359

NEWS &

COMMENT

Washington Perspective Uncelebrated

triumph of dental

health

How about, for a change, a tale of health care triumphant in the United States? Rare though this success story is, lessons can surely be learned from it. The reason the success has gone uncelebrated may be because it concerns dental health and dentistry. Both are routinely caricatured in popular culture, particularly in television comedy, which evokes laughter by equating dental treatment with the ultimate in pain. The root canal, usually treated with little discomfort, remains enshrined in the cliche hall of fame as being synonymous with torture. Dental care in the US has achieved a hallmark of success that continues to elude most areas of medical practiceeconomic stagnation, even decline, because of preventive measures that decisively reduce the need for many services. But when needed, those services are provided with increasing efficiency and little discomfort. One measure of success is the fading economic attractiveness of dentistry as a career. While medical school enrolments have weathered the recession almost unchanged at about 16 000 admissions per year, dental enrolments have been shrinking. Several dental schools have even shut down. In a counter-Marxian tour de force, the dental industry is tending towards putting itself out of business. The dental accomplishments were recently spelled out in a report (Estimated Savings in Dental Expenditures From 1979 through 1989) from the National Institute of Dental Research, part of the National Institutes of Health. The authors, L. Jackson Brown, of NIDR, and Tryfon Beazoglou and Dennis Heffley, of the University of Connecticut, credit fluoridation, major reductions in sugar consumption, and diagnostic and preventive care with bringing about a revolution in dental health, and huge economic savings along the way. Especially striking are the figures for refined sugar intake, down 33% in the 1980s, they report, while consumption of non-caloric sweeteners rose by 200%. All in all, they estimate that the dental problems and care avoided led to savings of about$100 billion (in 1990 dollars) from 1979 to 1989, with sugar credited for 60% of the winnings and innovations from dental research for the balance. The number of caries in children aged 5-17 fell from 7-11 in 1971-74 to 3-1in 1986, they report. Among 17-year-olds, the number of tooth surfaces affected by caries declined from 16-9 to 8-0 in those same years. Toothlessness, common throughout history and still prevalent in many lands, is a rarity among postwar generations here. In step with these changes, the character of dental practice has shifted from restorative services to diagnosis and prevention. In 1979, the authors estimate, 940 million dental treatments were provided, including 233 million restorations. In 1990, dental treatment totalled 1-1 billion, but restorations accounted for only 202 million. Amalgam

restorations, the commonest type, declined from 160 million in 1979 to 96 million in 1990, despite a population increase of about 20 million. These major improvements in dental health have been accompanied by remarkably light growth in expenditures on dental services. In 1990 dollars, total spending on dental services rose from$26-3 billion in 1978 to$30-9 billion in 1989-a mere blip on a national health-care bill of some $600 billion in that year. Dental expenditures per head (in 1990 dollars) reached a peak of$127 79 in 1981 and then declined slightly for several years before rising to$125.37 in 1989. The explanation for the recent decline in dental school enrolments may be found in these indications of a nearfinancial standstill in the dental economy. Although the overall income did not increase, the number of dentists did, from 141 300 in 1980 to 168 000 in 1989. In every year since 1975, the annual increase in the price of physician services has outpaced those of dentists. In 1985-87, the price of physician services rose 12-1%, according to the Public Health Service, whereas the price of dental services went up 8%; in 1989-90, the corresponding figures were 10-7% and 7-6%. Part of the explanation for the medical-dental disparity may lie in health insurance. About 85 % of the population is covered by some type of insurance for medical careprovided, in most cases, by employers or under government programmes for the elderly and the poor. Dental insurance, however, is far less common and generally provides lower reimbursement for services. In 1982, dental insurance paid 41-6% of the nation’s dental bills; by 1989, that had increased to only 45-2%. The main ingredients in this success story seem to be prevention and the limited presence of third-party payments that relieve the patient of concern about costs. Because of the ease of fluoridation and the availability of inexpensive and widely acceptable substitutes for villainous sugar, the promotion of dental health is particularly adaptable to preventive strategies. Few counterparts present themselves in the ills of the flesh. A notable point is that the educational barrage about dental health starts in early childhood and never ceases. For this, the dental profession, in tandem with the toothpaste industry, can be credited, along with the emphasis on dental aesthetics in the beauty standards of films and television. On the medical front, almost every effort to promote preventive strategies collides with a commercial interest-whether it is the meat industry scoffing at the damnation of fats or the tobacco industry craftily hinting that it isn’t so. Disputes rage over the actual share held by prevention research in the budget of the National Institutes of Health, with the management there insisting that it is generous and growing and outsiders complaining that it is paltry. In general, however, NIH moves on prevention in response to commands from its Congressional benefactors. The health-promoting effects of dietary greens compete poorly with molecular biology in

gaining attention in Bethesda.

360

The report on success against dental disease--surely one of humanity’s greatest miseries-has come and gone with virtually no public attention. Strange how one of the finest accomplishments of health care goes uncelebrated in this health-obsessed country. Daniel S.

Greenberg

Round the World France: Doctors face infected blood

charges over

HIV-

The trial of four doctors charged in connection with the distribution, by the former transfusion service, of blood products contaminated with human immunodeficiency virus (HIV) (Lancet 1991; 338: 809 and 1992; 339: 669) started on June 22 and ended this week. On trial were Michel Garretta, former director of the Centre National de Transfusion Sanguine (CNTS); Jean-Pierre Allain, who had been CNTS research director; Robert Netter, former director of the health service’s national laboratory; and Jacques Roux, former director of the health service. Garretta has been accused of knowingly distributing HIV-contaminated blood products, and Allain of not informing doctors and haemophiliacs of the possibility of acquiring HIV infection from the CNTS products; the charge against these two doctors is of deception over the quality of a product and carries a maximum sentence of 4 years’ imprisonment. Roux has been accused of not halting the distribution of CNTS products and Netter of not informing the appropriate authorities of the potential dangers of the CNTS products; they face a maximum of 5 years’ imprisonment for not providing assistance to people at risk. About 1200 haemophiliacs have acquired transfusion-associated HIV infection and of these some 250 have died. The story that has unfolded during the trial is that of how financial considerations took precedence over safety. In

February, 1983, Jacques Soulier, Garretta’s predecessor at CNTS, had drawn attention to possible HIV contamination of CNTS products. In May, 1983, the American firm Travenol Baxter had tried to sell to CNTS its heat-treated factor VIII, but Garretta did not take up the offer because, as testified by Allain, Garretta had to fulfil a mandate that France be self-sufficient in blood products. In 1984, several doctors and organisations protested against CNT S’ inertia by taking their own action to improve the safety of their blood products. The regional transfusion service at Lille started to heat-treat its products; Strasbourg’s centre took out an import licence for Travenol products; and Rouen’s plasma fractionation centre recalled contaminated lots and destroyed them. That same year Immuno, an American company, tried to sell to CNTS heat-treated factor VIII and its HIV-inactivating technique but negotiations were interrupted by Garretta, apparently for financial reasons. In 1984, too, two doctors in Paris Jacques Liebowitch, who had screened patients for HIV infection, and Francois Pinon, who had screened blood donors--calculated that 2500 patients a year (or 7 patients a day) would receive HIV-contaminated blood from CNTS. They expected CNTS to act on this information, so they wrote only to the director of public hospitals in Paris and to Roux, about their findings. Jean-Baptiste Brunet, a Ministry of Health epidemiologist, affirmed that he received

the letter in January, 1985, but did not believe the findings. He claimed that he transmitted the contents of the letter to Roux in March, 1985. Roux did not inform the Minister of Health until late June, 1985. Ironically, Roux had in June, 1983, recommended that all donors at risk of HIV infection be excluded as blood donors. On July 23, 1985, the then Prime Minister Laurent Fabius, signed a decree stopping the reimbursement of untreated blood products as from Oct 1, 1985. In the meantime, the CNTS policy was to continue to sell its stock of potentially HIV-contaminated products worth FFr 4 million. Two former CNTS employees testified that CNTS started to produce heat-treated factor VIII only in November, 1985. Fabius and Edmond Herve and Georgina Dufoix, two former health ministers, claimed that they took action to halt distribution of CNTS products as soon as they received alarm bells from their expert advisers, but Roux and Netter alleged that the two ministers had been informed from the start. Claude Weisselberg, a senior Ministry of Health official, has been said to have been slow to transmit Roux’s message to the minister. Michel Lucas, director of the inspectorate for social affairs (IGAS) reiterated the opinion he gave in his 1991 report Blood Transfusion and AIDS in 1985 that when, in early 1985, the scientific evidence for transfusion-associated HIV infection in haemophiliacs became strong, the CNTS should have put pressure on the Minister of Health to halt distribution of the potentially contaminated blood products. However, even the IGAS report was said during the trial to have been heavily censored; for example, alleged to be missing from the trial version is a passage referring to how, by recommending that no action needed to be taken to halt production or distribution of CNTS products betweeen July 23 and Oct 1, 1985, the Government was implicitly authorising the distribution of dangerous products. A Government minister cannot be tried in an ordinary court and the judge presiding over this case did not have enough evidence to try the ministers in a special court. The prosecutor has pointed out that the four men cannot be held responsible for the early cases of transfusionassociated HIV infection before screening tests became available. She said, however, that they were the doctors who knew of the dangers and who had the power to do something to rectify the situation. She has asked for 4 years’ imprisonment for Garretta and suspended sentences of 2-4 years for the other three. The court will give its verdict in October.

Jean-Michel Bader

USA: EPA

passive smoking report

Unsurprisingly, Tobacco Institute representatives have scoffed at what they call the "tortuous manipulation" of statistics in the new draft of an Environmental Protection Agency report that concludes that passive smoking causes 2500 to 3300 lung-cancer deaths a year among non-smokers in the US. But EPA researchers seem confident of their predictions. Criticism by the tobacco lobby came at the first meeting of the scientific advisory committee appointed to evaluate the report, which was revised in June from a 1990 draft. It remains to be seen whether the advisory committee, and eventually the EPA, agree with the conclusion in the present draft that second-hand smoke is a class A carcinogen. The final report is expected by early 1993. The report also concludes that 150 000 to 300 000 cases of

Uncelebrated triumph of dental health.

359 NEWS & COMMENT Washington Perspective Uncelebrated triumph of dental health How about, for a change, a tale of health care triumphant in the...
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