A PERSONAL CHANGE AND A CHANGING PANORAMA: LOOKING TOWARD THE NEXT DECADE
HAROLD C. SLAVKIN, D. D. S.
As we advance into the 21st century, change is perhaps the only constant. My five-year term as director of the National Institute of Dental and Craniofacial Research at the National Institutes of Health will end on July 14. At that time, my wife, Lois, and I will return to our four married children, six grandchildren, family, friends and colleagues in southern California. Therefore, this is my last column in a series of 55 monthly columns written while NIDCR director.
Since January 1996, you have joined me each month to explore how science, technology and health promotion make a difference in our lives and those of our families, colleagues, patients and communities. We have investigated how changing demographics, disease patterns, information technology, biotechnology and health care management shape our lives. We have pondered the remarkable world of atoms, molecules and biological mechanisms that serve as the foundation for human and microbial biology, as well as biotechnology. Through these monthly excursions, I have attempted to motivate, inform, educate and inspire our shared habits of mind—how we see, what we see and what we know—as well as offer encouragement to revisit and revise our broadening scope as health professionals.
Let’s now consider progress over the past century and what we can expect in the coming decade—changes in how health is perceived; the changing demographics of our nation in its ethnic makeup and age stratification; and the changing face of dental education, health care and clinical dentistry in the 21st century.
Although we often may think of health as meaning only the absence of disease, the etymological root of this word means the state of being whole. As we advance into this new century, the ancient meaning of the word health is coming back into the fore. Quality of life and well-being are the most significant considerations in health care today. And oral health is an essential part of a person’s quality of life. This transformation of how we view health parallels multiple changes affecting health care, including demographics, disease patterns, financing of health care and educating health professionals.
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CHANGING DEMOGRAPHICS AND DISEASE PATTERNS
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The past 100 years have resulted in remarkable improvements in the health of Americans. Infant mortality has decreased, and life expectancy has increased by more than 30 years. Much of the success has come from preventive efforts: water fluoridation, improved public sanitation systems, improved personal hygiene habits, nutrition, education and vaccinations. In the dental health care realm, health promotion and disease prevention still are as important as they were in the past and will continue to be dominant drivers in the future.
Changing demographics.
By 2030, it is estimated that there will be no racial majority in the United States.1 The widespread national and regional diversity will bring about changes in the patterns of disease, some of which we already can discern in black, Hispanic, Pacific Islander and Native American populations. Disparities in education, job opportunities, income and health access, among other factors, affect the health of people, families and communities (Figure
).
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Figure. Percentage of people below the poverty level by race/ethnic group and type of household, United States, 1996.
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The age stratification in the United States also is changing; the number of adults older than age 65 years is expected to nearly double over the next 25 years.2 This shift will lead to major modifications in how health is viewed, in federal and state health care policies, and the manner in which comprehensive health care access is administered. An increased average life span, as well as improvements in health indicators in older Americans, will lead to new patterns of diseases and disorders in this age group. This will require new ways of thinking about and new avenues of research into the aging process. The social, economic and political implications of changing demographics are enormous.
Patterns of disease.
A person’s health depends not only on genetics, but also on his or her socioeconomic environment. For example, life expectancy in the United States is about six years greater in women than it is in men. People living in households with incomes of more than $25,000 live three to seven years longer than people living in households with incomes of less than $10,000.3
Likewise, while some disease patterns are genetic and are affected by educational level or socioeconomic status, chemical, physical and biological factors also represent environmental influences. Often, these factors interact with one another, producing complex etiologies that require multiple solutions. Some examples follow.
- – A defective gene causes sickle cell anemia. Each gene in our bodies has two alleles: one we receive from our mother and the other from our father. People with two defective sickle cell alleles have sickle cell anemia; people who have only one defective allele do not develop the disease. About 1 percent of blacks have sickle cell anemia, and 14 percent are carriers. Carriers are not resistant to malaria; in regions of Africa where sickle cell anemia is most common, malaria also is very common.4
- – National Osteoporosis Foundation estimates that 89 percent of women older than 75 years of age have osteoporosis. Being female is the largest single risk factor for this disease. Because the number of women older than 75 years of age is increasing, osteoporosis is becoming more common. Many factors affect osteoporosis, including genetics. Genes such as apolipoprotein E-4 are being studied for their possible roles in osteoporosis.5
- – Type 2 diabetes mellitus is increasing in both adults and children. In 1994, obesity—a major risk factor of this disease—affected 23 percent of people older than 19 years of age.3 In 1992, type 2 diabetes mellitus accounted for as little as 2 percent of all childhood diabetes; in 1994, it accounted for 16 percent. Ethnic minorities, such as Native Americans, blacks and Hispanics, have higher rates of diabetes and obesity than do whites. The Pima Native American tribe has one of the highest diabetes rates in the world.
These examples, as well as many others, illustrate that a myriad of factors—genetic, behavioral and socioeconomic—are tied to health, quality of life and well-being. Over the past few decades, scientists have made giant strides in understanding each of these factors and how they contribute to health. The next century certainly will become the biotechnology century, as the human genetic lexicon of more than 100,000 genes is completed, annotated and used for a new generation of diagnostics, therapeutics, treatments and biomaterials. The genomes of other organisms—viruses, bacteria, yeasts, plants, fruit flies, zebra fish, mice and primates—also are complete or being completed, allowing us access to their various knowledge bases from which we can find patterns and new ways of understanding health and disease. Our investments in fundamental and patient-oriented science and technology in the last century have flowered into a "biological revolution" and the foundations of biotechnology.
And we have learned that behavioral, social and economic factors are intimately intertwined. Income and education inequalities factor into many health disparities in this country. In general, the groups with the poorest health are those with the least education and highest poverty rates. For example, people with household incomes of less than $15,000 are more than five times as likely to be in poor health, compared with people with household incomes of $50,000 or more.3 Those with lower incomes have less education and more often are ethnic and racial minorities.
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HEALTHY PEOPLE 2010
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Many public and private agencies, organizations and health advocacy groups now are working to quantify the changes necessary to catapult us further along in the 21st century and to improve the health of all Americans. For example, the federal government’s Healthy People, or HP, 2010 initiative aims to increase the life span and quality of life of all Americans, as well as eliminate health disparities. It includes 467 health objectives in 28 focus areas, including access to quality health services, family planning, human immunodeficiency virus and tobacco use.
HP 2010 also includes 10 leading health indicators that illuminate individual behaviors, physical and social environmental factors, and systemwide issues that affect health (Box, "Leading Health Indicators"). Research, strategies and actions that affect one or more of these indicators can have major effects on the health of people, communities and the country at large. Disease prevention always has been a touchstone for the dental health profession; the HP 2010 initiative recognizes the importance of prevention throughout its focus areas.
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FINANCING OF HEALTH CARE
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For much of the 20th century, health care was centered in the health professions and hospitals. This center, however, has shifted to health care plans, health care providers, employers and consumers. In addition, alternative forms of health care, such as mobile clinics, long-term care or assisted-living facilities, have formed new niches in the health care landscape.
As of 1997, more than 11 million children were estimated to be uninsured in this country.6 Most were members of families with working parents whose jobs did not provide insurance and whose salaries may not have allowed them to purchase insurance independently. Nationally, one in six black children and one in four Hispanic children were uninsured, compared with one in 10 white children. In addition, more than one-half of all children do not have private dental insurance.7 Reports indicate that nearly one in three high-school–aged children uses tobacco (cigarettes, cigars or chewing tobacco), and that 5 million children alive today eventually will die as a result of tobacco use.3
Limited access to care, coupled with a lack of education about the benefits of making healthy choices, can have devastating effects on future generations. We must find ways to reach children, even those without insurance. This can be done through prenatal care, early childhood education, school readiness programs, improved science and health education from kindergarten through 12th grade, culturally competent health services, improved child care and transportation, and better use of information technology for health promotion.
On the other end of the age range, health care for older Americans also is changing. The Medicare program covers more than 39 million Americans older than 65 years of age.8 Currently, Medicare does not pay for out-patient prescription drugs—only for drugs used in hospital or clinic settings. Medicare beneficiaries can purchase drug coverage separately, but one-third of Medicare recipients have not done so. And while people 65 years of age or older make up 12 percent of the U.S. population, they use 33 percent of all drugs prescribed each year.9 Proposals to provide prescription drug coverage to older Americans are being formulated. Progress in this area is crucial, as the number of Americans eligible for Medicare will only increase over the next 30 years.
The future of health care is an integrated system in which care is provided on a continuum by teams of professionals working toward common goals.
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CHANGING EDUCATIONAL PATTERNS
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Not only is health care in flux, but also the education of all health professionals—including dental health professionals. In the 1920s, the Gies Report10 clearly defined the future direction of dental education in America. It recommended that dental education be woven into the fabric of American universities with an emphasis on research, education, patient care and service. By the 1960s, American dental education grew and developed into a strength of academic health science centers and their parent universities. By the 1990s, science and technology had significantly improved the oral health of most, but not all, Americans. At the same time, oral health professionals were broadening the scope and addressing different burdens of disease including craniofacial-orodental birth defects, inherited genetic diseases, early childhood dental caries, bacterial infectious diseases, viral and yeast infectious diseases, craniofacial-orodental trauma, severe malocclusion, oral and pharyngeal cancer, periodontal diseases, temporo-mandibular joint diseases and disorders, oral infections and systemic diseases, oral complications of systemic diseases and conditions, and severe chronic facial pain such as Bell’s palsy and trigeminal neuralgia.
A 1995 Institute of Medicine11 study adopted eight principles, which it combined with an analysis of dental education’s present and future. The result was a broad picture of dental education in the future. One of the recommendations for dental education, which was based on the changing disease patterns, was that dental education should become more integrated with medicine and the health care system on all levels. This is a key point, and one that cannot be overemphasized. Oral health requires more—not less—scientific evidence for the management of oral and systemic diseases and conditions, and it requires more, not less, crossover between dentistry and the other health professions such as medicine, pharmacy, nursing and the allied health professions.
The leaps and bounds taken in scientific research and technology will continue to encourage these multidisciplinary connections, as will financial strains on academic health centers and their parent universities. The future of health care is an integrated system in which care is provided on a continuum by teams of professionals working toward common goals—health promotion, risk assessment and disease prevention, smarter diagnostics, more effective treatments and therapeutics, and an emphasis on biomimetic solutions to biological problems.
Dental education now rests on an enormous knowledge base, and that foundation is increasing rapidly. We need to know more, and we need to revise our clinical competencies more often than ever before in the history of clinical dentistry. The biological and information technology revolutions are affecting dental education. The Internet and conventional scientific articles in peer-reviewed journals have profoundly increased the volume of information that may affect how we see, what we see, what we know about and how we provide health care services. In tandem, many of us seek to help predoctoral and postdoctoral dental students learn critical thinking skills, independent and group learning skills, an appreciation of a changing knowledge base, bioethics and a commitment to life-long learning.
Learning always has been at the cornerstone of our profession. As we advance into the 21st century, we must continue to foster these goals, while expanding our profession’s involvement in health promotion, disease prevention, diagnostics, therapeutics, treatment, biomaterials, health outcomes and health services research. We need to continue to discover and provide innovations that improve the quality of life and that are cost-effective.
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GOOD-BYE
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I have thoroughly enjoyed an extended leave-of-absence from the University of Southern California that has allowed me the privilege of working in government. On Aug. 14, I will begin a new job as dean of the University of Southern California School of Dentistry. While there, I hope to make a different kind of contribution to the future of our dental profession. Thank you for making the time to learn with me during these past five years.
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FAREWELL, DR. SLAVKIN, AND THANKS
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Every month since January 1996, Harold C. Slavkin, D.D.S., has graced the pages of JADA with his thoughtful observations on the science of oral health. From his vantage point as director of the National Institute of Dental and Craniofacial Research, he has raised the level of scientific discourse within our profession, and we, all of us, have benefited from that achievement. Now Dr. Slavkin takes his leave. This month, he steps down as NIDCR director to return to his home turf, the University of Southern California, where he will serve as dean of the School of Dentistry. His departure from the Institute also means the end of his monthly column for JADA. When Dr. Slavkin joined NIDCR in August 1995, he pledged to stay five years but no longer. He is a man of his word. We thank Dr. Slavkin for his contributions over the years, and we wish him well. Neither NIDCR nor JADA will be quite the same without him.
—Lawrence H. Meskin, D.D.S. Editor
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Dr. Slavkin is director, National Institute of Dental and Craniofacial Research, 31 Center Drive, MSC 2290, Building 31, Room 2C39, Bethesda, Md. 20892-2290. Address reprint requests to Dr. Slavkin.
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REFERENCES
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- Council of Economic Advisers for the President’s Initiative on Race. Changing America: indicators of social and economic well-being by race and Hispanic origin. Available at: "w3.access.gpo.gov/eop/ca/index.html". Accessed May 22, 2000.
- National Institute on Aging. Aging America poses unprecedented challenge, says new census, aging institute report. Available at: "www.nih.gov/nia/new/press/census.htm". Accessed March 14, 2000.
- U.S. Department of Health and Human Services. Healthy People 2010: understanding and improving health. Available at: "www.health.gov/healthypeople/Document/HTML/Volume1/Opening.htm". Accessed April 11, 2000.
- Purves WK, Orians GH, Heller HC. Life: The science of biology. 4th ed. Sunderland, Mass.: Sinauer Associates Inc.; 1995.
- Slavkin H. Building a better mousetrap: toward an understanding of osteoporosis. JADA 1999;130:1632–6.[Free Full Text]
- Slavkin H. Dental and craniofacial science and education in 2020: American Association of Dental Schools 75th Anniversary Summit Conference, Minneapolis, October 1998. Washington: American Association of Dental Schools; 1998:111–5.
- Slavkin H. Science-based trends affecting the oral health of children: Surgeon General’s workshop and conference on children and oral health. Available at: "www.nidr.nih.gov/sgr/children/children.htm". Accessed May 1, 2000.
- Medicare basics: overview. Available at: "www.medicare.gov/Basics/Overview.asp". Accessed May 23, 2000.
- Medicare drug benefits becoming hot-button issue. Baltimore Sun. April 9, 2000;8A.
- Gies WJ. Dental education in the U.S. and Canada: A report to the Carnegie Foundation for the Advancement of Teaching. New York: Carnegie Foundation for the Advancement of Teaching; 1926.
- Field MJ, ed. Dental education at the crossroads: Challenges and change. Washington: Institute of Medicine, National Academy Press; 1995.
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