Dental Aid Network planned their third trip to Kashmir in October 2017. The team consisted of Dr Khurrum Shafiq, Dr Abdulwahab Aslam-Pervez, Dr Imran Shafiq, Dr Amer Mobarik, from Glasgow and Dr Zohaib Khan and myself (Imran Asghar) from Greater Manchester.
Many months were spent planning and organising. We assumed, as it was our third trip, that it would be somewhat easier, however this was our most difficult yet successful and rewarding trip.
Myself and Zohaib were planning to fly from Manchester and would meet the rest of the team in Pakistan. The flight had been in the air for approximately three hours when a medical emergency occurred. A passenger suffered a cardiac arrest and the pilot had to make an emergency landing in Greece. Above the sea he had to dispel most of the fuel before landing, as I believe landing with a tank full of fuel is dangerous. Seeing this was really a sight for sore eyes. Once the enormous Airbus A380 had landed, emergency crews came on board to take the patient away. The plane had to then undergo a security check and refuel. Finally, we were ready to take off and on the runway when suddenly the lights were switched back on and the roar of the engines faded away. To our shock, we were told there had been a second passenger who had suffered a cardiac arrest! This caused a huge delay for us, as we had missed our connection flight and arrived a day late.
Zohaib and I arrived at the hotel in Kashmir on 4.30am on Sunday 8th October whilst the rest of the team were sound asleep, exhausted. Fortunately, we had kept in touch with the rest of team and changed our concise plans accordingly over phone, so we all knew what the plan was for the upcoming day.
Sunday 8th October
The team finally met at breakfast at 8am and for some this was the first time we had met in person. The team was split into two. Four had planned to visit the Kashmir Orphans Relief Trust (KORT) to screen the children. We have been working with this orphanage for the past two years and were our main facilitators. Two dentists and helpers from KORT visited the dental wing of the local hospital which we have used previously. The hospital team cleaned all three surgeries, prepared our instruments and equipment including setting up the sharps boxes, local anaesthetic and restorative materials which we had bought from the UK. The team of four at KORT examined/screened all children new and old. We then listed the children who needed to attend the clinics for treatment in the coming days. Our main priority was pain but we did have many cases of hypoplastic anterior teeth, fractured upper incisors and periodontal issues which the children were concerned by. All were given oral hygiene, brushing and diet advice along with toothpastes. In addition, we applied topical fluoride varnish on all the children.
As this was our third year visiting the orphanage, we had individual record cards for all the children we had previously seen, so we could analyse what had been previously done and if any treatment had been left from the previous years.
It was pleasing to see the children that had been previously seen, required zero or minimal treatment as they had been following our dental advice. They were very keen to show us their teeth and how “white” they were. As the orphanage had taken many more children from our last visit, it was these children that we had identified as needing dental treatment. We were told these children had come from remote areas and villages affected by natural disasters. KORT had initially started just over ten years ago when the devastating earthquake hit Kashmir in 2005 resulting in hundreds of thousands losing their lives and resulting in an uncountable number of orphans.
Monday 9th October
After five hours of sleep, we travelled to a remote area of Kashmir called Bhimber, which was just over two hours away from the main area of Mirpur in which our hotel was situated. Here a UK citizen from London had donated his family’s land to build a small hospital for the community and help those much less fortunate. We visited this hospital in 2016 to assess if we could set up camp. We had a few meetings in the UK to plan this day.
A month prior to our arrival, banners and announcements were made to inform the local community and neighbouring villages of our arrival. We had no idea of how many patients would turn up. It was astonishing to see that women and children from as far as the Indian-Pakistan border, had been arriving by public transport and by foot!
We were told it was common for young mothers to die at child birth in this area due to the lack of medical facilities and professionals and if anyone had any medical or dental problems they would suffer in silence. The DAN team was the first dental camp of its kind in this area. As there was no formal dental set up, the only services we could offer were extractions, examinations and dental advice.
We spent just over an hour to set up our treatment rooms, delegate duties, arrange the waiting area, create a workflow and create a system to everyone would adhere. In addition, the trustees of the local hospital were there to give us a helping hand if needed.
We trained three of the hospital staff in giving tooth brushing and diet advice through the use of models and pictures and the patients started arriving. Every patient who arrived went through a detailed session on how to brush teeth/gums and learned how diet affects their dentition, which was then reinforced in the treatment rooms.
Unfortunately our portable autoclave stopped functioning early on in the day. This meant we could not sterilise the instruments once used, which made things a lot more difficult. Thankfully we had a large number of donated extraction forceps, luxators and elevators from dental colleagues.
Many of the patients who attended wanted to be given medicine to alleviate their dental problems and disease rather than having their offending tooth removed. A lot of time was spent with our rudimentary Urdu and with the help of the local pharmacist to help explain the dangers of taking antibiotics as we do in the UK. Furthermore, advice was given in regard to periodontal disease, orthodontic related issues, cleaning fixed and removable prostheses, effects of diabetes on dentition and smoking effects on the mouth including oral cancer advice.
The last patient of the day became a difficult extraction case. A young lady’s lower right second molar with slight cured roots became problematic in its removal. All six dentists had an attempt at removing these roots with no success. The main reason for this was that we only had a few instruments left, but they were not the ideal ones we needed. We required a small elevator or luxator but all of them had been used. The anaesthetic started to wear off so made the decision to abandon the treatment and dispense painkillers with antibiotics to the patient. We explained to the patient the exact problem we encountered and that we had made arrangements on the following day for her to be seen by a private dentist and have the roots removed without the patient having to pay for treatment or travel.
Later that evening we were invited to KORT’s annual remembrance event. The children put on a spectacular event with poems, songs, articulate speeches in English and Urdu and saddening plays of how the catastrophic the earthquake in 2005 had affected them in losing their parents and loved ones. However, they also informed us of how the founder of this amazing charity/mission and the staff and this orphanage gave them light at the end of the tunnel and a brighter future. They now had a new home and family.
Tuesday 10th October
The whole morning was spent treating all the young boys from the orphanage that we had screened on Sunday. We found that some treatment plans had to change, for example restorations to extractions if and when caries had reached the pulp. We had essential chair side help from the older children, who have been training with the DAN teams since 2015. This help involved suctioning, bringing the children in, calming very anxious children, mixing materials and giving post extraction instructions.
During the morning session, two colleagues visited Zobia school for special children. This was a small school which catered for children with special needs and disabilities. Our dentists were able to screen all the children with the help of the staff and note down those who needed treatment. The dentists were welcomed with flowers and cards from the children. The team also gave toothbrushes and pastes to all the children and carried out simple oral hygiene advice with the help of the staff and demonstration models.
After lunch, we visited and screened all the children at the AKAAB school for the blind which was based just outside the town of Mirpur. This educational facility was headed by a blind professor of English and comprised of children from the ages of six to twenty-two. Again, this establishment was mainly run on private donations from across Pakistan and the UK. We were given a tour of the whole facility from the deputy head teacher who himself was blind. He passionately showed us the well thought out and designed building specifically catered for blind children. We saw how the children learned braille and how to read it in Urdu and English. They had various classes from History, Music and Maths etc. It was astonishing to see how these children with their staff had achieved so much in academia but also entering sports, music and talent events throughout Pakistan and Kashmir!
The team paired up and visited each classroom as lessons were being conducted. With a simple head light, disposable mirror and probe and not forgetting our gloves we examined each child and noted those with dental disease. We listed each child with disease for treatment at the local hospital.
We were surprised to note that not as many from the hundred plus children needed treatment in contrast to what we had expected. We had assumed this cohort of children would have had the most dental disease but as we found out this was not the case. After the screening, we sat with the head of the institute who gave us his history and discussed his passion to build such a place which was the only one of its kind in the whole area. We were told that before a school like this most children who were born blind, had no future right from the very start, and at best some would be shoe cleaners or bread mixers and the rest would mostly be forced into begging on the streets unless they were born into a wealthy family. However due to this school, past children had gone onto become teachers, work in banking and finance and government jobs. The effect the staff and school had on these children was amazing and humbling to see.
We were then invited to take a tour of the local privately funded kidney dialysis centre, which was situated in the same hospital we were undertaking our dental work. The tour was given by a local private dentist who has aided our charity missions each year and has given us immense help and sacrificed a lot of his time. He had been involved with this dialysis centre for many years, raising awareness of the work that was being undertaken and how it was affecting so many lives. We had the chance to speak to patients who were undergoing treatment. Patients informed us that without such a service their lives would have ended many years ago. I spoke especially to one young man, who explained he was the only breadwinner for his family and without him, the family would and could be forced to beg on the streets.
This free service was segregated between Hepatitis positive and negative patients to prevent cross contamination. Again, we acknowledged that most of the funding was from private donations mainly from the UK with the government providing the only hospital itself. We spoke with the only specialist nephrologist in the entire city, a very valuable person indeed.
In the evening without any break we held a CPD event at the hotel. This was done with the help of our local dentist, the orphanage and friends of the charity who had helped us for the past two years. Lecture topics included oral cancer, hepatitis, orthodontics, trauma and introduction to the hall crown technique.
Wednesday 11th October
The whole morning involved screening children from the Kashmir Institute of Special Education (KISE) which educated children who were deaf and who could not speak. A few of the children who we had seen in the previous year remembered who we were and as soon as we arrived they gave us big smiles showing us their teeth and indicated brushing their teeth with their fingers. Again, we paired up and saw each child of the school and created a list of those we wanted to see at the dental clinic. We also took this opportunity to hand out tooth brushes, tooth pastes and toys to all the children. We also saw the amazing work the students and staff had been doing including the extracurricular activities the children had been involved with, especially with their art work.
The afternoon was spent treating all girls from the KORT orphanage with the help of the older children.
As we had finished on time for once, we took this opportunity to visit Dr. Tahir’s private dental clinic which was in walking distance from the hospital. It was pleasing to see a clinic where the team was caring, patient focused and how they took decontamination, single use policy and prevention of disease very seriously. The evening was spent at the KORT orphanage, handing out toys to the all the children which we had bought over from the UK. It was great to spend time with new and old faces but also to understand what these children had been through and what their lives could possibly be if it was not for this school and one person’s dream.
Thursday 12th October
This was a very busy day undertaking treatment on children who were blind, deaf and those who were wheelchair bound coupled with other disabilities. We had staff members from each school, assisting us in treating the children. All rooms including our stock room were used to carry out treatment. One colleague became a treatment coordinator and delegated treatments to each dentist which made the workflow easier. He also made sure our used instruments were being collected and sterilised and ready for use when needed. The day started at 8.30am and finished approximately 5.30pm with a short lunch break. Lunch was kindly delivered to us at the hospital to save time. The team was under pressure as these children could only come for treatment on this day, and there was no room for them to come back again for further treatment, so the aim was to get everyone disease free by the end of the day. We also took each treatment opportunity to reinforce tooth brushing advice coupled with diet advice.
Later that evening we were invited to a boating club and experienced high-speed boating on the famous Mangla dam. This was followed by tea and food with professionals from the community and the evening ended with our team individually going through personal feedback and thoughts of the mission; specifically, what improvements we could make for future trips and our own personal learning experiences from the trip. For some this was the first time they had ever done something like this and found it life changing.
Friday 13th October
The morning session was used to undertake treatment on all remaining older boys from the orphanage. We surprisingly successfully completed all treatment on all children we had seen from all four institutes. We noted that many of the had anterior incisors fractures through falls, running and cricket.
We gained a couple of hours to take stock of our remaining material and equipment. An inventory was made of all our stock and was stored in a secure location in Kashmir to be used for following aid trips.
I can truly say by the end of the week the whole team were extremely worn out and exhausted with no energy to pack our bags for the return trip!
We had successfully completed all our action plans and the trip was a huge improvement from the previous two years. Even though we were heavily delayed we managed to surpass what we had done in the past and the famous lines of Hannibal from the A team, “I love it when a plan comes together,” comes to mind.
We would like to thank all those involved from the UK to Kashmir especially to those who donated their time, money and efforts, namely Septodont for their safety plus syringes, KORT for always looking after us and making this possible each year, the children of KORT, local dentists and the people of Kashmir.
We hopefully plan to go again in November 2018.
Total number of patients assessed/examined 640
Total number of patients treated in the clinics 255
Total number of extractions 141
Total number of direct restorations 60
Total number of scaling undertaken 9
From Imran Asghar, GDP
Deeplish Dental Practice, Rochdale