Global Health Nexus, Winter 2002
Rising from the Ashes: Dentistry’s Role in National Security
As the world changes following the terrible attacks of September 11, I believe that the challenge to dentistry, as to every health-care profession, has become to function as a vital part of national security. Since that wrenching day, the pivotal roles played by dentists in triage at Ground Zero, in the critical science of forensics, and in helping to allay the fears of a concerned public have been extensively documented in the dental media and, in the area of forensic identification, in the popular press. But much remains to be done. In this time of crisis, where uncertainty is the rule of the day, there are nevertheless a few things of which I am certain. Namely, that dentistry must gear up to become an important resource for improved civil defense, and that there is a moral righteousness in having New York lead this effort.
Shortly after the September 11 attacks, the World Health Organization (WHO) declared that Countries around the world have to build up preparedness for biological warfare. As of now, most countries have no capacity to deal with such a catastrophic event should it occur.
Very quickly, and tragically, we learned that we are not prepared to respond to the bio-terrorist threat. While New York City and our state and federal governments responded brilliantly to what was an obscene but nevertheless somewhat conventional attack on September 11, they might not have responded so well if the initial terrorist attacks had been different. Suppose that the attacks had been with a highly contagious, deadly virus like smallpox or ebola?
Suppose further that we have just entered a 100 years war with no endgame in sight a war that will be fought not only by young soldiers in helmets and night-vision goggles in Afghanistan but by you and me and our children and our childrens children. Furthermore, while it made sense to respond to the attacks of September 11 by triaging everyone at a central site, it would not make sense to follow this procedure in the event of bioterrorism. Indeed, does it make sense for everyone to be moving to a central site where one person might contaminate thousands? Does it make sense for everyone to cluster at a place like Madison Square Garden that would immediately become a rich secondary target for another attack? Would it even be possible to move people large distances at a time of crisis with bridges and tunnels closed, and public transportation shut down? Perhaps it would make more sense, depending on the nature of the crisis, to send people to their local clinician* for advice, care, testing, and other appropriate services.
* The term "clinician" will be used whenever the article refers to a physician, dentist, or other health-care professional.
Today, every dentist, every person, knows about anthrax. And we also know about Cipro® and doxycycline. But until September 11th, Americans had never feared the threat of bioterrorism on U.S. soil. And our innocence and vulnerability were compounded by the fact that we have underinvested in our public health system for decades. The succession of events that has taken place since then has significantly changed the way we regard both our public health system and our personal security, and I believe that the parameters of our responsibilities as health-care professionals must also change.
Good information is the best weapon we have against terrorism and against terror. Accordingly, I would argue that as members of one of the most highly educated groups in our nation, we dentists have the potential and the obligation to equip ourselves with the education and training that will enable us to help protect our country, our families, our patients, and ourselves.
Here, then, is my proposition: The 110,000 private dental offices in the United States should aid in protecting our country by participating in a national emergency preparedness network. Consider the following. Although there are four times as many physicians as dentists, physicians tend to practice in groups, so that perhaps only 200,000 medical offices might be available in a crisis. Thus, dental offices could account for as many as one-third of ancillary sites for care.
Our private practices are a national treasure waiting to be tapped. Each year 63 percent of Americans visit a dentist. Dentists maintain a wonderful network of convenient, modern offices that, unlike those of some physician specialists (e.g., psychiatrists, allergists), are virtual miniature hospitals, with air, suction, radiology, sterilization equipment, refrigeration, etc., in place. In addition, almost every dental office has an Internet connection, and could contribute to a national system tracking suspicious symptoms. Such a network of clinicians would provide an early warning system of a disease outbreak and could be called upon in a crisis not as a National Guard but as national guardians of the publics health.
But thats not all dentists could do. We understand drugs and their dosages, know about barrier techniques and infection control, are trained in CPR, can take X rays, manage certain types of trauma, and suture wounds. And lets not forget that on the battlefield, military dentists function as medics. Accordingly, in times of great national need, and with appropriate legislation and training, dentists could be utilized to dispense medications, administer vaccines, culture throats, assess skin lesions, and irrigate eyes, among other procedures.
The dentists potential to fight terrorism goes even further than participating in early warning systems, communications networks, and triage. For example, with dentists ability to bond ID numbers onto first molars, an additional tool will be available to assist forensics specialists throughout the nation.
Obviously, dentists are not yet equipped to assume this larger role in protecting our country. But we will never be ready if we do not begin. The alternative simply hoping that there will be no new perils unleashed is not only unrealistic, it is potentially self destructive.
LAYING THE GROUNDWORK
The world, said Albert Einstein, is a dangerous place in which to live, not just because there are people in it who are evil, but because there are people who do nothing about the evil. Since September 11, many Americans have been participating in exuberant symbolic outpourings of patriotism. Now, dentists have the opportunity to demonstrate an especially meaningful form of patriotism by learning what we can do to maximize the powerful potential of our profession to address the gravest crisis our nation has ever faced.
As you know from reading Nexus, one of my key themes is NYU Dentistrys ability to act as a catalyst for change. Just as NYU Dentistry got the ball rolling to make oral cancer a national issue, we have now embarked upon a course of action that will enable dentistry to play a meaningful role in building national emergency preparedness. As a result:
- On October 25th, all five academic dental centers in New York State agreed to collaborate in an emergency preparedness initiative.
- On November 3rd, NYU Dentistry held the first course on bioterrorism for dentists in the region. It was free, informative, and attended by 350 dentists.
- On November 6th, a group of approximately 150 senior federal and state health officials from around the country responded very positively to the proposed initiative at a meeting held in Washington, D.C., on Healthy People 2010.
- On November 16, the New York State Dental Association (NYSDA) Board of Directors unanimously passed a resolution to study the development of a protocol for dealing with the threat of bioterrorism; to consider the training of practicing dentists to help if needed; and to include representatives of the five academic dental centers in the process.
- On December 4th, Dr. Gilberto Cardona, Acting Director of HHS Region II, and the physician who directed the medical response to the events of September 11 for the U.S. Department of Health and Human Services, reviewed the preliminary plan. He agreed that appropriately-trained private practicing physicians and dentists would be very valuable to the country in the event of a disaster of massive proportions.
- On December 5th at Columbia University, Dr. Dushanka Kleinman, Assistant Surgeon General, addressed a group of Columbia and NYU dental students on public health issues, including terrorism.
- Both the President and the Executive Director of the ADA have expressed interest in learning more about the New York State initiative.
- The CEO of the nations largest supplier of medical and dental supplies and vaccines has agreed to participate in the initiative.
The next steps will likely include development of a formal plan for emergency preparedness by the NYSDA; discussions with the New York State Health Commissioner, Dr. Antonia C. Novello, who was our graduation speaker last year; consultation with biological weapons and emergency preparedness experts, physicians, and additional public health officials; and development of a suitable curriculum and training manual for dental office personnel. In addition, we will need to prepare a legislative agenda to pass Good Samaritan type laws to allow dentists, in times of crisis, to perform medical procedures that would be outside the scope of dentistry in normal times. We will also need to engage the medical profession and our nations public health officials during the planning process to ensure that appropriate services are developed and that strong systems of coordination, communication, and esprit de corps are in place.
In the future, what might we expect? As mentioned earlier, I think dentistry may evolve into a system in which periodic EPR training is mandatory for dentists and their staff. We may be issued EPR identification cards that will give us travel privileges in times of crisis. We may also be issued training manuals, critical self-protective gear, and window stickers identifying our offices as emergency resource sites. We may be placed on a list of health-care sites to receive next day shipments of critical drugs and/or vaccines, depending on the health threat identified. We will likely be expected to log suspicious events and patient disease patterns on a Web site monitored by the CDC.
Indeed, this last responsibility might turn out to be the single most important service that the profession could render since the most critical aspect of managing a bioterrorism event is early identification and containment of the site. Our newly-prepared offices might become a high-tech version of the fallout shelters of the last century. And if, like last centurys fallout shelters, we never use them, we will all celebrate.
See an outline of Dean Alfano's proposed plan.