I visited Alaska as the Oral Health Section’s representative to the Alaska Native Health Consortium Outreach Trip organized by the Rasmuson Foundation of Anchorage.  Those participating in the trip included Edwin Allgair (Yukon Kuskokwim Health Corporation), Kathryn Atchison (AAPHD), Ann Battrell (CEO, ADHA), Jackson Brown (ADA Policy Committee), Jack Dillenberg (School of Dentistry and Oral Health, Arizona School of Health Sciences), Marge Green (ADHA president), Bob Herron (Yukon Kuskokwim Health Corporation), Lawrence Hill (AACDP), Stuart Hirsch (New York University College of Dentistry), Geraldine Morrow (Alaska Dental Society), Joel Neimeyer (Rasmuson Foundation), Kathleen Roth (ADA president), Mary Smith (ADA trustee), Russell Webb (ADA trustee), and Brad Whistler (Alaska Department of Health and Human Services). 

The first morning was spent touring two dental facilities in Anchorage.  We then flew to Bethel at noon to visit a dental facility.  Mid-afternoon, all but I flew to Toksook Bay to visit a sub-regional facility.  On day two, those who had gone to Toksook Bay and I met early afternoon in the village of Kasigluk to see a village clinic and visit with a dentist who was there for her periodic visit, after which we returned to Bethel to see the last dental clinic, have dinner and talk.  Having seen dental care being provided at all four levels (village, sub-regional, regional, specialty), the group spent three hours discussing the future.  It was agreed that a prospective study needs to be done to evaluate the outcomes of the DHAT program and to determine whether access to care improved because of the DHAT program.  It was agreed that a group would be convened for a two-day planning session to design the prospective study.  That group will at a minimum include representatives from the ADA, ADHA, AAPHD, CEC, and APHA.  It was agreed that all participants must support the design from the outset and agree to accept the outcomes and conclusions what ever they are in order to minimize, if not prevent, a situation from arising that after the data are in, one or more groups would consider the assessment inadequate because of insufficient data and so debunk the conclusions.  Kathryn Atchison will try to raise funds to engage the RAND Corporation to organize the two day event and lead the discussion.  It is my desire to be part of this planning process as at least one representative of the Oral Health Section of APHA.   

Alaska is a fascinating state.  It is one-fifth the size of the lower 48.  The IHS health care system has four tiers: village (171), sub-regional (20-25), regional (6), and specialty care in Anchorage.   Life from the regional to the village level becomes more and more primitive.  There are more paved roads in the city (not county) of Los Angeles than in the entire state of Alaska.  From the regional level down, there is little to no public water supply as we know it.  Rather, homes and other facilities have water reservoirs which are filled periodically.  Water is thus used sparingly.  There is also a limited sewage system as we know it.  From the regional level down, a “honeypot” found in every home and office is the way human solid excrement is handled (lots of Lysol is used).  There are 231 tribes in Alaska out of 540 nationwide.  One-fifth of Alaskans are native. About 85,000 people, mostly Alaska natives, live in small villages of 300-400 people.  There are 15 native ethnic groups in Alaska.  Alaska has the highest rate of health disparities in the country and the cost of care is the highest of any of the 50 states.  Because there are so few paved roads in the state, transportation is by plane (small 4-20 seaters flying at 900 feet, to commercial jets, and Med-Vac is the routine way those in need of care are transported to where they can get care), boat, ATV, snowmobiles and dog sled. 

Despite the vastness and primitiveness of the state, I sensed from every discussion I participated in that there is an extraordinary commitment by the health care providers.  The attitude is that the system works well, even though the demands for care far outstrip the availability of services.  At the village level, one finds Community Health Aides (CHA) who are trained to demonstrate how to brush, perform a toothbrush prophylaxis, educate, and apply varnish.  At the sub-regional and regional levels, one finds DHATs who, in addition to their regular hygiene duties, also can take and interpret X-rays, do simple extractions, administer local anesthesia, and perform restorations using the ART technique.  Both the CHA and DHAT are also intimately involved in making sure that all the necessities of life (e.g., diapers, parts for a snowmobile, etc.) are addressed.  There is little fluoridated water in the state, and bottled water costs more than soda pop.  Thus, many children are hydrated with soda pop.

This next section has been taken nearly verbatim from literature distributed during the site visit. 

For residents of nearly 200 small, isolated communities in rural Alaska, access to dental care services is a serious problem.  Alaska natives experience disproportionate oral health disparities including rates of dental caries two and a half times greater than the U.S. national rate.  More than one-third of rural Alaska school children miss school because of dental pain.  By the time Alaska natives reach adulthood, many have already experienced the devastating consequences of the lack of dental care.  Young children cover their mouths rather than smile, embarrassed by the condition of their teeth. The dental crisis is sufficiently severe that some adults forgo treatment for themselves so that their children can get care. 

Over and over, those involved in the program express extreme gratification for being part of the team addressing the dental crisis that exists today in Alaska.  Dentists employed by Alaska native tribal health organizations generally are only able to visit small villages for a week or two at a time once or twice a year.  Recruitment and retention of rural dentists is an ongoing challenge, as most dental school graduates choose private practice, not public health dentistry.  The current vacancy rate for dentists in the tribal health system is 25 percent.  One program has been waiting for seven years for a dental position to be filled. 

Beginning in 2003, Alaska native tribal health organizations and the Community Health Aide Certification Board, a federal agency, developed a new solution to addressing rural Alaska dental needs - the Alaska Dental Health Aide Therapist (DHAT) Initiative.  This initiative is part of the Community Health Aide Program (CHAP) which was developed by the Indian Health Service in cooperation with Alaska tribes in the ‘60s to address critical health problems in rural Alaska.  Twelve Alaska natives have enrolled in the DHAT program.  Eight have graduated and four have been practicing in rural Alaska since January 2005.  Currently, more than 550 indigenous medical providers work in small village clinics providing emergency, chronic and preventive services under the general supervision of physicians at regional hospitals.  CHAP is based on this medical model.  The program is a multifaceted approach to boost both the number of dental providers in rural Alaska and the level of dental services available to Alaska Native people.  There are several levels of DHA, ranging from primary (those who provide exclusively preventive services) to DHATs. 

All work is done under the general supervision of dentists at regional hospitals.  To be certified, all DHAs must meet qualifications set up by the Community Health Aide Certification Board, which is made up of experienced federal, state and tribal health professionals.  Continuing education is required.  Skills evaluation occurs every two years for re-certification.  The DHAT model is considered an essential component of dental health care in over 40 countries including New Zealand, Canada, and Great Britain.  The United States is the only industrial nation that does not have a mid-level dentistry practice for the general population.  Training for primary DHAs is provided in Alaska.  Training for DHATs has been provided through New Zealand’s Otago University School of Dentistry.  There was no mid-level Dental Practitioner training in the United States until January 2007 when the University of Washington began such training.  In September, 2006, the Alaska Native Tribal Health Consortium (ANTHC), in collaboration with the University of Washington’s School of Medicine’s Physician Assistant program, secured a four-year grant (2.8 million dollars) from the W. K. Kellogg Foundation to fund the establishment of an Alaska-based Dental Health Aide Therapist training program.  This support was supplemented by a $450,000 non-solicited grant from the Rasmuson Foundation.  Additional support has been received from federal and private financial entities including the Ford Foundation, the Alaska Mental Health Trust Facility and the Paul G. Allen Foundation. 

The training is being conducted in two phases.  The first is based in Anchorage, where trainees receive both didactic and clinical training from the University of Washington with the assistance of ANTHC training site employees.  Training is based on the very successful New Zealand/Canadian Dental Therapy Training Program curriculum.  The second year, a clinical clerkship will be offered in Bethel, in partnership with the People’s Learning Center and the Yukon-Kuskokwim Health Consortium (YKHC).  At the end of the second year of training (2,400 hours), each trainee will return to his/her sponsoring tribal health organization to complete an additional 400 hours of clinical preceptorship under the direct supervision of a dentist.  Once the preceptorship is completed, the DHAT can apply for certification from the federal CHAP Certification Board.  The CHAP Board can revoke or suspend certificates of DHATs who do not meet competency standards.  Tribal management of Indian Health Service programs is authorized by the Indian Self-determination and Education Assistance Act. 

In September, 2005, an Alaska assistant attorney general wrote an opinion that stated that DHAs may practice without a state license in native health clinics under the provisions of Federal certification.  Despite that fact, the American Dental Association and the Alaska Dental Society, in a lawsuit filed against several DHATs, argued that state licensure is necessary.