Peripheral innovation – the dental therapist movement in the US

                                                                                                                                                                   [Photo: Nhia Moua/unsplash]

Diffusion is known as a process that ties together the centers of the world ever more closely. Once the privatization of water supply made it on the international agenda, privatization soon became a topic in capitals all over the world. Once it becomes the world standard to have a ministry for digital affairs, governments around the world will establish such an organization. Still, there is another and more hidden network of diffusion: diffusion that connects the world’s peripheries – sites of marginalized populations both in the Global South and the Global North. Here, an innovation does not move between the centers of power; it moves between the peripheries forgotten by the centers.

Dental therapists in the US are a case in point of such peripheral diffusion. They deliver basic dental services to underserved populations in peripheries, services that are normally delivered by dentists. Dental therapists work around the world in sites that are considered underserved. The profession was first established for dental services to schoolchildren in New Zealand in the 1920s, following bad health status of recruits. Now, there are dental therapists in 53 countries, from Australia to Zimbabwe. In the US, they were introduced for the first time in Alaskan Native communities. Currently, the dental therapist movement is introducing this profession in peripheries all over the US.

This movement and the spread of dental therapists in the US draw attention to important features of peripheral diffusion in a globalized world.

Innovation & diffusion – facilitated by foundations

First, peripheries are interconnected and they diffuse knowledge amongst each other. While established theories of imperialism still highlighted that only centers are interconnected and part of the world of “flows”, the dental therapist movement illustrates that also peripheries are interconnected and networked across borders. In the US, the first six dental therapists started working in 2004 in Alaska. Currently, legislation for dental therapists is on its way in ten states. This fast diffusion is not a coincidence; there is a closely linked network of medical peripheries and community health activists in and beyond the US. Their activities are facilitated by several foundations specializing in introducing and financing new models of health care delivery for the underserved, for example, the Robert Wood Johnson Foundation, the Rasmuson Foundation, or the W.K. Kellogg Foundation. Such foundations financed the education and services of the first dental therapists and established a university-based education for dental therapists in the US, even before these professionals were allowed by states to practice. Furthermore, the professionals working in peripheries strongly connect with each other to share experiences and new models. The dental therapy model was first discussed in 2000 on a conference in Boca Raton, Florida. Afterwards, the dental therapist movement became established, connecting all interested associations and academics. There is an impressive degree of mobility of professionals working in peripheries; they constantly meet on conferences and work on establishing new platforms and associations.

Second, it would be misleading to consider peripheral networks merely as laboratories of global healthcare innovations. Some peripheral innovations are not designed to be introduced on a broader scale – the dental therapist movement remained in the periphery. In the language of postcolonial scholars, globalization “from the South” need not result in universal diffusion, it can also be diffusion within a transregional South. Several factors contribute to this spatial delineation.

Across the US, first, there are distinct medical institutions for peripheries. Innovations developed for one periphery can be better transplanted into other peripheries. Community health centers are especially set up in underserved areas and financed from a distinct federal funding stream. Furthermore, emergency rooms are important providers of dental care in all peripheries. Due to these shared institutional structures, an innovation can move more easily between peripheries.

Second, scaling the dental therapist model to the center – for example, to the urban middle class – is strongly contested by professional groups in the center. One might expect that such a minor event like six dental therapists practicing in remote Alaskan areas only led to a shrugging of shoulders in the center. The opposite took place. The American Dental Association (ADA) started a major lobbying campaign against the dental therapist model and against its state-wide introduction in Minnesota. In 2005, the ADA lobbied for a change in federal legislation to explicitly forbid dental therapy for native communities – still without success. In 2006, the ADA sued the Alaska Native Tribal Health Consortium, which hired the first dental therapists: Dental therapists conducted malpractice and endangered the public health of the population.

The periphery settlement

The momentary outcome of these struggles is a periphery settlement: In core states, the dental therapist model is restricted to peripheries. When they introduced dental therapists (or advanced dental hygienists), states included spatial restrictions into the legislation. Minnesota was the first state to certify dental therapists in 2009. Here, they must practice mainly in areas with health professional shortage or in areas that serve uninsured patients. Such or similar legislation is passed or currently discussed in  Massachusetts, Vermont, Michigan, New Mexico, Ohio, Kansas, North Dakota, and Connecticut. In a similar vein, the Alaskan model survived the legal challenges because it is regarded as specific intervention for Native Americans under federal legislation. This enabled a diffusion of dental therapy between peripheries inhabited by native peoples.

From a social justice perspective, this periphery settlement is a double edged sword. Dental therapists contribute to lower health inequalities between the periphery and the center. Many populations in the US lack basic dental services and often rely on emergency services such as pulling teeth. Furthermore, dental therapists often come from the communities they treat. Peripheries often have high rates of unemployment, racialized violence, and often a colonial past. Professionalizing these communities constitutes a professional empowerment of marginalized populations. On the other hand, peripheral diffusion manifests inequalities. With peripheral diffusion of dental therapists, peripheries have their distinct professionals for dental services with a lower range of skills. Inequality becomes institutionalized in professional jurisdiction. Peripheral diffusion empowers the periphery and deepens its “peripheralization” at the same time.

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