My trepidation scanning the access to care articles1–3 turned worse while reading the September JADA editorial by Dr. Raul Garcia ("Addressing Oral Health Disparities in Diverse Populations,"
JADA 2005;136:1210–2
). I found him a misleading advocate of nationalized health care and race-based admission for dental schools.
The first and last sentences, respectively, are to the point: "A society that does not view health as a basic human right is likely to experience disparities in health status."; and "It is becoming increasingly clear that enhancing the diversity of the dental profession is vital to successfully addressing the oral health needs of our nation’s increasingly diverse population."
I would like to parse these sentences and a few other ideas. I’ll start with the first sentence. Aside from arguing that it is improper for society to "view health as a basic human right," how does a society mitigate "disparities in health status"? In my experience, individual health status is tied to three areas: 1) the person’s heredity and predisposition to health or disease, 2) choices conducive to good or poor health and 3) availability of proper health care.
A percentage of a population will be unhealthy due to heredity and/or poor choices. Society has no control over heredity, and changing individual choice can require levels of coercion frowned on in America. The only way to eliminate disparities in health status would be to make every person in a group as unhealthy as the unhealthiest person in that group, whether his or her condition was due to heredity, poor choices or inadequate health care.
Since Dr. Garcia presents health as a basic human right, I am confident in concluding he wants society to limit disparities in health status with a nationalized system. Having lived for three years in England and six years in Germany, I believe nationalized health decreases the health status of some, while increasing it for others. Attempts are made to provide a mediocre level to all. Nationalized British dental care is an extreme example of providing a poor level of service to everyone. Is this editorial arguing to decrease the level of health of some to limit or eliminate disparities in health status?
Race and ethnicity are divisive topics in America. Dr. Garcia cites Brown and colleagues4 as "finding that minority dentists proportionately saw many more minority patients than did white dentists" to support his conclusion (which bears repeating): "It is becoming increasingly clear that enhancing the diversity of the dental profession is vital to successfully addressing the oral health needs of our nation’s increasingly diverse population."
I will ask the obvious questions first. Are white dentists qualified to treat "minority" patients, and are "minority" dentists qualified to treat white patients?
Since it is not probable that Dr. Garcia is writing about qualifications, his meaning is elsewhere. Most likely, he thinks nonwhite dentists will be more successful treating non-white patients, because of comfort, habit or proximity. Indeed, it may be more comfortable for some nonwhite patients to be treated by nonwhite dentists, just as some white patients may be more comfortable with a white dentist.
Furthermore, some minority dentists may be more likely to have practices in areas with higher percentages of minority patients, while white dentists might be more likely to have practices closer to higher percentages of white patients. However, is it desirable to encourage segregation? I believe race-based admissions encourage segregation.
To further illustrate where this line of reasoning leads, I have two hypothetical studies for Brown and colleagues.
To my knowledge, no one has had the temerity to study church groups. In my experience, some members of a congregation may be more comfortable with treatment from a dentist in their congregation, thereby making it more likely that patients receive care from a dentist in their church congregation. Dr. Garcia’s argument could then be construed to advocate admission of aspiring dentists from underrepresented churches.
Next, I would suggest a study of poorly educated citizens. I believe the poorly educated probably receive less adequate health care than the well-educated. Furthermore, in my social experience, one of the biggest determiners of comfort between people is their relative level of education, especially with regard to language. Should we then admit more poorly educated young people to dental school? Would poorly educated patients be more comfortable with poorly educated dentists?
While it may be desirable for our nation to have a health care force that mirrors society, Dr. Garcia’s arguments for that end are specious. Furthermore, I think there are only a few types of diversity that matter to Dr. Garcia. In the end, we are all Americans. Should we seek to divide ourselves by race or ethnicity?
Studies showing relative effectiveness of free services (presumably public) for HIV-infected women and Medicaid-eligible children are presented. Are free services to various subclasses desirable? What type of "diversity of the dental profession is vital to successfully addressing" these needs?
Finally, I would like to comment on this thought: "A key point made by Ramos-Gomez and colleagues is that the U.S. Hispanic population is not monolithic [uniform] ... . The time is long overdue for a national study of oral health and its cultural and behavioral determinants that appropriately samples multiple Hispanic subgroups."
Having treated children of recent immigrants from Russia and Albania, I feel confident in asserting that the Caucasian population is not uniform, and, in some cases, this is reflected in their oral health. I am confident in saying the same for Asian populations. Should investigators attempt to analyze the oral health of subgroups within Caucasian and Asian populations? Should society attempt to serve them better with special classes of "minority" dentists?
I found this editorial divisive and degrading of Americans.
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