Remarks as Prepared; Not a Transcript.

Vice Admiral Richard H. Carmona, M.D., M.P.H, FACS
United States Surgeon General
U.S. Department of Health and Human Services

Keynote Address at Academy of General Dentistry 2004 Annual Meeting

Friday, July 9, 2004
Anaheim, California

"Dentists' Many Roles in Prevention, Public Health Preparedness, Eliminating Health Disparities, and Improving Health Literacy"

Thank you, John. (Dr. John Chandler, President of AGD)

It's a pleasure to be here with you all today.

It's a tremendous honor to serve in this position and to travel the world speaking with people who are shaping the future of health care and education, the future of government and business.

As dental leaders, you are shaping all these areas, and more. You are truly shaping the future of life.

And to think that just two years ago, I was just a guy in Arizona, working as a trauma surgeon, a college professor, and a law enforcement officer.

The reality is that we don't ever know what the future holds. We don't in our lives, and we certainly don't in health care.

I want to thank all of you for being here, and for your continued commitment to improving the health and well-being of all Americans. Your mission is my mission.

Priorities

When President Bush nominated me to be Surgeon General, he asked me to focus on three priorities. I'm fortunate to work with a leader who understands the importance of health, who insists that evidence and the best science always guide our policies and what I do.

All three of my priorities are very strongly evidence-based. They are:

• First, Prevention. - What each of us can do in our own lives and communities to make ourselves and our families healthier.

  Our National Institute of Dental and Craniofacial Research, at the National Institutes of Health, is conducting and supporting research key research efforts that have the potential to change the way we approach oral health prevention and treatment.

  Just today we announced that scientists at NIDCR and their colleagues have isolated human postnatal stem cells for the first time directly from the periodontal ligament.

  These cells have tremendous potential to regenerate the periodontal ligament, a common target of periodontal disease.

• Second, and new to the Office of the Surgeon General, as none of my 16 predecessors had to deal with these issues: Public Health Preparedness.

  We are investing resources at the federal, state, and local levels to prevent, mitigate, and respond to all-hazards emergencies.

  For decades our nation's public health infrastructure deteriorated through neglect. Now, with the nearly $5 billion investment over the past three years to our nation's hospitals and state public health systems, we're finally catching up to where we should be.

  Not only have we increased the national pharmaceutical stockpile and increased our response mechanisms, we've improved communications, health care education, laboratory capabilities, and hospital capacity.

  While this fact is not well known by the public, dentists can play a critical role in America's response to the new threats we face.

  I want to thank you for your vision: the AGD was one of the earliest advocates for ensuring emergency support training for dentists.

  And dentists were very involved in development of the Medical Reserve Corps, which is the health component of President Bush's volunteer effort known as the Freedom Corps and the one I lead as Surgeon General.

  I encourage each of you to join your local MRC. These units are made up of volunteers - dentists, nurses, doctors, paramedics, and other professionals - who are trained to respond to health crises. MRC volunteers complement and assist full-time emergency first responders during large-scale disasters. They could be called upon to staff triage and decontamination sites, casualty collection centers, or mass immunization sites.

  The Medical Reserve Corps nationally are critical to our efforts on preparedness. They'll provide assistance and depth to the good emergency teams already in place.

  I encourage each of you to become members of your local MRC. Certainly they can use your expertise.

  I also want to thank those of you who participated in developing a plan of action to address dentistry's role in responding to catastrophic events, including possible acts of bioterrorism. It is through that type of collaboration and education that we make our nation stronger and safer. We need you to continue these efforts.

• The third priority I'm focusing on relentlessly is Eliminating Health Care Disparities.

  I am so happy and proud that President Bush and Secretary Thompson charged me with working with them and all of you to eliminate health disparities. Notice that they didn't just charge me with reducing health disparities. They said we will eliminate health disparities.

  America suffers from racial and ethnic disparities in oral health. From the very beginning of life, children of color are at a disadvantage.

  • Oral diseases are found primarily among the poor, people of color, and homeless and migrant populations. I was one of those kids who never saw a dentist.
  • Poor children are more than 3 times less likely to access dental care than their classmates.

  Things don't get better when kids grow up:

  • More than 50% of African American males have untreated dental decay (compared to 28% of white males).
  • African American males also have the highest incidence of oral cancer, are less likely to be diagnosed during the earlier stages of oral cancer, and have the lowest 5-year survival rates.

  This has very little to do with genetics, but it has a lot to do with certain aspects of culture and a lot to do with access to health care.

  We obviously have a lot of work to do. Where should we begin? To start, we must never again look at the oral health gap as:

  • An "African American problem."
  • An "Asian American problem."
  • A "Native American problem."
  • A "Latino problem."
  • It is an American problem that demands an American solution.

  To close the gap, we must:

  • Increase the racial and ethic diversity of the oral health workforce to reflect the nation's diversity;
  • Improve health literacy outreach to communities of color; and,
  • Expand and strengthen the capacity of the safety net system to provide oral health services.

  The Bush Administration recognizes these needs. This year, the Department of Health and Human Services, under the leadership of President Bush and Secretary Thompson, increased funding to community health centers to increase their capacity to provide oral health care to those in need. I want to thank AGD for all your efforts to help address the disparity in access to oral health care.

Health Literacy

An overall theme that cross cuts my three priorities is health literacy - an emerging area, and I know that the AGD gets it. I want to thank the AGD for your efforts to help address the disparity in access to oral health care and in your special efforts to address oral health literacy.

Dr. Chandler, your work to implement the agreements outlined in the Memorandum of Understanding that AGD signed with HHS in 2002 has been aggressive. We appreciate your partnership and that of your staff and your members as you work with Secretary Thompson and all of us at HHS to promote the Healthy People 2010 oral health objectives.

You are doing more than anyone else to teach Americans that oral health is overall health.

Federal Dentists

And because of your leadership, dentists throughout the world are standing with you.This includes my Chief Dental Officer Rear Admiral Dushanka Kleinman and other senior dental leaders throughout the Department of Health and Human Services.

It also includes the dentists in the Army, Navy, and Air Force. I want to acknowledge AGD's vision and commitment to representing all dentists by establishing a section for the Federal Dental Service.

And I want to recognize the military and PHS dentists here today, including Public Health Service Commander Doug Shepherd, who is the President of the PHS component of AGD's Federal Dental Service. Ladies and Gentlemen, thank you for your service to our nation.

SGR: Oral Health in America

It was no surprise to the AGD when the Surgeon General's Report on Oral Health in America found that oral health means far more than healthy teeth:

• We know that oral diseases and disorders affect health and well-being throughout life.
• We know that safe and effective measures exist to prevent the most common dental diseases - dental caries and periodontal diseases;
• We know that lifestyle behaviors that affect general health and well-being such as tobacco and alcohol use, and poor dietary choices, affect oral health;
• We know that associations between chronic oral infections and other health problems such as diabetes, heart disease, and adverse pregnancy outcomes have been reported; and,
• We know that there are profound and consequential oral health disparities within the U.S. population.

Coming from that report, we recognized the need to change perceptions regarding oral health so that it became an accepted component of general health.

Last year, I joined with partners to release a National Call to Action to Promote Oral Health. It builds on the objectives outlined by former Surgeon General Satcher in the Report on Oral Health.

The Call to Action I launched with partners from throughout the nation seeks to expand current efforts by enlisting the expertise of individuals, health care professionals, academia, communities, and policymakers at all levels of society.

I want to thank AGD for your full support of the Call to Action to Promote Oral Health, particularly your commitment to improving Americans' oral health literacy.

Health Literacy

Dentistry was making strides and - let's face it - making waves, in improving health literacy before other professions ever heard of it. You didn't always call it health literacy, because it was part of your overall effort to help patients and their families. But you are some of the original health literacy advocates.

Health literacy is the ability of an individual to access, understand, and use health-related information and services to make appropriate health decisions.

Right now low health literacy is a threat to the health and well-being of Americans and to the health and well-being of the American health care system.

Low health literacy adds as much as $58 billion per year to health care costs. More than 90 million Americans cannot adequately understand basic health information. People of all ages, races, incomes, and education levels are challenged by low health literacy, but the problems are most acute in communities of color.

Even the seemingly simple things that we can all do to stay healthy and safe, such as getting regular dental check-ups and eating healthy foods, can be struggles for people who don't have access to information that is presented in a way that they can understand.

Low health literacy has gone largely unrecognized and untreated for too long. I appreciate the strides that the AGD is taking in improving Americans' oral health literacy.

Your Oral Health Literacy Task Force, whose membership includes HHS dental leaders, is already doing so much to address gaps in oral health literacy.

And currently, the Task Force is developing a long-term research project that will test the hypothesis that oral health of children will be improved by providing comprehensive oral health education and access to preventive care. The program will involve the development of an oral health curriculum for grades K-12. Currently, no program of this kind exists, so we appreciate your innovation and your willingness to commit to its research and implementation.

As dentists, you are on the front lines of improving health literacy. I am asking you to find ways to ensure that your patients understand what they can do to stay healthy. You should offer the information even if your patients do not ask the questions.

I am ensuring that the Surgeon General communications are written in plain language that people can understand. In May, we issued the first-ever "people's piece" to accompany a Report of the Surgeon General. I issued the Surgeon General's Report on the Health Consequences of Smoking, a 960-page book, along with a full-color, magazine-style publication that is already being used in schools, community centers, places of worship, and many other settings to educate people about the dangers of smoking.

Health communication alone cannot change systemic problems related to health - such as poverty, environmental degradation, or lack of access to health care. But comprehensive health programs must clearly communicate health information to populations across our diverse nation.

I'm asking public health educators to keep following the science to develop communications that capture people's attention and imagination.

We're also training community health workers to help increase health literacy among groups that have traditionally lacked understanding about health and the health care system. They may be called community health advocates, lay health educators, community health representatives, or, in Spanish, promotores de salud. We need these knowledgeable people to serve as connectors between community members and health care professionals in culturally competent ways.

Pill Necklace

I learned this lesson more than 30 years ago, as a young Special Forces medic in Vietnam. I was a medic and a weapons specialist on an A-Team.

I learned first-hand then that how I communicated with a patient and her family could have direct effects on their outcomes.

These lessons that I learned in a very remote area, working with the Montagnard villagers, were lessons I have never forgotten. Montagnards in Vietnam are more or less analogous to American Indians here hundreds of years ago. They are wonderful people of great character and dignity, and their language at that point was only spoken. The reality was that they had no context to understand some of the messages that we wanted to give them about health.

This A-Team that I was a part of had a wonderful relationship with the Montagnards, and at one point in time when we were standing down for a couple days from combat operations, we went into the Montagnard village and did what was called a MEDCAP.

This was very early in my career; I was just shy of my 20th birthday. By that point in my life, I had taken care of gunshot wounds already, I had taken care of parasitic diseases, I had set up a sanitation system for the village, and I didn't realize at the time how important those lessons would be to me years later. In fact, more important to me today than they were back then, because I now work with very diverse populations and the unique needs of those populations.

In any case, we went into the village to do a Medical Civil Action Program, what we called a MED CAP. When you go into the village as Americans, you just want to run sick call.

You want to line everybody up and start diagnosing and treating their medical complaints.

Well, the Montagnard village leaders didn't want us meeting anybody or touching anybody until they knew who we were. So we had to sit for a while with the village chief and his family and get to know each other. We talked through an interpreter…the Montagnard interpreter. We had learned a little Montagnard, but not enough to fully converse.

The Montagnard interpreter would field questions from the village chief. The questions were largely, "Who are you?, Where are you from?, Are you married?, Do you have children?, What's your value system?" They wanted to know who we were.

Today, Americans are still on a fast track all the time. But that's not necessarily the best way to understand what is really happening with someone, within their culture. I sat down and learned that lesson. I had to share food with the village chief, which I did. To this day I'm not sure what I was eating, but I smiled.

And that wasn't all. We were in these thatched huts. They were on stilts, so that when the monsoons came, the water would run below and the houses wouldn't get washed away.

But underneath the chief's house; buried into the ground; connected with long, thin pieces of bamboo was this ceremonial wine that fermented through generation after generation.

So we sat in the middle of the house, and the bamboo straw came up, and we sat in a circle with the healer and the village chief, and we had to sip this stuff. Well, as soon as we smelled it, it was enough to just knock us out. And I wasn't a drinker. I had learned from my parents' bad habits, so I just pretended like I sipped it. And we sat there for what seemed like an extraordinarily long period of time drinking this stuff.

And when it was all over, the village healer started to bring some people in, because we had offered to look at them for conditions that the healer was not able to treat. And the first person who came up was the granddaughter of the village chief. I don't know how old she was, maybe 7 or 8. Mind you, in their language, they don't have words for time or days or years. It's sunrise, sundown. Passage of time is related to the crops and the cattle.

So when I saw her walking toward me, I thought, "I'm going to look brilliant." Her arm was covered with scabs, and I immediately recognized it as impetigo. Even as a 19-year-old Special Forces medic, I was thinking that I was going to look pretty good with this diagnosis and treatment.

For those of you who have been around for a while and are practitioners, you remember that we used to have these big green buckets of Phisohex. They weighed about 10 pounds.

So I put some of this Phisohex in a bottle that the villagers had. They didn't have running water, so we said, "Go down to the river, wash with this, don't pick at the scabs, let them fall off. Oh, and by the way, take these."

Back in 1969/1970 we only had two antibiotics - penicillin and streptomycin. So I gave them a little bottle of the PenVK and said, "Take one of these four times a day." There were 28 pills in the bottle, and I said, "I'll be back in a week or 10 days, and I'll check up on you when we come through the village."

So I went away, and then came back in about a week. We went through the whole ceremonial thing again with the food and wine and talking. Then the little girl was introduced as the first patient. She looked wonderful. The scabs were coming off her arm.

The village chief thanked me. They brought me some things. I got a Montagnard bracelet, a Montagnard ring, they gave me a crossbow, and made me an honorary member of the family. The village chief thanked me for all I was doing for his people. And then he showed me a little box and said, "And we thank you for this gift that you have given us."

He opened the box, and there was a necklace of 28 Pen VK pills.

Then the interpreter told me that now when people are ill, they wear the necklace so that it will ward of the disease.

The thing is that I thought I was a pretty good communicator. Obviously I wasn't, and I learned a lot that day. More than 30 years later I still think of that and what an invaluable lesson I leaned about never assuming that someone understands what you're talking about.

The Montagnard villagers had no idea what questions to ask me about the pills. This was the first time that they had ever seen a pill. To them, it looked like a bead. A medicine bead.

So they treated the vial of pills as a bottle of beads. And to take it four times a day, there was really nothing in the language to say that.

I wish I could have anticipated the misunderstanding. As a relative stranger to their culture and their way of life, I didn't even consider that the Montagnard people would see a pill as anything other than a pill.

Charge and Closing

Today, we are still grappling with cross-cultural communication. As our country becomes more diverse and enriched with the cultures of the world, we must respond every day to our communities' and patients' diverse needs.

Improving health literacy must be part of our response. It will save lives, save money, and improve the health and well-being of millions of people.

Health literacy is the currency of success for everything I am doing as Surgeon General. And I need your help.

At the Department of Health and Human Services, we are committed to improving health promotion and disease prevention, but the government cannot do it alone.

You are in a perfect position to act as a role model to your patients and to teach healthy behaviors. People will listen to you because you have the information they need and because you are a respected member of the community.

In the spirit of the National Call to Action to Promote Oral Health, and in the great tradition of the Academy of General Dentistry, I ask you to continue providing services to the underserved, to continue reaching out to the people who need you the most, and to find ways to contribute your time and expertise to your communities.

Helen Keller said: "I long to accomplish a great and noble task, but it is my chief duty to accomplish humble tasks as if they were great and noble. The world is moved along, not only by the mighty shoves of its heroes, but also by the aggregate of the tiny pushes of each honest worker."

My question to you today is not, "Will you be the hero?" My question to you is, "Will you be the honest, humble worker?"

Will you be the dentist who sets aside time every week to care for the poor; the disenfranchised; the men, women, and children who suffer because of lack of basic preventive care?

We are doing so much at the federal level to provide funding and programs, to make sure that there is a health care safety net for every American. And we need your help.

We need you to help us advance the policies, we need you to provide the services and the education, and we need you to teach the next generation.

Looking around this room; I know that through your individual efforts, your work with the AGD nationally and in your communities; and through your partnerships with President Bush, Secretary Thompson, and me we can make all this a reality.

I want to thank you very much for your dedication. I stand ready to work with you on any effort that is important to dentists and dentistry. Thank you.

###

Last revised: January 9, 2007