Subscribe
Share
Share
Embed
Welcome to Oral Health Matters, a brand new podcast from the Dental Public Health Group at University College London and presented by eminent dental public health expert Professor Richard Watt.
In this first series of our podcast, we'll be in conversation with researchers, policymakers and activists from around the world who are working to better understand the causes and consequences of oral diseases and to identify possible policy solutions to improve oral health.
So if you're a policy maker, clinician researcher, or member of a community who wants to know more about why oral health matters and what interventions and policies might make a difference, please follow us wherever you find your podcasts. Oral Health Matters is produced by the Dental Public Health Group at University College London, with support from Research Podcasts and funding from the UK National Institute of Health and Social Care Research.
Oral Health Matters - Ep1
Oral health: luxury for the few or fundamental
human right?
SUMMARY KEYWORDS
Oral health, inequalities, dental care, Marco, address, people, dental, communities, terms,
determinants, health, interventions, society, tackle, carol, oral, issue, discussing, agenda, general
SPEAKERS
Carol Guarnizo-Herreno, Marco Peres, Richard Watt
Richard Watt 00:04
So welcome to Oral Health Matters, a new podcast that shines a spotlight on oral health and calls for it
to be embraced as a key part of the global public health agenda. I'm Richard Watt, a Professor of
Dental Public Health at University College in London. In this first season of our podcast, I'm in
conversation with the members of the Core Research Programme, which is a team of researchers and
activists from around the world, who are working to tackle oral diseases in four countries: Kenya,
Colombia, India and Brazil. In this first episode, we're discussing why oral health needs to be a more
prominent feature of the global public health agenda and what some of the key issues are. I'm
absolutely delighted to be joined by two colleagues, Dr Carol Guarnizo-Herreno from the National
University of Colombia, in Bogota, and Professor Marco Peres, from the National Dental Centre in
Singapore. Carol is a co-lead of the core programme, and her main research interests lie in exploring
the political determinants of oral health inequalities. Marco is an internationally renowned researcher,
originally from Brazil, who is now leading a very successful research team in Singapore, if I can
perhaps start with a sort of provocative question. Is oral health a global public health priority? Or is it a
luxury for the few? Marco what would your response be to that statement?
Marco Peres 01:42
So this is a very good question. And I can see that this can vary according to different socioeconomic
status. And also according to different countries. Unfortunately, for the vast majority of people living in
low and middle income countries, and even living in high income countries who will face some
challenges in terms of socio economic status, dental care, and dance is still a luxury that very few can
enjoy. So this is the reality, despite of the enormous advances in terms of research and knowledge in
the last few decades. And this is a dilemma for us who are working in the public health arena.
Richard Watt 02:27
Okay, thank you, Mark Carroll, how would you respond to to that statement,
Carol Guarnizo-Herreno 02:31
Unfortunately, I would agree with Marco like, currently, unfortunately, oral health is, in many places a
luxury for the very few people. And, of course, I think and our view is that it must definitely be a global
public health priority, and actually a part of the overall right to health, because oral health has to do with
basic functions like eating, speaking, expressing feelings in other ways. And therefore, everyone should
be able right to enjoy their maximum oral health potential throughout the life course. Currently it is a
luxury - it is not viewed as part of as a human right as it should be. And unfortunately, is viewed as a
luxury for the wealthier, more educated people, which is very unfortunate. And if you ask me is also
unfair and it's not ethical. It's not ethical, from a human rights point of view I think.
Richard Watt 03:36
So we've already sort of risen an agenda of sort of human rights place. And that's something maybe
we'll come back to, but Carol, maybe following on from your point, thinking about defining oral health,
what do you think are the useful definitions that exist that that really explain the wide nature of oral
health?
Carol Guarnizo-Herreno 03:58
So I guess oral health can mean different things for people, you know, from different cultures,
socioeconomic backgrounds, and different global settings. And for many still there is this idea of health
being equal to absence of diseases. But I think generally there has been a slower conceptual shift over
time to broaden the definition beyond this biomedical view, to include more subjective and positive
aspects of oral health and psychosocial well being. We also heard from communities about the
psychosocial impacts of oral health and the effect of poor oral health on their general health and well
being, but I will highlight the human rights dimension of oral health. So oral health as a human right, I
think it's a powerful concept. And therefore, because that means it is the responsibility of governments,
not individuals and also is part should be part of the political agenda to achieve population health
overall, the general population health.
Richard Watt 05:08
So Marco, how would you respond to this issue of health as oral health has been a human right? And
therefore a collective responsibility of governments of society?
Marco Peres 05:20
Yeah, absolutely. I agree with Carol. And I have to say that, unfortunately, we are against the tide now,
because to claim as a human right, you need to deny the nature of oral health as a good or a
commodity. You know, I think that we need to close the artificial gap between oral and overall health
that, unfortunately, has been created for a century. So we can discuss the reasons of what this division
is still one, I think that it's a human, a fundamental human, right, that you need to fight. So in that
sense, the government, society, and importantly, the health systems can ensure that oral health and
health care, oral health care should be a right.
Richard Watt 06:19
So that's a really helpful, sort of fundamental issue that we've focused on, if we perhaps move our
discussion on a little bit and think about the global burden of diseases in terms of oral health. So as we
all know, the GBD, the Global Burden of Disease study has given us good insights into the burden of
disease. But Carol, what would you say are from your perspective, what are the major challenges that
we face in terms of the burden of oral diseases, maybe in Colombia, in particular?
Carol Guarnizo-Herreno 06:52
That's a key issue because we have many unmet needs in terms of oral health. So this huge burden is
not being like properly addressed by our very fragmented healthcare systems. So sometimes dental
care is not included in that in the general healthcare systems, especially in our low and middle income
countries. So that leads to people you know, use home remedies, self medicating or self extracting their
teeth even. So, in many instances, dental care, almost entirely privately funded. And that means that
people have to spend a lot of their own, you know, means resources to fund dental care. So I think a
main challenge there is how we improve the public provision of dental care, especially as I said before,
in our countries. But access is not the only issue actually, because also the approach to dental care
needs to change. So we know that currently is very technology focused, very interventionist,
biomedical, is focused on the individual behaviour as well. And that also has environmental impacts,
very, you know, important environmental impacts of dentistry. So we need to address this mismatch
between the oral health needs of communities and the availability, location costs and the type of dental
services provided. Because in our societies, the most disadvantaged groups and societies are faced
with the consequences of having their oral health needs unmet, whereas their wealthier counterparts
increasingly demand cosmetic and non necessarily dental interventions. And also, of course, we need
to seriously act on the upstream social and commercial determinants of oral health, because if we just
keep on treating, you know, oral health problems, but we don't address the root causes of them, then
there'll never be enough resources to tackle this huge burden of oral diseases.
Richard Watt 06:55
Marco, so how would you respond because Carol summarises sort of a major range of challenges
there. Thinking maybe about in Singapore and Southeast Asia, are we making progress in tackling the
social determinants of oral diseases in the systems that you're working with at the moment?
Marco Peres 09:31
Yeah, that's a really good question. And I think that the answer is not so comfortable to address,
because this is actually the burden of disease a combination of the risk factors that's it's a broad
determinants that's common to other non communicable disease, particularly sugar intake, and alcohol
and tobacco consumption. The societies through the governments have the right and responsibility to
control and to avoid the excessive consume of these products by many different ways: taxations and
labelling, food labelling, prohibit advertisements. But in addition to that, we need to manage the existing
disease. And for this, the dental care system should be integrated to the overall system and health
system and publicly funded and to guarantee the access and use of all citizens addressing it as a
human right. So it is a combination of upstream and downstream determinants. And then in that case,
in terms of dental care, the way that we are managing the disease actually is not contributing to reduce
the burden of disease. For example, the way that the dominant financial system, if fees for service
actually incentivize the interventions may result in over treatment. So this is a paradox, we have some
heavy users with a lot of treatment, sometimes unnecessary. And at the same time, a vast number of
people waiting for access to essential dental care. So I think that we need to, to address this issue to
integrate oral health into the health systems.
Richard Watt 11:26
What we're seeing, and what you've both described very, very clearly, is that dual challenge of, of
system change in terms of health services, but also policy agendas that really have some sort of
meaningful effect on improving oral health, globally. Now, moving that discussion on a bit, I suppose
one thing both of you have mentioned, is this problem of oral health inequalities. Now, maybe Carol, do
you want to say a little bit for you in South America, what does oral health inequalities look like? What
does that actually manifest for you in a country like Colombia?
Carol Guarnizo-Herreno 12:07
Yeah, well, we are one of the most or maybe the most unequal region in the world in terms of income,
you know, socio economic inequalities in general. And that, of course, has an effect on health, including
oral health. And we can see this huge gap staggering differences in health outcomes, including oral
health outcomes between, you know, groups with different socio-economic conditions, ethnicity as well,
gender inequalities. So it's a matter of social justice, if we take this human right rights perspective, it's
an issue of fairness is an ethic imperative. So those inequalities are really unacceptable, because they
are not random. They are the result of this unequal distribution of wealth, power, across social classes,
gender and ethnicity and other dimensions, they are not natural, and they are the result of this, the way
in which we organise our societies, you know, socially, economically, politically, culturally. So it's really
a key issue very close to my heart, all of our hearts, I guess. And it will mean for us to get involved into
the struggles, social movements for social justice in general, because that's the root cause of the oral
health inequalities. And we can do things at different levels. So what we were discussing before about
dental care, and healthcare systems, that, of course, will help, but we also need to tackle those, yeah,
very upstream determinants of inequalities in terms of employment conditions, you know, living
conditions, access to different services, education, housing, and so on.
Richard Watt 14:03
That's a great set of ideas. And, Marco, how about from your experience and scientific knowledge?
What's the evidence base for action to reduce oral health inequalities? Are there any particular things
that you think we should be doing more of that we should implement at scale? What would your
recommendations be in terms of of addressing these oral health inequalities?
Marco Peres 14:29
Thanks, Richard. This is a very good question, because I think that we have enough diagnosis of the
situation but unfortunately very few actions to reduce the known gap in terms of socio-economic
inequalities. But a recent study that has been involved in showing that for example, very, very upstream
intervention, if you reduce poverty is in a simulation modelling very interesting. If you reduce the
poverty, absolute poverty or relative poverty, taking the US context into account, we can reduce
dramatically toothache, dental pain. So this has been done by using a large population based data from
the US. So this is a clear demonstration that the agenda is not only a technical scientific agenda, but
this is a political agenda because the reduction of absolute and relative poverty, of course, is not a
dental or health agenda, but should be a societal agenda. So this is a very clear example in how this is
possible to reduce inequalities in oral health by addressing the core distil determinants in our society.
But even though we can tackle global oral health inequalities, also by addressing the social and
commercial determinants of health. So some examples that some public health measures like sugar,
taxation, and food labelling, can reduce simultaneously, the burden of oral disease, and also the socio
economic inequalities. So we need to highlight these recent findings. And unfortunately, this is very
small scale. But to scale up these studies to show in a more broad perspective, how this can affect the
global oral health.
Richard Watt 16:30
Another point to mention is the problems that we may create by accident. So these issues of
intervention-generated inequalities. So the inequalities that are created as a consequence of our own
actions. Now, Carol, any thought on what the problem of intervention-generated inequalities are?
Carol Guarnizo-Herreno 16:53
Well, that's a very interesting topic, actually, because, as you said, Richard, sometimes inadvertently,
we create more inequalities, we broaden the gaps. And there are very interesting studies showing that,
for example, the traditional way in which we do education for health, these traditional messages, which
are very standard for everyone, that do not recognise the differences across population groups, across
you know how to literacy but don't just these general messages that we sometimes try to convey to
everyone, some of those interventions actually can broaden the inequalities. Also, when we do
interventions, that though, do not take into account really, the differences in access barriers to services,
for example. And overall, I will say, it's not a good practice for us to have strategies, interventions that
do not take into account what people feel, think, experience in terms of their oral health. That's why it's
so important nowadays, for us to consider in every strategy, everything that we do, the core design, you
know, that the work with the populations, the communities that we will work on, in a team manner, not
as experts, you know, dictating what should be done, but actually understanding how the people live,
experience their oral health, and from that understanding co-designing the interventions and strategies.
Richard Watt 18:36
So, Marco, could you reflect on this issue of, of siloed working? Should we work in close partnership
with other agencies? Who should we work more with to address this isolationist approach?
Marco Peres 18:53
There is a clear recognition that we are working in silos and this is - I think that's pretty clear. How to
address this and how to tackle this is a different question. Some people are advocating for a
reunification, if you like, of dental with medical settings to move back dental to the medical schools,
because this was a division artificially created many years ago. And for some, this could be alternative
we share common risk factors with some non communicable disease., and so I think that's it's wise to
address the common risk factors with some allies, such people so professionals working in health
promotion, in you know, non communicable disease in public health. So I think that this is a way to
move to move forward.
Richard Watt 19:52
Okay. And Carol if we come back to you, because your your comment about the need to co-produce
co-design our interventions with our community partners, is an area that's a lot of work has been done
in global health, but in oral health, we're really we're still working in the beginning of such an approach,
perhaps tell us a little bit more about how we could co-produce or co-design interventions with our
communities.
Carol Guarnizo-Herreno 20:22
I think qualitative resources and resources from qualitative research and generally, more generally,
from social and human sciences, you know, approaches helps us a lot to engage with our communities,
and to understand how they experience their oral health. So I guess we need to learn a lot in oral health
and in health more generally, about, you know, approaching communities, gaining their trust. And then,
you know, co-producing co-designing these interventions. There are many tools out there how to do
this. But I think from the qualitative perspective, this approach is to first gain this trust, to know the
communities first, to learn from them to kind of take away, as I said, before, this hat of being the expert
or anything and being absolutely open and humble, to learn from the communities. That's so important.
And then there are many different strategies we can implement in terms of, you know, discussion
groups, and involving also people from different ages throughout the life course. So with children, we
can always play with them. And design things from those plays and those dynamics. I think that's so
important. And also we need to when you work with communities, it's so important to adapt to the times
to the rhythms, to their dynamics. So it's not as we impose our times, our days of availability or
anything. Sometimes you need to work on the weekends on the Sunday, if it's the market day, when
everyone, let's say in rural areas is the market day. So people from rural areas come to the town, that's
the best day to talk to people engage with them. So I think all those elements are so key, and actually
including this kind of training in our dental school, in our training of the oral health workforce, is also a
key aspect to move forwards in this field.
Richard Watt 22:30
So it sounds like our our workforce, oral health colleagues and professionals, need skills to be able to
communicate, develop trust, and work with our communities in a more effective and inclusive manner.
Marco do you have any experience of community engagement, linked to your work either in Southeast
Asia or Australia or Brazil?
Marco Peres 22:57
I've been part of a kind of committee in Brazilian universities, and in Australian universities, so called
the Diverse and Equity Committee. So this committee is, has been launched to address the inequalities
that happen not only in oral health or in health, but in terms of education. That's a point that I would like
to address. Because without good representation of the social strata, and ethnicities into the
universities, is very rare that the unprivileged people will be represented. Some actions, proactive
evictions, for example, in Australia, towards to to have more indigenous people when and
underrepresented minority communities, and even in Brazil, Brazil has the second largest black
community in the world after Nigeria. But even then, if you go to a dental school or medical school,
these people are very rare to be found. We need a change, to deliver health care to deliver oral health
deliver health, these professionals should represent the whole society. And unfortunately, this is not
happening. And even that recently seen the figures from the UK. So the ethnic minorities is really
underrepresented across as they call the prestigous professional in terms of academia. So this is
something that's very difficult to discuss. There are some policies in in America and in in Brazil, in
Australia, it's so called sometimes affirmative actions to tackle this inequalities in terms of access to
higher education as well. I think that this is a big a big problem. Because if those people who are going
to provide the care do not represent the population so it's hard that the population needs to be met.
Richard Watt 25:05
Okay. Well, look, I think maybe it's time to sort of pull things together because we've had a really
interesting discussion covering a range of really pretty fundamental questions and challenges. I think
our discussions have sort of highlighted. oral health is really a basic human right. societal responsibility.
I think we've heard from both of you of some of the challenges or system level failure and the need for
approaches to tackle that and then the political agenda and advocacy that promotes policy
development. And then lastly, I think a very important issue we've discussed is this need for inclusive
community approaches to promoting oral health. So I think it's been an excellent discussion. So I'd like
to thank our guests Carol and Marco, and to you for listening to our first episode of our podcast. Our
next episode we'll be discussing the challenges and opportunities for oral health research in the global
south with Dr. Regina Mutave from Kenya, and Professor Manu Mathur from India. Oral Health Matters
is produced by the Dental Public Health Group at UCL with production support from Research
Podcasts, and funding from the UK National Institute of Health and Social Care Research. Many thanks
for listening and goodbye.