September 2012, Volume 8, Issue 9
Published by AEGIS Communications
Caswell A. Evans, Jr., DDS, MPH
A childhood stoopball accident ignited an interest in dentistry in this public health leader from Harlem who is now the Associate Dean for Prevention & Public Health Sciences at one of the nation’s most diverse dental schools.
INSIDE DENTISTRY (ID): What led you to a career in dentistry?
CASWELL A. EVANS (CAE): I would have to say it happened accidentally—literally. A childhood accident while playing stoopball, a popular game in my Harlem neighborhood in New York City, placed me in the care of an orthodontist. It was this experience that ignited my interest in the specialty, which I sustained throughout college and dental school at Columbia University.
However, while my first thought was of practicing in Harlem to care for people of modest means like my own family, at some point in dental school, my interest shifted to prevention. This led me to Dr. Irwin Mandel, who was not only able to answer my questions but was able to reassure me that I was asking the right questions for someone interested in preventing dental disease. Irwin, who established the Center for Clinical Research in Dentistry at Columbia and was a pioneer in salivary research, became my mentor and guiding light.
ID: How would you describe your vision of the best practice of public health?
CAE: When public health is successful, it’s invisible. That is, nothing happens, because there are no emergencies, such as disease outbreaks or food-borne illnesses. The unfortunate thing about this is that it’s hard to celebrate or take credit for something that doesn’t happen, or to gain appreciation and continuing support for the adverse events that don’t occur because of the dedication and hard work of public health workers. While no one complains when fire trucks don’t leave the firehouse for a week because of successful fire prevention, it remains a challenge to derive that type of appreciation for successful public health efforts.
But beyond the emergencies, public health endeavors to promote health, which the World Health Organization defines not just as the absence of disease, but also physical, emotional, mental, and spiritual well-being. Even so, what we do as healthcare providers is far less influential in terms of health status than the environment, the economy, employment, and education. In that regard, employment, the economy, and education become significant elements of concern and activity in public health because they all have a bearing on the health of populations.
ID: What attracted you to pursuing a career at the University of Illinois at Chicago (UIC) College of Dentistry?
CAE: UIC to me is a unique dental school in that it has made a very strong commitment to addressing the issues of health disparities and the plight of underserved and vulnerable populations. Its 2010 vision statement focuses on patient-centered, evidence-based clinical care founded on the preventive and public health sciences. It is also among the most diverse dental schools in the country, serving one of the most diverse populations in the country. My own title and rank within the school—Associate Dean for Prevention & Public Health Sciences—reflect its dedication to producing dentists who are much more knowledgeable regarding the issues of access to care and health disparities in underserved populations and holding the dental education institution responsible for producing that type of dentist as a product of its education and training efforts.
With that type of support, we have developed a remarkable set of community-based service-learning experiences beginning in the first year, but culminating in a fourth-year course during which students rotate through three, four, and sometimes five different community-based service settings, with a format of 1 week at a site followed by 1 week at the college for an 8-week cycle. The process is repeated at another site for another 8-week cycle, and so on. This is a required 12-unit course that is for credit and graded. The sites are specifically selected to provide a full and rich range of different types of delivery systems. For example, we partner with several Federally Qualified Health Centers (FQHCs), and each is based in a different kind of community or serves a specific population—eg, rural, predominantly Hispanic or African American or migrant workers in Colorado—or serves a specific population, such as developmentally disabled patients. Two sites provide care via mobile vans. We also have centers in Guatemala and China and expect to have one in Tanzania in the near future. Each of our 20 partner sites is a medical–dental facility in which oral health is highly integrated into the healthcare delivery system.
Beyond the issues of access to care and oral health disparities, and because a purpose of these experiences is for students to develop a greater understanding regarding the richness and diversity of the health service delivery system, the course has had an insight-expanding influence on the students. In addition, many students find positions with these healthcare centers after they graduate.
ID: Do students have opportunities to interact with other health professionals in this program? Does UIC also promote student research?
CAE: Students have ample opportunity to interact with nursing staff, medical staff, or whoever else is involved in the health clinics in which they serve. We are also currently in discussion with other colleges here at the university that are interested in exploring the possibility of using our community-based service-learning framework for their students seeking placement in community-based settings. It would be a wonderful model to have dental, medical, nursing, and pharmacy students, as well as those in public health, simultaneously experiencing these types of exposures to the different facets of the health system at these sites.
There is no conflict at all between community-based learning and research. Students are encouraged to become involved in research, and Clinic and Research Day at UIC College of Dentistry is always well attended. For students who are particularly committed to research, this course provides some flexibility to accommodate their research interests. A few students here are in the DMD/PhD curriculum in which there would be a greater emphasis on research.
ID: What is the significance of Surgeon General’s Reports in general and the Surgeon General’s Report on Oral Health in particular?
CAE: Surgeon General’s Reports are very important. They can be authorized for any number of reasons to make the public aware of health issues, such as new developments or prevention opportunities. They are also relatively rare; when the Surgeon General’s Report on Oral Health was completed in 2000, there had only been about 50 previous Surgeon General’s Reports, and about half of them were part of a series on tobacco use and health that was mandated by Congress.
I was pleased when I learned that there was an intention to develop a Surgeon General’s Report on Oral Health—not dentistry—and was thrilled to be asked to play a lead role in developing the report. The report was released during the term of Surgeon General David Satcher. It was a great experience working on the report for Dr. Satcher, and especially rewarding, given all the frequent references still made to it in the current literature.
In terms of main findings—eg, those included in the executive summary—some may be intuitive for those of us who work in the field. However, when placed in the context of being spotlighted by the Surgeon General, a position appointed by the President of the United States, they are quite profound and impactful. The messages that resonated then and continue to resonate are those that make it clear that oral health is more than teeth. It established that oral health includes the entirety of the oral cavity, but even beyond that, it is how people see themselves and how others see them; it affects their ability to be employed in certain settings, as well as their ability to be promoted.
Other critical components that had previously received scant public attention are the issues of oral health disparities and access to care. The report also drew out the connection between oral health and general health and welfare—that is, the report provided a powerful reminder that the jawbone is connected to the “toe bone” and is influenced by everything in between. It made it clear that the mouth should not be considered an “out of body experience.” The report stated that everyone has a stake in oral health and should be concerned about their oral health status as well as that of their family and community.
ID: What main benefits followed that raising of awareness to the issues and the public debate that ensued?
CAE: To make firm causal attributions to a Surgeon General’s Report for any specific subsequent developments is difficult because there is no associated programmatic infrastructure for implementation or for evaluating outcomes. However, it seems to me the composition of the groups and people involved in oral health have substantially increased and now are vastly different than before the Surgeon General’s Report on Oral Health was released. I have to credit some of that development back to that report. I believe that the discussions we are having today—particularly on access to care and health disparities—had their recent seminal origins within the report. Even more importantly, these discussions are also now taking place outside the dental and oral health community. What we now have is a far richer variety of organizations, interest groups, and activists at the oral health table, because they see the linkages between their agenda and an improved oral health agenda.
We can also trace the origins of several state oral health plans and initiatives such as the Robert Wood Johnson Foundation’s Pipeline Project, which proved to be of great benefit to many dental schools, to the Surgeon General’s Report on Oral Health. Several other foundations also structured their project solicitation proposals on the thematic framework of the report.
There were responses from groups that surprised me. They included the business community, which was made aware of the toll that poor oral health takes on their workforce in terms of absenteeism, and advocacy organizations, which came to recognize facets of those oral health concerns as being among the issues of social justice and social welfare.
ID: What led the Institute of Medicine to form a committee—on which you served—and write a report on improving access to oral healthcare for vulnerable and underserved populations? What was the gist of that report?
CAE: In 2011, the Institute of Medicine produced two reports related to oral health, one on advancing oral health in America and one on improving access to oral healthcare for vulnerable and underserved populations. I was privileged to serve on the committee that produced the improving access report.
Both of those reports were commissioned by the Health Resources and Services Administration (HRSA), and both reports were commissioned in the context of providing suggestions and recommendations to HRSA regarding actions relative to its organizational oral health initiative. The initiative is intended to provide a basis for a greater coalescence for various activities in HRSA that fall under oral health. While both reports were specific to HRSA, the nature of the questions were generic to the point that they would have applicability outside HRSA, not only in terms of the questions but the deliberations and rationalizations for answering the questions. So while these reports can be viewed as IOM’s response to HRSA, they were also distributed among the public and within Congress. IOM Reports, just like Surgeon General’s Reports, have a wide readership.
The report that focused on access to care for the underserved included the recommendation that HRSA should convene stakeholders from public and private sectors to develop a core set of oral health competencies. These competencies could then facilitate workforce expansion that would enable additional healthcare professionals and other health workers to provide oral health services to fill in gaps in the current system of dental care and disease prevention. This could mean additional opportunities to apply occlusal sealants and fluoride applications, and to offer health education and prevention messaging for a broader range of patients. Another issue raised in the report was the need to attract a more diverse student body and faculty in keeping with the demographic profile of the population. This point addresses a known barrier to access to care, as it is common for people to seek out and gravitate to providers who share their cultural identity.
ID: How would you characterize the access to care issue and how can it best be addressed by the profession?
CAE: I think that oral health today is, across the board, better than it was 20 years ago largely because of the greater ability to prevent dental caries—for example, through community water fluoridation, increased use of sealants, and fluoride gels and varnish, among other interventions. However, there is clear evidence that the office-based oral health benefits are not spread evenly across society. Populations that are disadvantaged and subject to health disparities make up approximately one third of the US population; they are generally composed of those of low socioeconomic status and include young children, adolescents, women who are pregnant, people with special needs, the elderly, people of color, those in rural or urban underserved areas, the uninsured and publically insured, the homeless, and institutionalized people.
That broad sections of the population have not received many of the benefits of greatly improved oral healthcare should be a concern to all practitioners, as a matter of pride. If we as a group are the only ones licensed to provide this care, and broad segments of the population don’t have access, it seems to me there is an obligation to then step up to the plate and develop new models and systems through which care can be provided so we don’t have disparate opportunity regarding to access to care.
To both dentists in practice and students contemplating practice, my message is this: This is something we all need to be serious about and working on more diligently. I don’t think anyone benefits when we have such large segments of the population that are left out.
The challenge is to develop functional and reliable means by which equitable access to oral health care can be achieved for all, dissipating health disparities. Doing this won’t require a lot of sacrifice on the part of any single individual. However, if everyone did at least a small part to ameliorate these problems, their magnitude could be reduced.
About Dr. Evans
Caswell A. Evans, Jr., DDS, MPH, is the associate dean for prevention and public health sciences at the University of Illinois at Chicago (UIC), College of Dentistry and has a joint appointment as the UIC School of Public Health. He has been appointed to the Chicago Board of Health and is a member of the Institute of Medicine. Dr. Evans was the executive editor and project director for “Oral Health in America: A Report of the Surgeon General,” released in May 2000, and subsequently directed the development of the National Call to Action to Promote Oral Health, released in April 2003.