Introduction

February 2017. The world is recoiling from a political rollercoaster that left us all dazed and confused. Brexit. Trump. Farage. May. Assad. ISIS. This global game of chess enters a new phase of unpredictability while the rest of us pawns hold our breath. February 2017. Sixteen thousand, seven hundred and sixty-five more refugees have arrived on the shores of Greece by sea alone since the turn of the New Year.1 More will arrive tomorrow and tomorrow and tomorrow. Since the abrupt closure of 'The Jungle' camp in Calais, Refugee Crisis Foundation (RCF), a voluntary organisation that delivers crucial aid to refugees, have moved their operations to Athens where they've partnered with a number of non-governmental organisations (NGOs) to deliver targeted healthcare and welfare aid to communities in need. Crucially they are sending multi-skilled teams out monthly to give regular aid to vulnerable groups of refugees. A group of eight volunteers, including a dentist, pharmacist and dental students from King's College London and Barts and the London School of Medicine and Dentistry, visited the refugees in Athens in February 2017.

Athens

Dental clinic at the Khora Community Centre

Our first port of call was the Khora Community Centre in central Athens. This humanitarian cooperative foundation focuses on the holistic provision of services for refugees, providing language classes, healthcare facilities, legal services, food, art and music workshops, and sports classes. The centre caters for hundreds of refugees per day and is run on the hope, compassion and hard work of its volunteers and donors from around the globe.

After a brief induction to the dental clinic, the paperwork and the rules and regulations we were ready to go. The dental clinic has only one chair but is fortunately well-equipped relying on stock donated by dentists and dental companies the world over.

The clinic had been booked out all day to see children from the Skaramagas camp located on the coast just outside of Athens. The children had presented with emergency dental pain to British Red Cross at the camp who had triaged them before Organization Earth had kindly driven these children and their parents from the camp to Khora to be seen at the dental clinic. It was a real team effort, prioritising the care of the refugees above all else.

'Thumbs up or thumbs down' was the nature of communication with most of our paediatric patients. You would be surprised at how far sign language can take you when attempting to review treatment as well as diagnose patients. However, with a fluent Farsi speaker on the team, the barrier in communication quickly resolved with Farsi speaking patients (Fig. 1). By speaking to the refugees in their language there was an immediately elevated sense of comfort and trust from both the patients and their parents. Anxiety levels actively dropped and coupled with a friendly face and open body language rapport quickly developed. What seemed like an emergency appointment with the dentist turned into the refugees opening up to us and sharing their troubles and their optimism for a brighter and stable future.

Figure 1
figure 1

Khaleda Zaheer, a dental student speaking in Farsi to a nervous paediatric patient

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Most memorable was when an Afghan couple attended with their two daughters, aged three and six. The six-year-old girl was understandably extremely anxious as she had never seen a dentist before and required five restorations. We did not have the luxury of time and hence the process of desensitising the patient to the environment and dental team had to be considerably sped up – a non-invasive first appointment was not an option. Therefore, we heavily relied on 'tell-show-do' by demonstrating the slow handpiece on the fingernail of the patient, counting up to ten in Farsi multiple times, with constant positive reinforcement and holding the patient's hand. Five glass ionomer cement restorations later, our patient was relieved to skip off the dental chair and show off her new teeth – just as long as the burs were out of reach... After the treatment the children's father shared his story of making the tortuous journey to the West with his family because of the constant death threats he received in Afghanistan in hope of a better future – not for him, but for his girls. We looked around to see the two little girls playfully teasing each other in all their innocence and hoped that one day these brave parents may see the life they dreamt for their daughters come to fruition.

With such little access to oral hygiene aids and every changing circumstance it is unsurprising that all patients presented with grossly carious teeth and poor oral hygiene. A quick discussion about their diet revealed that chai (tea) consumption was extremely high with copious amounts of sugar added (with some regularly reporting up to seven teaspoons of sugar in one cup). As a result, we focused heavily upon prevention by delivering chairside oral health information and diet advice, and applying topical fluoride varnish where appropriate.

As we were wrapping up for the day, we saw a group of adults that had presented with emergency pain waiting outside the clinic for more than three hours hoping to be seen. While we were able to see some on the day, we couldn't attend to them all as we were limited by a single chair and had to book them for the next available appointment – more than two weeks away. Further supplies, although graciously donated, were limited and it was a constant challenge to sterilise reusable instruments and burs in-between the patients.

Oral hygiene workshop at the Skaramagas Camp

Globally, the high burden of oral disease is attributable to several factors but within this population, lack of access to oral healthcare, poor oral hygiene and a cariogenic diet explains the disease pattern. The FDI World Dental Federation vision for 2020 shifts the traditional curative approach to addressing oral health problems to focusing on prevention and promoting good oral health.2 In line with this vision, we designed the 'Healthy Smiles' programme, an oral hygiene education and dietary advice workshop to deliver to children in the Skaramagas camp. Our aim was to improve the oral health literacy of this population. In collaboration with Organization Earth, the workshops were to be delivered to children aged between 5-17 years old in four separate schools within the camp: Hope School, The British Council School, International Rescue Committee and Save the Children.

The Skaramagas refugee camp is home to over 3,500 refugees of Syrian, Kurdish, Iraqi and Afghan origin. Disturbingly, half of them are children, of which 200 are unaccompanied minors. The camp itself is government controlled with very strict access in and out to not only refugees but NGOs and charities alike. On entering the camp, passing through tall fences and stubborn security, we were shocked at how clean, organised and well-maintained the camp was. Being used to the chaos of 'The Jungle' at Calais, we were not expecting anything of the sort. Containers were converted into schools and houses, with two families per trailer sharing a toilet. A donated astro-turf football pitch and a children's playground sat in the middle of the camp. They even have their own football team, Hope Refugee United, with a busy fixture list. Several NGOs and charities had their own containers and serve three meals a day to the refugees. Despite the infrastructure and number of charities working on the ground the refugees here are desperately in need of further help and are still stuck in relatively poor and desperate conditions.

The workshops ran simultaneously throughout the day in separate schools and trailers, each one led by a pair of volunteers including at least one dental student. Each pair had their own method of delivery and tailored the information depending on the age group and previous knowledge of the camp. The majority of the classes consisted of children from mixed ethnic backgrounds and therefore were run in multiple languages. The younger children were very difficult to control as they were extremely excited by the freebies as well as the models that we used for teaching. However, knowing that children can only be attentive for a short period the sessions were made very interactive and engaging.

We started the workshop by introducing ourselves with the help of the interpreter translating into the three commonly spoken languages: Arabic, Kurdish and Farsi. We asked the children what their favourite foods were and how many sweets and how much sugar they consumed in a day (Fig. 2). This gave us insight into their diet allowing us to tailor the advice to be delivered, which included reducing the frequency and amount of sugary food and drinks. Using a large mouth model and toothbrush, we asked the children to show us how they brush their teeth. Then we demonstrated brushing techniques and taught the children how many times they should brush in a day and for how many minutes. It came as a huge surprise to the teachers, interpreters and children alike when we taught them to spit and not rinse after brushing! An oral hygiene pack, an activity book and crayons were given to each of the children as well as a leaflet reinforcing the oral hygiene instructions, dietary advice and tobacco cessation advice translated into the three languages.

Figure 2
figure 2

Zain Rizvi (on the right hand side), undergraduate dental student, engaging with children at the workshop with the help of a volunteer, Saleh Zaheer

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Contrastingly, an hour-long session to a class of 17-year-olds had a different energy where the teenagers contributed heavily to the discussions. With a mature group with previous knowledge, the first step was to encourage open discussion, ascertain what they knew and to get them comfortable talking before dispelling any myths or inaccuracies. In this way the class were afforded the respect they deserved and maintained enthusiasm for an admittedly otherwise dull subject matter. Furthermore by allowing regular intervals for open discussion the students were able to answer each other's questions and as a collective maintain their curiosity and enthusiasm. The high level of discussion and inquisitive nature of all of these students was far beyond what we were expecting and frankly rivalled most university seminars we have participated in. However, this seminar styled open discussion surfaced the reality facing these bright individuals. These young adults were not always in the unfortunate position they find themselves in now. They are old enough to remember a stable life back home, wherever that may be, before the very Earth changed around them; a life that promised them untold possibilities for their futures, for their families and for their communities. They are all students, only a few years younger than ourselves, who have had their dreams ripped from underneath them, who have had the fires of their youth extinguished and all this through circumstances entirely not of their own making. They have, for the most part, lost their very way of life yet refuse to lose hope that their futures will not be left unfulfilled. And like the Lost Generation they find themselves disaffected by the very establishment that was meant to protect them.

A new perspective

We arrived in Athens with the mission of helping to address the pressing need for dental treatment and followed a preventative model to improve the oral health literacy of displaced migrants. We hope that we have carried out some good work and helped those who desperately need it. However, being already used to delivering aid in refugee camps we did not expect to leave with such an impression made on us by the people we met. The future seems bleak for these people who were no different to us before war and poverty snatched the livelihoods they had built so tenderly for themselves and their families, leaving us with not only these reflections but crucially the responsibility to advocate on behalf of them for constructive solutions to meet the increasing needs of refugees. If you would like to get involved then please do email info@refugeecrisisfoundation.com to find out how.