(This article, featuring Mary Williard, class of 1981, appeared in The Ohio State University Dental Alumni Society Quarterly, summer/fall 2004 and was reprinted on the website of the Yukon-Kuskokwim Health Corporation)
 

A different path in dentistry
by Donald F. Bowers, D.D.S.,
and Kathy Baird

Reprinted with permission from The Ohio State University Dental Alumni Society Quarterly, summer/fall 2004.

Dr. Mary Williard’s career in dentistry reflects the essence of Robert Frost’s poem, The Road Not Taken:

…Two Roads diverged in a wood, and I – I took the one less traveled by, And that has made all the difference.

It was after her graduation from the OSU College of Dentistry in 1994, and during a general practice residency at the Carolina Medical Center in Charlotte, that Dr. Williard, a Columbus native, had the opportunity to do a two-month externship in the U.S. Public Health Service (U.S.P.H.S.). This experience brought her to a fork in the road, and instead of pursuing private practice, she chose a road less traveled: She joined the United States Public Health Service Commissioned Corps.

While on her first assignment at the Navajo Reservation in Shiprock, New Mexico, she met a recruiter from Alaska who tempted her to visit a U.S.P.H.S. clinic in the city of Bethel. There, adventure beckoned. She discovered a large service area with a population that was still practicing the subsistence way of life. “What struck me most, and ultimately swayed me to go to Bethel, were the friendly people,” Dr. Williard recalls. In addition, “Bethel had opportunity for me to work in the operating room as I learned during my residency.”

Bethel, with a population of 6000, 70 percent of whom are Native Alaskans, is located on the mouth of the Kuskokwim River, forty miles inland from the Bering Sea. It has an average snowfall of 50 inches. Summer temperatures range from 62 to 42 degrees, and winter temperatures are as cold as -20 degrees. There are no highways to Bethel. To visit the city, one has to fly in a small aircraft from Anchorage, 450 miles away.

Today, six years later, Dr. Williard has carved out a career and a life in Bethel, as the deputy director of the Yukon-Kuskokwim Health Corporation Dental Clinic. For her, outreach takes on a dramatic perspective. Dr. Williard is one of eight dentists who serve the citizens of Bethel as well as forty-eight towns in a surrounding area as large as Wisconsin. “The villages in our service area can be as small as 40 people or as large as 1,200,” she notes. Time spent in each village depends upon the number of residents and the need. “Our staff tries to visit each village at least once per year,” she says.

As with Bethel, there are no roads to most of these village locations and small aircraft is the usual mode of travel. “We usually travel out to the villages in small prop planes,” she explains. “Occasionally, in the winter we can travel to the closer villages by snowmobile or by truck on the river ice road. Regardless of the mode of travel, portable A-dec units and compressors, folding dental chairs, kavoclaves, and the basic instruments and materials – about 700 pounds in all – are trekked in with the dentists.

The “base” clinic in Bethel is highly modern. “Our equipment in the Bethel clinics, sub-regional clinics and the new village clinics are state-of-the-art operatories with digital x-ray and intraoral camera capabilities, electronic records, and new or nearly new A-dec units,” Dr. Williard explains. “Some of the newer clinics have a dedicated dental room with a fully outfitted dental operatory.”

In contrast, “Our travel gear does not have all the new gadgets, and can be more physically demanding to work on,” she notes. “We provide a more restricted array of services when working in a village with portable equipment.” For this, she draws upon her OSU experience. “I learned very good, basic principles of dental care while at Ohio State,” she recalls. “I have always felt I got a good education at Ohio State and am grateful for that.”

When traveling, the accommodations also can be primitive. “It is often like camping when you are out on a village trip,” she says. “In the villages, we usually set up in the village clinic or school,” she explains. “Some of the villages have beds in their clinics for itinerant health care providers; many do not. I have usually ended up sleeping in the school on the floor of a classroom,” she says. In fact, though, the schools are comparatively luxurious. “I like staying in the schools because they usually have running water,” she notes. “Many of the villages do not have piped water to the clinic and homes. It is not uncommon that you may not have access to a shower during a week in a village.”

While providing dental care, she often relies on her assistants to translate, as many local people – especially the elders and young children – do not speak English, and the guttural local language is difficult to learn.

The demand for dental care is great. “We have a hard time keeping up with the demand, which is not a new problem,” she notes. “There are lots of obstacles to getting to see a dentist, including limited number of dental providers and geographic barriers,” she observes. In fact, a trip to the dentist can be a major undertaking. “If a person in the village has a toothache, they usually have to fly in to Bethel, then sit and wait in the clinic to be seen. They also have to pay for a place to stay overnight since they often can't make it in, get seen and get back home on the same day,” she explains. “This is one reason why we really try to get out to work in the villages at least once a year. Some people will forgo getting treatment due to the time and money it costs to get in to Bethel, so they are very glad to see us in the villages.” Despite efforts to serve the need, “We are often turning away patients in the villages and in Bethel, because of the high rate of dental disease,” she notes. “The demand is much greater than our staff can meet even though we often work from nine in the morning to ten at night while we are in the village.”

“We have a serious problem with dental caries,” Dr. Williard adds. “The predominant ethnic origin of the people that we treat is Yupik Eskimo. Alaskan Native children have a caries rate at least 2.5 times that of the rest of the U.S. when looking at all races,” she points out. “We are finding that nearly half the children in the area need referral to the operating room for full-mouth dental rehabilitation due to severe early childhood dental caries.”

Yet, there are some positive aspects to local dental health. “One thing that we do not see much of, yet, is periodontal disease,” she notes. “There are some elders who have lived traditional lifestyles who have all 32 teeth without a single cavity.” However, “These elders have significant attrition due to the abrasive traditional diet and the sand and grit found everywhere.”

“You may see many people here with missing teeth, and no partials or bridges, because we do not have the resources to provide these types of services,” she explains. “If a patient wants dentures or crowns and bridges, then they must usually travel to Anchorage or beyond for these services. Often patients will choose extraction over endodontic treatment because they do not want to have to travel back in for additional treatment.”

Although aspects of day-to-day life are very different in Bethel, the outside world still is having an impact. “Things have changed significantly in the area in the past few years,” she notes. “The introduction of processed foods, refined sugars and planeloads of pop and candy has led to a dramatic increase in the caries rate.”

“In Bethel, we have – or can get – most of the same amenities that you have in most ‘lower 48’ cities,” she notes; however, they are less readily accessible. “The only fast food in Bethel is Subway, which came to town two years ago. There are no fast food places in the villages. There is no mall. We have some general stores in town for groceries, clothes, furniture, gifts and movie rentals. There is no movie theater here.”

Prices are much higher. “Milk is more than $6 per gallon; bananas are $2 per pound,” she says. “I will usually try to buy most of my dry goods in Anchorage when I am there – it is cheaper. Most of my kids’ clothes are ordered on the Internet.”

“While not all the houses have piped-in water, we do have water delivered by truck to our homes which allows us to have running water,” she explains. “You just have to get used to watching the water level in the tank to make sure you don't run out before the next truckload.”

There have been efforts to fluoridate water, but it has been difficult to implement due to lack of trained operators or local tribal government support. Even when water is fluoridated, “the residents often don't drink it, preferring the taste of rain water or ice melt,” she says. Due to such obstacles, “We are basically facing an epidemic of caries in our area.”

The local Yukon Kuskokwim Health Corporation is working to address this caries problem by looking into alternative treatment models for local villages. Under development is a statewide Dental Health Aide program which will utilize multiple levels of providers to perform dental disease prevention, education, and basic care to village residents. Training local people to provide these services builds a local, sustainable dental workforce and should also benefit area residents.

Travel and housing pose additional challenges in such a primitive setting. “Most of our roads are dirt, so four wheel drive is very handy,” she notes. “In the spring when the river ice breaks there is often flooding, and most of the houses are built on high stilts. Some years I have to have a canoe to get from my house to the higher part of the road during flooding,” she recalls. “The other reason that our houses are on stilts is so that they are not sitting directly on the tundra and melting the permafrost. If this happens, then the house tends to gradually sink into the ground!”

Recreation is a by-product of the environment. “I have a waterway behind my house which leads to the Kuskokwim River, so I enjoy boating and paddling in the summer,” she says. “In the winter we can snowmobile and cross-country ski for miles. Many of my neighbors have dog sled teams and this is a fun way to travel. Hunting, fishing and trapping are a very big part of life for most people here.”

Even family life for her in Bethel has taken on a slightly different perspective. Dr. Williard has adopted three Yupik Eskimo children – nine-year-old Matthew, eight- year-old Shawna, and four-year-old Jayden – after serving three-and-a-half years as their foster parent. “They have brought lots of excitement and joy to my life,” she says. “I feel strongly about keeping them in the area to be able to learn their native culture,” she emphasizes. Her two older children spoke Yupik as their first language, and her eldest daughter is enrolled in the Yupik Immersion School, reinforcing that language knowledge.

“In Yupik culture, family is very important and includes distant relations,” Dr. Williard says. So, this summer, she has invited the children’s paternal grandmother to join them at their fish camp on the river to show them how to clean, cut, dry and smoke salmon. Biking, snowmobiling, sledding and camping are a few other popular pastimes. “We also are starting to learn gun safety and subsistance hunting,” Dr. Williard says. “I am learning all of this right along with my children,” she notes. “For example, Matthew and I both got our first rifles for our birthdays this year.”

At least once a year, Dr. Williard takes her children to visit her family in Columbus. he children love the trees, the stop lights and the automatic doors at the department stores.

What are her plans for the future? “Having a family and a career is tiring, and I am on the verge of making the transition to working part-time to allow more time for my kids,” she says. Meanwhile, Bethel will remain home, as she forges a life many can only imagine. For Dr. Mary Williard, the road less traveled – though often paved in dirt – has become a highway to contentment.

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