Vol. 53, No. 2/ Spring 1993 115

Future Dental Public Health Programs: Forging Community and Academic Collaborations“

Linda C. Niessen, DMD, MPH Department of Public Health Sciences Baylor College of Dentistry 3302 Gaston Avenue Dallas, TX 75246

Obsolescence is afate devoutly to be wished, lest science stagnate and die.

Stephen Jay Gould ’Wonderful Life”

Admiral Collins, President Isman, dental directors, dental officers, colleagues, friends, as a former active duty PHS dental officer and current PHS inactive reserve dental officer, it is indeed a pleasure to speak with you this afternoon.

Stephen Jay Gould’s quote from his book ‘Wonderful Life” is the story of the reinterpretation and the develop- ment of a new model for the scientific understanding of the archaeological findings of the Burgess Shale in Can- ada (1). The book puts forth a new model for interpreting these findings. In fact, it forced paleobiologists to rethink and reformulate their vision of the past. This afternoon, I would like to submit, for your consideration, several issues/concepts as we reformulate our vision of the fu- ture for public health dentistry.

Obsolescence, quite frankly, was never a fate for which I devoutly wished. In fact, often it was my worst night- mare. However, Gould’s quote helped me understand that the flip side of obsolescence is continuous learning and change, concepts with which I felt much more com- fortable. Change is sometimes nothing more than reex- amination and reinterpretation of old data. The variables that spur reexamination, reconceptualization, or para- digm shifting (if you are from California) often come from a variety of sources.

Probably the most significant change that we all have felt in the past 10 years is budget retrenchment. The $40 billion deficit budget that President Jimmy Carter pro- posed for fiscal 1980 is a far cry from the $400 billion deficit that will occur in fiscal 1993. This budget deficit is added to a national debt that has gone from $1 trillion to $4 trillion in 10 years and a debt service that now accounts for almost one-third of the federal operating budget, a sign that does not bode well for future public programs.

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*Keynote address at the Public Health Service Dental Officers Lun- cheon, 1992 National Oral Health Conference, Scottsdale, AZ. Manu- script received 4/27/92; accepted for publication: 4/28/92.

In 1990,34 states also had budget deficits. These federal and state fiscal issues will clearly put added pressure on the health and human services sector at the federal or state level. These services also appear to take dis- proportionately large hits in their budget. Let me remind you that this has not necessarily resulted from presidents and governors not believing in the importance of these services, but oftenbecause the only discretionary services where cuts can be taken are located in these areas. For example, in Texas we had a $4.3 billion deficit for the last biennium. (Texans distrust government so much they only let them meet every two years.) During the next biennium we are preparing for increased budget cuts in higher education-not because Governor Ann Richards does not think higher education is important-quite the contrary-but because 60 percent of the discretionary portion of the Texas budget lies in higher education. It is the only place available to cut.

Our vision of the future for oral health improvements has been well documented in Healthy People 2000 (2). Healthy P q l e 2000 serves as the strategic plan for im- proving the oral health of the public. The oral health objectives, which many of you helped to formulate, are much broader than in the past, both in types of oral diseases addressed and age of constituents. And as a result, the constituencies needed to accomplish these objectives will also need to expand. The issue I put forth for your consideration today is the expansion of your constituencies to include higher education. Now, I realize this is not a novel idea and it has been done very success- fully in some locations. In fact, I’d like us to reexamine the settings in which these collaborations have worked well to see if they are reproducible in other locations. Many of you already participate in successful collabora- tive models. Can they be expanded and exported?

Budget deficits have already affected many of you in the dental public health community. These deficits have also affected dental higher education. We are all trying to do more with less. (In the VA, we call this TQI or CQI- total quality improvement or continuous quality im- provement.) It is for this reason that there may never be a better time to develop collaborative relationships be- tween the dental public health community and the higher

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education community. M~ definition of higher education iS inclusive, from

junior colleges housing dental hygiene programs to four- year colleges, to academic health science centers. Just as yesterday’s session on increasing access included the words flexibility and inclusion, these issues will be Criti- cal to the public health-academic linkage.

Higher education’s mission usually includes educa- tion, research, and service in varying combinations. The community service mission is often the broadest and vaguest of the academic missions. Public institutions of higher education are already being held accountable for meting various community needs. This accountability can only be expected to increase as states attempt to ration even more limited resources. The future will re- quire that professional schools serve a more active role as community resources.

Joint public-academic dental public health residency arrangements have been in existence for quite a while. The residencies usually consist of a collaboration which includes a public health agency, either a city or state health department, and a dental school or school of pub- lic health (3). Boston, New York, and North Carolina are but a few. Baylor and the VA just collaborated to establish a funded DPH residency and the University of Texas at San Antonio just established a DPH residency using an- other creative funding mechanism. Th~s is the conuner- cia1 message: two DPH residencies are available in Texas this year. Anyone interested, see John Brown or me. For overall public health training, the School of Public Health in Albany, New York, is an excellent example of a creative joint venture between the State University of New York at Albany and the New York State Department of Health.

The community service mission, while not foremost, is often a source of high visibility, constituency satisfaction, and goodwill for the university. In other words, it is a narrowly focused institution that fails to see the PR value of community service programs. However, the strength of the university usually lies within the research capabil- ities of its faculty, not its community organizing skills. Thus, whde dental schools may have a community ser- vice mission, it is often limited to provision of lowcost dental care. However, the potential for broader-ba& community education programs certainly exists. What I wouldn’t give for a Smile Alaska-style program or a J & ~ the Dental Coyote in Dallas. But that’s not the ”compar- ative advantage,” to use the economists’ term, of aaylois faculty. we need you and your expertise to accomplish these programs. voila! Therein lies the basis of just the first win-win possibility.

able to quantify and define their population needs and evaluate program effectiVeneSs. Dental higher education often has individuals capable of assisting with the research or anal- ysis = P e n t of an oral health survey or program evalu- ation. A collaboration of this type with h e dental public

State and local health departments must

health and the dental academic community Can meet the mission of both organizations-valid, reliable data for the public health program administrators; publications for fie faculty member. North Carolina has mastered this concept and has used it effectively for many years (4).

Another example lies within the educational mission of the academic community. Those of you in clinical practice settings offer the possibility of a wonderful ex- ternship for third- or fourth-year dental students. Having the opportunity to practice dental hygiene or dentistry in a fully equipped operatory, complete with modern ma- terials and maybe even a dental assistant, in an environ- ment where you are treated as a colleague (with respect), sounds like nirvana to any junior or senior dental or dental hygiene student. Actually, what sounds like nir- vana is not being in the dental school for a week or two and still getting academic credit. I am excited to report that, as we speak, Baylor College of Dentistry’s first externship experience in a PHS facility is taking place at the IHS facility in Keams Canyon, Arizona. This summer, Baylor will have its first dental student participating in COSTEP. The University of Texas at San Antonio has served as a model for us in understanding the value of the COSTEP program for dental students. In addition, new accreditation standards for dental hygiene curricu- lum call for community experience. This may provide expanded opportunities for dental hygiene students.

A spillover benefit of externships, as you know from the COSTEP program, is that these experiences also Serve as a recruiting device for dental public health. I fear, my friends, that we may face a recruiting crisis in the future. With the number of graduates estimated to decrease to below 4,000 per year, with populations increasing, dental needs increasing, and dental expectations rising, the call of private practice may be loud and fiscally strong. A modification of the Chet Douglass theory, ”The cavities are coming, the cavities are coming,’’ to “The dollars are coming, the dollars are coming.” The collaboration with the academic community may help make dental public health come alive for students whose dental public health experience consists of being bored by epidemiology, treatment needs, demand of care, etc. (I can say this with no disrespect to my academic colleagues, I am currently One of the borers-not to be confused with the bores!) But Perhaps the greatest benefit of externship program is the OPpOmfity offered dental students to practice in a different type of clinical practice, a practice that corn- bines Clinical dentistry with population-based preven- tive programs.

The future of clinical dental public health programs is the second issue I would like to address. It is clear that advancing technology, increasing consumer expecta- tions, and regulatory activities are changing fie nature of clinical practice.

In 1989, I had the good fortune to do a two-week temporary duty in the Public Health Service. It was a tale

Vol. 53, No. 2, Spring 1993 117

of two programs. Both were run by their respective Na- tive Corporations. Both programs were based on the needs of the respective populations, but the programs were quite different in clinical scope. One program was the traditional public health program based on the population’s high birth rates and incredibly high oral disease levels. It was primarily treating children, with adults receiving care on an emergency basis. Even when every dental chair in the lochair clinic was filled, you still felt as if the tide of disease was rising faster than you could quell it, even with the community-based preven- tion programs in place.

The second program provided comprehensive dental care to all ages, stainless steel crowns to porcelain crowns, from cradle to grave. Over 300 people were enrolled in the perio recall program. The staff provided hygiene and dental services to the Native people residing in the local nursing home, in addition to the coordinating community water fluoridation programs in the villages. It was fascinating to be part of a program of this kind. It was out of sync with my concept of a public health program. However, it made me rethink our approach to clinical care. It also made me realize that as our public health population’s oral health needs begin to approxi- mate the majority population, this type of practice will result. This type of program can also result from con- sumer demand. It clearly was consistent with the needs of the people running the Native Corporation. Already, in IHS in Oklahoma, there may be some communities ready for this type of “private practice plus” model. The ”Private Practice Plus” concept is a program that pro- vides community-based preventive programs, and com- prehensive high quality, state-of-the-science dental care, well integrated into the existing medical or hospital pro- gram. I add this last phrase because the natural conse- quence of providing comprehensive dental care, includ- ing adults, is that you will care for more sick adults.

In addition, some of our constituencies are demanding esthetic dentistry. What is the role of esthetic dentistry in public health programs? Is the question of esthetic den- tistry today where the question of the need and respon- sibility to provide orthodontics was 20 years ago? What about the new esthetic materials? How do dental public health programs begin making resource allocation deci- sions in such an era? What is the role of esthetic dentistry and implants in public health programs, particularly if the programs are based on consumers’ needs and de- mands? Your consumers are reading the same magazines and watching the same TV as the rest of society. Implants and esthetic dentistry are regular features in many pop- ular magazines. How will individuals’ self-esteem be factored into the public health model? We know that job potential changes when one has a complete complement of 12 anterior teeth. How will conservation of toothstruc- ture through new adhesive, more esthetic materials, which are also more time consuming or labor intensive,

enter into the equations of cost effectiveness and effi- ciency? Idon’t have the answers to these questions. I raise them because as our programs, clients, and technology become more sophisticated, we may be addressing these questions sooner than we think.

The themeof this meeting is ”strategies for meeting the oral health needs of children and their families.” The family is an interdependent unit. Children, when young, need parents. Parents, when old, need children. Simi- larly, both the public health and the academic communi- ties are interdependent. Both groups are committed to improving society, the one through education and ser- vice, the other through education and research. Both receive limited public dollars. With the guidelines of flexibility, cooperation, and inclusion, the linkage be- tween public health and academia will serve to strength- en both arenas.

Future public funding initiatives may provide greater opportunities for collaboration. For example, Ryan White Funds, which provide reimbursement for dental care for HIV-infected patients, are directly benefiting dental schools. While assisting the schools in meeting their ser- vice mission, caring for HIV-infected people reinforces the dental curriculum in the area of ethics by caring for the medically compromised. It also serves to validate the infection control curriculum.

The Administration on Aging funds numerous com- munity education programs. Several universities and public health programs have competed successfully for funds and have developed some creative programs for older adults. Jack Dillenberg, in the Arizona Department of Health, and Ron Ettinger and Hermine McLeran, at the University of Iowa College of Dentistry, have developed some incredibly creative materials. We need to widen the distribution of these resources.

Funding for Advanced Education in General Dentistry programs has served successfully to staff some public hospital dental services. Perhaps these programs could be sponsored jointly by health and academic institutions. The residents would benefit by having the opportunity to provide care in a unique setting, like a neighborhood health center. The center benefits by having an additional person providing services.

The research potential is boundless. The study exam- ining periodontal disease among certain Native Ameri- can populations here in Arizona is an excellent example of win-win collaboration. You care for unique popula- tions, with many unanswered questions. This is a natural area and a very comfortable area for higher education.

In October 1991, the Pew Foundation published a re- port titled ”Healthy America: Practitioners for 2005” (5). The Pew Health Professions Commission recognized the need for reform in the health system. The commission also recognized that the change can come from the top down by reforming the financing or from the bottom up by training a new type of health professional. The com-

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mission chose to concentrate its efforts in this latter direc- tion. As a result, the commission developed a set of competencies that future practitioners will need. These include:

Care for the community's health-a population perspective in addition to the individual perspective.

Expand access to effective care-practitioners should participate in efforts to expand access.

Practice prevention. Promote healthy lifestyles. Improve the health care system. Accommodate expanded accountability. Participate in a racially and culturally diverse mi-

Continue to learn. These are only a few, It sounds to me like a public health agenda for health professions education.

Similarly, the Robert Wood Johnson Foundation is placing a strong emphasis on creative solutions to im- prove access to basic health services. I believe the aca- demic community must be involved with the public health community to accomplish these initiatives.

Perhaps one of the most exciting initiatives on the dental horizon, which will enable all the dental commu- nities of interest to work together to improve oral health, is "Oral Health 2000." This consortium is composed of private, public, consumers, dental practitioners, and cor- porate America, of which you have already heard from Dr. Robert Klaus of the American Fund for Dental Health. "Oral Health 2000" may be the first opportunity that we

in dentistry have had to get such a diverse array of people and organizations working together to meet the Healthy People 2000 oral health objectives.

Enthoven and KroNck have described the American health system as a "paradox of excess and deprivation" (6). Nowhere is this more clearly seen than in the oral health arena. Those of us in the public health and aca- demic communities usually see the deprivation. Only by working together, understanding and respecting themis- sion of each of our institutions, can this deprivation be eliminated. And in the process, the obsolescence we face may offer exciting new potential for improving the oral health of our constituents.

Thank you.

References 1. Gould SJ. Wonderful life: the Burgess Shale and the nature of life.

New York: Norton, 1989. 2. Healthy People 2000: National oral health promotion and disease

prevention o b p v e s . Washington, DC. US Department of Health and Human Services, 1991; DHHS pub no (PHS)91-50212.

3. Weintraub JA. The advantages of indudingdental public health in schools of public health in the United States. Community Dent Health 1991;8:59-67.

4. Hughes JT, Rozier RG, Ramsey DL. Natural history of dental diseases in North Carolina 1976-1977. Durham, NC: Carolina Aca- demic Press, 1982.

5. Shugars DS, 0"iel EH, Bader JD,eds. Healthy America: practition- ers for 2005, an agenda for action for US health professionalschools. Durham, NC: Pew Health Professions Commission, 1991.

6. Enthoven A, KroNck R. A consumer choice health plan for the 1990s: universal health insurance in a system designed to promote quality and economy. New Engl J Med 1989;32029-37.