Lois Cohen

In the beginning

My earliest career exposure began in 1964, other than being a lifelong dental patient and growing up before widespread community water fluoridation nor fluoride–containing dentifrice were available. I was a newly minted Ph.D. in sociology who was recruited to the Division of Dental Health in the then-called U. S. Department of Health Education and Welfare (n.b. now known as the U.S. Department of Health and Human Services or DHHS). (1) That Division already had employed a complement of social and behavioral scientists in their Social Studies Branch but they wanted another sociologist to work with Robert M. O’Shea, a pioneering sociologist whose work focused on oral health and health care. Bob O’Shea mentored me and gave me my first assignment to read The Survey of Dentistry (2). It was the final report of the Commission on the Survey of Dentistry in the United States of the American Council on Education and published in 1961. This volume served as my orientation to the field and the window through which I would learn to know the state-of-oral health of the U.S. population, its oral health workforce for clinical practice, education and research and how that workforce was organized, educated and financed. Since then, there has been no update in a single volume but rather documents from the Surgeon General on specific aspects of either the nation’s oral health(3), the National Academy of Sciences  reports on the ability to deliver care to the nation(4), the health professions educational needs(5) or most recently workforce needs(6).

The very first research project to which I was assigned focused on the problem of low compliance by the nation’s dental clinicians of oral cytology that was heavily promoted by the U.S. Public Health Service for the early detection of oral cancer. Much money had been spent through the State Health Departments to provide access to laboratory analysis and to reimburse practitioners for each cytology and biopsy taken.  Bob and I both worked with the dental public health officials, oral pathologists, organized dentistry and surveyed a sample of dentists, even identifying leaders and followers to assess communication patterns. The idea was that using sociometric methods to determine leaders, these leaders might serve as persuasive change agents to speed adoption of the then new innovation for the benefit of their patients. Those early intervention studies that utilized tailored materials to appeal to the experimental group of leaders, yielded surprising clues for us that had less to do with the problems associated with cytology but more to do with the reluctance of clinicians to deal with ‘life-death’ decisions(7).  It was not because they were too busy or were not being paid to adopt either soft tissue screening or biopsies, rather they had not felt comfortable at that time dealing with soft tissue. They were trained to deal with hard tissue. They viewed soft tissue issues to be in the domain of physicians and it was difficult to persuade them that by the time they see a lesion for referral to a physician, it may be too large and too late for the patient’s survival. It became clear that the implication for expanding the scope of the dental profession basic education had not yet been tackled in the nation’s dental schools. Medical schools at the time, and still today, lack curriculum related to the oral cavity…suggesting the black-hole that was being ignored. Such was my first real hands-on exposure to what a sociologist might term ‘culture lag’…reflecting the disconnect in time and understanding between the state-of-the-science and the adoption of scientific innovation. This phenomenon was to repeat over the years, the science related to fluorides and the adoption of fluoride varnishes or the use of sealants…and the resistance of the public to vote for community water fluoridation…were all examples of that notion.

There were other studies commissioned by Federal dental staff that required the perspective of other social science disciplines: public opinion polling was done on a regular basis and probed knowledge and reported attitudes and practices related to personal dental health, pre-paid dental care, prestige of the dental professions (as there had been a shortage of personnel in the 1960s), oral cancer, periodontal disease, experience with auxiliary personnel and the provision of care by women dentists and more. Questions were asked related to who becomes a dentist and why, recruitment strategies, educational research focused on incorporating community and public health into the dental curriculum as well as material on disease prevention and health promotion. The talents of medical anthropologists, political scientists, health economists, health educators, health services researchers were added over the years. Many of these studies were contracted for with external organizations or supported through research grants primarily awarded to academic institutions. These studies have been reviewed and results summarized in a number of publications but at least three books co-published with the Federation Dentaire Internationale (FDI) document those achievements (8) (9) (10). In 1981 an historical overview was published of the field as it existed and as the community was about to set forward a research agenda for the next decade and beyond (11). It was on this occasion that it was noted that cross-national research was essential for solving the social problems endemic in one’s own social and cultural context. Finding ‘out-of-box’ ideas required the broadest perspective possible without being limited to geographic boundaries in which any investigator worked nor from whence came the source of his/her research support.

Expanding horizons beyond the U.S.

The search for answers to the questions faced in the U.S. could not be addressed adequately by limiting ourselves to our own national borders. This fact became crystal-clear in the late 1960s during the term of U.S. President Richard M. Nixon as his Republican Administration had proposed a national health program to cover Americans health needs. At that point the President’s proposal resembled the Japanese health care systems in which half the population was covered by employer-based health schemes and the other half of the population, not working in large corporate settings, would be covered by a national government program. Late Senator Edward Kennedy, a Democrat from Massachusetts, had proposed a single-payer scheme similar to UK’s National Health Service model. Others proposed models similar to that of the Federal Republic of Germany, which started in Bismarck’s time, included 2000+ social insurance funds to which most people, except the most wealthy, belonged and those funds negotiated fee-for-service rates with the national authority on an annual basis. While there were other schemes proposed, the U.S. dental community was at a loss to come up with recommendations as the only evidence we had resulted from the fee-for-service system prevalent in the U.S., as there was very little happening in the pre-paid dental insurance field in those days. Our Chief Dental Officer, and Assistant Surgeon General, John C. Greene, agreed that there was a need to examine the evidence from other countries where dental services were included in national health plans. He approached the Chief of Oral Health at the World Health Organization in Geneva, Vladimir Rudko, a Russian national and both agreed (despite the ‘cold war’ between our countries) that we needed an international collaborative study that was systematic, scientifically designed and neutral to assess the structural characteristics of dental systems with their oral health outcomes, measuring both effectiveness and efficiencies. Thus in 1970, the first contractual arrangement was signed and the WHO/USPHS International Collaborative Study of Dental Manpower Systems in Relation to Oral Health Status was launched. Dr. Rudko designated David E. Barmes, his WHO oral epidemiologist and Dr. Greene designated me to co-lead this effort that after much site visiting and review finally encompassed ten industrialized national sites in the first study: Australia, Canada, Democratic Republic of Germany, Federal Republic of Germany, Ireland, Japan, New Zealand, Norway, Poland and the U.S.. Partnering were the FDI and all the respective national dental associations and the national governments who contributed to the collaborative support of this enormous undertaking. It was the largest dental study ever launched with over 30,000 public respondents in total, representing three age cohorts. I addition data were collected from 100 dental providers and other administrative personnel in each national site (12). A second international collaborative study, paralleling the first but extending the age cohorts to include a 65-74 yr. old elderly sample was implemented more than a decade later (13).

The intent of all participating governments and academic colleagues was to look at their own dental delivery system and also to look across systems to identify structural characteristics that might work effectively and efficiently. The intent explicitly was not to adopt entire systems to transplant those to another geographic and/or socio-cultural or economic context…though there were some dental leaders who had been advocating such an approach over the preceding years.  While the length constraints of this manuscript do not permit summarizing all the results, the major point to make is that the quest for evidence-based answers lies not only within one’s national borders…but must allow for viewing a diversity of options anywhere on the planet where alternative ideas might exist. Just to give the reader a flavor of some major policy issues that resulted from that effort included: the value of dual systems for children and adults; factors driving sustained utilization of services across the life-span; the power of prevention and the balance with curative treatment services; the importance of culturally-driven practices and norms for oral health; and issues of retreatment needs and the quality of services. Hypotheses that drove the design, specifically that the more available, accessible and acceptable the dental services were, the better the oral health of the respective populations, were rejected hypotheses in the end for the policy issues enumerated above seemed to explain more the variance in oral health (14).

The enigma of disparities

For me, out of all the provocative findings of both the ICS-I and the ICS-II as these studies became known, I was most startled by the fact that while my own country’s average oral health scores appeared favorable when compared cross-nationally, those outcomes were ranked the worst when the scores were disaggregated. In other words, the gap between the very best scores and the worst scores was widest in the U.S. than for any of the other country samples(15). The difference between those who had the very best health outcomes and those who had the worst is what today we call the oral health disparity.

Those discussions of health disparities are global as evidenced by the need for the WHO Commission on Social Determinants of Health (16), the latest report of Sir Michael Marmot’s The Health Gap (17) and to the International Association for Dental Research’s Global Oral Health Inequalities Research Agenda (GOHIRA) (18), the focus is on reducing, and, hopefully, eventually closing those gaps in health and oral health.

Similar discussions in the field of public education occur in the U.S. as we rank globally lower than desired in the STEM fields. From all these discussions and others, the concept emerges of equity vs. inequalities. Equity and equality are two different policy approaches to arrive at fairness. Equality assumes everyone starts out at the same level and we can treat everyone the same. We also know that is not the case in most places, or anywhere for that matter. The genetic and biologic variation alone, coupled with social and environmental exposure predispose to differences in health need. Equity becomes the option of choice as it implies that policies should be adjusted to meet the needs of each individual. Equity is more difficult and expensive a choice and might appear unfair as some people will not understand why others receive fewer or more services. And yet an equity framework is one that makes the most sense if the intent is to close the gap between need and health services. Let us think about this in more concrete terms. Take children’s health, as a case in point. If we were to provide every school with a school dental nurse, this would be an ‘equality’ strategy. Equity, on the other hand, would suggest setting a ratio of specified services based upon the oral health needs of the children in a given school. Fixing inequities requires intentionality, taking calculated risks of setting personalized goals. Am not certain that our community has begun to think in these terms… but I may be wrong.

An equity framework to deal with the burden of oral diseases

The global burden of oral diseases continues to be documented (19) (20) (21) and may be known in the oral health community…though certainly not all of the oral health professions pay attention to global health. Educational material on global health is not required, nor evident, in many of the U.S. dental schools. There is a fledgling effort to develop global oral health competencies but there is not yet a systematic curriculum module (s) devoted to this domain (22) (23) (24).

An even greater political issue is that those in the global health community who influence academic, national and global health policies, rarely address the global burden of oral diseases. That, perhaps, is a consequence of where articles are published: most are published in dental journals rather than in global health journals. Such circumstances represent a double burden of failure to recognize a ‘social problem’ when documentation for the social problem exists either within a given country, a set of countries or a region of the world. What is needed is an advocacy function at several levels: grass roots among oral health practitioners of every category; and advocacy at the broader public policy levels reaching out to partners in the health team initially but to partners outside the health sector subsequently.

I have come to this place in my thinking and career development through the realization that advocacy is not a subject taught in the dental professions, nor even in academic sociology of my own background. It certainly is a skill not learned on my job either as Federal employees are restricted in this area. Yet, it is a necessary piece in the process of translating and exchanging what we know as scientifically obtained data to the user communities of interest.  After a career as a research sociologist, a health policy analyst, a health science administrator, I find myself in semi-retirement mode serving as an advocate (i.e. consultant and Paul G. Rogers Ambassador for Global Health Research). Basically, I am free to share knowledge, opinions, beliefs, even values, and I have chosen to do this in partnership with institutions and organizations in the public and private sectors…but more of this later.

Suffice it to state that an attempt was made by Scott Tomar and myself, prior to the enactment of the Affordable Care Act (ACA) legislation signed into law by President Barack Obama, to identify attributes of an ideal oral health care system (25). We examined policy statements and position papers prepared by the WHO, the U.S. National Academies of Science, the U.S. Government’s Healthy People documents and documents produced by the American Public Health Association (APHA) and the American Association of Public Health Dentists (AAPHD). While the U.S. had made strides in achieving some of advances proposed in those documents, particularly in the area of prevention and oral health monitoring, in many other areas notably, integration of oral health with the rest of the health care system, the U.S. fell short. Perhaps one of the reasons might be argued that the organized profession chose that dental services be considered separately.

Being at the table

Advocacy for inclusion of oral health as part of a health rights agenda with the purpose of improving population health in the U.S. or elsewhere on the globe, requires the inclusion of ‘oral health’ players at the table where other stakeholders are convening and developing equity dialogue (26). Perhaps no greater opportunity has presented itself as the one occasioned by the United Nations Political Declaration of the High-Level Meeting of the General Assembly on the Prevention and Control of Non-Communicable Diseases (27). This 2011 declaration represents only the second time in the U.N.’s history that health was a subject for heads-of-state; the first was in 2001 when they held their summit on human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS). In 2011, the heads-of-state for the very first time included oral health, recognizing oral diseases as a major public health problem and that these diseases share common risk factors with other major non-communicable diseases (NCDs) as heart diseases, cancer, respiratory diseases and diabetes (28).

To quote from the editorial some of us authored soon after this meeting,

 “what does this political declaration mean for oral health? We believe that it provides recognition and clarity, integrates oral diseases into one of the emerging mainstreams of the international health discourse, and constitutes an obligation for governments, but first and foremost for the international oral health community.” (28)

This NCD declaration marks a shifting movement from global health as an infectious disease-focused movement towards that of chronic diseases and by so doing, allows for the possibility even of a double burden of diseases, infectious and chronic, that characterizes so much of the least developed nations of the globe. Certainly mixes of infectious and chronic diseases exist everywhere in varying proportions. However, what is crucial is that oral diseases are not an after-thought but can be addressed as an essential part of a nation’s development plan. As the Head of the U.N. Development Programme, Helen Clark, told the audience assembled by Tanzanian President Jakaya Kikwete during the summit at New York University on Putting Teeth into NCDs…”oral diseases are obstacles to development. Something as preventable as tooth decay can impair people’s ability to eat, to interact with others, attend school or work. These consequences all detract from human wellbeing, economic potential and development programs.” (29)

License to act

As a result of this proclamation, the health agency of the U.N., the World Health Organization (WHO), was directed to develop targets and indicators for the NCDs. Using its authority to set norms and standards and articulating policy options for Member States’ consideration, WHO provides technical support and helps monitor and assess health outcomes. It does this from its central headquarters in Geneva and through its six regional offices, the largest of these is WHO-AFRO in that it encompasses 47 of the 54 countries on the African continent. Perhaps because then President of Tanzania was the leading head-of-state to push for putting teeth into NCDs, that WHO-AFRO office has clearly taken a leadership role in spelling out the strategic options for action in that region. I commend the article by the Regional Advisor for Oral Health, Dr. Benoit Varenne, in the Journal of Dental Education, May 2015 (30). In this article, he lays out key interventions for each of four strategic orientations: 1) making operational disease prevention and oral health promotion; 2) scaling up universal access to oral disease control in primary health care; 3) strengthening oral health information systems and integrating surveillance of common risk factors; and 4) building up intersectorial action and sustained political leadership. He also identifies eight key expectations of the international oral health community expected by countries and programs:

  1. Hasten the generation of scientific evidence on the relationship between oral diseases and other non-communicable conditions, as well as their related risk factors.
  2. Contribute to the production and distribution of affordable quality oral hygiene products for all children.
  3. Contribute to research and development of a quality dental filling material that is affordable, safe, and environmentally friendly.
  4. Support operational research for development of preventive oral disease interventions integrated with NCDs (“Best Buys”) having significant public health impact that are highly cost-effective, inexpensive, and feasible to implement, especially in primary health care.
  5. Make use of information and communications technology to improve the capacity for surveillance and monitoring of oral health data, as well as awareness and education campaigns against oral diseases and common NCD risk factors.
  6. Increase emphasis on integrated prevention and treatment of oral diseases with NCDs into health professions training curricula at all levels.
  7. Advocate an increase in political commitment at the highest levels in favor of NCDs and related risk factors, as well as reinforcing public/private partnerships to support multisectorial actions.
  8. Mobilize resources and promote investment in all integrated programs of prevention and control of oral diseases with NCDs.

While this represents the first regional policy with an emphasis on integrating oral health within a more comprehensive strategy to achieve population health, it stands as an example of very specific guidance for advocacy. The final version of the AFR/RC66/5 Strategic document entitled “REGIONAL ORAL HEALTH STRATEGY 2016–2025: ADDRESSING ORAL DISEASES AS PART OF NONCOMMUNICABLE DISEASES” is now available. See attachment or click on the following link: http://www.afro.who.int/index.php?option=com_docman&task=doc_download&gid=10216&Itemid=2593 . In addition, the resolution AFR/RC66/R1 related to the oral health strategy  adopted by Member States the same day and that gives a supplementary political strength to the strategic document can be downloaded here: http://www.afro.who.int/index.php?option=com_docman&task=doc_download&gid=10440&Itemid=2593

It seems clear that academics, research institutions, oral health professionals have responsibilities, if not marching orders, to make a contribution to the future oral health of generations to come. While the NCDs will stand as one of the top priorities in the health agenda of the next decade or more, oral diseases have to become a priority target in that global framework.

Can we act and how?

Can we actualize any or all of these challenges and what will it take? Am not sure we have any existing template from the oral health community…other than our push to include oral diseases in the U.N. Proclamation on NCDs through the leadership of President Kikwete and his UN Ambassador, Modest Mero…that in the end activated other ambassadors of the UN membership. Before that, I am reminded of David Barmes’ target goal of 3 DMF when he held the position of leadership for oral health at WHO-Geneva and he was able to persuade and mobilize the network of WHO Collaborating Centers for Oral Health and all the Chief Dental Officers sent by their Ministries of Health to meet at the FDI World Dental Congresses and at the annual sessions of the International Association for Dental Research, both organizations in formal affiliation with the WHO. He managed to integrate 3 DMF as a target accepted by the World Health Assembly and consequently could be adopted by member governments. (31) (32)

Let us posit that the first step is to recognize leadership and to agree to work in a collaborative-participative style to effect systematic, consistent and reliable joint activities to reach a common agreed upon goal or set of goals. This is one strategy if that leadership could be identified, accepted and sustained over time.

An alternative model put forward by Paul Farmer, Jim Yong Kim, Arthur Kleinman and Matthew Basilico in their book, Reimagining Global Health (33) borrows lessons learned from the HIV/AIDS advocacy movement and its successes. This model of grass roots advocacy suggests that supporters of global health equity do not need to be in positions of authority or power but rather involve students, health workers, lawyers, people living with the disease and others who have meaningful roles to play…that they be engaged. Specifically the authors suggest:

  • Engage in critical self reflection
  • Find good partners
  • Know the issues
  • Start a dialogue with policymakers
  • Highlight key issues by writing letters, calling on officials, seeking public commentary, setting up meetings with change agents, placing commentary in the media
  • Organize a public demonstration
  • Build a coalition
  • Be the change- listen and have one-on-one conversations with peers. Create solidarity around a cause.

The authors go on to cite a hero of mine, the late former Surgeon General of the U.S. for whom I had the privilege of working both in Washington but also after he returned to Harvard University , Julius Richmond. He taught us three essential ingredients of policy: data or the knowledge-base; political will and social strategy (34) While any of these components is not easy to achieve, the third is the most difficult as the forces to maintain the ‘status quo’ are rooted in the prevailing social structures of the political economy.

As has been written by many others, the gradients for inequity are patterned by large forces beyond our own oral health community and lie in areas associated outside the health sector itself. Education, housing, agriculture, water supplies, jobs, cultural practices and norms, and the like are areas essential to health. The ‘Health-in-All-Policies’ (35) addresses this fact…but it need not be the insurmountable barrier towards getting started in this most critical challenge…advocacy for concerted and strategic action to impact population health.

Building the knowledge-base for change

Without an adequate body of evidence, gleaned from research specific to oral health outcomes, there is low probability that any social strategy could mobilize political decision-makers and public pressure to advance positive change. While the range of evidence from basic science to clinical and translational science as well as implementation science are all relevant and I have argued that all are essential and critical for investment by sponsors of research, the dental public health field uniquely lends itself as a natural vehicle for assessing and developing communications strategies to advance the body of evidence towards community and population health (36) (37). Whether one argues for increased investment in global health research in the US, as I do, but anywhere, the essential point to make is that such research can assist in closing the gap between what we already know and the reality of inadequate oral health for any given population in the industrialized world or in the developing world. Finding and testing affordable preventive, diagnostic and treatment strategies to deal with shortages of trained dental practitioners is a challenge for all nations.  The quest for answers to problems might exist anywhere as science knows no geographic boundaries. The model for carrying out the research, however, might be changing. As scientists working alone in their own laboratories have given way to collaborative team science, extending those teams to include interdisciplinary teams across national borders must supplant the old ways to embrace global alliances. The challenge is that research capacity does not distribute itself necessarily where scientific opportunity may reside. Consider the finding that 90 percent of research funds are concentrated on the problems of 10 percent of the world’s population: the 10/90 gap (38). Building research capacity where 90 percent of the world’s population lives becomes a real operational and morally-driven task to accomplish. Very often the diseases we need to study are found in greatest numbers and severity among this 90 percent. Performing ‘helicopter research’ to find the solutions to those problems is akin colonial exploitation. We need to address this dilemma both for global health research generally, but also, specifically, for building oral health research capacity. There is much that is being done, mostly in the biomedical area and sadly very few resources are being made available for oral health.

Global health diplomacy and its role

In my own capacity as an ‘ambassador for global health research’, I found myself involved in this emerging field of global health diplomacy. According to Tom Novotny and Ilona Kickbusch, two proponents and educators, global health diplomacy is a political activity that serves to improve health, while strengthening international relations (39)

The roots of global health diplomacy probably go back to the time of the first human migrations from Africa to other parts of the world – or at least to biblical times. For the sake of brevity, let’s only go back 160 years to 1851. In that year, European diplomats and physicians met in Paris to discuss and seek collaborative partnerships to secure commercial interests for their populations against repeated visitations of ‘pestilence’. In those days, ‘pestilence’ referred to the quarantinable diseases of cholera, plague and yellow fever.

While that occasion was followed by subsequent conferences over the years, today’s revised International Health Regulations (IHR) represent a consensus agreement within the World Health Organization’s  (WHO) Member States to support global responses to critical public health problems to share information as well as responses to these problems. (2) Whether the problems are named SARS, TB, H5N1, Avian Flu, MERS, Ebola, Zika or something else, it has become crystal clear from recent events that disease can stop nations from working, producing, exporting their products and services – thus putting those nations at an economic disadvantage in a global market. And in so doing, poverty grows and with poverty, political instability grows too. In such a context, health, foreign policy and diplomacy start to come together in ways that are tangible and real.

The Framework Convention on Tobacco Control (FCTC) is yet another example and was the very first treaty adopted on May 21, 2003 and implemented under WHO’s constitution. It has been signed by 168 countries and is legally binding.

Other examples of global health diplomacy have national security as a key driver. The control of biological weaponry to prevent either accidental or purposeful use, involving infectious agents or even non-communicable diseases, remains an important priority of most nations.

For many years, and perhaps the oldest example of global health diplomacy, represents a third driver. We are all aware of the mission of many evangelical organizations who provide health services globally in the cause of equity and social justice. Their example has spawned other non-governmental organizations to do the same.

Whether the driver is economic (in that weak economies effects poor health and development or that economic gain can accrue from growing markets  for health goods and services); or security (fearing global pandemics); or social justice ( reinforcing health as a social value…albeit a basic human right) – all are integral to global health diplomacy and all are relevant and directly applicable to global oral health.

NCDs can serve as a scenario for global health diplomacy. While oral diseases and conditions are clearly connected to the major life-threatening diseases of the heart, cancer, respiratory system and diabetes…through common risk factors as sugars, tobacco and alcohol use…and oral diseases are clearly ubiquitous and constitute an enormous burden on society…particularly where there are few if any oral health personnel to deal with prevention or treatment, a committed group of civilian powered diplomats can be a potent force for good…even for peace. Oral health and health share social determinants and in turn, those social determinants link to socio-economic development and those in turn, link to the Sustainable Development Goals…also newly adopted by all heads-of-state at the UN (40).

The movements to integrate oral health into the NCDs has involved hard work by many individuals and organizations and include the FDI, the American Dental Association, the International Association for Dental Research, the WHO staff in Geneva, the Americas and at the AFRO office. This is an example of global health diplomacy as they engage political leaders in real time. In this process of engagement, we learned some lessons. Four leap to mind:

  1. The health professional workforce and the diplomatic workforce together really are insufficient to tackle global health problems, oral or otherwise.

 Lesson: Collaborative partnerships are essential to engage civilian stakeholders.

  1. There is a strengthening of the science-base that indicates that the mouth is indeed connected to the rest of the body and many of the risk factors for diseases are shared in common.

Lesson: Collaborative partnerships with other health professionals and those from across other sectors of society associated with the common risk factors… need to be forged.

  1. Integrating global oral health initiatives with other global health initiatives, particularly those emphasizing prevention, together with development initiatives… would seem to make logical sense.

Lesson: Develop, test, disseminate and implement valid and reliable models of integrated initiatives (e.g. Fit for Schools (31A)).

  1. The pressure of global economic crises reinforces the need to leverage scarce resources. We need new models where all stakeholders are accountable. We need to learn from the newest of the economic powerhouses in China, Brazil, India and South Africa.

 Lesson: How to work in a multilateral way – involving countries in their own decision-making, fostering country  leadership, ownership and responsibility.

I share these thoughts expressed in August 2011 on the occasion of the launch of the Alliance for Oral Health across Borders, a non-governmental organization established at Temple University in Philadelphia, Pennsylvania. I asked at that time

What Can the Alliance Do?

  • Foster an academic response: Incorporate global health diplomacy into curricula, especially focused on executive training for mid-career and senior professionals.
  • Sponsor symposia in fora where business and industry meet, where academics and scientists meet, where clinicians meet, where policy analysts and policy-makers meet…and where they can share information and explore collaborative opportunities.
  • Advocate for the support of global health research that would include integrated oral health components…persuading policy-makers, legislators and donor agencies and organizations nationally and globally. (UN Heads of State are a good example)
  • Support evaluation and further research on the subject of global health diplomacy.
  • Award successes in diplomatic relationships…Peace through Oral Health. When something works, spread the good news so contagion can set in!

Global health diplomacy is a field in the making…ever-changing and ever-challenging. It is closely linked to foreign policy but it can only work if many nations collaborate and engage with many stakeholders…over and above diplomats talking with other diplomats. Civilians can influence decisions related to the public’s health and they too can be a part of the negotiation process, the essence of diplomacy. This is ‘soft power’. This is one important way in which Cuba influences Venezuela. Brazil has learned these lessons and China is using them now in Africa. Make foreign policy work for health that includes oral health. Work for intersectoral policies that make more coherent initiatives across government ministries/departments.

These are presented as ideas of how to forge our agenda to become part of a larger global health equity movement. It would be wonderfully fulfilling if we found ourselves to be wise enough and strong enough to join with others and not lose confidence in our ability to influence change for the good.

Pathways to Change

Where do we go from here? We need a map that lays out a plan of action…a coherent strategy. But not a map we alone devise but rather one that represents the knowledge that countries and regions of the world possess. How to mobilize such a potentially powerful array of knowledgeable planners presents the first challenge. For these planners and their constituencies represent both essential leadership and the ‘community-base’ for participative planning, operationalization of those plans as well as the testing and refinement of those demonstrations and ultimate ‘scaled-up’ versions that extend pilots to become sustainable entities. The full continuum from the discovery of needs to the implementation of integrated strategies, as well as the identification of unanticipated consequences …should guide when to act on existing evidence.

Envisioned elements in the map would include:

  • Country-led plans that allow for local area adaptations and recognizing prevention and health promotion strategies as priorities.
  • Comprehensive health system that include integrated oral health components such as clinical services, public health policies, shared and integrated health records, integrated financing/payment systems tied to performance.
  • Capacity-building to strengthen inter-professional education and collaborative practice arrangements, as well as integration at the primary point-of-contact level of community workers.
  • Capacity-building for needs assessment, evaluation research, implementation sciences and associated research from basic to translational…to ensure sustainability and vitality of the health system.
  • Creating platforms for sustained collaborative partnerships among organizations in the public and private sectors, including not-for-profit groups working in-countries and across countries. The extension of such platforms necessarily would include entities beyond the health sector that address the social determinants of illness: key players in education, housing, agriculture, water resources, sanitation, environment, social services, etc..
  • Development of a viable governance structure for essential coordination of planning elements, technology, tools and data, metrics for success and indicators of progress.

While oral health often suffers from the lack of political clout, recent surveys in the U.S. serve as potential signs of encouragement in my own home country.  From a survey of adults age 18 and older conducted in December 2015 and January 2016, 41% wanted to see a dentist more often (more than other health practitioners) and that 79% surveyed agreed that there was a connection between oral health and general health and that 63% reported that having good oral health helps them feel confident on a daily basis, compared with 56% for having clear skin and 50% for being in shape. (41) In another survey there was overwhelming support (80%) for the concept of dental therapists, a new type of mid-level provider similar to a nurse practitioner. The results of this 2016 telephone survey were almost identical from a 2011 poll (42). While change takes time, there might be the ‘tipping point’ when the social will may take hold and communicate their wishes to the political change-agents. Keeping in mind the need for evidence (knowledge base) + social will + political will = public policy, it may be possible to plan strategically for a world in which oral health and general health are viewed as inextricably linked and in which care delivery and public policies are aligned to meet the needs of human health.


  1. Dworkin, S.F. “The Emergence of the Social and Behavioral Sciences in Dentistry: Lois Cohen as Principal Architect”, J. Dent. Res. (78) 6, 1999, pp 1192-1196.

  2. American Council on Education, Commission on the Survey of Dentistry in the United States, The Final Report (Byron S, Hollinshead, Director): Washington, DC, 1961.

  3. U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: National Institute of Dental and Craniofacial Health, National Institutes of health, 2000.

  4. Institute of Medicine, National Academies of Science, Public Policy Options for Better Dental Health: Report of a Study, Washington, DC: National Academies Press, 1980 and Improving Access to Oral Health Care for Vulnerable and Underserved Populations , 2011 and Advancing Oral Health in America, 2011.

  5. Institute of Medicine, National Academies of Science, Dental Education at the Crossroads: Challenges and Change, 1995.

  6. Institute of Medicine, National Academies of Science, The U.S. Oral Health Workforce in the Coming Decade: Workshop Summary, 2009.

  7. Cohen, L.K., “Dentists and Oral Cytology”, J.American Dent. Assoc., 1967, 74, pp. 967-970.

  8. Richards, N.D. and Cohen, L.K., eds. The Social Sciences and Dentistry: A Critical Bibliography, London: Federation Dentaire Internationale , June 1971.

  9. Cohen, L.K. and Bryant, P.S. eds., Social Sciences and Dentistry, Vol. II, London: Federation Dentaire Internationale and Quintessence Publishing Co., August 1984.

  10. Cohen, L.K. and Gift, H.C., eds. Disease Prevention and Oral Health Promotion: Socio-Dental Sciences in Action, Copenhagen: Munksgaard Press, 1995.

  11. Cohen, L.K., “Dentistry and the Behavioral/Social Sciences: An Historical Overview”, J. Behavioral Medicine, 1981, 4, 3, pp. 247-375.

  12. Arnjolt.H.A., Barmes, D. E., Cohen, L.K., Hunter, P.B.V., Ship, I.I. Oral Health Care Systems: London: Quintessence Publishing Co., 1985.

  13. Chen, M, Andersen, R.M., Barmes, D.E. et.al., Comparing Oral Health Care Systems: A Second International Collaborative Study, Chicago: World Health Organization and Center for Health Administration Studies, The University of Chicago, 1997.

  14. Cohen, L.K. “World Health Organization/U.S. Public Health Service International Collaborative Study of Dental Manpower Systems in Relation to Oral Health Status”, chapter in Ingle, J.I. and Blair, P. International Dental Care Delivery Systems, Cambridge, Massachusetts: Ballinger Publishing Co., 1978, 20: 201-214.

  15. Chen, M-S. “Oral Health of Disadvantaged Populations”, chapter in Cohen, L.K. and Gift, H.C., eds. Disease Prevention and Oral Health Promotion: Socio-Dental Sciences in Action, Copenhagen: Munksgaard Press, 1995, pp. 153-212.

  16. http://www.who.int/social_determinants/thecommission/en/

  17. Marmot, M. The Health Gap: The Challenge of an Unequal World, USA: Bloomsbury Publishing, Nov. 3, 2015.

  18. Sheiham, A., Alexander, D., Cohen, L.K., Marinho, V. Moyses, S., Petersen, P.E., Spencer, J.E., Watt, R.J., Weyant, R. “Global Oral Health Inequalities: Task Group – Implementation and Delivery of Oral Health Strategies, Advances in Dental Research, 20111, 23, 2, pp. 259-267 and Sgan-Cohen, H.D., Evans, R.W., Whelton, H, Villena, R.S., McDougall, M., Williams, D.M., IADR Steering Task Groups, IADR Global Oral Health Inewualities Research Agenda (IADR-GOHIRA): A Call to Action, J. Dent. Res., 2013, 92, 209.

  19. Marcenes, W., Kassebaum, N.J., Bernabe, E., et.al. “Global Burden of Oral Conditions in 1990-2010: A Systematic Analysis”, J. Dent. Res. 2013, 92, 7, pp.592-597.

  20. Kassebaum, N.J., Bernabe, E., Dahiya, M., et.al. “Global Burden of Severe Periodontitis in 1990-2010: A Systematic Review and Meta-Regression”, J. Dent. Res. 2014, 93, 11, pp. 1040-1053.

  21. Kassebaum, N.J., Bernabe, E., Dahiya, M. et.al., “Global Burden of Severe Tooth Loss: A Systematic Review and Meta-Analysis. J. Dent. Res., 2014, 93, 7 suppl, pp. 20S -28S.

  22. Seymour, B., Barrow, J., Kalenderian, E. “Results from a new Global Oral Health Course: A case Study at One Dental School”, J.Dent. Educ., 2013, 77, 10, pp. 1245-1251.

  23. Seymour, B. Barrow., J. “A Historical and Undergraduate Context to Inform Interprofessional Education for Global Health”, J. Law, Medicine & Ethics. Winter 2014, pp. 9-16.

  24. Benzian, H., Greenspan, J.S., Barrow, J., Hutter, J.W., Loomer, P.M., Stauf, N., Perry, D.A., “ A Competency Matrix for Global Oral Health”, J.Dent. Educ., 2015, 79, 4, pp. 353-361.

  25. Tomar, S.L., Cohen, L.K., “ Attributes of an Ideal Oral Health Care System”, J.Public Health Dent., 2010, 70, pp. S6-S14.

  26. Preet, R., “ Health Professionals for Global Health: Include Dental personnel Upfront!”, Glob. Health Action, 2013, 6, pp. 1-4. http://dx.doi.org/10.3402/gha.v610.21398

  27. United Nations General Assembly, Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases. Resolution A/66/L1.2011.

  28. Benzian, H., Bergman, M., Cohen, L.K., Hobdell, M., Mackay, J., “Editorial- The UN High-level Meeting on Prevention and Control of Non-communicable Diseases and its Significance for Oral Health Worldwide”, J. Public Health Dent., 2012, 72, pp.91-93.

  29. Cohen, L.K., Benzian, H. Bergman, M., “UN Summit: Stepping Up Efforts to Address Oral Diseases”, Compendium, 2012, 33, 4, pp. 7-10. Videocast of Summit side event on ‘Putting Teeth Into NCDs”, www.dentalaegis.com/go/cced103

  30. Varenne, B. “Integrating Oral Health with Non-Communicable Di seases as an Essential Component of General Health: WHO’s Strategic Orientation for the African Region”, J. Dent. Educ., 2015, 78, 5, Suppl. Pp. S32- S37.

  31. Barmes, D.E., “Indicators for Oral Health and their Implications for Developing Countries”, Int. Dent. J., 1983, 33, 1, pp.60-66.

  32. World Health Organization, Oral Health, Oral Health Information Systems, http://www.who.int/oral_health/action/information/surveillance/en/

  33. Farmer, P., Kim, J.Y., Kleinman, A., Basilico, M. Reimagining Global Health: An Introduction, Berkeley and Los Angeles : University of California Press, 2013. See Chapter 12, “A Movement for Global Health Equity?”, pp. 340-353.

  34. Richmond, J. B., Kotelchuck, M., “Political Influences Rethinking National Health Policy”, in Handbook of Health Professions Education, ed. McGuire C.H., et.al. (San Francisco: Jossey bass, 1983), 386-404.

  35. Adelaide Statement on Health in All Policies- Moving Towards a Shared Governance for Health and Well-Being, Report from the International Meeting on Health in All Policies, Adelaide 2010, http://www.who.int/social_determinants/hiap_statement_who_sa_final.pdf

  36. Cohen, L.K. “Editorial- A Collaborative Model for Global Health Research: Investing in Oral Health for All”, J. Theory and Practice of Dent. Public Health, 2013, 1, 2, pp.1-4.

  37. Cohen, L.K. “Global Health Research for America’s Vital Interest”, J. Amer. Dent. Assoc., 2007, 138, pp.1444-1447.

  38. 10/90 Gap (Global Forum for Health Research- 1990), https://en.wikipedia.org/wiki/10/90_gap

  39. Novotny, T.E., Kickbusch, I. with Leslie, H., Adams, V., “ Global Health Diplomacy- A Bridge to Innovative Collaborative Action” in Global Forum Update on Research for Health, Vol. 5, pp.41-45.

  40. Sustainable Development Goals, United Nations (2015), http://www.un.org/sustainabledevelopment/

  41. http://www.fox34.com/story/34179142/dentists-top-the-list-of-health-practitioners-americans-want-to-see-more-of ; http://www.drbicuspid.com/index.aspx?sec=sup&sub=pmt&pag=dis&ItemID=320901

  42. http://www.drbicuspid.com/index.aspx?sec=sup&sub=pmt&pag=dis&ItemID=320902 ; http://www.communitycatalyst.org/


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