A Conversation with Saskia Estupiñán-Day, DDS
This leader in international public health and oral health research is also a track and field Master’s athlete.
INSIDE DENTISTRY (ID): What was it about a career in dentistry that attracted you to the profession, and to choose two such different specialties—pediatric dentistry and oral and maxillofacial surgery—as well as public health?
Saskia Estupiñán Day (SED): After graduating from high school—the American school in Ecuador—at 16, I had the opportunity to be an exchange student through an exchange program known as the American Field Service. I had been considering a career in medicine, but while living with a family in Simi Valley, California, for that year, I learned about dentistry through my host family mother, who was a dental hygienist. When I returned to Ecuador, I visited both dental and medical school and decided on dentistry.
My choice of specialties and the decision to focus on public health was greatly influenced by my association with Ronald H. Guderian, MD, a pathologist from my church who was working on prevention of onchocerciasis (river blindness) and malaria, in some parts of Ecuador, including the Amazon jungle. In the villages where we worked, there was a great need for dental extractions in addition to malaria and onchocerciasis treatment. So, working with him during dental school vacations, I developed the skills to perform these extractions, which prompted me to take a residency in oral surgery. I came to believe that preventing the dental disease that led to the need for extractions was ultimately more important to me than performing the surgery. I found that I liked working with children, so the prevention and the pediatric dentistry fit in quite well.
ID: For almost 20 years you have worked for the World Health Organization’s (WHO) Pan American Health Organization (PAHO). What is the mission of WHO as a United Nations (UN) agency? What are the skills necessary for working there, and how did you develop them?
SED: The main responsibility of WHO is to direct and coordinate global health matters within the United Nations system. It can shape the direction of health research, and is responsible for setting norms and standards—including evidence-based policy—and provide technical support. They monitor and very closely assess health trends. PAHO, one of the agencies, is a regional office for WHO. PAHO is the oldest international health agency in the world, predating even WHO. Like WHO, it is committed to providing technical support and leadership for its membership, which includes 35 member states. PAHO seeks to raise awareness and eliminate inequities in the populations in the region. Our mission really is to lead and work together with our partners and other countries—both public and private sectors—to combat disease and improve the quality of life of the people of this region of the Americas.
It was during my UCLA pediatric dentistry residency that I met the PAHO oral health focal point and decided that I wanted to develop the skills needed to someday qualify for similar post in oral health, within PAHO/WHO. For the next 10 years, I worked in public health, received further training, and returned to the Amazon jungle villages to work on prevention strategies. After I married my husband, we moved to Africa and lived in Togo, where I worked on family planning and strategic planning. So, by the time the oral health PAHO position opened up in Washington DC, I had acquired new skills—particularly in strategic approaches to public health interventions, capacity building, and partnerships development. Although I had gotten somewhat out of oral health, I was offered the job.
Much has changed since I began this position almost 20 years ago, when PAHO was mainly a male-physician–dominated organization. The needed skills and competence have evolved from being technical to managerial, multitasking, and working in multidisciplinary teams. It is important to have a broader vision of where oral health fits into the larger picture and to be able to work as a team and communicate. The current economic environment—particularly the onset of the global financial crisis, and the increasingly complex global health landscape—which includes scarcity of resources and a shift from disease-specific funds to systems-strengthening approaches—requires more than integrated strategies to leverage new resources for the delivery of favorable health outcomes, and resources are critical within the UN system, but particularly with WHO and PAHO. Therefore, mobilization of resources and managerial skills are now as important as technical expertise.
ID: What individuals or events influenced your chosen career pathway?
SED: The first person who influenced my going into public health obviously was Dr. Guderian, the pathologist with whom I was working on onchocerciasis. However, there are others who have influenced and shaped my career in public health dentistry. The most important would be my husband, Laurence M. Day, PhD, MPH, who is a public health expert. What I’ve learned from Larry’s guidance over the years is how to think outside the box. I value his wisdom, but what I value most—professionally—is his ability to look at the big picture. Rather than focus on a small aspect of dentistry or oral health, he understands the need to have a more of a multidimensional view of things and he also gets the managerial aspect of public health. To these two major influences on my professional life, I would add two others. As I am dedicated to the use of fluoride for the prevention of caries, I include Herschel S. Horowitz, DDS, MPH, who was a pioneer in clinical trials, fluoride research, and prevention of oral diseases and conditions and a major advocate for community water fluoridation. Finally, I include Lois K. Cohen, PhD, Paul G. Rogers Ambassador for Global Health Research, who has been a true friend and has been really my closest colleague in the field. From her, I have learned the wisdom of and the ability to stick to the goals, the targets, and just move forward.
ID: What are the major improvements in oral health that you have witnessed throughout the region? What offers the greatest promise for the future?
SED: The oral health status of the Americas has improved to the point that most countries were classified as having improved their oral health and caries rate in the 2000s. Data from 56 national oral health surveys indicate a marked decline on the prevalence of dental caries ranging between 35% and 85%, attributed mostly to the development of cost-effective salt and water fluoridation programs in the 1990s,, followed by increased access to dental treatments and services in the 2000s. A third important development has been the recognition of the link between oral health and chronic diseases, sharing common risk factors, which was highlighted at the United Nations High Level Meeting held in 2011, where heads of state focused on the four most prominent worldwide non-communicable diseases, namely, cancer, cardiovascular diseases, chronic respiratory diseases, and diabetes and the four risk factors—tobacco, alcohol, diet, and physical inactivity. The aim of the summit was to agree on a global strategy to address non-communicable diseases (NCDs). The high-level meeting was the second of its kind to focus on a global disease issue. The first UN Summit related to health was the HIV/AIDS meeting in 2001 that led to the creation of the Global Fund. The NCD crisis was placed at the top of the global health agenda and social development for the coming decades.
A complex process lies ahead as world leaders and the international health community will have to define and set measurable targets, goals, and how these can convert into specific policies and practical solutions. Setting the targets and allocation of resources are among the many challenges ahead, particularly for planning purposes and adopting policies to curb the NCDs epidemic and extend life expectancy in low-and middle-income countries while the world struggles with financial instability.
Our prospects for achieving more of our goals through a true integration of oral health into the primary healthcare delivery system has been bolstered by the United Nations’ recent passage of a NCD agenda. This has prompted PAHO, which places a priority on finding practical solutions to problems involving access to oral health services, to focus on how we integrate oral health into efforts to prevent and control NCDs—eg, diabetes, cardiovascular disease, cancers, and chronic respiratory diseases by focusing on risk factors including smoking, obesity, physical activity, and alcohol use.
ID: What are the implications of this high-level meeting for the dental workforce?
SED: I totally believe in and I have hope that the dental workforce can be at the frontline for early detection of risk factors, but we need to change our mindset to work on an integrated approach for early detection of those risk factors. The oral healthcare profession must work with its colleagues to devise its own specific targets in keeping with the NCD targets. To maximize efforts to identify oral health risk factors, we need to train healthcare providers outside organized dentistry as well as dental personnel to recognize the oral manifestations of risk factors that lead to NCDs. In addition, dentists themselves should be trained to detect these risk factors and also to provide some level of treatment, for which they would be reimbursed.
We are looking into the future into this cross-cutting, inter-programmatic, and multidisciplinary approach where the profession cannot just be limited to the oral cavity. This is an opportunity for dentists to become integrated into the health workforce in a way we have not seen previously.
A multidisciplinary and integrated common risk factor approach is now proposed under the caries-free initiative to integrate oral healthcare into primary healthcare prevention strategies. This approach is a best-practice model and reorients oral healthcare toward prevention; tackles common risk factors for NCDs and oral health such as smoking, alcohol consumption, and poor diet. Primary healthcare workers can reduce the risk of both oral diseases and NCDs by promoting smoking cessation, reduced alcohol consumption, and adopting a healthy diet.
To develop disease-prevention strategies, a shift of the current paradigm is required. The control and prevention side embraces first the notion that people of all ages must be empowered through awareness and knowledge of protective factors, such as appropriate oral self-care practices; effective use of fluorides; and healthy lifestyles in relation to diet, nutrition, personal hygiene, and smoking and alcohol consumption.
ID: What is the Caries Free Communities Initiative and what are its goals?
SED: From the oral health surveys I mentioned earlier, we were able to see that caries was being prevented mostly due to fluoridation programs, but that there also were inequities that affected mainly the lowest socioeconomic population. The Caries Free Communities Initiative (CFCI), which was launched in 2009, in Mexico City with the participation and collaboration of chief dental officers, dental associations, academia, and the private sector, is an 8-year plan that represents an effort to combat the great burden of dental caries throughout the Americas by 2015. The CFCI called to action the private sector and other stakeholders to address the inequities and invest in dental public health projects while supporting PAHO’s strategic goals.
Almost every country in the Americas participated in the initiative. The initiative basically involves having small communities in the countries implementing their own programs, training community health workers to diagnose oral health, so there’s also a tie-in with the NCDs; they are all kind of interconnected. Rather than allocating responsibility mostly to dentists, it creates something more sustainable by empowering community health workers. This is the first time PAHO has worked with the support of major donor modules to train community health workers to diagnose oral health diseases, and, if possible, provide simple treatments. For example, when a mother takes her child to see a physician or to have the child vaccinated, this first entry point can be used to begin oral health treatment—including fluoride varnishes as well as the vaccine—and parent education. This is the one way in which we see a true integration of oral health into the primary healthcare delivery system.
It took us over a year to develop the modules. We are going to do the pilot study in Colombia later this year to test whether it is feasible for a healthcare provider giving a vaccine to a child to also do fluoride varnishes. We believe this concept of oral healthcare services delivery by the primary healthcare provider is very feasible; once it is tested, we will scale up to eight countries in Latin America.
ID: What is Atraumatic Restorative Therapy (ART)? How is it carried out and what are the benefits?
SED: First of all, we have changed the name to procedures for restorative atraumatic treatment—PRAT—because ART also stands for antiretroviral therapy for HIV. It also reflects the fact that PRAT is more than a technique; it is actually the broader concept of having someone other than a dentist provide cost-effective interventions—eg, sealants and restorations—to provide a satisfactory oral health procedure with good outcomes and acceptance by the health community. PAHO provided the evidence that it was cost-effective; we were able to demonstrate that the cost of doing ART—a noninvasive method of excavating dental caries and restoring the cavity with glass ionomer—was lower than an amalgam, but just as effective. But most important was demonstrating that community health workers could be trained to do ART, which also sends the message that interventions beyond the CFCI can similarly be shifted to community health workers to treat NCDs. This means we can bring the cost down and we can have more providers giving oral healthcare services—not just preventive care—to the population.
ID: In 2010 Haiti suffered a series of devastating catastrophes. How were you and PAHO involved in the immediate relief efforts?
SED: The difficulty encountered in delivering resources during the emergencies in Haiti made clear the need for oral healthcare guidelines for disasters. Once we at the Regional Oral Health Program of PAHO were able to conduct a needs assessment and create a wish list of what was needed, a coalition of dental schools, professional associations, foundations, US government agencies, and other organizations began sending their donations and supplies, including dental materials and equipment for prevention, infection control, dental restoration, and surgery.
Our work in Haiti serves as a good example of how a community that wants to help after such a disaster can create a coalition and conduct a needs assessment to offer the help that is actually needed in an organized way, not based on what or whom the donors think they should send.
Beyond dealing with the emergency, we have been able to make a significant impact on their oral healthcare system by creating an approved plan for oral health, helping install a person devoted solely to oral healthcare at the ministry of health, and seeing oral health included in the major primary healthcare plan for the country. This has led to an initiative to move from cholera control to cholera elimination. This is especially important, because the eradication of cholera will force the country to put in place systems for social development, including water and sanitation, and will include a healthy-school initiative to put forward this concept of healthier schools for the children. We hope to mobilize some resources for this initiative.
I myself was greatly affected by this experience personally. When you see devastation such as there was in Haiti and are also able to witness an entire oral healthcare community that wants to reach out, you cannot turn your back. You have to have the passion to move forward and to really set goals. I saw this as an opportunity to include oral healthcare in the ministry of health’s plan. We had to be smart, come up with good solutions with lasting impact. I would say probably one of the most rewarding things I have done in my career with PAHO has been the assisting I did in Haiti.
ID: As an accomplished track and field athlete, would you says there are similarities between your approach to sporting competition and to your work striving to improve health and quality of life?
SED: I have been a runner since I was 13, becoming a champion first in Ecuador, then later in the United States. So track and field is part of me. I am who I am because of track and field. Just as an athlete, I had to literally run through hurdles, in life, I’ve needed to overcome hurdles—obstacles—to reach goals. Every goal involves a race to a finish line. In life, you need to choose your competition, the battles you want to fight. You need to evaluate the challenge and either go through them as quickly as possible without becoming frozen, or fall, then get back to where you are supposed to be. So the concept of track and field has definitely affected the way I have recognized strategies for oral health, identified goals, and the obstacles to achieve them. I also have been able to distinguish between the “races” in which I can or cannot be most effective.
ID: While caries is preventable, do you think it will ever be eradicated?
SED: I don’t believe caries will ever be eradicated. There are only a few diseases in the world that we have been able to eradicate, and most of them were caused by viruses, which can be tackled. Caries is highly preventable but, unlike a virus, it involves too many factors to be similarly eradicated.
ABOUT DR. ESTUPIÑÁN DAY
Saskia Estupiñán-Day, DDS, is Oral Health Senior Advisor of the Pan-American Health Organization Regional Office of World Health Organization. She has worked extensively with international organizations and has advised agencies including NASA, Kellogg Foundation, and the World Bank. She is also is a track and field Master’s athlete, ranked 9th worldwide in the 80-meter hurdles among women in her age group, and is currently writing a book called Hurdling Through Life Without Fear.
