DEIB: Looking to a future of Equity and Excellence

Steven W. Friedrichsen, DDS, and Nader A. Nadershahi, DDS, MBA, EdD

GUEST EDITORS

Steven W. Friedrichsen, DDS, is professor and dean emeritus of the College of Dental Medicine at Western University of Health Sciences in Pomona, California. With a lengthy history of engaging faculty and staff to build a more diverse and inclusive profession, he helped secure funding that included the Summer Select Program, Robert Wood Johnson Foundation awards at two dental schools, the Summer Health Professions Education Program at WesternU and several Health Resources and Service Administration grants. Dr. Friedrichsen has served his profession in numerous capacities for the Commission on Dental Accreditation, the American Dental Education Association, the California Dental Association and the Idaho State Dental Association. Conflict of Interest Disclosure: None reported.

Nader A. Nadershahi, DDS, MBA, EdD, is dean of the University of the Pacific, Arthur A. Dugoni School of Dentistry and vice provost of the San Francisco campus. He is the first Iranian American dean of a dental school in the U.S. Dr. Nadershahi serves on the boards of the Bay Area Council, the San Francisco Chamber of Commerce and was appointed by the governor to the California Health Workforce Education and Training Council. He is the chair of the American Dental Education Association Board of Directors and has been a leader at the California Dental Association, American Dental Association and is a member of the Santa Fe Group. Conflict of Interest Disclosure: None reported.

It is a documented fact that the United States is becoming a more diverse nation. 1 That statement does not represent breaking news but a population trend that has been developing for years. Nor should it be a novel concept that race, ethnicity, gender, religion, socioeconomic status and multiple other identifying factors can influence access to health care and health care outcomes — including oral health care. As a profession, we have the collective obligation to provide for everyone’s care and oral health. This issue of the Journal of the California Dental Association highlights several aspects of diversity, equity, inclusion and belonging (DEIB) with a focus on impacts to patient care. This issue also parallels the thoughtful conversations being held by our CDA boards, leadership and delegates to strengthen our profession and the critical service that we provide for our communities.

As will be established by multiple authors in this issue of the Journal, the influences can be described as “pervasive” (Chávez) and difficult to rectify. Although the challenges appear daunting, they also provide our profession with the opportunity to achieve greater success going forward.

We recognize that these issues may be personal, emotional and uncomfortable. However, to grow and strengthen our great profession, we must work together and push beyond these issues that have held us back from achieving our true potential. The authors provide multiple perspectives that will give the reader an overview of the issues we face as a society and as a profession in assuring that all individuals can access quality care and attain optimal oral health. It will become apparent that there is no one solution or one certain pathway to achieve our shared goal. Achieving equitable access and outcome will be, as they say, “a journey.”

The starting point for our journey is a view of the profession from the outside. Dr. Mary Lomax-Ghirarduzzi is a national figure and scholar in the world of DEIB. She provides us with a candid view of dentistry, both historically and as it exists today. Her views provide a glimpse of how others see us. Although that view may be difficult to acknowledge, it is important that we recognize how others view dentistry and the oral health care system.

Next, Dr. Elisa Chávez provides a substantive overview of the literature outlining areas where we are as a profession. She provides evidence of our progress as well as where we have not made significant headway over the past two decades since the “Oral Health in America: A Report of the Surgeon General.” 3 There are areas of laudable success and areas where we have many opportunities for improvement.

The next stop on our journey takes us through a series of vignettes by Dr. Pamela Alston and colleagues that help us understand the complex interplay of factors involved in the provision of care on a daily basis. Experienced oral health care practitioners understand that patients bring a level of complexity that is not easily replicated in a scientific study, cannot be addressed in a single-issue policy or solved without significant political will. In the world of DEIB, the concept that patients bring several identities that influence their ability to receive care is entitled intersectionality. As practitioners, we see this in virtually every patient. Each person we treat is a unique individual with all the complexity they bring to the health care process.

Looking to the future, Dr. Marisa Watanabe and colleagues look at how dental education is developing new approaches to education that help assure that the profession mirrors the face of a changing nation. They also preview examples of didactic and clinical curricula that help students understand the challenges their patients face. Additionally, dental education can and should provide the essential evaluation of the effectiveness of our efforts. Building the body of scientific knowledge beyond the challenges to assessing the outcomes from our policies, programs and practices is critical to our future as a profession.

Finally, in recognition of the still nascent nature of DEIB, we offer a glossary of terms 5 to help us communicate with a common language. Even though it seems rudimentary, our professional and political discourses are often fueled by use of terms without a common definition. Using the same word or term with a different meaning can be a source of considerable friction and misunderstanding. Think for example of the first time we all began to learn the new language of tooth nomenclature and morphology — without commonly accepted terminology, it would be impossible to communicate clearly.

As we have progressed through the development of the submissions by multiple authors and considered their collective efforts, there are four observations we would like to share as guest editors of this issue of the Journal. Each of these observations provides the profession with an attendant opportunity for greater success in the future.

First, although the concepts of DEIB have been considerations for decades, there remains significant variability in the terms and language used. This is to be expected in an area of continuous movement and change. At the same time, our opportunity is to support development of a consistent lexicon that helps us communicate. An opening is available through the glossary on page 623 and in making this a part of how we craft our messaging to all communities of interest.

Just as patients present with multiple intersecting oral health care needs, they also face multiple structural and social determinants of health.

Second, being embedded in the profession of dentistry, we recognize and value the many efforts to address the issues of DEIB and assure equity of access and care for all. Unfortunately, those outside the profession may not see and perhaps don’t value what we have done to work toward equity, inclusion and belonging. This is an opportunity to communicate our efforts more robustly to those outside the profession of dentistry. We have multiple pathway programs with state and federal support and safety net care systems for those without access to the more dominant practice models. As a profession, we have been strong advocates for care to underserved populations and opportunities for students seeking to become health care professionals. In a word, we need to let the world know more broadly of our efforts to become part of the solution.

Third, most academic studies are of large numbers of patients or populations and, of necessity, are designed to isolate factors so that the findings can demonstrate suitable scientific validity. On the other hand, oral health care is provided to one person at a time and rarely does that patient have only one issue. Just as patients present with multiple intersecting oral health care needs, they also face multiple structural and social determinants of health. As a profession, we would benefit from building on the practitioner-based research network concept (PBRN) to evaluate the structural and social determinants of health (SSDH) as well as the aggregate effects of their intersectionality. These are complex problems, but we are a profession composed of highly intelligent and compassionate people who take care of other people — the solutions are not beyond us.

Fourth, the bulk of the literature cited by all of the authors elucidates and illuminates the challenges. At this point, we can say that we have a comprehensive understanding that race, gender, ethnicity, orientation, etc., influence care and access. The opportunity is to shift our scientific focus to understanding how those factors work in concert to magnify the challenge. We also can do a better job of elucidating the outcomes from our efforts. What aspects of pathway programs, outreach or collaboration agreements help reshape the profession and which don’t? How effective is an access program at increasing penetration among the populations the program was designed to serve? Those two and dozens of other questions regarding our efforts need to be answered so that we may continue assessing the value of our work and modify those strategies that are suboptimal and look elsewhere when something simply doesn’t provide an acceptable outcome.

The inherent and advancing diversity of our state and country provides us with historical and ongoing challenges to equitable care and outcomes. As a profession, we have the responsibility to redirect those challenges into opportunities that demonstrate we are inclusive in every dimension, are supportive of equitable care and are working to create an environment of belonging for all members of our society.

As Dr. Martin Luther King Jr. once said, “Injustice anywhere is a threat to justice everywhere. We are caught in an inescapable network of mutuality, tied in a single garment of destiny … Whatever affects one directly, affects all indirectly.”

Our shared efforts to improve access and care for those historically underserved and underrepresented will make our profession stronger for everyone. We thank the authors for their important contributions and thank you for taking this journey with us and for your good work.