STATEMENT OF DR. I. LAWRENCE KERR, MEMBER OF THE COUNCIL ON LEGISLATION OF THE AMERICAN DENTAL ASSOCIATION, REPRESENTING THE AMERICAN DENTAL ASSOCIATION AND THE AMERICAN ASSOCIATION OF DENTAL SCHOOLS

Dr. KERR. Mr. Chairman, I personally am appreciative of the opportunity along with the extension of the appreciation of the American Dental Association and the American Association of Dental Schools to testify before this committee on this bill.

I would like to submit to the committee an expanded version of some remarks that I will make in the reading this morning, if I may do that, sir.

Mr. Moss. Those will be incorporated in the record.

Dr. KERR. And, we will confine our remarks to a very limited amount of time.

Mr. Moss. Thank you.

(Dr. Kerr's full statement follows:)

STATEMENT OF THE AMERICAN DENTAL ASSOCIATION AND THE AMERICAN ASSOCIATION OF DENTAL SCHOOLS, PRESENTED BY DR. I. LAWRENCE KERR, MEMBER OF THE COUNCIL ON LEGISLATION OF THE AMERICAN DENTAL ASSOCIATION

Mr. Chairman and members of the committee, I am Dr. I Lawrence Kerr of Endicott, N.Y., where I am in private practice as an oral surgeon. I am a member of the Council on Legislation of the American Dental Association. I am accompanied by Mr. Hal M. Christensen, director of the Washington office of the American Dental Association. I have been asked by the Secretary of the American Association of Dental Schools to speak for that association also. Both associations are in agreement that H.R. 12453, the President's International Health Act of 1966, can contribute to existing Federal Government and private international health and health training activities.

H.R. 12453 would strengthen health services in foreign lands by sending specially trained American health workers to those countries striving to develop improved health services for their people. The special training of personnel for international health services would be accomplished through (1) Federal grants to schools of health to finance programs designed to train students for international health work, (2) authority for the Public Health Service to appoint members of the health professions to the Regular or Reserve Corps for assignment as trainees (associates in international health) for health work in a foreign country to special advanced training fellowships at schools of health and to make such advanced training available to commissioned PHS officers also, and (4) authority to appoint to the Public Health Service Regular or Reserve Corps members of the health professions for assignment to other Federal executive agencies or certain international organizations for duties related to health work in foreign countries or for assignment directly to a foreign country at the request of the Department of State.

The term "school of health" is defined to include dental schools. The grant program to schools of health would be for 5 years with authority to appropriate $10 million in fiscal 1967 and "such sums as may be necessary" for each of the next 4 fiscal years.

DENTISTRY'S RELATION TO INTERNATIONAL HEALTH ORGANIZATION

The dental profession and the dental schools are engaged in several international health activities. Most of this effort is a joint one with the Federation Dentaire Internationale, a worldwide organization of national and regional dental associations. The American Dental Association is one of the principal contributors to FDI and, because of its superior sources, has provided the leadership for many projects in international dentistry. One such activity was sponsorship of a "Conference on Public Dental Health: Worldwide," held in San Francisco in November 1964 in conjunction with the annual sessions of the American Dental Association and Federation of Dentaire Internationale. Highlights of the conference were reports from southeast Asia and the western

Pacific regions, Africa and the eastern Mediterranean regions, and from the Latin American nations.

America's dental profession and dental schools also maintain active liaison with the World Health Organization, the World Medical Association, the Pan American Health Organization, the Agency for International Development, the Institute of International Education, HOPE, MEDICO, and several private foundations concerned with international health. A noteworthy effort was recently initiated with the Inter-American Association of Sanitary Engineering to advance community fluoridation projects in the Latin American countries. There is, of course, a close relationship also with those agencies of the Public Health Service engaged in international activities.

EMPHASIS ON TRAINING NATIVE PERSONNEL TO PROVIDE HEALTH SERVICES

In 1947, this committee conducted extensive hearings to assess the benefits flowing from international health activities of U.S. agencies, both Federal and private. In its report, the committee made the following comments:

"The greatest obstacle to the development and expansion of health programs in other countries is the lack of professional personnel *** Most of the underdeveloped countries neither have such personnel now nor have the facilities for training them *. From the long-range viewpoint, it is most practical and economical to help countries develop their own national and regional training centers for most of the health personnel they need rather than have them depend indefinitely upon training facilities of the United States and Europe *

The committee report goes on to describe several successful examples of U.S. efforts in creating or expanding regional and national health training centers, notably in Lebanon, Pakistan, Egypt, the Philippines and, to a lesser extent, Thailand and Colombia.

Unquestionably the key component of any plan to bring health services to those in the underdeveloped lands must be enlargement of native facilities for training competent native professions. The fact that our supply of health manpower is faced with an immense task of keeping up with domestic needs lends impetus to this point. Since the 1957 report of this committee, we understand that progress in constructing and staffing native facities has been most heartening.

Training competent personnel from the underdeveped nations in U.S. schools can also do much to expand health services in those lands. The 1957 report of this committee noted that: "About 1,000 health trainees are in the United States in any given year: 800 on grants from the International Cooperation Administrtaion and 200 on World Health Organization fellowships."

INTERNATIONAL ACTIVITIES OF THE DENTAL SCHOOLS

For many years, the dental schools of the United States have been engaged in both student and faculty interchange with other countries throughout the world. By and large, these interchange activities have been sporadic and informal, mostly because there has not been adequate and consistent financial assistance available to support the establishment of a regular, continuing program. About 3 years ago, the American Association of Dental Schools made a survey of the dental schools in the United States to determine, among other things, the extent to which these schools were involved in teacher and student exchange programs. It was apparent at that time that relatively few institutions were actually en. gaged in some form of interchange activity in dental education or dental teaching, but nearly one-half of the dental schools in the United States indicated an interest in developing such programs if sources of financial support could be found. The following quotation from the 1963 report of the American As. sociation of Dental schools is presented to illustrate the attitude which exists among the dental schools of this country:

"There was considerable agreement of opinion on the obligation of American dental schools to provide education at the graduate and postgraduate level for foreign dental graduates which would permit them to return to their native countries with increased capabilities to teach or to perform dental research. The chief barrier to these education services seemed to be finance."

Since its 1963 survey, the American Association of Dental Schools has continued its search for methods of strengthening international educational exchange 1 H. Rept. 474, 85th Cong., 1st sess.

activities in dentistry. Following 2 years of study, the House of Delegates of the American Association of Dental Schools adopted a "Statement of Principles Regarding the Acceptance of Dental Graduates from other Countries" which states that "insofar as teaching resources, university policies, and governmental regulations will permit, the dental schools of the United States and Canada will extend their educational and research programs to members of the dental profession throughout the world, under the provisions outlined in this statement." In 1964, the American Dental Association, the American Association of Dental Schools, and Federation Dentaire Internationale combined their common interests in the development of an expanded international educational interchange program and established an ad hoc committee charged with the responsibility of developing principles and guidelines for the administration of an international program in dentistry. At the present time, that ad hoc committee is engaged in a worldwide study of dental educational institutions and dental organizations to determine (a) the nature and extent of the interchange program which would be desirable, (b) the educational facilities available for utilization in an interchange program, and (c) possible sources of financial support for educational preparation of dental manpower, including travel support for teachers and research scientists. Although the results of the study of the ad hoc committee will not be available until July of 1966, there is not the slightest doubt that the largest, most insoluble problem will prove to be the difficulty of financing training opportunities.

GRANTS TO SCHOOLS FOR TRAINING FOR INTERNATIONAL HEALTH WORK

The associations which I represent are pleased to note that schools of dentistry are specifically included in the institutions which will be eligible for grants to establish, expand, and operate programs for the specialized training of health personnel for service in foreign countries. We are particularly pleased to note, as well, that the proposed legislation provides authority for the payment of travel both for dental educators from this country to others throughout the world where dental education is less well developed and for assistance to teachers and scholars from other countries to travel to the United States. In this regard. I should like to quote again from the "Statement of Principles Regarding the Acceptance of Dental Graduates from Other Countries" of the American Association of Dental Schools with respect to the high priority which the dental schools in our country have placed on a teacher interchange program:

"The American Association of Dental Schools concurs with the basic philosophy expressed in the Report of an Expert Committee on Dental Health (World Health Organization, Technical Report Series, No. 244, 1962) to the effect that the permanent solution of dental health problems throughout the world will be achieved only through the development of adequately educated local personnel created by a cadre of dental educators in less well developed countries by means of formalized interchange programs for teachers. The American Association of Dental Schools is willing and anxious to cooperate in the development of an effective international teacher interchange program."

Both the American Dental Association and the American Association of Dental Schools have recorded their intention of participating in the establishment and maintenance of a list of dental faculty members who are interested in teaching positions in other countries, including their qualifications for interchange teaching appointments. In addition, the two associations are prepared to cooperate with individual dental schools in the development of specialized training programs for dentists interested in foreign assignments and to serve, if the need develops, in a coordinating capacity in this area.

DENTAL DISEASE IN UNDERDEVELOPED NATIONS

The expansion and improvement of health services in the underdeveloped lands is a goal this Nation, with the other advanced nations of the world, has striven to accomplish for many years. Yet today, with all of the effort put forth, we must admit that millions of persons in the less developed countries are suffering and dying simply because health services are not available to them. There must be an intensified dedication by the United States as the leader of Western civilization to contribute much more to alleviate unnecessary suffering and death in the African nations, India, Pakistan, Vietnam and many other less fortunate countries.

No one dies of dental disease, it has been said. With the exception of oral cancer, this may be almost a truism in the United States. But in many other

countries, untreated dental disorders rapidly advance to such gross conditions that death may be a direct result. Where there is little or no professional dental services available, the dental disease problem approaches a magnitude beyond the belief of United States dentists. Let me illustrate by quoting an oral surgeon, Dr. Herbert J. Bloom of Detroit, who has served aboard the S.S. Hope as dental director. In a report of Hope's 1961 mission to southeast Asia, Dr. Bloom recounted one of his experiences as follows: 2

***** The 60 dentists of Vietnam can no more cope with the oral problem of more than 12 million people than can the 300 dentists of Indonesia meet the requirements of population that exceeds 90 million. ***

"Although Project Hope provided facilities and staff for a complete dental teaching-service program, the most urgent needs of the land visited fell within the scope of oral surgery. The problem of high incidence of oral disease is made worse by the almost total absence of advanced oral surgery teaching in the curriculums of the schools of dentistry. Lack of educators in this field, meager school equipment, few of even the minimal scientific publications and the sharp delineation and poor communication found between the medical and dental professions have had a decidedly adverse effect on the professional personnel qualified to deal with the mass of oral infections, tumors, and deformities. The limited number of general surgeons are so overburdened with general surgery that the oral and maxillo-facial disturbances are left untreated. These conditions often progress to fatal termination; other unfortunate victims who are left must adjust to living with terrible disfigurement and associated personality problems. ***”

In a letter to one of his colleagues in the United States, Dr. Bloom dramatically summed up his southeast Asia experience on Hope in these words:

"I will never forget the day I left Saigon; there were hundreds of people on the dock, holding up their children showing us the cases of cleft palate, tumors, malignancies that we had not the time to treat. If I could put in a word what their eyes so poignantly cried out, it was "hope." We in the United States must answer it because we are humanitarians, and we must answer it if we ourselves are to survive in this world."

RECOMMENDATION

The American Dental Association and the American Association of Dental Schools believe that H.R. 12453 can significantly contribute to the expansion and improvement of health services for people in foreign lands, principally in the underdeveloped and less developed nations of the world. The two associations believe that the policy stated in section 2 of H.R. 12453 is sound. It is "to provide assistance to those countries who are working to help themselves develop needed health services." In 1957, the House Committee on Interstate and Foreign Commerce in its report on international health activities of the United States declared an almost identical position: "In helping a country build up its health facilities, emphasis is placed upon the self-help principle * * the responsibility must be assumed by the people themselves. Time and again this approach has proved successful."

*

The American Dental Association and the American Association of Dental Schools believe further that the training of native personnel to provide the needed health services in underdeveloped countries is a first priority. This should be done through expansion and improvement of programs in U.S. schools for training personnel from needy countries. Again to quote from the 1957 report of this committee:

"Eventually, all countries may have their own, indigenous facilities for training the health personnel they need. In the meantime, however, their progress toward self-sufficiency can be speeded up by providing key workers with the advanced training that is available only in the United States and other highly developed countries ***."5

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Dr. KERR. Mr. Chairman and members of the committee, my name is Dr. I. Lawrence Kerr of Endicott, N.Y.

I am in private practice in that city and am, in addition, a member of the Council on Legislation of the American Dental Association.

2 Journal of the American Dental Association, vol. 65, August 1962, p. 277.

The Alph Omegan, December 1961, p. 188.

H. Rept. 474, 85th Cong., 1st sess.

5 Ibid.

I am here today representing that association as well as the American Association of Dental Schools. Accompanying me is Mr. Hal M. Christensen, director of the Washington office of the American Dental Association.

In addition to that I have extended myself to certain areas of health resources and so have been very interested in this and other similar types of legislation.

Our associations, Mr. Chairman, favor H.R. 12453 and believe it will further the work being done in the field of international health by private and governmental agencies. This measure, we believe, is in keeping with the tradition of this Nation in helping others to help themselves.

Surely, there can be no better application of this principle than in the field of health, for the diseases that scourge mankind respect no national boundaries and the cures we are seeking can be applied as effectively in Brazil or Thailand as in California or New York.

Within the proper professional sphere, the dentists of the United States have long taken an active interest in international health

matters.

The American Dental Association is a principal contributor toand leader of the programs of Federation Dentaire Internationale, the worldwide association of national dental groups.

The association has, as well, supported and helped identify and secure personnel for such programs as Hope and Medico as well as maintaining active liaison with the World Health Organization, the Pan American Health Organization, the Agency for International Development, and the Institute of International Education.

One present project of note is with the Inter-American Association of Sanitary Engineering and is directed toward advancing community fluoridation in Latin American countries.

For several years, in addition, the dental schools of the United States have been engaged in both student and faculty interchanges with other countries of the world. Just a few years ago, the American Association of Dental Schools made a survey of its members to determine the extent of this involvement.

It is apparent from the study that the program is more sporadic than it should be, primarily because the severely limited funds available to dental schools are exhausted by other, higher priority demands.

The survey, however, also made two other points clear. First, that the dental schools were agreed that they had an obligation to provide education at the graduate and postgraduate level to prepare some of our dentists to help underdeveloped nations to organize educational systems and dental public health and care programs; always, of course, looking to that time when such nations would be capable of taking over the entire responsibility for their health care systems.

A number of the Nation's dental schools indicated readiness, in the survey to which I have referred, to undertake such programs quickly if sources of financial support could be found. H.R. 12453 would provide some help in this regard.

The support that H.R. 12453 would make available, of course, does not touch all aspects of the international health effort. It does not, for example, provide an expanded opportunity for professional personnel from other lands to seek graduate or postgraduate education in this Nation's health schools.