My father-in-law David is a dentist and he recently emailed me an astonishing, must-watch video, "The Dentist of Jaipur." A short documentary by Falk Peplinski that made the rounds of film festivals in 2006 and 2007, the four-minute film shows two men in this famed city in Rajasthan, India practicing dentistry on the streets.
The short, jaunty film begins with the opening of a rusty toolbox containing a stained and well-used toothbrush, tweezers and assorted metal implements. Ungloved hands unload and carefully lay out tools trade on a red blanket - medicinal bottles, dentures, mouth mirrors, pliers, a spoon. One man deftly pulls the cap off of a syringe, and rubs his fingers down the needle. Those cursed, fat flies that are omnipresent in India flit through the video resting on dentures and dental molds.
A street dentist in Bangalore with sets of individual teeth and dentures in 2006. Image: Matthew Logelin, Creative Commons. You can see more of Mr. Logelin's work at his Flickr account here.
Pushkar and Pyara Singh, otherwise known as Doc-Junior and Doc-Senior, practice their trade on a sidewalk near a pretty fuchsia bougainvillea bush outside an unidentified train station, close to a stash of rickshaws awaiting customers disgorged from the busy station. Pyara Singh earnestly tells the camera, "The only difference between the rich doctors and us is that they have fancy chairs, fan, servants, x-ray and other gadgets. They take a lot of money. Normal people can't afford that."
In the film, the duo mix methyl methcrylate paste, repair and install dentures, file teeth, inject who-knows-what substances and "practice dentistry" to their best ability without gloves, face masks, autoclaves to sterilize equipment and tools, or any proper sterile technique or infection control practices out on the open street. In one viscerally tough scene, the men inject a watery rose-colored liquid into a middle-aged woman's mouth then use pliers to wrench a tooth that's promptly discarded for the flies on the sidewalk. The scene made me squeal in terror so, for the faint of heart, know that the scene starts at 2:52 and lasts until 3:12.
For those that aren't familiar with the kaleidoscopic charms of India, one of the most fascinating aspects of the country is its massive street economy. You can find anything you want on the sidewalks of this country, whether it's fried delicacies, tattoos, freshly pressed fruit juices, sex or bus tickets, you just need to know where to look. I lived in India for nine sublime months in 2007 and 2008, mainly in Mumbai and Kolkata with extensive traveling in between. I saw an enormous amount of this massive country - Rajasthan, Maharashtra, Goa, Karnataka, Kerala, Tamil Nadu, West Bengal, Uttar Pradesh - traveling alone on trains and buses and rickshaws and I fell deeply in love. I definitely partook in the street economy - fried food, hot chai, juice. If you can name it, I probably ate it on a street in India. Though I never saw any instances of street dentistry, barbers shaving patient men on sidewalks were a commonplace sight throughout the many cities and towns I traveled through. And many of the friends I made on my travels received haircuts and shaves from these street barbers.
In one of my more vivid memories, I saw a young man in Kolkata that was setting up a blanket and carefully laying out tools in preparation for tattooing any willing pedestrians. I remember being absolutely gobsmacked as this man noticed me stalling pedestrian traffic on the sidewalk, my jaw gaping and eyes wonderstruck, and he eagerly beckoned me to get a quick tattoo under the underpass of a bustling intersection where many buses dropped off passengers. For months I had seen hundreds of Indians sporting black and fuzzy tattoos on their inner forearms and hands, typically of the om or aum symbol that is ubiquitous in the country. This sacred syllable was spray-painted on walls, incorporated into restaurant names, depicted as glittery stickers sported on buses and trucks and sported proudly on many Hindus as a poorly drawn tattoo. You may have noticed in the "Dentist of Jaipur" that the Singh duo both sported fuzzy tattoos on their hands.
A roadside barber shaving a customer in Varanasi. Image: R Barraez D´Lucca, Creative Commons. Click to see more of D'Lucca's work.
These types of intimate professions - dentists, barbers and tattoo artists - that practice on the streets and sidewalks of India can play a vital role in the transmission of infections in their clientele. Unsafe, communal practices with razor blades, syringes and any tools that break the skin barrier are tailor-made for the spread of bloodborne infections. These are high-risk procedures conducted in a country with staggeringly high rates of hepatitis B and C, the two most serious bloodborne infections in the hepatitis family (1). Though the Singh dentist duo are obviously fulfilling a need in the community, they're doing it with quack science and medicine. These guys can't possibly deliver good healthcare beyond performing primitive mechanical work. What they're really doing is jeopardizing their clients' health by performing medical procedures with no regard to the spread of possible infections from the environment, themselves and from their own customer's bodies.
A few public health studies conducted in India have found that street barbers in particular are quite adept at spreading bloodborne infections. A 2010 study found that patronage of local barbers in Bangalore was a major risk factor for hepatitis B virus among blood donors; a customer that frequents barbers in this fast-moving technology hub is more than four-times more likely to carry the hepatitis B virus (2). Another study found that visits to roadside barbers was a major risk factor for hepatitis C (3). Getting tattooed in the country is also another predisposing and risky behavior (4).
"Dentist of Jaipur" points out that the dental work by the Singh duo can cost as little as 80 rupees, about $1.50 today. For most people in India that live on less than $2 a day, this is already an expensive transaction so imagine the costs of receiving care from trained professionals with, as the elder Singh puts it, "fancy chairs, fan, servants, x-ray and other gadgets (5)." Though Doc Junior compares the work they do to fixing a bike, these guys aren't replacing a bike's inner tube or aligning its wheels - they're tampering with a temperamental ecosystem of bone and tooth and blood and bacteria. Whatever analogy you try to extend this to, our mouths are not anything like bikes.
The street dentists are clearly fulfilling a much-needed service but that cheap and fast procedure, whether it's a new tooth, tattoo or clean-shaven face, comes a much greater price - gambling with one's long-term health. So, please, reconsider that appointment you made with your local street dentist.
Resources Infections such as hepatitis B and C may be spread at the Hajj, the annual Muslim pilgrimage to Mecca, due to the unygenic practices of street barbers that shave the faithful following the end of their pilgrimage. You can read my article about the phenomenon at Buzz Kill: Blood-Borne Disease Transmission at the Hajj.
There are SO MANY photos of street dentists on Flickr. Go here
to take an Internet nosedive into this niche of street culture. Wikipedia has a nice little article on the phenomenon of street dentists here
. References (1) Abraham P (2012) Viral hepatitis in India. Clin Lab Med.32(2): 159-74 (2) Jagannathan L et al (2010) Risk factors for chronic hepatitis B virus infection among blood donors in Bangalore, India. Transfus Med.20(6): 414-20 (3) Thakral B et al. (2006) Prevalence & significance of hepatitis C virus (HCV) seropositivity in blood donors. Indian J Med Res. 124(4): 431-8 (4) Kumar A et al. (2007) Prevalence & risk factors for hepatitis C virus among pregnant women. Indian J Med Res. 126: 211-215 (5) "India - New Global Poverty Estimates
Abraham, P. (2012). Viral Hepatitis in India Clinics in Laboratory Medicine, 32 (2), 159-174 DOI: 10.1016/j.cll.2012.03.003