school. I interviewed throughout the whole year and was fortunate enough to get into a few places. I ended up choosing Harvard, again, to do my dental school education because Harvard is one of the few dental schools in the country that teach dental students alongside medical students. Since I have such a strong interest in medicine, I really wanted to go through the process and learn as much as I can about medicine. That’s where I am right now.

The summer after the first year of dental school (last summer), I interned at the Pan American Health Organization, or PAHO for short. PAHO is the branch of the World Health Organization that serves North America, South America, and Central American countries. Its goal is to provide technical support and advice to these countries. It focuses work mostly on the Latin American countries. Some of its main goals are to fight infectious diseases, improve access to vaccinations, and increase health education. I worked specifically in the oral health department. I was only there as an intern for eight weeks.

In the field of oral health, in many countries, there is a severe shortage of oral health care providers. That is a huge problem for many countries in Latin America, for instance, Peru, Haiti, Bolivia—I can go on and on. One of the things that PAHO is trying to do is to find ways to bring oral health care to the people without making it too expensive or too difficult for them to access. The main project that I worked on when I was there was to figure out if there was a way for PAHO to recommend these Latin American countries to start training non-dentists to provide some preventive oral health care measures, specifically fluoride varnishes, which, when applied on children’s teeth, can basically prevent them from getting cavities for up to a year. This is a procedure that can be very simply done by anyone: parents, teachers, nurses — it doesn’t have to be a dentist. The idea was to see if we could find ways for countries to agree to training people in rural communities or communities without dentists to do this for all their children. That’s the main problem we were trying to tackle.

People have to eat every day. If you could think of a time that you had a minor toothache or even a severe one and how much it prevented you from going about your daily business or eating, I think that it doesn’t take a huge leap to realize that oral health is extremely important for not only happiness but also health. One can imagine that with a lot of tooth pain or missing teeth, eventually, people are not going to be able to eat as well as they would like and then end up getting poor nutrition. That leads to a huge host of problems. The issue in a lot of Latin American countries is that people—especially people who are of lower socioeconomic status, people who live in rural areas, and women—are unable to go to a dentist or dental nurse for care. For instance, they might not know what they should be doing at a daily level to try to prevent some of these oral diseases. As a result, the level of cavities is extremely high in many countries. This is a huge problem. The problem can also be broadened because, in the field of oral health, we have to be constantly fighting for legitimacy for funding.

In global health, I think a lot of diseases get more attention than others, but that’s not to say that those who don’t get the attention don’t have as important of an impact on people’s quality of life as those who do get the attention. Even though dental caries may not kill people right away, they cause tremendous suffering. Tooth cavities can often affect as high as 100% of the population in some communities, meaning that in some places, everyone really suffers from some degree of this. That’s what makes it a pressing issue that we should be working on.

I went in with a specific job description. As a research intern, not only was I supposed to help out with any of the day-to-day activities that the oral health department was working on. The main project I went into work on the issue of task shifting and fluoride varnishes in Latin American countries. By the end of the project—my internship lasted for eight weeks—I, along with another intern, produced a 16-page draft document, making the recommendations why countries should train non-dental providers to provide fluoride varnish. PAHO works by advising countries on what to do, not necessarily going in and implementing anything for those countries. My role was to create the draft document that the Oral Health Department—my boss—would eventually present to the ministers of health in other countries to have them go ahead and implement these things.

The schedule at PAHO was pretty relaxed. I think that is one of the perks of working amongst people who are all from the Latin American countries. One would get there around 9. Sometimes, there would be floor meetings that were entirely in Spanish, which I did not speak. I tried to attend a few for the experience, but what I got out of it was pretty limited. I think I’m now very good at telling apart different Spanish dialects. In the morning, generally, there were floor meetings, or I would meet with my boss, Dr. Saskia Estupiñán, and she would tell me, “No. Here are some goals you should figure out and try to meet by the end of the day.” Overall, it was very flexible. There were no hard deadlines, and I usually chatted with another intern with whom I was working on this project. We tried to figure out if there were any other resources we should be researching.

Lunch was two hours in the middle of the day. In the morning, I tried to do most of my substantial work, and in the afternoon, I would try to talk to student interns who were in the other departments at PAHO. I think that was one of the great benefits from being able to intern at PAHO. Even though I was in the Oral Health Department, I was able to interact and befriend a lot of interns from the other departments. Whether they were working on maternal and child violence, or improving access to vaccines, they all brought their own set of skills and their backgrounds. I got to talk to them and learn about their experiences. I also worked closely with Dr. Nancy Valencia, who is a consultant of PAHO for the Oral Health Program. She was working on a similar project. Throughout the summer, I helped her a little bit with her project, whether it involved typical intern things like photocopying documents or doing research for pulling up facts that she needed or making PowerPoint slides for her. The day typically ended around 6.

I think the single most important skill that would help in this role is the willingness to try new things. I know that doesn’t sound like a skill, but I think without it, you wouldn’t go far in global health or in public health. The internship was pretty flexible. There weren’t that many hard-and-fast deadlines. That meant (a) you had a lot of free time or (b) no one was breathing down your back to produce things. That required that you be self-driven. But in order to get the most out of the internship, you had to be able to go out and make your own goals, whether they fell immediately within the purview of your internship or not.

I think that for anyone doing this job, it’s important to have basic research skills, and some Spanish skills would have greatly helped. But ultimately, no one’s there to tell you what to do, so if you are not self-driven, then you’ll just spend eight weeks realizing what you did, which is very little. Our boss, Dr. Estupiñán, was really great because she encouraged us to not just spend the entire internship in the PAHO building. Because there was a lot of free time and because I could really do my work somewhere else, I actively sought out site visits or places. I did a lot of my work at the Library of Congress. I arranged several site visits myself. For instance, while I was there, I, along with the other interns at PAHO, was able to visit and learn from people at the World Bank, the National Institute of Health, and the Inter-American Development Bank. I even got to schedule a meeting with the state representative from Wisconsin, where we talked about the huge student debt issue. He was very sympathetic. I think that even though these experiences did not fall within the strict expectations of the program, I took advantage of the fact that I was in D.C., in the capital, where all these major global players were. I made the effort to go and see people and learn from them.

For my internship, I worked most closely with another student intern from the Harvard Dental School. We worked pretty closely to create this draft document recommending teaching non-dentists to provide fluoride varnishes. Whenever I needed thoughts or consultation, I worked with Dr. Valencia, who was the PAHO consultant, and Dr. Estupiñán, who was the head of our department. Whenever she was around, she would hop in and pop in. We would talk about the direction for the project. We had reached out to another consultant from the NIH. She also gave us some input on our project.

The cool thing about working at PAHO is that, with the horizontal floor space, many departments were sort of all crammed into one floor. My desk was surrounded by people who were working on non-oral health things. Whenever I needed new ideas or if I wasn’t sure what resources within PAHO I could find, the people around me who were there for much longer than I had been were able to help me out as well. In addition, back at Harvard, I had a faculty mentor to help me with the research project.

I arranged this specific internship at PAHO through the Harvard Dental School. The Harvard Dental School, fortunately, had an agreement with the PAHO Oral Health Department to send a student to intern there over the summer every year. I found out about this project from a fourth-year dental student whom I had previously met at a global health and dentistry student mixer. We immediately clicked because he was interested in essentially the same things as I was. In dentistry, people are also interested in public health; it’s a pretty small world. We ended up talking. He told me about this internship, and I was immediately interested, not only because I’ve always wanted to spend a summer in D.C. but because I had previously done some work in global health but had never really seen how a multinational health organization like this worked. I immediately jumped at the opportunity. I bugged him for all the details, and he told me that the head of the department would be coming from D.C. to give a presentation. I made the time to attend the presentation. I asked her and told her afterwards that I was interested in this internship. She basically interviewed me on the spot and did not say in so many words that I got it, but I was pretty sure I did. There was a formal application process that was handled through the Pan American Health Organization. They have an official internship program. For anyone who’s interested in working at PAHO, not just in the oral health department, you can apply through that.

I was very fortunate. I ended up crashing for the whole summer with the friends of a friend of a friend. Living in D.C. is not cheap by any stretch. I had received the stipend from the Harvard Scholars in Medicine Office, which supported my summer research, but it wouldn’t have been enough for me to live in a safe area or anywhere near where the PAHO building was. I asked around. Thankfully, many Harvard graduates do end up in D.C. I reached out to a few of them and asked if they knew of any places where I could crash at. Through that, I was very fortunate to find a very small attic in Georgetown, so I was not complaining.

One thing that surprised me about this internship was I thought that there would be more intense deadlines. It turned out that in public health, things sort of move along at a leisurely pace until things really need to happen. I had friends who did D.C. internships before, and they worked 12 hours a day with bosses breathing down their necks, but here, I was given general directions, and you were expected to go and take that how you wish. Initially, I worked very intensely, and then I realized that my boss didn’t really expect me to be producing this until later. I was able to slow down a little bit and then take the time to do the other activities and help out the other people in the department.

I have thought that if you produced a document like this, there would be a lot of collaboration, a lot of double-checking your facts, or very rigorous research methodologies, but I realized—at least for the specific document I was working on—that was not the purpose. The purpose was to have a general view and have a convincing argument. I ended up learning, while I was there, that anything that I’d do and write would be rigorously fact-checked by people after I had written the document—not while I was writing the document. That was something I didn’t expect.

I pursued this internship because I’ve wanted an experience in a multinational organization. I wanted to see how an individual could make a difference at an organization as large as the World Health Organization without being swallowed within the seas of people and all the hundreds of departments that they have, all working on meaningful causes. One of the takeaways that I realized was global health is very collaborative. While I was there, I saw my mentor, Dr. Estupiñán, reach out across the department. She worked pretty closely with people in the vaccine department, people in the child health department, and even people in the cancer department because one of the projects that she was working on involved the link between HPV and oral cancers.

I think that in global health, if you just do work by yourself, it’ll be pretty difficult to gain traction, attention, and, subsequently, funding. Collaboration is really important. Generalizing on that, having relationships with non-health organizations or even other health organizations can be really helpful. I think that’s a big takeaway of having lived in D.C. for a summer. Now that I have visited at and spoken with people who work at the World Bank, the International Monetary Fund, the CDC, and all these research and financial institutions, I sort of understand now where health fits in the bigger picture. Having spoken with a US congressman and being in the waiting area, seeing all these lobbyists and sort of just really understanding how policy is made, and learning about the relationship between policy and research and global health implementation—how complex that is but also how interesting it is to maneuver between these relationships—that was a takeaway for my role. I think that being just a dental student there, seeing all this, seems quite daunting. But I actually feel great seeing and learning this at such a young stage in my career. I think that this internship gave me more confidence to want to tackle this complex relationship rather than run away from it in the future.

Advice number one would be: Do not be afraid to go for these kinds of roles. Many of them will have scary-sounding applications. They will say that they’re very selective, but if you don’t apply for them, you will never know if you could have done that or not. I’ve had friends do internships at the World Health Organization in Geneva or intern at the White House or intern at NASA—all these really cool experiences—just because they asked and applied.

Advice number two, the follow-up, would be: Don’t apply blindly. When you’re applying for something that’s this competitive, think of ways to make yourself stand out by reaching out to the people running these application services or to the people who run these programs or have done these programs so you can speak more intelligently about what you’re getting yourself into.

Advice number three would be: When you’re seeking experiences to be had, think broadly. As a dental student, if I had thought, “I’m just going to do dental research in a lab,” or, “I’m just going to work as an assistant in a dental clinic for a whole summer,” that would have been very instructive, but I think it would not have been as mind-broadening as my experience was. Regardless of what field you’re in, you can think of ways to broaden your understanding of the field. For me, it was through seeing how global health policy worked in dentistry. I think the possibilities are pretty endless.

The ultimate vision would be to have everyone in Latin America have better oral health. That could mean a variety of things, whether it means they can easily get to the health care that they need affordably, within reach, whenever they need it. That’s number one. Number two, the vision is to work so that people understand the importance of oral health, not only policymakers, who need to be supporting these policies for these things to happen, but also every individual man—whether it’s a farmer in rural Peru or a schoolteacher in urban Lima—so that they can teach the importance of oral health to future generations. A lot of things can be done to get there. The proposal that I had worked on, which I really believe, is a feasible way to quickly increase the number of people who are providing this basic oral health care. Anyone can provide fluoride varnishes, and it’s been shown to be very effective at reducing cavities in children. Simply teaching people who aren’t dentists to do this for children in schools, I think, would be a huge step toward reducing childhood cavities.

In high school, I was inspired by this account of the adventures of Paul Farmer. The book I had read for that was called Mountains Beyond Mountains. That’s a great book. If you don’t have time to read the whole thing, definitely read the first chapter or so. Later on, I became very interested in social histories, psychology, and economics just to feel or try to understand why the world operates the way it does and what drives people, individuals, societies, and communities.

One book that I’ve recently read that was really great was called Poor Economics. This book explains why poor people or people in poor nations often behave in seemingly irrational and predictable ways. For instance, why is it that if you give people who live on less than a dollar a day extra 50 cents, they immediately spend it instead of save toward something better? The book, by using case studies, mini-experiments, and economic theories, explains in very simple language why people make these decisions that actually are rational once you think about it in a different way. It also talks about how, given this understanding, we can tackle poverty. That was something I really enjoyed.

Beyond that, I recommend reading the Washington Post because everyone should try to read one newspaper article a day just to be on top of what’s going on in the world.

I really like to read. Lately, I’ve been reading a lot of this nonfiction stuff, but whenever I’m on break, I tend to binge-read detective mystery novels, especially Sherlock Holmes. Actually, right before this interview, I went to the Harvard bookstore, and I bought two Sherlock Holmes books. I own more than 40 Sherlock Holmes books—the entire canon in two different versions in three different languages—and books that are outside the official canon written by other authors but still revolving around the Sherlock Holmes–John Watson mystery stories. I love reading detective stories because it’s like solving a puzzle, and it’s about having this belief that there is a solution out there. If you just think hard enough or figure out ways to test your hypothesis, then you can attain the solution, and the world will be back in order at the end of the day. I like doing that. Similarly, I like watching TV shows, procedurals, for that reason.

I love making origami, especially modular origami, which is the kind of paper folding where you fold maybe thirty to a hundred of the same pieces, piece them together like a puzzle, and then create something really breathtaking. You would never think that all I did was fold thirty simple things and putting them together. I love swimming. I like blogging. The list goes on and on.

Regarding my career, the biggest thing that drives me is that I believe everyone should use their abilities and circumstances to effect the greatest positive change in the world as possible. In the past, I used to think that medicine was the only way; that was what made me so bent on pursuing surgery. As I went to college and spoke with different people with different passions, whether it’s in the arts or even finance, I realized that the most legitimate way I can generalize this value is just that anyone should not squander the opportunities they have been given and to use it to make someone else’s life better even if it’s in a small way. But the larger the way, the better.

On a personal perspective, I believe in not judging people for what they do. A lot of arguments I get into with my parents or with my friends—these philosophical debates of what is right and what is wrong—involve my belief that people exist within their own sphere of reality and that they make decisions that, at that time, make sense and are logical to them. I think this is really important in not judging a friend’s choice to pursue a career or a relationship, but it’s also important when we make greater generalizations about groups of people. I think we see a lot of that going on in the political arena, where we say, “Half this country are takers, and the other half are the hard workers, “ or, “Some people just want to not work and suck money from the government,” or arguments that can be generalized made for undocumented immigrants, for instance. I think that the best way, the most just way, to approach these issues is to have faith that people make decisions that are logical from that perspective and not to assume that people don’t make sense.