The oral history of remote Australia

Marc Tennant is a busy man. As well as holding the position of Winthrop Professor at the University of Western Australia’s Faculty of Science, he is the director and founder of the International Research Collaborative – Oral Health and Equity, advising governments not just in this country but around the world on oral-health reform. We at Hames Sharley first crossed paths with him almost two decades ago, while designing the Oral Health Centre of Western Australia, just one of the many projects Professor Tennant and his team have been involved in as they have worked to raise the standard of dental practice in Australia.

But while he is clearly a man with a mission, it’s not a mission he ever planned to take on.

“I’m the first to admit that dentistry wasn’t the most logical choice,” he says. “I left high school without any idea what I wanted to do. My next-door neighbour was actually an academic at the dental school, and just because I had that interaction I became a dentist. I worked for three years or so in a caravan behind a mortuary at a country hospital but at the end of that period I went back to study to do my doctorate in biology – coronary bypasses and the cells in bypasses. Then I ended up mentoring or managing a dental education provider in South Australia!”

At that time, Australian dental education was a small field and shrinking rapidly. Indeed, the future of the entire profession in this country was at risk. “We were training fewer dentists in the late 90s than we were at any time since World War 2, and we had at least two of the five dental schools in Australia considering closure,” he recalls.

After a couple of years working in Adelaide, he returned to Perth to work on the redevelopment of the city’s dental school – eventually to become the state-of-the-art Oral Health Centre of Western Australia – and it was there that his work took an unexpected but decisive turn.

“I got rung up by a medical colleague up in the Kimberley,” he explains. “The conversation was about a difficult dental problem for a patient up there and his last sentence was, ‘What are you going to do about the issue of Aboriginal health in Western Australia?’

“You know how it only takes 30 seconds to change your life; that was my 30 seconds.”

Getting together with some friends who were equally keen to volunteer, he was soon investigating the problem. “The first thing I did was visit some places. I just went to their health services, looked around, talked to people. Then I came home with some ideas about what we could do.”

But the more they investigated, the more the team found the parameters of their new mission shifting.

“We started off with the goal that every Australian have great oral health,” he says. “We came down to simply not wanting to see anyone in pain or with pus, to get the rate of Aboriginal kids being hospitalized for their dental care to be the same as for non-Aboriginal kids. Now for a clinician that’s a horrible thing to have as a goal. The reality of the gap is enormous on the ground – when you’re in a place where one in three of the adults are under some sort of custodial position, where one in three or four will have some sort of diabetic issue by the age of 20…I don’t think many city-dwelling people recognise the level of tragedy that produces.”

Before tackling the problem of attracting dentists to work in remote communities, there was a more basic issue to address: the lack of dentists overall. “Because dental schools were near closing and collapsing, there was a workforce crisis. That influenced pay; dentists could earn a far greater amount in the city and in private practice. I had new graduates on first-day salaries bigger than a senior academic. So, we weren’t going to compete on price.”

The immediate solution may seem obvious to us now, two decades later, but at the time it was extraordinary.

“The plan was literally asking dentists, ‘Give us one week a month.’ Then we brought together all those weeks a month from different people and said, ‘Right, we will fly you there and look after you and keep the continuity,’ and so we had a sequence of personnel who went out and provided care. I was brought up in the period of fly-in fly-out mining and so there was a model there which literally I stole!”

A point of pride for Professor Tennant was that his team didn’t just roll into town and take over; it was vital that structures and services already in place were respected. “The clinics were embedded in existing Aboriginal health services: they were not our clinics. They were and to this day remain the local people’s clinics. We were ghosts, we just came and supported the network.

“Addressing any type of health problem with Aboriginal people is about community-driven collaborations. The Aboriginal community and culture get the social and human side of healthcare better than any group I have met; our mainstream systems could learn a great deal from this community-driven perspective. I know many government health services in this country where, if you’re 10 minutes late, your appointment is cancelled and there’s a cancellation fee. But what if you don’t own a watch, a car or have no access to a phone? Or you speak English as your third, fourth or fifth language, there’s no point in writing down a time to come. These are things most of our mainstream tertiary systems have difficulty coming to grips with.”

But tackling these issues required boots on the ground, meaning the problem also had to be addressed from another angle: the strain on the supply of dentists themselves.

“It was many times more expensive to train a dentist than a doctor,” he says. “Today – I’ll make a guess – to train a dental student is something like a half a million dollars each. Dental education systems in those days could not sustain the cost of training, and with the five dental schools we had being in the middle of major cities, that didn’t help poorer community involvement either.”

Again, twenty years on, the solution seems to be common-sense. “We put students out on placement. Today, placements are all the thing in every discipline, but in those days dental schools were like castles: everyone went in, the drawbridge was raised, and five years later they came out.

“Dental students in their senior years provide end-point care, under strict supervision, so where you have a school, you have a service. With those out-placements, you could build satellite clinics in places of need and so bring the service to the location.”

Out-placements were also economical. “All of a sudden, dental schools were a reality for many universities who had just looked at them and said, ‘Well, we can’t afford half a million each.’ We went from five dental schools in the core cities to adding four or five more in regional rural and remote Australia. We doubled the number of dental schools and doubled the output.”

This, too, had a knock-on effect. “If you take a person who has lived in rural and remote areas, they are about three times more likely to go back and practise in those areas. We now have more people going back into rural and regional practice than ever before, and we have more Aboriginal and Torres Strait Islanders training than in the cumulative history of dental education in this country. It’s not a big number, but it’s a start.”

The foundations laid by Professor Tennant and his colleagues have not only been proven to affect positive change in Australian communities, they’ve also been adopted in other countries where the standards of care are limited by distance and poverty. While he is now heavily involved in rolling out these international projects, however, the professor is still committed to his work in this country.

“We should all be working on this every single day of our lives,” he says. “When a doctor or nurse from remote Australia rings up for advice, we shouldn’t take it as an annoyance. They are 1000 kilometres from help! There are many good things to do in the world, many problems to solve. Don’t just stand back; do more.”

After so many years of striving to improve lives, some might succumb to compassion fatigue. But if there’s one thing you take away from talking to Professor Tennant, it’s his undeniable sense of hope for the future and those who will steer our communities onward.

“I have great positivity about our world. I see a level of social justice that is in-built into the upcoming generation; it’s natural for them to have social justice and social care, and believe in society. We must give some space to this intellectual next generation…it’s a different world. It’s great, and I look forward to it.

Professor Tennant was speaking to us to coincide with National Reconciliation Week, which begins 27 May and promotes better understanding and respect between Indigenous and non-Indigenous Australians. To learn more about Professor Tennant and his work visit the International Research Collaborative – Oral Health and Equity website.

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