A Preliminary Plan to Implement Salt Fluoridation in Port-au-Prince, Haiti
Nicholas B. Gordon, DMD, MPH
Background
Water fluoridation is the most efficient way to prevent tooth decay and its safety and efficacy is
supported by over 60 years of research. The CDC named water fluoridation as one of the top 10 public
health achievements of the 20th century. Water fluoridation continues to reduce the prevalence of
caries by 20-35% in the U.S. Today about 405 million peoples worldwide in over 60 countries received
the benefits of water fluoridation (American Dental Association, 2005). In countries that do not have an
adequate central water supply, salt fluoridation is the more feasible option. Countries like Colombia,
Costa Rica, Jamaica, Mexico and Uruguay have successfully implemented salt fluoridation programs in
the 1980s and have all seen over 40% reduction in caries (Estupinan-Day, 2004). Despite the evidence
that fluoridation programs are safe and effective in reducing caries prevalence, some countries still have
not implemented a fluoridation program. Haiti is one of those countries.
Located in the Western half of the Isle of Hispaniola in the Caribbean Sea, Haiti is the third
largest and second most populous Caribbean nation, with an estimated 10.7 million people. With an
annual gross domestic product estimated between $410-$1,200 per person, Haiti is the poorest country
in the Western Hemisphere (Psoter, et al., 2005). The oral health infrastructure of Haiti is very limited,
illustrated by population ratio of 0.12 dentists per 10,000 people (Psoter, et al., 2005). The extremely
low numbers of dentists in Haiti results in reactive care with most people not having adequate access to
preventive oral health services. The capital city, Port-au-Prince, which is located in the “Ouest
Department” of the country, has an estimated population of 897,859 people. One study found a caries
prevalence of 22% and 34% for 12 year olds and 15 year old Port-au-Prince adolescents respectively
(Psoter, et al., 2005). The prevalence of caries increases in rural areas. Additionally 75 water samples in
suburban, urban and rural areas were found to have uniformly low, non-therapeutic fluoride levels
(Psoter, et al., 2005). Currently the city of Port-au-Prince has no fluoridation program. Although a water
fluoridation program may not be feasible at this time, a salt fluoridation program in Haiti’s capital city
would bring the benefits of fluoride in caries prevention directly to about a million people.
A plan to implement a salt fluoridation program in Haiti consists of three phases. The first phase
consists of collection of baseline oral health data. A cost benefit analysis of salt fluoridation will also be
conducted to determine if it is financially feasible for such a program. The second phase of this plan
consists of meeting with various stakeholders in Port-au-Prince to educate them about the burden of
oral health in Port-au-Prince and discuss strategies, such as salt fluoridation that the city can implement
to prevent caries. The third phase of this plan consists of meeting with local and national organizations
and policy-makers to advocate for salt fluoridation in Port-au-Prince, Haiti. The following is a more
detailed description of a plan to implement a salt fluoridation program in Port-au-Prince, Haiti.
Phase I
1. Collection of baseline data to assess oral disease in Port-au-Prince, Haiti
a. Currently there is limited data on the prevalence of dental caries in children and adults
in Port-au-Prince, Haiti. The University of Haiti (UH) School of Dentistry is the only dental
school in Port-au-Prince and possibly the whole country. The UH School of Dentistry has
established itself as an institution committed to teaching the next generation of Haitian
dentists and providing dental care to the surrounding community. Working with faculty
and students from the dental school, a survey will be developed to assess the
knowledge of and attitudes toward oral health among adults in Port-au-Prince. These
survey participants will be solicited from local churches and places of worship since
these are frequented for worship and social gatherings. In addition to the surveys, oral
examinations by licensed Haitian dentists will be performed at selected local elementary
and middle schools to determine the caries prevalence of children and adolescents.
2. Preliminary cost-benefit analysis will be conducted to determine the financial feasibility of a salt
fluoridation program in Port-au-Prince.
a. The current salt production method in Haiti is outdated and needs to be improved
(Munger, 2013). Salt produced in Haiti today contains magnesium and calcium, which
make it difficult for fluoride to attach to the surface of the salt. In addition to improving
working conditions for women salt workers, a more modern salt production system
would be provide salt fortified with fluoride that would be available for consumers
(Munger, 2013). A cost benefit analysis will include this information and also highlight
the fact that various countries in the Americas, including Haiti’s neighbor, the Dominican
Republic have saved more money in preventing caries than they spent in implementing
a salt fluoridation program. This analysis will also incorporate findings from baseline
data collected from surveys and examinations as mentioned previously, in order to
show the improved quality of life and prevention of dental caries that can occur with
such a program.
Phase II
1. Meet with various stakeholders in the country to educate them about the oral health status of
children and adults in Port-au-Prince, Haiti and develop a constituency of support for salt
fluoridation.
a. Following Phase I, Phase II will consist of educating faculty and students at the UH
School of Dentistry about the burden of dental caries among adults and children in Portau-Prince, based on past studies that were conducted and baseline data collected in
Phase I. Included with the data will be strategies to prevent dental caries in Port-auPrince, including salt fluoridation. Evidence-based data on the safety and effectiveness
of salt fluoridation will be presented as well as a cost-benefit analysis for the
implementation of the program in Port-au-Prince. This information will be disseminated
to the Ministry of Health, the Ministry of Public Health and Populations, as well as local
city health officials. Medical and dental societies will also be informed through literature
and presentations during society meetings. These efforts will help gain buy-in and
support for caries prevention strategies and aid in the establishment of a constituency
to support salt fluoridation.
Phase III
1. Meet with local and national organizations and policy-makers to advocate for salt fluoridation in
Port-au-Prince, Haiti.
a. “Aba Grangou”, which is the First Lady of Haiti’s initiative to combat hunger by
combining the efforts of the Ministry of Health and the Ministry of Agriculture, is
currently responsible for salt iodization and fortification in partnership with the
University of Notre Dame. The University of Notre Dame is contracted by the Ministry of
Health to operate iodization equipment which was donated to the Ministry by the
United Nations International Children’s Emergency Fund (UNICEF) (Munger, 2013).
Following phase II of this plan, it would be important to meet with Rev. Thomas Streit,
who is the founder and principal investigator for the Notre Dame Haiti Program. This
program, in partnership with the Haitian Ministry of Public Health and the Population
and the Congregation of the Holy Cross, recently dedicated a new salt plant in Delmas,
which is located in the Port-au-Prince metro area. This plant will produce clean, foodgrade quality salt prior to being fortified with iodine and packaged for distribution and
sale (Healey, 2015). Since the University of Notre Dame already has a contract with the
Ministry of health, it would be important to inform Rev. Streit and leaders of Aba
Grangou about the prevalence of caries in Port-au-Prince and the role of salt
fluoridation in preventing dental decay. Since salt is already fortified with iodine, this
may make the case for salt fluoridation stronger. Meetings Rev. Streit and his staff will
also provide information regarding the legal process of gaining approval for salt to be
fluoridated in Port-au-Prince.
Implementing a salt fluoridation program in Port-au-Prince, Haiti is a challenge since the city is
vulnerable due to a lack of infrastructure. The 2010 earthquake crippled much of Port-au-Prince and
crumbling buildings, poor roads, and a weak enforcement of laws and regulations in Haiti today are a
bleak reminder of the poor infrastructure on which Haiti’s public sector sits. Haiti faces real challenges
that make it almost impossible to prioritize which issues should be addressed first. Thirty-five to fortyfive percent of the population of Haiti is illiterate. Only 39% of the population has adequate access to
safe drinking water. Major causes of childhood mortality and morbidity are malnutrition and infection
with diarrhea and acute respiratory infections responsible for almost half of the under-5 mortality rates.
Tuberculosis, malaria, dengue fever and hepatitis are other diseases prevalent in childhood (Psoter, et
al., 2005). With a gross natural product of between $410-$1,200 per person, Haiti is very limited in
financial resources to address these issues and oral health is not a national priority at this time. This is
exemplified by the fact that the Ministry of Health does not have a dental health officer as they have
had in the past. This salt fluoridation plan consists of the initial steps it would take to assess, educate,
and build capacity and support for a fluoridation program. This initial plan is project to take about 5 to 6
years to complete. Following the initial plan, full implementation of a salt fluoridation program in Portau-Prince would occur in 4 to 5 years.
One positive outcome of the devastating earthquake that happened in Port-au-Prince 5 years
ago is the opportunity that the city has to build back a better city than before. This may be the best time
to advocate for and implement a population-based caries prevention program such as salt fluoridation
in the city of Port-au-Prince.
Bibliography
American Dental Association. (2005). Fluoridation Facts. Chicago: American Dental Association.
Estupinan-Day, S. (2004). International Perspectives and Practical Applications on Fluorides and
Fluoridation. Journal of Public Health Dentistry, 40-43.
Healey, S. (2015, January 5). Salt Processing Plant Dedicated in Haiti. Retrieved from Haiti Program:
Neglected Tropic Disease Initiative: http://haiti.nd.edu/news/54997-salt-processing-plantdedicated-in-haiti/
Munger, A. (2013, June 6). Salt Fortification Projects in Haiti. E-mail Correspondence.
Psoter, W. J., Saint Jean, L. P., Morse, D. E., Prophete, S. E., Joseph, J.-R. E., & Katz, R. V. (2005). Dental
Caries in Twelve-and Fifteen-Year-Olds: Results from the Basic Oral Health Survey in Haiti.
Journal of Public Health Dentistry, 209-214.