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Temple University School of Dentistry: Empowering Communities

 Media: The Inside Scoop


November 2009


Amid I. Ismail, BDS, MPH, MBA, DrPHIn 1917, the American writer H. L. Mencken published an essay on the ephemeral nature of chasing one’s muse.  On the good days, he wrote, “all of the processes and operations of mind take on an amazing ease and slickness.”  On the bad days, life is a hair-pulling, eye-straining quest for elusive ideas that he lyrically described as “the particular penalty of those who pursue strange butterflies into dark forests, and go fishing in enchanted and forbidden streams.”  Mencken then asked half rhetorically why must inspiration come and go?  He answered with the now classic line – “There is always an easy solution to every human problem – neat, plausible, and wrong.”

Mencken’s “neat, plausible, and wrong” quip captures the never-ending challenge of health disparities research.  Scientists would like nothing more than to develop a neat, plausible, one-size-fits-all solution to a public health problem.  The problem is, by nature, American society is a culturally diverse and socially dynamic web of interactions.  What works in one neighborhood may be a poor fit elsewhere.  Or, the intervention may require the integration of additional, seemingly unrelated public resources, or social systems, to implement successfully.  This perpetual moving target has forced many researchers to think more broadly about how to best to address oral health disparities.  One scientist who continues to give this issue a great deal of thought is Dr. Amid Ismail, dean of the Maurice H. Kornberg School of Dentistry at Temple University in Philadelphia. 

First item of business, what should we call this area of research?  Some people have noted the term “disparities research” emphasizes the social differences in health status.  That’s an aspect, not the whole, of the research. 

Actually, the term, “disparity” is fine in many ways.  It connotes the condition or fact of being unequal, and that’s certainly accurate.  Maybe the better term is “research on social inequities.”  It lays out more of the mission statement behind the work.  We are looking into social inequities, and these inequities have a tremendous impact on health. 

How so? 

America shines on the strength and ingenuity of its people.  This drive to accomplish great things exists on all rungs of the social ladder, from top to bottom.  That’s why equal access and opportunity for all, particularly when it comes to public health, can only be a good thing for the nation.  It’s a rhetorical point, but I think it’s worth framing as the starting point to discuss these issues.

 

It starts the conversation on a more empathetic note. 

That’s right.  We must approach the issue of social inequity from a more bottom-up, holistic perspective. 

 

What will that perspective provide? 

The social dynamics.  When launching a research project, it’s always important to know how a community functions on a daily basis.  In other words, what are the social systems that people depend on to bring stability to their lives?

 

What do you mean by “social systems?” 

I mean it in the most composite sense.  I mean the social services, healthcare resources, educational systems, neighborhood centers, religious institutions, transportation systems, and, of course, the family unit.  It’s absolutely essential to recognize that every family, every neighborhood, and every community has different sets of issues to overcome.  Each is as unique as a fingerprint.  That’s why we can’t do this type of research from our university offices.  We can’t start from the premise that we have the solutions filed away in our heads.  We don’t.  We need the people in these communities to work with us and to tell us how best to move forward from the bottom up.

 

And that’s not happening? 

Well, it’s not the traditional approach.  Right now, traditional disparities research follows a laboratory model.  It is largely powered one hypothesis and one potential intervention at a time.  That’s too narrow of a focus to empower people, neighborhoods, and communities.  In other words, this research investment will have no direct impact on reducing social inequities.

 

But history shows that the hypothesis-driven model does work? 

It does – but with an asterisk.  The traditional hypothesis-driven model works well within socio-economic groups that have a pre-existing orientation for and ability to implement prevention strategies.  But for a large percentage of the American population, that’s not the case.  Socio-economic, racial, and community barriers exist that confound the smooth implementation of prevention strategies.  Let’s take prevention research as an example.  Imagine that I’ve launched a research project to evaluate a new model to prevent tooth decay, or caries.  That’s a worthwhile scientific undertaking, no doubt about it.  But the scope of my research doesn’t allow me to address the dental care that community members already need.  Nor does it address how these individuals will receive care in a week, a month, or a year.  You see, this other side of the healthcare equation is so often omitted from the discussion among academics. 

 

Why? 

Dentist and young girl at Temple University outreach activity Researchers and research organizations aren’t typically tasked to provide care.  But I think it’s incumbent upon us to find ways to do so.   As I see it, healthcare delivery is fundamental to establish an integrated system of care, and that’s the best way to have an impact and ultimately make prevention more viable in communities that have higher and/or a greater number of social barriers.

 






But if we go back to the various social systems that you just named, each exists in its own self-contained orbit.  How can researchers make linkages with, say, a shuttle bus service?  What’s in it for them?
 

It’s a two-way street.  Research projects have an inherent value to a community, and so do the social systems.  The key is to partner these values and increase their collective worth within a community.  Let me make the point a little differently.  One of the real revelations of the past decade in science is that the traditional barriers between disciplines are in many ways artificial and self limiting.  When multi-disciplinary teams are assembled to undertake a project, the research effort has broader intellectual power and potential to break through the biological complexity at hand.  Well, it’s the exact same story for research into social inequities, and that’s where we need to be headed, too.

 

In other words, the role for dental researchers is to show the other members of the system that collaboration is a win-win-win situation. 

Yes, that’s right.  And, as a part of this win-win-win equation, we need to address the issue of sustainability.  For every research project, we need to ask, “Can I sustain this community resource when the research is completed.”  That’s a really important point because communities have discovered that too often we go there, conduct our projects, pull up our stakes, and leave.  That’s not a winning proposition for the community.  We must value and bring value to our communities.

 

And when you say this, you’re not talking in the abstract.  This is what you did in Detroit with your previous NIDCR-supported disparities center. 

Well, this is what I started to do with my colleagues in Detroit.  That said, I started out with a traditional hypothesis-driven approach to disparities research.

 

What changed your mind? 

Detroit faces so many challenges right now.  I found that we could conduct our research, collect the data, and stay above the fray, so to speak.  But at some point, it became incumbent upon us to address the care issues.  They just couldn’t be ignored anymore.  That’s where I reached the conclusion that research on social inequities works best when it employs a systems approach that integrates effort within a community.  But I also learned something else.

 

What’s that? 

I learned there is hope.  These communities possess a wealth of human capital, and so many of those with whom I worked in Detroit approached life with an inspiring energy and profound wisdom.  Remember a moment ago I said the drive to accomplish great things exists on all rungs of the social ladder?  Well, you really see it in the children who live in these communities.  They have so much to offer this country, but they need a hand to reach the next rung of the ladder.  And that’s where what I do, working in partnership with other community members, can truly help to fill a gap.

 

Given that the gap has been there for a while, how is oral health perceived?  Do people feel powerless to keep their teeth disease free? 

Many do, and we certainly encounter quite a bit of what’s often called dental fatalism.  It’s a belief that I can’t do anything to improve my teeth, so why even try?  But all ideas are subject to change, and the key here is to refocus the issue.  That begins with the message that you can have a better quality of life through prevention and better care of your oral health.

 

Focusing on life, not disease? 

Absolutely.  It’s not just the availability of dental care.  It’s also what happens in the home, and also what happens in the practice.  If we address these two issues, then we’ll make significant progress.

 

How might that be done? 

The answer brings us back to the start of our conversation. We need not only to understand but also to embrace the complexity of life in these communities.  That means tapping into the social systems within the community that we discussed a moment ago.  For example, you just mentioned linking into a shuttle bus service.  Medicaid already provides vouchers for its recipients to receive transportation to its clinics. So there are systems up and running.  But because they are not integrated into other systems, many people don’t necessarily know about them.  You don’t have to reinvent the wheel; you just need to know your communities from the ground up.

 

You’re now in Philadelphia serving as the dean of Temple University School of Dentistry.  How are you continuing your work there? 

As the dean, I want to operate from a model that integrates a community-health approach with the delivery of clinical care.  The community-health component addresses the social, behavioral, nutritional interventions, and so on.  The care component will be provided through a network of federally qualified health centers and the Temple dental school.  In fact, the dental school soon will open its own community clinic with staff dentists.  So it’s a unique opportunity for me to bring my experience in Detroit to the community here in North Philadelphia.

 

And that’s just a start? 

That’s right. To address the issues of housing, transportation, employment, economic development is beyond my capacity. But we’re trying to develop a model at Temple whereby the schools of education, engineering, business, dentistry, medicine, and so on work in their respective areas to develop community improvement projects.

 

So within the university itself, the traditional departmental walls are being lowered a bit? 

Well, we’re discussing it. Temple is an urban community-oriented university, and it has a good track record of reaching out to its neighbors.  I hope that we can do more to help our communities.

 

Thanks for sharing your thoughts, and best of luck in the future.






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This page last updated: February 26, 2014