The Global Children’s Oral Health and Nutrition Program: Students Learn by Doing Good

Every year since 2010, Dr. Karen Sokal-Gutierrez, Dr. Susan Ivey, and a group of students have taken toothbrushes, toothpaste, and a big pink and white model of teeth to Latin America, and since 2011, Asia. There, they teach communities about nutrition and oral health. The Global Children’s Oral Health and Nutrition Program was created to stem the epidemic rise in tooth decay in developing countries around the world. Sokal-Gutierrez is an associate clinical professor and Ivey an associate adjunct professor in the UC Berkeley School of Public Health. Both teach in the UC Berkeley-UCSF Joint Medical Program.
The program began in El Salvador in 2003, where Sokal-Gutierrez noticed a trend in tooth decay of children up to six years old. Since then, the program has expanded to Nepal, India, Vietnam, Ecuador, and Peru. Sokal-Gutierrez and Ivey estimate that the program has served about 10,000 children and their parents since its inception. But the Children’s Oral Health and Nutrition Program has also made another big impact, this time on the UC Berkeley campus: bringing transformative experiences to students launching their careers in public health, medicine, and dentistry.
“How can we do our best to improve the health of children, and how can we do our best to mentor the students and give them this good hands-on opportunity?” asks Sokal-Gutierrez. “I’m always trying to pay attention to both of those things.”
In the decade since it began, nearly 200 volunteers have participated in the program. Most are UC Berkeley undergraduates who plan to pursue careers in public health, medicine, and dentistry. They also include graduate students and professionals from the fields of medicine, dentistry, and public health. Additionally, Sokal-Gutierrez and Ivey often seek out students whose families emigrated from countries where this program might be needed. It offers a chance for students to connect abstract concepts to real-world scenarios, take on positions of leadership, and be mentors in medicine and public health.
A lecture in Wheeler Hall leads to India

Priyanka Athavale conducts a dental check-up

Priyanka Athavale conducts a dental check-up on a child in India.

When Priyanka Athavale first attended a lecture by Sokal-Gutierrez as a sophomore at Berkeley, she didn’t realize the class would change her life. Along with more than 500 other undergrads, Athavale was taking Public Health 116: Social, Political, and Ethical Issues in Health and Medicine, a two-unit, pass/no-pass class in Wheeler Auditorium. The topic that day was nutrition, and Sokal-Gutierrez was visiting to tell students about the Children’s Oral Health and Nutrition Program.
“I’m not the kind of person who will e-mail professors after a guest lecture,” Athavale says, “but her lecture was really inspiring.”
Athavale began volunteering with the Children’s Oral Health and Nutrition Program, and soon joined the Hasilo (“smiley” in Nepali) Nepal team during her winter break. It would be her first foray in public health outside the classroom. In the rural Nepalese countryside, Athavale taught kids and their parents how to properly brush their teeth; created nutrition profiles recording their height, weight, and how many cavities they had; and applied fluoride varnish to kids’ mouths.
“It’s like nail polish for your teeth,” Athavale says. “They never do it there, and it’s even shown to cut tooth decay by fifty percent.”
Athavale says that the experience opened her eyes to public health. Where they worked in Nepal, nearly 40 percent of children were moderately or severely malnourished and 67 percent had mostly untreated tooth decay. She realized that the same things happening in Nepal were happening all over the world. Over the last several decades, countries in Asia and Latin America have experienced a “nutrition transition” as Western junk food and soft drink manufacturers expanded into new markets, creating a shift from traditional diets to heavily processed foods. In countries like Nepal, the growth of junk food has outpaced advances in dental care. The same thing is happening in many other parts of the world, and the evidence lies in the growing number of cavities in children’s mouths.
Though she grew up in the United States, Athavale was born in Mumbai, India. After returning from Nepal, she realized she’d seen the same problems in her home country while visiting family. She proposed to Sokal-Gutierrez that they take the program to Mumbai, this time focusing on residents of India’s urban slums. Sokal-Gutierrez accepted, and suddenly Athavale, a college sophomore at the time, found herself directing India Smiles, an international health program.
She now found herself writing research proposals, designing surveys, and coordinating collaborations with non-governmental organizations (NGOs) abroad. In India, she set up health camps and made PowerPoint presentations to train local health workers. There were big challenges—like locating NGOs from another country—and little ones, like figuring out how to make double-sided copies in India. In all, she managed 14 volunteers from Berkeley and coordinated with three NGOs. The program provided services and collected data on 470 children and their mothers.
“It’s easy to be organized when you’re here at Berkeley,” Athavale says. But working in India taught her to be committed and organized under more difficult circumstances. She credits much of her success to Sokal-Gutierrez and the leadership she provided.
“She wants us to develop those skills and she wants us to hit road blocks and then overcome them,” says Athavale.
Since volunteering with the Children’s Oral Health and Nutrition Program, Athavale has declared as a public health major at Berkeley. She’s currently a senior and, after graduating, plans to attend medical school and continue working in the field of global health as a physician. In the meantime, she is staying involved with the project and teaching other undergraduates what she has learned.
A trip to Ecuador provides unexpected expertise

It’s easy to notice the number of childhood cavities in Sokal-Gutierrez’s photos. They show kids under seven years old with rows of blackened, decayed teeth. But in these same communities, there’s a less obvious side effect of eating too much junk food and soda: malnutrition and obesity. Preventing these health problems is the other big priority of the Children’s Oral Health and Nutrition Program.

Ana Levin with a group of children

Ana Levin with a group of children at an educational event in Ecuador

“I got interested in this project because I was interested in child obesity,” says Ana Levin, a graduate medical student in the UC Berkeley-UCSF Joint Medical Program. In the summer of 2013, she went to the Eastern Amazon region in Ecuador as a volunteer with Alli Kiru (“beautiful teeth” in Kichwa), the Children’s Oral Health and Nutrition Program in Ecuador. Levin, who is from Southern California, has family from Mexico and is fluent in Spanish. Working with kids and their parents in Ecuador was a natural fit, she says.
In the indigenous communities Levin visited, 88 percent of young children had untreated tooth decay. Nearly half experienced mouth pain while eating, which prevented them from eating healthy foods. Over one third suffered from malnutrition. According to Sokal-Gutierrez, drawing connections between poor oral health and poor nutritional outcomes is a big part of the program.
In Ecuador, Levin assisted with dental exams, weighed and measured children, and gave tooth brushing demonstrations. She interviewed parents about their kids’ oral health and diets.
From working in Ecuador, Levin found her own medical interests changing. Working with parents, caregivers, and health workers was her first exposure to qualitative research. During group discussions with elders, the conversation quickly focused on how western companies have infiltrated local diets with cheap snacks and sugary soda. These conversations caused Levin to refocus her work from youth medicine to maternal health. As one of the few graduate students involved in the program, she also helped the undergraduates from Berkeley.
“That was part of the deal, I would help mentor undergrads who might not be familiar with how the public health and med school process works,” she says. For many undeclared students, the Children’s Oral Health and Nutrition Program is their first exposure to public health fieldwork, one that offers a chance to experience health and medicine.
“I think a lot of young women are interested in knowing how they’ll be able to go to medical school and also get married and have kids. There’s a little bit of panic around that,” Levin says. She also explains that many Latino undergrads are balancing responsibilities of caring for their families and going to school. Working with undergrads in Ecuador provided her with an opportunity to talk through these issues. Like Athavale, Levin credits the success of the Children’s Oral Health and Nutrition Program to Sokal-Gutierrez’s leadership.
“That’s the great thing that she does. All of a sudden, things become your responsibility. She helped us at the beginning and then after a while, we knew more about it than anyone else did,” says Levin.
From sophomore to supervisor of six

The Children’s Oral Health and Nutrition Program operates in each country for three to six years. After that, the programs are transitioned to local community leadership. During those initial years, students and researchers collect large amounts of data about the children, their families, and their communities. The data are analyzed to present back to the communities, tailor the educational interventions to local needs, and track improvements over time. Kimberly My-Linh Ngo is one of a few students making sense of those numbers of children’s height, weight, and cavities.

Kimberly My-Lihn Ngo and volunteer

Kimberly My-Linh Ngo (right) and another volunteer discuss data from the Vietnam Tooth Project.

When Ngo first heard about the Children’s Oral Health and Nutrition Program she was taking a student-led class about health disparities among Asian-Americans. Ngo, who is Vietnamese, was a freshman.
“I thought it would be interesting to get involved in this kind of research,” she says. “It’s something I wanted to give back to my community.”
Over the past year, Ngo has collaborated with Ivey, compiling data from the Vietnam Tooth Project. She compiles and analyzes nutrition data and helps with language translations. In doing so, Ngo has charted frequencies of tooth decay and increased rates of obesity in children. Her work helped develop new questions for field work. After working on the project for a year, Ngo now supervises a team of six other students.
“I’m the kind of person that likes to try to do what I can, myself,” she says, “so I kind of learned to step back a little and let people take on responsibilities.”
Ngo says seeing doctors who are doing community health work has given her a new perspective on how medicine and public health work together.
“Your health is not just because you get sick. There are all these other socio-economic factors,” she explains. Ngo is getting ready for medical school, where she hopes to work in primary care.
Building community health and students leaders

Over the past 10 years, the Children’s Oral Health and Nutrition Program has made big strides. Preliminary data show community-wide improvement in parents’ knowledge and practices regarding nutrition and oral health, and reductions in the prevalence and severity of tooth decay, mouth pain and malnutrition. The El Salvador program was successfully transitioned to the Salvadoran Non-Governmental Organization, Asaprosar, in 2010. The program in Vietnam ended in 2013 and is now being handed off to health workers there. 2014 is the last year for the Ecuador project before locals take over, and there is also one more year for the Nepal project.
But, despite these successful pilot projects, the problems of poor oral health and nutrition are by no means going away. According to Sokal-Gutierrez, these health trends have moved through Latin America and Asia and are now emerging in Africa. In response, this past summer marked the program’s first year operating in Kenya in collaboration with Rotary Club and Kenyan academic, public health, and dental organizations.
In the meantime, while creating sustainable solutions for the communities where they work, the program is helping student volunteers develop skills and career goals.
“I found that the more responsibility I hand over to them, the more they rise to the occasion and they do amazing things,” says Sokal-Gutierrez.
She believes that what the students gain—knowledge of health issues, leadership and organizational skills, and how to work on multidisciplinary teams and in clinical settings—is almost a perfect match to the core educational objectives in public health, medicine, and dentistry. “These dedicated students will go on to become future leaders and mentors in the health fields,” she says.