THE ROLE OF THE STATE HEALTH AGENCY

what

can

be done about it? In the December

Journal,

Dr.

Poor

described

a

regional approach.

Here is a discussion of the role

of state

health

departments in dealing with this problem.

DENTAL

MANPOWER

AND THE PUBLIC'S

HEALTH:

THE ROLE

OF

THE

STATE HEALTH AGENCY

Wesley 0. Young, D.M.D., M.P.H., F.A.P.H.A.

W HEN ALICE, Lewis Carroll's

im-mortal creation, visited the land

"ThroughtheLooking Glass" she found many contradictions. Sitting down to rest after running a consider-able distance she found herself un-der the same tree from which she had started. Nonplussed, she turned

to the Red Queen who explained, "Now

here, you see, it takes all the running

you can do to keep in the same place. If you want to get somewhere else, you must run at least twice as fast as that!" In recent years the maintenance of an adequatesupply ofdentists inthis coun-try has presented a problem much like that described by the Red Queen. For there are few states today which have

managed to "keep in the same

place"

and fewer still which have been able to "get somewhere else." Indeed, "to get somewhere else"-to solve our dental manpower problem-remains, for most of us, one ofthe most serious challenges facing those concerned with the im-provement of dental health.

The basic objective of public dental health programs is to improve the oral health of the public through organized

community activities. However, with the exception of water fluoridation, al-most every effective method for the im-provement of dental health is dependent

upon the availability of trained profes-sionalpersonnel-either dentists or den-tal hygienists. Raising the level of oral

health, therefore, requires both an in-crease in the supply of dental personnel and the greater utilization of the avail-able resources. Otherwise, dental care in the future may well be available to a smaller, rather than to a larger, seg-ment of the population.

State dental health programs

tradi-tionally have been concerned with the

quality of dental care provided within their jurisdiction. Unfortunately, there has not always been an equal concern for the adequacy of the supply of den-tal personnel available to provide care.

Frequent references have been made in

public health literature to the shortage of dentists. Preventive programs, such as water fluoridation, have been

advo-cated as effective methods of reducing

the demand for care and thus easing the shortage of dentists. Organized

community programs to promote early

and regular dental care for children also have been advocated for the same purpose. Less frequently, however, has there been any real action in regard to the most directmethod of solving the

problem-training more professional

personnel.

Probably, this fact is not surprising.

A.J.P.H. 46

DENTAL MANPOWER

Education in the health professions is a complicated and expensive task. The cost ofbuilding andequippingamodern dental school is enough to make any agency hesitate. Furthermore, given the physical plant, the vexing problems involved in assembling a competent

teaching staff and providing operating

fundsimpose stillfurther hurdles.

Con-sequently, the establishment of new

facilities or the expansion of existing ones necessarily are long-term projects.

Nevertheless, astatehealthagencywhich fails to concern itself with dental man-power problems is shirking its

reponsi-bilitytothepublic and totheprofession. The responsibility for providing an adequate supply of dentists and dental

hygienists does not rest solely with the statehealth agency, but isshared, within the state, bythe educational institutions, the dental profession, the state adminis-tration and legislature, and the public.

It is evident, therefore, that successful

manpower activities require cooperative action. Cooperative action involves not

only officialandvoluntarystateagencies, but as well a number of regional and national organizations, such as the

American DentalAssociation, thePublic

Health Service and the regional agen-cies of higher education like the

South-ern Regional Education Board and the Western Interstate Commission for HigherEducation.

The role of the state health agency in cooperative endeavors to solve man-power shortages can perhaps be out-lined best by citing specific examples

of action which have taken place within oneregionin recent years. In 1956 the

Western Interstate Commission for

Higher Education published a study of dental manpower requirements in the 11 western states and the territories of Alaska and Hawaii.' This study indi-cated that by 1975, if current condi-tions continue, the supply of dentists in the West will fall 4,000 short of the number needed merely to maintain the

relative supply of dentists existing in 1955 and almost 19,000 short of the number that probably would be neces-sary to take care of both an expanded population and anincreased demand for care. It also indicated that the western states would face a deficit of 4,000 den-tal hygienists by 1975. This study has served bothtostimulate interest in man-power problems inthe West andto pro-vide basic data for planning on the

local level. The manpower activities

currently being carried on by state agencies in the western region can be summarized by considering the current situation in four states: New

Mexico,

Colorado, Idaho, and Nevada.

The study of dental manpower

re-quirements in the West provided infor-mation on the needs of each state, but its primary emphasis was on the devel-opment of regional estimates of need and recommendations for action. The

dentalprofession in New Mexico desired morespecific information about its own state. The Dental Society and the Den-tal Division of the State Health Depart-ment, therefore, initiated a cooperative study of the supply of dentists. The State Dental Society provided the funds

for the study and made arrangements for the Bureau of Business Research of the University of New Mexico to con-duct the investigation. The bureau had access to social and economic informa-tion about the various areas of the state. The State Health Department

supplied additional information which wastabulated, analyzed, and interpreted

by the staff of the Bureau of Business Research. Results of this study will pro. vide a guide for action in New Mexico for anumber of years. Initial planning by dentists in NewMexico indicates that an effort will be made to obtain legisla-tive appropriations to provide space for New Mexico students in a new dental school in Colorado. In addition, con-sideration is being given to the inaugu-ration of a dental hygiene curriculum

The interest indenttlmanpower prob-lems in Colorado preceded the forma-tion of the Western Interstate Commis-sion for Higher Education by several years. The only dental schools in the

West are located in the three states bordering the Pacific Ocean. More than 10 years ago dentists in Colorado

be-came aware of the need for training

facilities in the Rocky Mountain area.

Preliminary studies conducted by the State Health Department and the State Dental Society confirmed the desirabil-ity of a dental school in connection with

the medical school at the University of Colorado. Subsequently, a close co-operative relationship between the State Health Departmentand the State Dental

Society has assured successful progress throughthe tedious steps of initial plan-ning, arranging conferences of inter-ested agencies, obtaining the approval

of the university, soliciting public sup-port, and finally obtaining legislative

approval. Morerecently, the dental man-power study of the Western Interstate

Commission for Higher Education

helped clarify

the role of the dental

school in Colorado as a regional institu--tion and provided data which made it possible to estimate enrollment which would serve not only Colorado but neighboring states such as New Mexico and Wyoming. When the proposed school opensitwill bea

regional

facility

servingthe

Rocky

Mountain area. States

without a dental school will send their

students to the

University

of Colorado

and participate,

through

the student ex-change program of

WICHE,

in the cost

of financing the school.3

Theinterest indentalmanpower

prob-lems in Idaho also

predates

the WICHE

regional

study

of dental manpower

needs. In 1952 an

analysis

of

man-power

problems

was conducted by the 'Dental Division of the State Health

Departmentand the Public Health

Com-shortage ofdentists, an uneven

distribu-tion of dentists that left sparsely pop-ulated and isolated areas inadequately supplied with personnel, and not one dental hygienist in practice in the entire state.

A number of agencies were involved in attacking the problem of dentist

supply and distribution. The

Legisla-tiveCommitteeof the State Dental Asso-ciation worked closely with the State

Medical Society and a number of other

agencies in securing ratification of the InterstateCompact which allowed Idaho to join the Western Interstate Commis-sion for Higher Education. An appro-priation was secured from the Legisla-ture to send students to dental schools in other states through the student

ex-change program. The State Dental Di-vision, the Public Health Committee,

and the State Board of Dental Examin-ers worked together to improve the

methods of conducting licensure ex-aminations and to encourage larger numbers of graduating dentists to take these examinations. The Dental Divi-sion studied the needs of various areas

of the state and worked with the State Board of Dental Examiners and repre-sentatives of local dental supply com-panies in encouraging dentists to locate insmaller communities which were with-outdentalservice.

In order to increase the supply of dental hygienists in the state, the State Dental Society established scholarships for dentalhygiene students andthe Den-tal Division conducted an extensive re-cruiting program in high schools and colleges throughout the state. At the same time there was a continuous infor-mational program designed to acquaint all practicing dentists in the state with ways of using hygienists in their prac-tices and the advantages accruing from suchemployment.

In 1957 a second manpower survey

A.J.P.H.

DENTAL MANPOWER

showed that, for the first time since 1920, the ratio of persons per dentist was becoming more favorable. The number of dentists in activepractice had risen from 206 in 1952 to 256 in 1957. In 1952 seven of Idaho's 44 counties did not have a dentist, butin 1957 only three counties-all with a population

of less than 2,000 persons-were so situated. The supply of hygienists also had shownsomeimprovement-whereas

there were no hygienists in 1952, there were six in practice in 1957.5

The recent state dental manpower

study confirmed the findings of the

re-gional manpower report by WICHE

which indicated that Idaho's supply of dentists would be reasonably adequate

to meet future needs, but that dental hygienists would be in short supply. Fortunately, the data published in the WICHE study made it possible to esti-mate the number of hygienists that will be needed in the state and to analyze

the major problems to be overcome.

This analysis indicated that the most

satisfactory solution to the hygienist shortage was the establishment of a school for dental hygienists in one of

the state's institutions of higher

educa-tion. At the present time committees of the State Dental Association, the Dental Division of the State Health Department, faculty members of Idaho State College, and the State Board of Education are conducting a series of

conferences to outline plans fora school which would offer both certificate and

degreeprograms in dentalhygiene. The proposed school would be large enough to provide adequate numbers of dental

hygienists for Idaho and also to serve the surrounding states through the re-gional student exchange program.

A recurrent problem in dental man-power is the tendency of dentists to concentrate in urban areas

leaving

sparsely settled sections of the state un-derstaffed. Frequently thiscanbe over-come by activities to encourage dentists

to locate in the areas where the need is greatest. Sometimes, however, more direct action is necessary. Atleast five states have established scholarship pro-grams to assist dental students in financ-ing their education. State scholarships in Florida, Virginia, and North Caro-lina are granted only to students who agree to practice in rural areas of the *state for a specified period.0 The State

of Nevada, which has an extremely un-even population distribution, has at-tempted tosolvethisproblemin another manner. An analysis of the

manpower,

distributionproblem bytheState Dental

Society and the State Health Depart-ment showed that many of the isolated areaswithout dental service did not have an adequate population to support a

dentist. The State Dental Society pro-vided funds to purchase a completely

equipped dental trailer which travels to

the isolated areas of the state. Patients

utilizing the services of the mobile unit pay for dental care of the basis of cur-rentfees in the state, thereby providing

sufficient funds to operate the unit.7

These activities in the western region

have been reviewed briefly in order to indicate, by example, the type of activi-ties that must be carried out to solve dental manpower problems and the role

of the state health agency in these activities.

Four basic steps are involved in

pro-viding adequate supplies of dentists and dental hygienists. First, it is necessary todeterminethepresent andfuture man-power needsandthe supply ofpersonnel available to meet these needs. Second, if

the supply will not meet the expected

demand, appropriate agencies must work together to organize new facilities or to expand existing ones. Third, plans should be made for the maximum utili-zation of existing or contemplated edu-cationalfacilities bothto meet the needs of the individual state and to solve

re-gional problems through interstate co-operation. Finally, an equitable

distri-The role of the state dental division inthese activities can be summarized as the performance of three functions: (1) to stimulate interest and action, (2) to coordinate joint cooperative ac-tion, and (3) to serve as a source of

technical information.

This role is not simple or easy. To

discharge effectively the responsibilities

implicit in these functions the staff of a dental division must have akeeninterest in the problems of manpower

supply-an interest sufficientto insure that these activities will have a high priority for

time and effort. Successful coordina-tion of joint activities requires skill in

dealing with people and with the com-plex relations involved in bringing

to-gether many agencies which are con-cerned with manpower problems. The

public health dentist must understand

the role of each agency and be able

to assist all those involved in reaching mutual understanding and agreement on a course ofaction. To serve as a source of technical information the person-nel of a dental division must have a

knowledge of all of the problems

in-volved in providing adequate dental service to the public. This knowledge

must include familiarity with national and regional trends in dental demand and the supply of personnel, since, in this modern age, no geographic unit is an entity in itself. It is also neces-sary to have an intimate acquaintance

information about present and

antici-pated demands for dental service, and

with the characteristics of the popula-tion and the distribution of dentists.

Although the problems of dental man-power supplycannot be solved easily, it is imperative that a state health agency take an active role in manpower pro-grams. Otherwise, it is doubtful that its over-all objective of improving the oral health of the public willbe attained. The activities of the past 20 years have not beensufficient for the supply of den-tal manpower to "keep in the same place." It is evident that all the agen-cies having a responsibility and a role in the solution of manpower probems must take action-must take heed of the

Red Queen'swords to"run atleasttwice asfast"-to solve the growing shortages

ofdentalpersonnel. REFERENCES

1. U. S. Public Health Service, Division of Dental Resources. Dental Manpower Requirements in the West. Boulder, Colo.: Western Interstate Commis-sion forHigher Education,1956.

2. Ximenes, V. T. Demand for Dentists in New

Mexico. Santa Fe, N. M.: Department of Public Health, 1957.

3. Downs, R. A. Personal communication, October 10, 1957.

4. Young, W. 0. Dental Manpower in the State of Idaho: 1952. Boise, Idaho: Department of Public Health,1952.

5. . Characteristics of Idaho Dentists and

Their Practices: 1957. Newsletter, Idaho State

Den-talAssociation (Nov.),1957.

6. House of Representatives, Committee on Interstate and Foreign Commerce, Staff Report. Medical School Inquiry. Washington, D. C.: Gov. Ptg. Office, 1957.

7. Dentists' Donations Buy Mobile Unit for Nevadans. J. Am. Dent. A. 55:440 (Sept.), 1957.

Dr. Young is director,Division of Dental Health, State Board of Health, Boise, Idaho. This paper was presented before the Dental Health Section of the American Public Health Association at the Eighty-Fifth Annual Meeting in Cleveland, Ohio, November 12, 1957.