SAN SALVADOR โ What could beย duller than waiting to see the dentist? โMuyย aburridosโ โ so bored! โ four boys say asย they roll their eyes. Itโs just after noon, andย Oscar, Josuรฉ and Eduardo, all 10, as well asย Vladimir, 11, are in line with hundreds ofย others at a government building in Santoย Tomรกs, El Salvador. Theyโre waiting to seeย one of the Canadian doctors or dentists whoย are here on a Canadian medical mission organizedย by Speroway, a faith-based charityย started 13 years ago to help the needy. Likeย the boys, many of those in the queue haveย been here since 7 a.m. to ensure they snagย a place with one of the health professionals.
Itโs boring and hot. The temperature has inched well above 30 degrees C and the youngsters slack their thirst swigging Kolashampan, a bland El Salvadoran soft drink. The boys would prefer to drink a Coke, which has more cachet. Coca-Cola is โcachimbรณn,โ they say. Translation: itโs the cool drink.
But ask them if they know soda pop is bad for their teeth and the boys, smirking now, shrug off the question. โBebemos muchoโ โ we drink a lot โ they reply, then turn to devouring pupusas, a traditional El Salvadoran corn tortilla that one of the mothers brings them.
The Canadians are here giving medical and dental care to those who canโt afford treatment. Theyโve set up makeshift stations in the interior of the building, which offers minimal respite from the noonday sun. In one room, nine dentists, with just a metre of space between them, hunch over patients who obediently keep their mouths wide open; with the exception of one small patient โ an outraged girl about eight years old and dressed in sparkly pink pants.

Sheโs roaring like an animal. Her legs flail in the dental chair, which is actually a zero gravity backyard lounger brought from Canada. Her mother holds her down as Ian McConnachie, whose day job is at Woodroffe Pediatric Dentistry in Ottawa, tries to fill a cavity in her tooth. McConnachie, the only childrenโs specialist on this medical mission, feels a chomp on his thumb.
โHazard of the job,โ he says, inspecting the bloody bite mark and a thumbnail morphing blue. When done, the little girl happily leaves with a bit of bling โ a sparkly costume ring โ that matches her pants. She also leaves with free toothpaste, mouthwash and a toothbrush, plus extras for the siblings at home and instructions for mom on oral care.
McConnachie will see about 20 childrenย before the day is out. He treats all ages: toddlersย to younger teens who exhibit identicalย dental problems โ โteeth that are bombedย out with decay.โ The pattern of rot he routinelyย finds: teeth blackened along the edgesย and gum line. It reveals that the cause of theย dental caries is chronic exposure to sugarย from candy and soft drinks. Pop is cheaperย to buy than bottled water, and tap water isย often contaminated.
The result: 80 per cent of Central American youth aged six to 19 have dental caries, according to the Geneva-based World Dental Federation (FDI). The majority go untreated, leading to tooth loss, malnutrition and infection.
This makes tooth decay the most prevalent condition among the 291 diseases surveyed in the Global Burden of Disease Study (1990-2010), a report put out by the Institute for Health Metrics and Evaluation at the University of Washington. Ironically, because it is caused by a high-sugar diet and a lack of brushing, it is also entirely preventable.
Globalization, however, has made cheapย Western food products available to eagerย new consumers in Latin America, Africaย and Asia. The fact that sipping a Coke givesย Oscar, Josuรฉ, Eduardo and Vladimir moreย strut in their caminar shows how effectiveย these products are being marketed.

Science links sugary drinks to a myriadย of health problems, and this raises importantย questions. To what extent should beverageย companies be held responsible, or holdย themselves responsible? Tobacco companiesย argue that smokers are aware of the risksย related to cigarettes; that smokers are simplyย exercising their freedom to choose. Butย can this rationalization apply to beverageย drink makers that market their product toย children? Does it apply to people who live inย poverty, are illiterate and uneducated?
As part of their medical mission, the Speroway dentists and doctors discuss the effects of poor diet on general as well as oral health with their patients. The message, however, is often lost in translation. The advice to replace soft drinks with water and brush teeth are superseded by the reality of poverty, which makes travelling to the city to see the dentist or buying bottled water and toothpaste expensive luxuries. This reality is one of the reasons the Speroway team makes annual visits to El Salvador, and continues to brainstorm on ways to improve oral health messaging in developing countries.
The lack oral health knowledge is obvious. In El Salvador, cavities develop in babiesโ first teeth because mothers put soda pop and juice in their bottles. Ironically, just outside the temporary clinic, street vendors are hawking a variety of sweets โ marshmallow kebabs on sticks, juices and colas โ to those waiting in line to have teeth pulled, cavities filled and painful tooth infections treated. El Salvadorans are simply not connecting cause and effect.
A coke and a smile
A few metres from McConnachieโs workspaceย is Jack Cottrell, a dentist at the Portย Perry Dental Centre in Ontario. He leadsย the dental team at Speroway, which to dateย has carried out six medical missions to Elย Salvador. Cottrell is drilling, filling, grindingย and bonding the blackened front teethย of a teenager.

โThis is a beautiful young lady and Iโm going to rehabilitate her smile,โ says Cottrell, whose dental assistant and wife, Michelle, hands him instruments andย suctions saliva. Cottrell, who has led missions throughout Central America and Haiti, carries on a running conversation as he works. Such caries, he says, are caused โ80 per cent from the diet and 20 per cent from not brushing the teeth.โ
He looks over his shoulder and nods his head in the direction of a young boy with a small plastic bag filled with chilled cola. The boy is watching his sister undergo treatment. Such bags are sold for a few pesos by vendors. By sucking on the bag, the treat can last for hours. Unfortunately, this creates a continuous bath of sugar, caffeine and acid that rots the teeth, says Cottrell.
Jerry Isenberg would certainly agree. A tall and lanky dentist who works with Cottrell back home, Isenberg shakes his head in frustration as he fills or extracts teeth from one of the 30 patients he will end up seeing on this day. โItโs that damn Coke,โ Isenberg says. โPeople are damaging others simply for the sake of profit.โ
This assertion is not without controversy. Some take the position that whatever is poured or popped into your mouth is solelyย your responsibility. Last October, however,ย Advertising Standards Canada (ASC)ย decided that this thinking doesn't applyย to kids. The ASC announced changes toย the Canadian Childrenโs Food and Beverageย Advertising Initiative, including aย pledge not to undertake advertising thatย is โdirected primarily to children underย 12,โ when children make up 35 per centย of the audience. As well, advertising toย children should only promote โbetter forย youโ products. A nutrition guide is partย of the ASC initiative and, while it doesnโtย specifically mention soft drinks, doesย recommend โlimiting foods and beveragesย that are high in sugar.โ Both Cocaย Cola and PepsiCo Canada signed on toย the changes.
According to Coca-Colaโs U.K. website,ย a 375 ml can of Coke contains 39 gramsย of sugar, or nearly eight teaspoons. It alsoย contains carbonic acid (making it fizz) andย phosphoric acid, which acts as a preservativeย and adds tartness. The larger 600 mlย Coke bottle holds 63.6 grams, or about 15ย teaspoons of sugar.
Sugar is a carbohydrate, an essentialย source of energy. It is found naturally inย fruit and honey as well as corn and sugarcane.ย But natural isnโt always better. Decadesย of studies link the amount and frequency of sugar consumption not only toย tooth decay but Type 2 diabetes, obesityย and cardiovascular disease. Sugar and teeth,ย McConnachie explains, have an unfortunateย relationship. Common oral bacteriaย like Streptococcus mutans metabolizesย sugars into acids that eat away tooth enamel.ย The more snacking in between meals,ย the more decay.
The lack of tooth decay can ironicallyย signal other problems. McConnachie pointsย out that the only place heโs been in the developingย world where kids arenโt suffering fromย tooth rot is in Haiti. The trade-off, however,ย is hunger. Extreme poverty means manyย children eat only one meal a day.
In a statement that has not endeared itย to processed food and soft drink companies,ย the World Health Organization (WHO) lastย year announced new sugar consumptionย guidelines. The Geneva-based organizationย recommended that a mere 5 per cent of anย adultโs daily caloric intake should come fromย sugar. This is 25 grams of sugar โ less thanย the amount found in a single can of Coke.
Francesco Branca, the WHOโs directorย of nutrition for health and development,ย admitted that 5 per cent might be a bit optimistic,ย and advocated trying to at least limitย the daily intake of sugar to 10 per cent forย positive health impacts.
There is no question the global communityย has a sweet tooth. According to Statistics Canada, the average Canadian consumes 26 teaspoons of sugar per day, which is 21 per cent of daily calorie intake. The American Heart Association (AHA) reports that U.S. citizens are consuming about 20 teaspoons of sugar, mostly from sugar-sweetened beverages. The AHA recommends men consume at most nine teaspoons a day and that women not surpass six teaspoons.
Are North Americans addicted to sugar? Findings from the U.S. National Institutes of Health did suggest sugar might be addictive, sparking calls last year by U.K. health officials to tax โfizzy drinks.โ
Statistics from the Oral Health Atlas, compiled by the World Dental Federation (FDI), which represents more than one million dentists worldwide, indicate that El Salvadorans consume as much sugar as Canadians do โ up to 44 kilograms annually, or about 25 teaspoons daily. The big difference, says Cottrell, who is a member of the governing council at the FDI, is that nations like El Salvador are decades behind the West when it comes to oral health awareness.
Marketing sweet spot
The knowledge deficit might not beย such a problem if it werenโt for the advertisingย campaigns of the soft-drink leviathans,ย which have turned attention to developingย markets as a source of growth amid stalledย or declining sales in Western markets.
In El Salvador, Coca-Colaโs trademarkย red and white is everywhere. Enormousย billboards with the iconic, long-necked Coca-ย Cola bottle stand tall over urban centresย and slums alike. Coca-Cola tree decorationsย adorn fake evergreens in San Salvadorย shopping malls during the Christmas season.ย The Coca-Cola factory outside the capitalย city conducts school tours. The smallest,ย most meagerly stocked snack shack isย brightened with Coca-Cola signs.
Pepsi-Cola competes aggressively withย Coca-Cola with its own slick campaigns,ย painting tiny roadside kiosks in the brandโsย distinctive blue, red and white, and givingย out matching canvas-tie aprons to proprietors.ย (Neither Coca-Colaโs nor Pepsi-ย Colaโs media relations offices responded toย several requests for comment.)

Penny Collenette is an adjunct professorย of law at the University of Ottawa andย corporate social responsibility specialistย who developed the course, โA New Internationalย Corporate Reality: The Businessย of Human Rights.โ Collenette believes softย drink companies do have a responsibilityย to educate consumers about the downsideย of swilling their product. โRecent evidenceย about sugar has led to serious questionsย about obesity and health,โ Collenette says.
โGiven this global knowledge, ethically itย is incumbent upon Coke and Pepsi to atย the very least warn consumers of the riskย of over-consumption of their products. Iย would think the government as well as theย medical community should play a regulatoryย role,โ Collenette says.
Itโs an odd notion, perhaps: the thoughtย that Coke and Pepsi should or would helpย tackle health problems linked to their products.ย However, it doesnโt stretch incredulity to think that the two multinationals could help mount effective oral health programs.
The marketing tactics of Coca-Cola โ the largest beverage company in the world โ are designed to crack open new markets in the most far-flung places. It is so effective that Melinda Gates of the Bill and Melinda Gates Foundation holds up the companyโs strategy as a model for development agencies to emulate.
โIโm startled by all the things [people] donโt have, but I am surprised by one thing they do have: Coca-Cola,โ Gates marveled in a 2010 TED Talk, titled โWhat non-profits can learn from Coca-Cola.โ By relying on local entrepreneurs, who use bicycles, pushcarts or wheelbarrows, Coke gains access to the most inaccessible communities. โIn Tanzania and Uganda, they represent 90 per cent of Cokeโs sales,โ said Gates.
In El Salvador, Cokeโs and Pepsiโs marketing strategies can only be described as masterful. Family-run restaurants and tiny remote roadside kiosks sport branded signs, fridges, tables, clothing and exterior paint. But corporate gain is El Salvadorโs pain. Back at the makeshift dental office, the next patient in line is a four-year-old boy, his face mottled from crying. He refuses to get into the dental c hair. Cottrell has checked his teeth and noted several large cavities.
โHe probably cries himself to sleep atย night because of the pain and thatโs whyย he doesnโt want us to touch him,โ Cottrellย says. Lack of cooperation from the boyย leaves only one solution โ sedation. Theย youngsterโs mother maneuvers her son intoย another room where physician Anthonyย Brown is stationed.
Brown gives the boy a syringe of sedatingย liquid, which the boy tries to spit out. Butย enough gets down to make him more placid,ย allowing McConnachie to take over to tackleย the cavities. The decay is so severe, however,ย that one of the teeth has to be pulled.
Sugar-rotted teeth arenโt the only problem in El Salvador. The country also has a high obesity rate. The World Health Organization identifies obesity caused largely by diet (sugars and simple carbohydrates like cornmeal tortillas and bread) as a risk factor for Type 2 diabetes. It is a condition Sperowayโs doctors will see often on this mission.
The International Diabetes Federationโsย (IDF) 2014 statistics put El Salvadorโsย diabetes rate at 10.6 per cent of theย population โ higher than the world average,ย but still lower than Canada and theย United States, where diabetes afflicts 11.6ย per cent and 11.4 per cent of the population,ย respectively.
To say that education is needed is an understatement.ย The IDF reports that the Elย Salvador government hasnโt even begun toย discuss โpreventative polices.โ Yet the needย for a strategy is evident in municipalitiesย like San Pablo Tacachico, which is northย of San Salvador. Thatโs where Else Orellanaย lives. Sheโs a pretty 17-year-old who livesย across the street from a small tienda whereย Coke is sold for 35 cents. Thatโs five centsย cheaper than the bottled water.
Orellana has just bought a 1.25 litre bottleย of Coke, which she plans to crack openย and enjoy with her noon meal. Her uncle,ย Milton Cruz, operates a nearby fruit stand.ย Cruz, 38, was recently diagnosed with diabetes,ย something the doctor linked to hisย own litre-a-day Coke habit.
Is Orellana on the same path? Doesnโt she realize the health risks of drinking so much pop? She shrugs. Maybe sheโs a bit โnecio o burroโ โ stubborn like a donkey โ but when itโs a hot day in El Salvador, nothing beats the heat like an ice cold Coke, she says with a shy smile, before turning away to prepare lunch.