Global Oral Health- Seeing My Reflection in a Changing Tide

ABSTRACT

Global oral health is an evolving field with perhaps the most significant global policy milestones happening in recent years. Through a first-person account of one global health professional’s evolving career, this discussion article considers landmark events and reports from the past 15 years that have shaped modern day global health and global oral health. The historical review highlights impactful successes and ambitious policy goals while also posing challenging questions confronting dentistry today. It concludes with a call to action, urging the dental profession to capitalize on policy opportunities that can change the future of the profession and global oral health.

KEYWORDS:

• Global oral health
• dental careers
• oral disease burden
• mission trips

Discovering Global Oral Health

“Yesterday I was clever, so I wanted to change the world. Today I am wise, so I am changing myself.” First declared by thirteenth century philosopher and poet Rumi, this quote became my call to action as a newly graduated dentist. I had started a private practice and the state of oral health in my community and worldwide was catastrophic. The Bulletin of the World Health Organization described an oral health crisis globally, with oral disorders, including dental caries, found to be among the most prevalent of all diseases.^1,2 Even the United States Surgeon General had named oral diseases a silent epidemic.³ To counter this crisis, I began volunteering my services, first locally, and then globally. In 2008, I traveled to Brazil on my first dental outreach trip to, as the hosting nonprofit advertised, “change the world through service.” One of my journal entries described the arrival to our bright yellow ‘posada’ (hostel) settled in a historic neighborhood of colorful buildings, cobblestone streets, and a church on every block. Favelas (informal settlements where we would be volunteering) lined the hills. The life expectancy of the residents living in the favelas was only 48. I became particularly fond of a young boy not quite five years old. Like all the children we treated, he had rampant dental decay, plus a host of other health challenges. Not long after I returned from the volunteer experience, I received a heart breaking phone call from our host in Brazil. My young friend had passed away. His death triggered a bleak acknowledgment. I could no longer ignore the stark health disparities I was witnessing at home and around the world.

Training in Global Oral Health

I enrolled in an evening global health class at the nearby university. I learned about coordinated global level entities working to address the world’s most pressing challenges, such as the Millennium Development Goals (MDGs), the World Health Organization (WHO), and the Global Burden of Disease (GBD) studies (I won’t go into details on these, but they are worth reading about further). I discovered that my young friend in Brazil tragically became one of the nearly 9 million children that year who did not survive to see their fifth birthday.⁴ Even though the Journal of the American Dental Association editorial declaring our “dental care system is stuck”⁵ wouldn’t be published for another decade, I already saw it to be true. The status quo of our dental care system was siloed from the rest of health care, neglected tenants of prevention and health promotion, and did not account for social determinants of health.⁵ It was perpetuating a model where oral health was a privilege for the few rather than a right for all. When my evening course concluded, I took a sabbatical from practicing to pursue a Masters in Public Health (MPH) with a concentration in global health.

Unfortunately, oral health was notably absent during my MPH program. My program experience became a blend of educating my peers and professors on the relevance of oral health while also learning all about global health policy agenda-setting. I applied for a one-month winter practicum program in India. This particular program gave students a great amount of autonomy within a relatively unstructured practicum experience, which allowed me to integrate oral health into my project. I was assigned to work with a community health center in Shivaji Nagar, a government-recognized informal settlement about 45 minutes outside of Mumbai. The residents of Shivaji Nagar lived on just over three dollars a day (which amounted to about $1095 per year), hovering not far above the global threshold for extreme poverty. Our team would be conducting community health events, screenings, and educational sessions. I was invited to collect oral health data during the events, though polio, tuberculosis, and diarrheal diseases were our primary focus.

I still haven’t forgotten the first case of severe childhood diarrheal disease I witnessed. From my journal, “The words circled through my head, ‘Number two killer of children worldwide, right behind pneumonia.’ And the number two killer was right before me, in a toddler the age of my nephew (2 years old).” Though I never found out how the child faired, statistically, his odds for survival were good. My practicum mentor was Dr. Richard Cash. Professor Cash is credited with conducting the first clinical trials for Oral Rehydration Therapy, a groundbreaking yet simple solution of salt, sugar, and water administered to combat severe hydration due to diarrheal diseases. Even though he published about the discovery in 1968,⁶ it wasn’t until 1978 that the invention became more widely adopted. The 1978 Alma Ata Convention, a WHO conference that focused on primary care and redefined the definition of health, called for low-cost, accessible, effective treatments for common ailments. As Dr. Cash explained, ORT was the ‘poster child’ for this, and he was ready. UNICEF, USAID, and others soon adopted ORT internationally.⁷ After a slow start, ORT has since saved an estimated 54 million lives.^7,8

I found my practicum challenging, and so did my classmates. For budding global health professionals, the experience tested our readiness and commitment. Of the four of us placed, only two of us stayed. Most challenging of all though was the worry that the widespread oral infections and dental pain we recorded would never be resolved. As my time in India came to an end, I wrote my final report and entered in my journal, “I was unable to sleep tonight. The rooster is now crowing outside my window and the sky is turning a soft pink, morning is creeping up, and I needed to write.” I was extremely grateful for all I learned from Prof. Cash. Severe childhood caries was rampant in Shivaji Nagar and yet it could never be prioritized over the many other pressing needs. Addressing common causes, integrating oral health into existing public health programs, and refocusing on primary care and prevention over costly (and practically unavailable) treatment would be the only way to ensure any kind of attention to dental health.

These notions were of course not my original ideas, they were the product of strong didactics combined with effective experiential learning. Two papers had a large impact on my learning during my MPH training. The first was Sick individuals and sick populations by Geoffrey Rose, a classic paper commonly assigned in epidemiology courses. Essentially, his work taught me that individual approaches applied to populations don’t yield measurable shifts in population health.⁹ Translated to the goal of reducing the burden of oral diseases, Rose’s work explained in part why, for decades, individual-level treatment had not been effective in reducing the disease burden. Oral health improvement must shift toward population-level approaches that better identify and address upstream causes.⁹ The second paper was Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. The authors affirmed health professions education must reach “beyond the confines of national borders and the silos of individual professions.”¹⁰ In a globalizing world, risks, causes, and solutions flow across permeable geographic borders. The report stressed a need for interprofessional education that would better align health professionals’ competence with population needs. It also emphasized core values of social accountability, patient-centered and team-based care, and global learning.¹⁰

In the timespan between my acceptance into the MPH program and my matriculation, the concentration area I chose transitioned from ‘international’ health to ‘global’ health. By the time I graduated, the International Health Medical Education Consortium became the Consortium of Universities for Global Health.¹¹ Graduate-level education saw the use of the phrase “International Health” tapering while the frequency of the term “Global Health” was rising sharply.¹² These examples represented the tenants of the ‘global’ in global health, far beyond merely geographic reference. The shifts demonstrated a distinction between health ‘here versus there’ and health ‘everywhere.’ They underscored a global perspective on interdisciplinary scientific inquiry and practice, beyond political boundaries or individual professions. The change perhaps most importantly acknowledged the multidimensional aspects of health, disease, and care- a global vision that integrated social and environmental determinants and multi-systems approaches for health improvement for all.¹³

Practicing Global Oral Health

As a dentist, my lens changed drastically after I returned from India, as had my understanding of the patient experience in my practice and our dental care delivery system more broadly. I sold my private practice and began a career in academic dentistry, the first faculty member hired as part of a burgeoning global oral health initiative at the school. On my first day in the new position, I boarded a plane to Kigali, Rwanda to learn about what would become known as the Human Resources for Health Rwanda program (HRH). Led by the Government of Rwanda, we joined an interdisciplinary group of more than 100 health professionals from Rwanda and the United States. We were introduced to ambitious goals and unprecedented strategies for training a large, diverse, and competent health workforce and strengthening the capacity of academic institutions in Rwanda. The key features of this pioneering program aligned with the United Nations global development goals, and all else I had studied in global and public health. These principles included equitable stakeholder partnerships and strong coordination, alignment with local needs and priorities, country ownership, competency-based training, capacity-strengthening, and sustainability.¹⁴ The plan also included creating the first dental school in Rwanda. After the HRH launch in Kigali, I wrote in my journal on the flight home, the breathtakingly expansive Sahara Desert 35,000 feet below us. Though at that time we didn’t know if the ambitious HRH program would succeed, I described how it contrasted with my volunteer outreach experience. I didn’t know it then, but within the first five years of HRH, Rwanda would have the strongest health care system in the region.¹⁴ Within a few more years, the first dentists in Rwanda would successfully graduate and become a brand new cadre of oral health professionals in the country. They would call themselves the Pioneerz.¹⁵

The same year I was in Brazil on the outreach trip, dental educators were reexamining their responsibility in global health. An intriguing article was published in the Journal of Dental Education, asking the profession, “Isn’t it time [to include a global oral health course in the dental curriculum]?”¹⁶ By 2013, we had done just that, creating the first course of its kind in dental education.¹⁷ We became part of a national and global conversation about how dental schools should be preparing our students for a globalizing world. It was widely recognized that volunteerism, charity outreach, and similar short-term trips were common approaches for addressing the unmet burden of oral diseases.¹⁸ One paper reported that 91% of dental students agreed their schools should offer international exchange missions for this reason.¹⁹ Another reported more than two-thirds of U.S. dental schools offered international volunteer programs.²⁰ However, despite their popularity, the ethics and sustainability of these models were under increasing scrutiny. Critics pointed out these models prioritized providers’ values over the community’s, exacerbated harmful power dynamics, and unintentionally undermined local health leaders and priorities.^21,22 To combat these shortcomings, the Advocacy for Global Health Partnerships group organized conversations with stakeholders from around the world, resulting in the Brocher Declaration. The declaration detailed ethical principles to guide the design of short-term engagements including host community empowerment, mutual and bidirectional learning, humility, sustainability, and accountability. Others built from the declaration and urged the decolonization of global health, a field whose history is steeped in the roots of colonization and its legacy, including missionary medicine.²³

Modelling the vision for health professions in the 21st century, with an eye toward more ethical and sustainable outcomes, leaders developed a competency matrix for global oral health. The document identified a series of knowledge, skills, and abilities across three domains of global oral health for a range of groups, including dental students and dentists.²⁴ This matrix provided the first consensus and targeted guidance for competency-based global health curricula and programs in dental education. We expanded our initial course into a full curriculum, integrated these new competencies, and released an open access version now utilized in many U.S. dental schools and institutions in more than 30 countries.²⁵ As dental educators were strengthening global health offerings for our students, global oral health policy was also taking shape in historic fashion. The Lancet, among the most respected and impactful scientific journals in the world, published a ground breaking series reiterating the challenges confronting dentistry, outlined a radical policy agenda,²⁶ and established the Lancet Commission on Oral Health.²⁷ The World Dental Federation released FDI Vision 2030, forecasting healthcare professionals will have the competence to contribute appropriately to the effective prevention and management of oral diseases and collaborate across health disciplines to improve health and well-being.²⁸ What could turn out to be among the most significant events in my career happened on January 21, 2021. The WHO adopted a resolution on oral health during the annual World Health Assembly, a convening of the highest governing body in the world,²⁹ and published the first ever Global Oral Health Status Report the following year.³⁰ A 2023 article reminded us that “when the WHO speaks, the world listens.”³¹

Case in point: By the end of the WHO’s relatively brief Millennium Development Goal timeframe of 15 years (an era which encompassed the launch of my global health career), I witnessed in real-time the 53% reduction in child mortality, 50% reduction in extreme poverty, 45% reduction in maternal mortality, 40% reduction in new HIV infections, and the 45% and 58% reduction in mortality from tuberculosis and malaria respectively.³² When oral rehydration salts were adopted by the WHO Expert Committee on Specifications for Pharmaceutical Preparations,³³ deaths from diarrheal diseases decreased by 34% among children and by 21% overall.³⁴ Historically, this is the kind of progress that results when the WHO speaks and the world listens. The global burden of oral diseases has not experienced meaningful reduction in nearly 40 years, but we have reason to be optimistic. I reflected with my students in the fall semester of 2022 on the significance of the WHO Resolution on Oral Health and Status Report. We reviewed history together, noting significant milestones through time, such as the landmark 2011 United Nations summit recognizing oral diseases as a major global problem.³⁵ Thirteen years ago, sitting in an auditorium, watching world leaders gather and listening to them speak about oral health at the oral health side session, I journaled that moment felt like the tipping point.

The Future of Global Oral Health

We have been witnessing these many significant moments in history cumulatively building toward a changing of the tide. This slow yet steady shift in momentum was reflected in my career as I progressed from private practice to global volunteering to a global health profession. My dental career is one of many reflected this tidal shift. Afterall, as poet Julia Carney wrote, “Little drops of water make the mighty ocean.”³⁶ If the metaphorical ocean tide is truly changing, and I believe it is, I grapple with pressing questions for our profession and our ongoing role in global health. Where does outreach and short-term clinical service volunteering fit within the modern global oral health agenda? How can we reorient dental education from a primarily curative focus to one that emphasizes partnership in health promotion, one that incentivizes interdisciplinary prevention and holistic health, rather than disease and siloed treatment? Can we truly decolonize global oral health and place the power and priority back into communities, while still engaging in this work? Relatedly, is “glocal” the new “global?”³⁷ Is it time to shed antiquated models that perpetuate the message that oral health and appropriate care are a privilege rather than a universal right?

The dental profession must collaboratively undertake these critical questions with purpose and intention. I recall something Prof. Cash said when discussing the 10 years it took for oral rehydration therapy to finally gain recognition following the Alma Ata convention. “We were lucky,” he said. “We were in the right place, at the right time, in the right situation. And that was important.” Then he added, “Now, chance – as Louis Paster said- chance does favor the prepared mind.”⁸ If we’re indeed witnessing a historic changing of the tide, let’s ensure we are a profession prepared, because this is our chance.

Acknowledgments

I wish to acknowledge the many mentors, leaders, colleagues, peers, students, trainees, funders, and supporters from across the world who have impacted, guided, and inspired my career.

Disclosure Statement

No potential conflict of interest was reported by the author(s).

Additional information

Notes on contributors

Brittany Seymour

Brittany Seymour is Associate Dean for Faculty Affairs and Associate Professor at Harvard School of Dental Medicine. She holds a full-time appointment in the Department of Oral Health Policy and Epidemiology. Her work focuses on interdisciplinary approaches for oral health improvement at the global level through education and workforce development. She has held leadership positions at the American Association of Public Health Dentistry and the Consortium of Universities for Global Health’s Global Oral Health Interest Group. She was a contributing author to the FDI World Dental Federation’s Oral Health Atlas 2nd Edition and Oral Health in America: Advances and Challenges- A report from the National Institutes of Health.