4 The Practice of Dental Public Health
Public health is one of those aspects of life that most people take for granted, or more likely don’t think about at all. We take for granted that we can drink a glass of water without thinking about cholera, choose a restaurant without concern about rats in the kitchen, and buy a can of vegetables without worrying about botulism. The source of the occasional outbreak of food poisoning is rapidly identified by the authorities, and thoughts of scarlet fever, typhoid, and poliomyelitis simply never enter our heads. To many of the younger generations, dental caries is almost as distant as those infectious diseases of the past. But this happy state of affairs has not just happened; rather, it is the end point of years of public health research and practice.
The low profile of public health has both good and bad aspects. Although it is good that mostly invisible basics like drains, sewage treatment, fluoridated drinking water, and immunizations against infectious diseases are part of the accepted institutions of modern life, it is not good that most people have so little grasp of how public health functions. It is not good because, without a constituency to press for it, funding and legislation for public health can be eroded, with subsequent threats to health and the quality of life. By way of contrast, everyone is acutely conscious of access, or lack of it, to personal health services, and that subject is a constant political issue. As is described later, development of the public health infrastructure has taken a long time and has required some painful lessons in lifting our quality of life to its present level.
The purpose of this chapter is to examine the structure and practice of dental public health in the United States and to develop the theme that dental public health and private dental practice need to work together for the good of the community’s oral health.
Health is an elusive concept to define. The World Health Organization (WHO) definition64 is often quoted. It states that “health comprises complete physical, mental, and social well-being and is not merely the absence of disease.” Noble indeed, but too idealistic to be of much practical value. A sociologist’s more pragmatic definition is that health is “a state of optimum capacity for the performance of valued tasks.”37 This is a more useful definition in that it presents health as a means to an end, that of maximizing the quality of life, rather than as an end in itself.
Public health, too, does not lend itself to easy definition. Among the many definitions that have been formulated, Winslow’s is the most widely accepted and quoted. Winslow defined public health as “the science and art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts.”63 The generality of Winslow’s definition has much to do with its widespread acceptance; however, it still provides little working knowledge of public health. A more businesslike definition is “the organization and application of public resources to prevent dependency which would otherwise result from disease or injury.”39 In this context, dependency is defined as a condition in which external resources, such as an attendant or medication, are required for the individual to carry out the routine activities of daily living. Just as some definitions of public health can be vague and idealistic, however, this one might go too far in viewing dependency as the only outcome to be avoided. Public health should deal with quality-of-life conditions, rather than just those that result in death or dependency, when it is economically reasonable to do so.
A more useful definition of the public health mission, one that accepts health as a means rather than an end, is “fulfilling society’s interest in assuring conditions in which people can be healthy.”23 That seems to encompass everything from maintaining the stratospheric ozone layer to picking up the garbage to providing recreational facilities, decent housing, or dental care where needed. This definition might have been ahead of its time in stressing the public responsibility for a healthy physical and social environment, while still leaving some room for personal choices (“… in which people can be healthy”).
These three domains have become the foundation for evaluating many aspects of the public health mission. The 1988 IOM report concentrated primarily on the role of governmental agencies in public health, and it came up with the somber conclusion that the public health system in the United States was “in disarray,” deficient in many areas: availability of trained personnel, communications, networking, and of course funding. The IOM’s follow-up assessment in 2002 found that too many of those problems were still present.24
This 2002 IOM report incorporated the broader, more inclusive view of public health that emerged with the new century. This view states that, although governmental agencies remain the backbone of the public health system, they cannot and should not do the job alone.24 The IOM report goes beyond the traditional view of individual responsibility for health and bases its recommendations on the concept of population health, alluded to in the 1988 IOM definition but not clearly spelled out. Population health is defined as “the health of a population as measured by health status indicators and as influenced by social, economic, and physical environments, personal health practices, individual capacity and coping skills, human biology, early childhood development and health services.”24
The essence of understanding population health is grasping that people’s health is a function of more than just biology and other individual clinical factors. People influence, and are influenced by, the values and beliefs of the broader community in which they live and work. To illustrate, exhorting a person to stop smoking is likely to be fruitless if everyone in that individual’s world smokes and smoking is an important part of the person’s social interactions. Attempts to persuade a person to eat more vegetables will fail when the social environment calls for a diet of deep-fried foods or when local food stores do not stock the needed items. All of this means that, in the promotion of public health, the governmental public health agencies need to coordinate with community-based organizations, the health care delivery system, academia, business, and the media if good population health is to be achieved. A shift of the mindset more toward population health and away from purely individual health could help the United States reduce anomalies such as expenditure of 95% of health care dollars on medical care and biomedical research when there is evidence that behavior and environment are responsible for 70% or more of avoidable mortality.24 The United States is easily the world leader in health care expenditures, but its scores on health status measures are well down in the list. A shift in where we invest our health care resources would help redress that imbalance, though this is not easy in a society in which individualism is dominant (see Chapter 3).
The core of public health practice is shown in Box 4-1, which presents a succinct definition of the mission and essential services that only public health can provide. This statement, developed by the American Public Health Association in 1994, has since received virtually universal acceptance.
Ask people in the street whether they consider human immunodeficiency virus (HIV) or West Nile virus a public health problem, and most will give a resoundingly affirmative reply. What about deaths from traffic accidents? There will be more equivocation, even though the number of deaths from road accidents in 2000 was three times higher than that from HIV-related disease.58 Substance abuse similarly is seen by most as a major social and public health problem, but fewer would view infant mortality as such a problem, even though the United States had only the twenty-eighth lowest infant mortality rate globally in 1999.59 So, given that handling a public health problem demands some allocation of resources and some opportunity costs, how is a public health problem determined?
Over the years some criteria have emerged for its definition. Blackerby, for example, listed them as the following: (1) a condition or situation that is a widespread cause of morbidity or mortality, (2) there is a body of knowledge that could be applied to relieve the situation, and (3) this body of knowledge is not being applied.10 However, these criteria seem unduly restrictive. For example, the Black Death in the fourteenth century killed off one third of the population of Europe in 3 years. There is no question that it was a public health problem, even though there was no body of knowledge on how to deal with it. Subsequent epidemics of typhoid, cholera, yellow fever, and other infectious diseases were also public health problems before there were effective means to deal with them, and the same can be said for some viral infections today. The nonapplication of effective treatment for a problem, as suggested by Blackerby,10 is more a breakdown in public organization, funding and personnel resources, or political will.
Additional criteria can broaden the scope of what constitutes a public health problem. Public perception is one, as in the earlier example of the HIV epidemic. If enough of the public perceive a public health problem, then the mandate exists to allocate resources to deal with it. HIV is in that category (even though the only means to prevent its spread, apart from the barrier precautions in medical and dental practice, are behavioral modifications). Not only public perception, but governmental perception, goes far toward defining a public health problem. When a government assigns a problem to its public health agency for attention, virtually by definition it is a public health problem. If a president, governor, or mayor defines a public health problem by decree, then a public health problem it is, whether or not public health professionals agree. These latter two types of decision, legislative mandate and executive order, can have the advantage of ensuring immediate action as well as the potential disadvantage of disturbing the orderly process of program planning and operation.
To use cigarette smoking as an illustration, the first condition has been satisfied based on the first report of the Surgeon General of the United States in 1964,53 and there is no question that the second condition has also been met. These criteria have also been met for the HIV epidemic. Allocation of public resources to deal with a recognized problem is a logical consequence, although not a criterion for problem recognition. In the case of cigarette smoking, there has been considerable action through widespread public education campaigns, advertising bans, and efforts to block the sale of cigarettes to minors. On the other hand, the public is divided about condom distribution and needle-exchange programs intended to inhibit the spread of HIV infection.36
Early public health practice in the colonies on the eastern seaboard naturally reflected the English experience. The first English Poor Laws, dating from the seventeenth century, put the burden of caring for the disadvantaged on the local community. This was rational enough in an agrarian society when people didn’t move around. However, when the Industrial Revolution took hold in Britain during the late eighteenth century the Poor Laws broke down, for industrialization was really a massive social revolution.51 Mass migration to the cities created overcrowding, disease, and epidemics, while the laissez-faire economic attitudes of the time led to great wealth for some, the emergence of a middle class, and appalling squalor for many. The Poor Laws, which dealt only with the relief of destitution, were not designed for these completely new kinds of social and health problems.
The ideology of laissez-faire economics in Victorian Britain, combined with an acceptance of Malthusian theories of population growth, led to only grudging action to improve the lot of the destitute. Malthus, a nineteenth-century English country clergyman, wrote that unrestricted growth of population would eventually exceed the expansion of the food supply.32 The growth of population therefore needed to be checked, either by “moral restraint” or by the inroads of starvation, disease, or other disasters, which Malthus grouped under the cheerful heading of “misery and vice.” Public attitudes at the time were such that Malthus struck a sympathetic chord with his views that terrible living conditions were not the result of uneven socioeconomic development but rather the consequence of necessary natural laws. Given these views, new public welfare programs that were degrading to their recipients were perceived as being in the public interest as well as morally justified.
Although British provision of health services subsequently turned full circle to the establishment of a National Health Service in 1948, these condescending views on public health and welfare were the norm when organized public health development began in the United States during the nineteenth century. It was an environment in which public health could not grow much beyond attempts to limit the spread of epidemics. Not surprisingly, nineteenth- century industrialization produced the same pattern of social turbulence in the United States that had occurred earlier in England.13 At a local level, similar upheavals are seen today, when the abrupt closure of an industry can blight the vacated community. These disruptions take place now in a highly mobile society, in which the old Poor Law approach that local communities should be fully responsible for public assistance is clearly obsolete. In modern-day industrial and postindustrial society such problems are national in scope and should be treated that way.
One reason why the modern American approach to public health and welfare differs from the current British model is that the stern puritan views of the early European settlers have had a more sustained influence on public policy in the United States than they did in Britain and Europe. One expression of the puritan ethic in the United States was that general welfare relief and payment for health care services for the indigent remained linked together longer than they did in European countries, which compounded rather than disentangled the problems.49 When this is added to the American culture of individualism and the relative freedom from the wartime cycle of social disruption and reform, we can see why communal attitudes toward health and environment have never really flourished in the United States (see Chapter 3).
Dentistry did not play a significant part in the early development of public health in the United States. Oral health was of little concern at a time when the population was decimated periodically by typhoid, diphtheria, cholera, smallpox, and gastroenteric diseases. Although a few public clinics were established on a voluntary basis by dentists as early as the mid- nineteenth century, public dental care facilities remained almost nonexistent for many years.42 The U.S. Public Health Service, for example, did not employ dentists on a regular basis until 1919,43 and philanthropic dental clinics such as Eastman, Forsyth, Guggenheim, Mott, and Strong-Carter all opened between 1910 and 1930.
Dental public health is one of the nine board-certified specialties of dentistry in the United States and was certified in 1950. The American Board of Dental Public Health adapted Winslow’s definition to develop one subsequently approved by the American Association of Public Health Dentistry, the Oral Health section of the American Public Health Association, and the American Dental Association (ADA). That definition is as follows:
Dental public health is the science and art of preventing and controlling dental diseases and promoting dental health through organized community efforts. It is that form of dental practice which serves the community as a patient rather than the individual. It is concerned with the dental education of the public, with applied dental research, and with the administration of group dental care programs as well as the prevention and control of dental diseases on a community basis.2
Implicit in this definition is the requirement that the specialist have broad knowledge and skills in program administration, research methods, the prevention and control of oral diseases, and the methods of financing and providing dental care services. Box 4-2 is the dental corollary of the essential public health functions summarized in Box 4-1, a concise listing of the essential functions of dental public health (sometimes referred to as core functions) as adopted by the Association of State and Territorial Dental Directors (ASTDD).