moving forward and looking back: the intersection of race and

Moving Forward and Looking Back:

The Intersection of Race and Dentistry

john a. powell

Williams Chair in Civil Rights & Civil Liberties, Moritz College of Law

Executive Director, Kirwan Institute for the Study of Race and Ethnicity

The Ohio State University

http://www.kirwaninstitute.org/

Presentation to the College of DentistrySeptember 23, 2004

http://www.kirwaninstitute.org/

Presentation Overview The Construction of Race & the

Framing of Disparities

Disparities in Dentistry

Diversity in Education

Diversity in DentistryDeveloping Cultural Competence

The Need for Research

Moving Forward & Progress

The Construction of Race and Framing of Disparities

“Health is the place where all the social forces converge.”-Reed Tuckson, M.D., Vice President, American Medical Association

The Construction of Race and Framing of Disparities

We overestimate our civil rights gains; racial disparities still exist on many levels.

We will examine the concept of race in our society, how it was constructed and the historical framing of disparities.

Disparities: Civil Rights Era & Today The typical Black family had 60% as much income as a

white family in 1968, but only 58% as much in 2002. Black infants are almost two-and-a-half-times as likely as

white infants to die before age one – a greater gap than in 1970.

At the slow rate that the Black-white poverty gap has been narrowing since 1968, it would take until 2152, to close.

For every dollar held by Whites in 1968, Blacks had only 55 cents. By 2001, Blacks had only 57 cents for every dollar held by Whites. At this pace, it would take Blacks 581 years to get the remaining 43 cents.

While white homeownership has jumped from 65% to 75% since 1970, Black homeownership has only risen from 42% to 48%. At this rate, it would take 1,664 years to close the homeownership gap – about 55 generations.

Source: State Of The Dream 2004 (United for a Fair Economy)

The Construction of Race: BiologicalRace was once considered biological:

The common 19th century theory of racial ethnic, and gender inferiority.

Blacks were considered to be intellectually, culturally, morally and physically inferior to whites.

Physicians claimed that African-Americans had unique physiological and anatomical features such as small brains, thick skin, high tolerance for heat, sun and pain, etc.

This rationalized slavery and the unethical use of African-American men and women as medical research subjects.

Tuskegee syphilis study

Genetic testing/sickle cell screenings in the 1970’s

Forced sterilization of Black women in the 1970’s

Source: Eliminating African-American Health Disparity via History-based Policy. Harvard Health Policy Review, 2002.

Although countless studies have documented that race is not biological, researchers in 2001 found that most citizens believe that race is a biological construct.

If race is not biological, then what is it?

The Construction of Race: Biological


Disparities have more recently been attributed to individuals and culture: the idea that individuals alone can (and should) rise above their conditions of poverty, and the idea of a defective “culture of poverty”.

This illustrates our deep beliefs about success and failure.

Personal responsibility

Meritocracy (basketball/gym analogy)

Where to these beliefs come from?

The Construction of Race: Deficit Perspective

This approach leads to focusing on personal racism and explicit legal discrimination.

Diversity training

Neutralizing the language in laws

Focus on intent

Research has shown that personal prejudice and racial attitudes are improving steadily (maybe), yet racial disparities persist on every level.

Disparities also continue despite the seemingly neutral language in policies and laws.

What does this suggest about this approach to alleviating racism and remedying disparities?

The Construction of Race: Personal Racism

Biased Structures

Disparate Outcomes

De JureNeutral

Structures

Disparate Outcomes

What is occurring here to replicate the outcomes today?

Historically Today

Model for Disparate Outcomes

Biology

Individuals/Culture

Structures/Opportunity

In order to understand disparities that are not explained by personal discrimination or explicit laws and policies, we must look at the relationship between individual attitudes, structures, and outcomes, as they are all interrelated.

Institutional and public arrangements influence our private choices and resources.

People usually make reasonable choices given their constraints and opportunities, but these constraints are not necessarily rational.

We need to examine those constraints in order to understand the limitations placed on individual choices.

Model for Disparate Outcomes

Although Individual attitudes towards race have improved over the past decade, there has been less institutional change.

Race is an expression of social structuring. Social structuring cannot arise from personal feelings alone.1

We often fail to acknowledge the ways that race has been a fundamental axis of social organization in the US, and how structures have historically been organized to establish and maintain racial hierarchy.

Even within neutral arrangements and without racist actors, disparities can still exist.

Therefore to eliminate disparities, we must address the social structures & institutions that have created and perpetuated them.

The Construction of Race: Social Hierarchy

Source: 1. Martinot, S. (2003). The Rule of Racialization.

Structural Racism (SR)

A structural racism approach examines how history, public policies, norms, institutional practices and arrangements can interact to maintain racial hierarchies and inequitable racial group outcomes.

What are the inequality generating processes?

How do we make meaning of durable inequality?

Racialized outcomes do not require racist actors, theoretically neutral policies and practices can function in racist ways.

These policies and practices are not neutral however, and as a result the burdens are distributed unevenly.

These burdens, or disparities are the symptoms of structural racism.

Structural Racism (SR)


“Of all the forms of inequality, injustice in health is the most shocking and the most inhuman.”

-The Rev. Martin Luther King, at the Second National Convention of the Medical Committee for Human Rights, Chicago, March 25,1966


Craniofacial, oral, and dental diseases and disorders are among the most common health problems affecting all people at all stages of life.

Blacks, Hispanics, American Indians and Alaskan Natives have the poorest oral health of any population group.

Poor oral health has significant long-term impacts on individual’s life opportunities and quality of life.

Many of the existing problems are treatable and preventable.

We will examine these disparities, considering both the cause and the long-term impacts of them.

Sources: A Plan to Eliminate Craniofacial, Oral, and Dental Health Disparities. The National Institute of Dental and Craniofacial Research, February, 2002.


Many American suffer from oral pain and disease, but racial and ethnic minorities, low-income populations, and special care groups suffer disproportionately.

Access to basic oral healthcare is a human right. Although 43 million Americans have no private

health insurance, more than 150 million Americans have no dental insurance.

This has significant impacts on the attainment of oral care for low-income populations, particularly people of color.

Source: The Disparity Cavity: Filling America’s Oral Healthcare Gap. Oral Health America & The Kellogg Foundation, 2000.

Percent Who Visited a Dentist or Clinic in the Past Year by Income

56.5%

66.0%

79.0%

49.8%

73.2%

85.1%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

Less than15k

15k-Lessthan 25k

25k-lessthan 35k

35k-lessthan 50k

50k to lessthan 75k

75k and up


Data source: Behavioral Risk Factor Surveillance Survey, 2002


Percent Who Needed Dental Care, Including Checkups, During the Past 12 Months But Could Not Afford It

31%

19%17%

0%

5%

10%

15%

20%

25%

30%

35%

Hispanic Non-Hispanic Black Non-Hispanic White

Data source: National Health Interview Survey (NHIS), 2001

Disparities in Dentistry: Children

According to the National Institute of Dental Research, dental caries is the most common, preventable disease in children.

Professional care is necessary for maintaining oral health, yet 25% of poor children have not seen a dentist before entering kindergarten.1

Poor children have 5 times more unfilled, decayed teeth than children above 300% of the poverty line.2

80% of tooth decay is found in 25% of children, concentrated in minority populations.2

Mexican and African American children have twice the number of untreated cavities as white children.

Sources: 1. Oral Health in America: A Report of the Surgeon General. Executive Summary, 2000. 2. The Disparity Cavity: Filling America’s Oral Healthcare Gap. Oral Health America & The Kellogg Foundation, 2000.


Routine dental care for children is also important for diagnostic reasons:

Examination of the teeth and mouth can detect signs of abuse and neglect.

A dental exam also picks up on poor nutrition and hygiene, and growth and development problems.


The social impacts of oral disease in children is substantial.

More than 51 million school hours are lost each year to dental-related illness, an average of 1.17 hours per child.1

Poor children suffer nearly 12 times more restricted-activity days than children from higher-income families.2

Pain and suffering due to untreated diseases can lead to problems in eating, speaking and attention to learning. This interference with a child’s normal development will have significant long-term effects on that child’s future.

With early preventative dentistry, cavities in children could be avoided entirely.

1. The Disparity Cavity: Filling America’s Oral Healthcare Gap. Oral Health America & The Kellogg Foundation, 2000. 2. Oral Health in America: A Report of the Surgeon General. Executive Summary, 2000.

Disparities in Dentistry: Adults Regarding access to dental care, there is a four-fold

difference between high- and low-income groups. Less than two thirds of adults report having visited a

dentist in the past 12 months. Those with incomes at or above the poverty level are twice as likely to report a dental visit in the past 12 months as those who are below the poverty level.

The percentage of African Americans who have untreated caries is twice that of whites.

For adults in low income groups, half of the teeth that have decayed have never been filled.

Among low-income people over the age of 35, 1/3 have no teeth. The difference between lowest and highest socioeconomic groups is eight-fold.

Sources: 1. The Big Cavity: Decreasing Enrollment in Minority Dental Schools. The Kellogg Foundation, March 2001. 2. Oral Health in America: A Report of the Surgeon General. 2000.

Disparities in Dentistry: Adults The mouth is considered “the laboratory of the body”.

An oral examination of the mouth can detect early signs of diabetes, bone and joint disease, and cancer as well as general infection and stress.

Sores and ulcerations can also diagnose herpes, mononucleosis, or HIV infection.

A number of recent studies suggest that there may be links between improper oral hygiene and several diseases and conditions such as heart disease, stroke, diabetes, and premature delivery.

We have the potential to have a major impact on health through a minor investment in dental care.

Source: A Plan to Eliminate Craniofacial, Oral, and Dental Health Disparities. The National Institute of Dental and Craniofacial Research, February, 2002.

Disparities in Dentistry A number of preventative measures have been

implemented within recent years, overall lowering the percentage of Americans who get cavities.

This success does not translate to all groups, however. Statistics show that for those who do get cavities, the percentage of those who have them repaired is declining.

Preventative measures have been incomplete, and not universally available to all.

Although it was introduced almost 60 years ago, approximately 40% of the public still does not have community water fluoridation.

Dental sealants are found in only 23% of youth under age 8 and in less than 10% of low-income minority children.

Source: Nation Brings Home a Lackluster C on Oral Health Report Card. Oral Health America. April 23, 2003.

Disparities in Dentistry Oral diseases and disorders affect health and well-being

throughout life.

Healthy People 2000 found that more than 2/5, or 93 million American had limited their activities because of dental problems.

In one year, 164 million work hours were lost, an average of 1.48 hours per worker.

Dental problems may:

Undermine self-image and self-esteem.

Discourage normal social interaction, and lead to chronic stress and depression.

Interfere with vital functions such as breathing, eating, swallowing, speaking and sleeping.

Impact economic productivity, making it difficult to get and keep a job.

Source: The Disparity Cavity: Filling America’s Oral Healthcare Gap. Oral Health America & The Kellogg Foundation, 2000.

Health

Childcare

Effective Participation

Employment

EducationHousing

Transportation

Opportunity Structures

Disparities in Dentistry A web of structures exists in which individuals live

and operate.

This web helps us conceptualize the interaction among these structures and the impact disparities may have on a variety of levels.

For example, Medicaid recipients have less disposable time, yet wait almost 40% longer for their first appointment than persons with private insurance. They also have on average less transportation options and less disposable income, yet must travel much further to reach a dentists who will treat them.1

Source: 1. Berthold, M.. Dental Medicaid Studied. American Dental Association. April 5, 2005.

Disparities in Dentistry What else might affect an individual’s overall oral health?

Neighborhood Resources: Grocery stores as opposed to convenient stores

Availability of dentists in the area

Employment: Health Insurance

Ability for an individual to take time off work to visit a dentist

Childcare: Whether that person has childcare available so they may attend a dental appointment

john-I thought his slide could have potential to instead use as the interactive/discussion piece.

Disparities In/Out Cause/Effect

Disparities are often the result of inadequate sets of inputs/developments.

Disparities can generate new disparate outcome.

Disparities in Dentistry Because of this complex web, disparities in dentistry

have far greater implications than just oral health; oral health ultimately affects a multitude of life opportunities.

Inequality matters; group inequalities matter more. Why?

When disparities are durable and cumulatively visited on certain groups, this bring into question the fairness of larger structures and arrangements.

Structures in society can start off fair, but because of their interaction and changes in the environment, become unfair.

Disparities in Dentistry: Healthcare In examining structural arrangements, consider healthcare. How

accessible is our healthcare system in America, and to whom? Oral health care in America is financed principally through private

sources. Studies have demonstrated that insurance is a major determinant to

dental utilization: 70% of those with insurance reported having seen a dentist in the past year as opposed to 51% of those without insurance.1

Uninsured children are 2.5 times less likely than insured children to receive dental care; children from families without dental insurance are 3 times more likely to have dental needs.2

A growing number of adults are facing difficulties in accessing care, as states cut Medicaid dental benefits and unemployment continues to rise.

Elderly individuals also face unique challenges to accessing dental care. Many lose their dental insurance when they retire, particularly older women who have on average lower incomes and may never have had insurance.

Source: 1. A Plan to Eliminate Craniofacial, Oral, and Dental Health Disparities. The National Institute of Dental and Craniofacial Research, 2002. 2. Oral Health in America: A Report of the Surgeon General. Executive Summary, 2000.

Disparities in Dentistry: Healthcare In the US, the healthcare system is least accessible to low-

income individuals and families. The organization of our society is such that healthcare is only truly accessible to the middle and upper classes (work-based healthcare insurance, etc.).

Black men in the United States, as compared to individuals in third world countries, are financially richer. Despite this, African Americans have an absolutely lower chance of reaching mature ages than people of many third world countries such as China, Sri Lanka, and parts of India.1

Can we translate our resources into capacity enhancing outcomes/utilities?

Europe, for example, considers healthcare a basic right of citizenship. Countries such as the United Kingdom, France, Spain, and Japan provide universal healthcare.1

Source: 1. Sen, A. (1999). Development as Freedom.

Disparities in Dentistry: Healthcare Roberto Unger argues that the state and government

have a civic responsibility to address persistent disparities in a meaningful way; the role of society is to make up the social capital that the parent or family is unable to provide.

This organization of civil society is lead by what can be described as the caring economy or the practical organization of social solidarity. This includes the practices by which we care for the very young, the very old, the infirm or the disabled.

If we are arranged as a middle-class society, how do we reach those who are being left behind?

Source: Alternative Law Forum, Public talk on Innovation and Inclusion in the World Economy by R. Unger.

Diversity

What is it?

Is it important and if so why?


“Student body diversity promotes learning outcomes, and 'better prepares students for an increasingly diverse workforce and society, and better prepares them as professionals.‘”

Grutter v Bollinger Et. Al., 2002

Brief for American Educational Research Association et al. as Amici Curiae 3


In order to address some of these disparities, the pursuit of increased racial and ethnic diversity in dentistry has been suggested.

How does a diverse dental class and administration lead to reduced disparities?

Diversity should not be thought of just in terms of numbers.

We need what is called structural diversity or transformative action.

Diversity in Education It is probable that no other area in American

higher education is so severely segregated by race as professional schools of dentistry.

Nearly 40% of all black students enrolled in dental programs are enrolled at the two historically black universities (Howard and Meharry).

Blacks make up only 3% of the students at predominantly white dental schools; In the U. S., blacks constitute 12% of the total population.

Source: Racial Segregation Persists in American Schools of Dentistry. Journal of Blacks in Higher Education, 2002.

Diversity in EducationDental School Graduates by

Race/Ethnicity 2000-2001Race and Ethnicity in

the U.S., 2000

Data Source: American Dental Education Association Data Source: US Census Bureau

Diversity in Education In 1995, there were 951 black dental students

in the United States. In 2002 there were 832, a reduction of 12.5%.

During the same period, overall enrollment was up by 6%. What contributed to this decline?

Lack of academic preparation

Decline of affirmative action programs

Why be concerned with those who didn’t make it in? If the admissions process is colorblind, does that means it is fair?

Source: Racial Segregation Persists in American Schools of Dentistry. Journal of Blacks in Higher Education, 2002.

Diversity in Education Consider for a moment those factors which you

attribute your admission into dental school to: Education, Family Influences, Hard Work, etc.

Now consider the quality of your primary and secondary education. Did you have textbooks available, was the building safe, were the teachers qualified?

Should an applicant get special consideration if they succeeded in the face of adverse circumstances such as these but may not have scored as high on the DAT?

Where does this leave us with those who are shut out of higher education as a result of such failing schools? And why should we be concerned with pursuing racial and ethnic diversity in dentistry?


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

White Asian African American Hispanic

Undergraduate Enrollment, 2000 Dental School Enrollment, 2000-2001

Dental School Faculty, 2000-2001

The representation of African American and Hispanic Students gradually decreases from undergraduate enrollment, to dental school enrollment, and finally as dental school faculty.

Data Sources: US Census Bureau, American Dental Education Association


The 2002 Affirmative Action case Grutter v Bollinger Et. Al. asserted that integrated, equitable education:

Is needed for individuals to function in a multi-racial society.

Leads to better citizenship.

Is necessity for the American economic system and even national security.

In the field of healthcare, integrated education is even more crucial in order to train and prepare students to serve diverse populations.

A diverse and culturally competent workforce is necessary to meet the oral health needs of the nation.

Diversity in Education Studies have shown that students of color are more likely

than white doctors to serve in communities where there is a shortage of physicians, and to treat minority, sicker and poorer patients.

These doctors more often serve as a community spokespersons, addressing key health problems and service needs.

If given a choice, people also tend to select health providers from their own racial group: one survey found that 60% of African American dentists’ patients are African American; 45.4% of Hispanic American dentists’ patients are Hispanic American.1

Because of both patient preferences and the tendency of dentists of color to work in underserved communities, increasing the number of minority dentists is critical to serving our country’s oral health needs.

Source: 1. The Big Cavity: Decreasing Enrollment in Minority Dental Schools. The Kellogg Foundation, March 2001.

Diversity in Dentistry

“There is a lack of racial and ethnic diversity in the oral health workforce. Efforts to recruit members of minority groups to positions in health education, research, and practice in numbers that at least match their representation in the general population not only would enrich the talent pool, but also might result in a more equitable geographic distribution of care providers.”

-Oral Health in America: A Report from the Surgeon General, 2000.

Diversity in Dentistry: Shifting Demographics Each year more dentists will leave the profession

than graduate from dental school, and there are already not enough future practitioners of color in the pipeline to replace those currently in practice.

This projection does not take into consideration the changing demographics of our country. Over the next fifty years, the white population is expected to decline from 73% to 53%, while Hispanics and African American populations will increase from 10.8% to 25%, and 12.1% to 13.6%, respectively.1

These shifts have important implications not only for the recruitment of African American and Hispanic dentists, but for the training of all dentists.

Source: 1. Statement on the Roles and Responsibilities of Academic Dental Institutions In Improving the Oral Health Status of All Americans. ADEA House of Delegates Manual. Feb5, 2003.

Diversity in Dentistry: Cultural Competency Certain racial and ethnic groups face unique

obstacles to accessing healthcare, such as language barriers.

Other cultural factors impact care as well, such as African Americans’ mistrust of the healthcare system and providers.

Healthcare professionals may also need to serve as change agents, bring care into communities through mobile clinics and reaching minority patients through churches and community groups.

In order to provide and serve these diverse communities with effective and competent care, it is imperative that healthcare professionals undergo culturally competency training.

This acquisition of knowledge, awareness and skills begins in institutions of higher learning.

Programs across the country are recognizing this need and are implementing cultural competency curriculums.

Cultural competency training can work towards eliminating disparities through the infusion of culturally competent principles into the policies and practices of organizations providing dental services.

Diversity in Dentistry: Cultural Competency

The field of dentistry also faces significant research challenges:

Need comprehensive data on health, disease and health practices and care use, especially for racial and ethnic minorities.

Need consistent data on patient provider race, ethnicity and language, as well as how these might affect the process, structure and outcomes of care.

In order to achieve statistically valid results, we need to make sure that all racial and ethnic groups are adequately represented in research.

Cultural quality assessments of patient care should be collected by race and ethnicity.

We need to not only better document race-related differences in health outcomes, but to also vigorously investigating the cause of these disparities.

Diversity in Dentistry: Research

Despite the growing list of research needed, there is a shortage of qualified researchers.

One impediment to this, as well as the lack of dentists in low-income communities, is the great financial burden students face following dental school.

With debt from anywhere between $100-150k, it is difficult for graduates to accept lower paying positions at a university or in a community.

Loan Repayment Programs are one effort to address this.Faculty loan repayment programs: Funds are used to repay qualifying health professionals’ educational loans in return for serving at least 2 years as a full-time faculty member.

Loan repayment programs also exist to incentivize students to work in underserved communities.

Diversity in Dentistry: Incentives

Structural Diversity

What would this look like in higher ed?

What does this look like in dentistry?

Summary

“We are all caught up in an inescapable network of mutuality, tied in a single garment of destiny. Whatever effects one directly effects all indirectly.”

-The Rev. Dr. Martin Luther King, Jr.

How does a structural racism approach differ from other approaches to addressing oral health disparities?

Continue pursuing initiatives designed at alleviating inequities in healthcare.

But,Instead of viewing them individual and independent, work from a more cohesive approach.

For example,When providing care to low-income patients, consider the impediments they face such as transportation, childcare, etc.

How are other institutions and structures pursuing the outcome you are seeking? Is there room for collaboration (i.e. medical practitioners)

Moving Forward

We have and can make progress.

Our efforts in the past have been transactional, we are making small changes- incremental gains within existing arrangements.

Including people where they once were excluded is a step in the right direction, but it is not enough.

For low-income, African American and Hispanic patients, we need to examine where the healthcare system is failing and seek change at that level.

We need to consider ways to bring more students and administrators of color into dentistry. Instead of focusing on this goal when they reach the doors of the university, we need to extend our efforts into middle schools and high schools.

Progress and Next Steps

Next Steps

We need transformative thinking to combat structural racism.

For example, all of our efforts at reaching underserved populations are within the current medical model. We have seen for decades the failure of this model for this nation’s poor and people of color.

Instead of continuing to try to make incremental changes within this structure, we need to challenge it and reshape it.

“The separation of oral health from systemic health in the U.S. health care system has resulted in a disciplinary chasm between oral health providers and the rest of medical care to the detriment of the patient, especially the underserved.”

-2003 ADEA House of Delegates Manual

Unless we work towards large-scale change we will continue only making adjustments which are all too often negated by other impacting factors.

Our focus should be outcome-oriented, not just simple process or input focused. We must identify our goals, then align our institutional arrangements to produce those desired outcomes.

If we are seeking a diverse workforce in the field of dentistry, we must start with this goal and adjust our institutions and structures to achieve this.

Next Steps

We cannot issues or marginality without disturbing the center.

Because of the multidimensional nature of our laws and policies, progress in one area can cause retrenchment in another.

We must examine the social forces that are compounding healthcare disparities and remedy them through the pursuit of specific racial- and ethnic-targeted health policies.

Next Steps

In order to improve disparities, there have been several initiatives suggested:

Identify and inequality producing processes that impact healthcare

Design better means of care delivery, including the location of health care facilities

Elucidate risk factors and facilitate means of risk reduction

Enhance health-promoting and care-seeking behaviors

Pursue a diverse study body and faculty in higher education.

Public education is one key component that we must include. One 2001 study found that most middle-class white citizens

believe that health status is negotiated by self-determination, choice and individual responsibility. This undoubtedly has effects on contemporary epidemiology and health policy development.1

We need public support and for that we need public education, to begin working on a policy agenda that will address healthcare inequities.

Next Steps


Summary We must expand our notion of what

equality means, taking into account access to opportunity. We must offer solutions that do not seek to affect transactional change, but transformational change and stop pursuing avenues which aren’t yielding measurable results.

At the same time, we must understand that it is often important to work on many levels at once to create change, and that it is impossible to know concretely whether a change can be transformational. Coalition building and community rather than simply criticism.

Why do this?

Or why would those who are doing well disturb the current arrangements?

Why would you or me?

www.KirwanInstitute.org

moving forward and looking back: the intersection of race and

Documents

martin luther king

loan repayment programs

racial segregation persists

american health disparity

minority dental schools

dental health disparities

cultural competency

dental school