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Tuesday, November 21, 2017

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Sheree Crute

Sheree Crute

This post is by Sheree Crute, an Independent Journalist in Brooklyn, NY, and Chairperson of the National Advisory Committee for the Center for Health, Media & Policy.

Smiling and confident, Samantha Brown is proudly explaining her commitment to her new career to an audience of dentists and health advocates visiting Bethel, AK. Like so many young Alaska Natives, Brown, who is training to become a Dental Health Aide Therapist (DHAT), has seen the impact that poverty and poor access to care has had on the oral health of the children from her community.

“I am from Kotzebue, a town of 3500 people about 30 miles above the Arctic Circle,” says Brown, whose family is Inupiaq “Over the years, I’ve seen a lot of little children needing their four front teeth extracted or needing complete dental surgery. I hope to change that.”

Dental Health Aide Therapists spend two years being trained by dentists to diagnose dental problems, provide protective services to children, clean teeth, fill cavities, perform simple extractions and initiate community health programs. After accruing the 2000 hours of practice necessary for certification, they work under a dentist’s supervision.

DHATs are mid-level health care providers who can offer lower cost, often desperately needed care to medically underserved populations.

Kotzebue is one of 200 rural villages along Alaska’s Yukon-Kuskokwim Delta that are home to more than 85,000 Alaska Natives. The Delta, a broad stretch of tundra laced with rivers, lakes and one of the world’s largest populations of waterfowl, is an unlikely place for a revolution in oral health care, but that’s exactly what’s happening here.

dental-posterA Quiet Crisis

For many years, the Alaska Indian/Alaska Native (AI/AN) population endured the highest rate of dental caries in the country, five times the national average in children 2 to 4 years of age, twice the national rate for children ages 6-14. The inability to access dental care (there’s one dentist for every 2,800 individuals in the Indian Health Service and Tribal Clinics) is a large part of the problem in an area where temperatures can drop to 12 below zero and winter travel may require a plane or boat.

“I can recall young ladies graduating high school with full sets of dentures,” says Valerie Davidson, senior director for Legal & Intergovernmental Affairs for the Alaska Native Tribal Health Consortium (ANTHC). A member of the Yupik tribe, Davidson grew up in Bethel.

Modeling the DHAT program what Davidson describes as “a long tradition of community health aides who traveled by boat to carry medicines to children,” the ANTHC sent their first class of DHAT students off to train in New Zealand—one of 54 countries with DHATS–nearly ten years ago (they now train in Washington State).

Fire in the Blood, a new documentary by Dylan Mohan Gray will have its NYC release on September 6th at the IFC Center in lower Manhattan. I strongly urge anyone in public health and medicine to see this film. It tells the story of the struggle to gain access to treatment for people living with AIDS in the developing world. The focus is on how western pharmaceutical companies and governments blocked access to low cost medicine that could have saved millions of lives in the 90’s and early 2000’s. It is at times a harrowing tale.

The film explains how companies hid behind patent laws that prohibited many developing countries from making the generic versions of AIDS drugs –the only affordable option for most people living with the virus. I learned how a group of dedicated activists from around the world found ways to change this, applying constant, public pressure and finding loopholes in international law until lives could be saved.

Photo by Erich Ferdinand

Photo by Erich Ferdinand

What a difference a state makes. Ask my friend, a laborer whom I’ll call John.

Some months ago, John realized that a cyst-like lump on his trunk was growing and becoming bothersome. He has no health insurance so he paid out-of-pocket for a physician to examine it. Tests were negative and he was told it was “probably nothing.” The lump continued to grow and became uncomfortable, but John couldn’t afford to have it removed. When he shared this information with me, I told him that he probably qualified for Medicaid in New York State. He looked into it and discovered that he did. He signed up for it and went to a surgeon to remove the lump, now the size of a baseball and causing him increasing discomfort. After the test results came back, the surgeon told John that it was a malignant tumor. Fortunately, there is no evidence of metastasis, and John can proceed with the necessary treatments under Medicaid.

This story would likely have a very different outcome if John lived in Florida, Maine, Idaho, Kentucky or another of the 26 states that have not signed up to expand their Medicaid programs, as called for under the Affordable Care Act (ACA). As of September 2013, only 24 states plus the District of Columbia have committed to expanding their Medicaid programs.

How can this be? The 2012 Supreme Court’s review of the constitutionality of the ACA supported the federal government’s right to require that individuals purchase health insurance (the “individual mandate”), but it struck down a requirement that states expand their Medicaid programs to all adults under the age of 65 years who earn 138% or less of the federal poverty level (FPL) (in 2013, the poverty level is $15,626 for an individual and $32,499 for a family of four). States that failed to do so were to have forfeited their existing Medicaid programs that covered mostly women and children under the FPL. (Children ages 6 to 18 who fall at or under the FPL were covered by the existing Medicaid program; under the ACA, they are now covered up to 138% of the FPL under a separate section of the law that is untouched by the Supreme Court ruling.)