- Email: [email protected]
MORE ABOUT INCOME INEQUALITY
L E T T E R S
to say that the preponderance of dentists are supportive of the free-market economy. With that in mind, I feel it is the ADA’s place to stay out of politics and refrain from supporting this type of article. This article seems to be one of those in which the conclusion was made first, and then the authors set out to provide information to prove it. As for decay being related to income inequality, a book written in the 1930s by Weston Price2 (and published in updated editions through the years, most recently in 2008) provided interesting information about decay. He indicated it was the types of food in the diet and not income that yielded more tooth decay. The JADA authors’ main variable is one of economics. From my long history of being involved with dental short-term mission projects, I feel comfortable in saying that social views probably play a major role in health issues, including decay. This article did allude briefly to the fact that social issues are involved, but they were given a minor role. At this point, I’m willing to assume this article was an inadvertent publication, and the leaders of the ADA were unaware of its political implications. That being said, I do feel the ADA should come out with a statement expressing that it is a nonpolitical organization in its views and also, in the future, should refrain from printing articles of this type. If embracing socialistic principles is going to be the wave of the future in the ADA, my choice will be to conclude my membership with this organization. J. Franklin Whipps, DMD, MS Centralia, Ill.
1. Skousen WC. The 5000 Year Leap. 15th ed. Washington: National Center for Constitutional Studies; 2009. 2. Price W. Nutrition and Physical Degeneration. 8th ed. La Mesa, Calif.: PricePottenger Nutrition Foundation; 2008.
MORE ABOUT INCOME INEQUALITY
It’s not often that a cover story headline and the composite cover photograph in JADA catch my attention (Bernabé E, Hobdell MH. Is Income Inequality Related to Childhood Dental Caries in Rich Countries? JADA 2010;141[2]: 143-149). Well done. The phrase “income inequality” and the lad with the aura balancing the globe like a pint-sized Atlas drew me in. This “study” is not so much about making the readers aware of “income inequality,” as the authors define it, and the correlation they make with the incidence of dental caries, but rather [it is about] their opinion on how to reduce “inequality” for society at large. Wow. The good Drs. Bernabé and Hobdell are trying to positively affect large problems of high order. As a practicing dentist and one who sees dental caries in the workplace every day, I can tell you with certainty that the primary determinant(s) of dental caries is right there within the individual. I believe it is due to a multifaceted set of chemical, physical, dietary and environmental factors and reactions within the oral cavity. Yet, the conclusions of this study state, “Beyond a certain level of economic growth, income inequality surpasses per capita income as the primary determinant of childhood dental caries.” That is quite a leap from what I’ve been taught and have witnessed. Would a dentist conducting a similar study come up JADA, Vol. 141
with that conclusion? Am I so attuned to fixing and correcting teeth with dental caries that I can’t see the forest (income inequality) for the softened trees? I can make sense of drawing correlations between income, or lack thereof, and the incidence of tooth decay. I find a correlation between Dr. Glick’s February editorial, “Whether Industry-Supported or Otherwise, Trust Is Key to the Acceptance of All Research” (JADA 2010;141[2]:127-128), about the selection process for publishing articles and my next sentence. The “leap” in this case is confirmation bias, which simply means bias toward concepts or things that confirm what you believe to be true. To the point: whatever the problem (and the authors name a few in their article, such as educational performance, prison population size, increased violence [do demographic changes in London and Western Europe play a role too, Dr. Bernabé?], teenage pregnancies and gathering data for fighting climate change per their reference No. 231), now let’s add childhood caries to the mix. The liberal progressives’ solutions typically are the same. Liberal progressives call for larger government, global governance (as shown in their reference No. 52), progressive taxation, a large(r) welfare system and redistribution of wealth for the society at large. It appears that Drs. Bernabé and Hobdell have devised another vehicle to promote the cause célèbre of socialism and its big brother, collectivism. I congratulate the authors for being clever at delivering their inclinations. Was it random or tandem that Dr. Glick’s editorial defining various biases was http://jada.ada.org
Copyright © 2010 American Dental Association. All rights reserved. Reprinted by permission.
May 2010
499
L E T T E R S
published in the same issue as this article? Make no mistake, the authors are trying to sell a product—not a typical dental one, mind you, but one of a geopolitical nature. Gregg L. Lage, DDS Denver 1. United Nations Development Programme. Human Development Report 2007/2008. Fighting climate change: human solidarity in a divided world. New York City: United Nations Development Programme; 2007. “http://hdr.undp.org/en/reports/global/ hdr2007-2008/”. Accessed Jan. 4, 2010. 2. Labonté R, Schrecker T. Globalization and social determinants of health: promoting health equity in global governance (part 3 of 3). Global Health 2007;3:7.
SOCIAL ENGINEERING
I read with interest Dr. Eduardo Bernabé and Dr. Martin Hobdell’s February JADA cover story, “Is Income Inequality Related to Childhood Dental Caries in Rich Countries?” (JADA 2010;141[2]:143-149). The reported aim of the article was to assess the correlates of income and income inequality with dental caries in the various countries studied. As such, it was a study worthy of space in the scientific journal representing organized dentistry. What I found odd and out of place was the section on “reducing inequalities.” While reading through the statistical data, I wasn’t aware that the authors planned to go beyond their stated aims, which did not include advocating some sort of social engineering. After examining their list of references, it became obvious that more than a little bit of political editorializing was an unstated goal. Reference No. 16 by Wilkinson and Pickett, “The Spirit Level: Why More Equal Societies Almost Always Do Better,”1 and reference No. 23, “United Nations Development Programme. Human 500
JADA, Vol. 141
http://jada.ada.org
Development Report 2007/2008. Fighting Climate Change: Human Solidarity in a Divided World,”2 are meant to point out that greater income equality should be a goal. These two articles cite Nordic countries, which achieve greater income equality through progressive taxation or through legislating earnings and redistributive taxes and benefits. Wrapping up their admonition, the authors point out that a society with a strong political commitment to achieving a more equal society would more likely reduce the inequities reported in their study. I’m sure somewhere in their research, cultural differences and dietary habits came into play along with relative income, although it is not clear what emphasis was attached to these. Perhaps their next study could be to analyze obesity among America’s welfare class. I’m guessing no link to income will be found. When I look for sources of political commentary, I must say the last source I would turn to is JADA. Peter Muehleis, DDS Sheboygan, Wis. 1. Wilkinson RG, Pickett KE. The Spirit Level: Why More Equal Societies Almost Always Do Better. London: Penguin Books; 2009. 2. United Nations Development Programme. Human Development Report 2007/2008. Fighting climate change: human solidarity in a divided world. New York City: United Nations Development Programme; 2007. “http://hdr.undp.org/en/reports/global/ hdr2007-2008/”. Accessed March 29, 2010.
Authors’ response: We welcome the opportunity to respond to the comments raised in relation to our recent publication. As both dentists and epidemiologists, we believe that debate and interchange of ideas always are relevant and useful. The aim of our study was to
provide evidence, from the dental field, on the income inequality hypothesis about health that, beyond a certain level of economic development, income inequality is more strongly related to population health than is national income.l The original income inequality hypothesis was developed after examining variations in mortality rates between countries.2 Later, the importance of income inequality to health was found to hold true for several other health and social problems, both between countries and within the same countries.2,3 Using obesity as an example (as mentioned by one of the letter writers), prior research has shown that more adults are obese and children overweight in more unequal countries2,4 as well as in more unequal U.S. states.2,5 Within the limitations of our data, we found that the income inequality hypothesis also applies to childhood dental caries (that is, decay of primary teeth). As highlighted at the end of our discussion, it would be interesting to explore whether similar patterns exist for other oral diseases, such as chronic destructive periodontal disease and oral cancer, and for different age groups. Our preliminary assumption is that they do and we are conducting further analyses to determine if this really is the case. The question remains: “Why is it that so many health problems (including childhood dental caries) are related to such a broad macroeconomic indicator as income inequality?” This begs a further question: “Is this association spurious?” By using sophisticated statistical multilevel modeling, which allows the disentanglement of the influ-
May 2010
Copyright © 2010 American Dental Association. All rights reserved. Reprinted by permission.
to say that the preponderance of dentists are supportive of the free-market economy. With that in mind, I feel it is the ADA’s place to stay out of politics and refrain from supporting this type of article. This article seems to be one of those in which the conclusion was made first, and then the authors set out to provide information to prove it. As for decay being related to income inequality, a book written in the 1930s by Weston Price2 (and published in updated editions through the years, most recently in 2008) provided interesting information about decay. He indicated it was the types of food in the diet and not income that yielded more tooth decay. The JADA authors’ main variable is one of economics. From my long history of being involved with dental short-term mission projects, I feel comfortable in saying that social views probably play a major role in health issues, including decay. This article did allude briefly to the fact that social issues are involved, but they were given a minor role. At this point, I’m willing to assume this article was an inadvertent publication, and the leaders of the ADA were unaware of its political implications. That being said, I do feel the ADA should come out with a statement expressing that it is a nonpolitical organization in its views and also, in the future, should refrain from printing articles of this type. If embracing socialistic principles is going to be the wave of the future in the ADA, my choice will be to conclude my membership with this organization. J. Franklin Whipps, DMD, MS Centralia, Ill.
1. Skousen WC. The 5000 Year Leap. 15th ed. Washington: National Center for Constitutional Studies; 2009. 2. Price W. Nutrition and Physical Degeneration. 8th ed. La Mesa, Calif.: PricePottenger Nutrition Foundation; 2008.
MORE ABOUT INCOME INEQUALITY
It’s not often that a cover story headline and the composite cover photograph in JADA catch my attention (Bernabé E, Hobdell MH. Is Income Inequality Related to Childhood Dental Caries in Rich Countries? JADA 2010;141[2]: 143-149). Well done. The phrase “income inequality” and the lad with the aura balancing the globe like a pint-sized Atlas drew me in. This “study” is not so much about making the readers aware of “income inequality,” as the authors define it, and the correlation they make with the incidence of dental caries, but rather [it is about] their opinion on how to reduce “inequality” for society at large. Wow. The good Drs. Bernabé and Hobdell are trying to positively affect large problems of high order. As a practicing dentist and one who sees dental caries in the workplace every day, I can tell you with certainty that the primary determinant(s) of dental caries is right there within the individual. I believe it is due to a multifaceted set of chemical, physical, dietary and environmental factors and reactions within the oral cavity. Yet, the conclusions of this study state, “Beyond a certain level of economic growth, income inequality surpasses per capita income as the primary determinant of childhood dental caries.” That is quite a leap from what I’ve been taught and have witnessed. Would a dentist conducting a similar study come up JADA, Vol. 141
with that conclusion? Am I so attuned to fixing and correcting teeth with dental caries that I can’t see the forest (income inequality) for the softened trees? I can make sense of drawing correlations between income, or lack thereof, and the incidence of tooth decay. I find a correlation between Dr. Glick’s February editorial, “Whether Industry-Supported or Otherwise, Trust Is Key to the Acceptance of All Research” (JADA 2010;141[2]:127-128), about the selection process for publishing articles and my next sentence. The “leap” in this case is confirmation bias, which simply means bias toward concepts or things that confirm what you believe to be true. To the point: whatever the problem (and the authors name a few in their article, such as educational performance, prison population size, increased violence [do demographic changes in London and Western Europe play a role too, Dr. Bernabé?], teenage pregnancies and gathering data for fighting climate change per their reference No. 231), now let’s add childhood caries to the mix. The liberal progressives’ solutions typically are the same. Liberal progressives call for larger government, global governance (as shown in their reference No. 52), progressive taxation, a large(r) welfare system and redistribution of wealth for the society at large. It appears that Drs. Bernabé and Hobdell have devised another vehicle to promote the cause célèbre of socialism and its big brother, collectivism. I congratulate the authors for being clever at delivering their inclinations. Was it random or tandem that Dr. Glick’s editorial defining various biases was http://jada.ada.org
Copyright © 2010 American Dental Association. All rights reserved. Reprinted by permission.
May 2010
499
L E T T E R S
published in the same issue as this article? Make no mistake, the authors are trying to sell a product—not a typical dental one, mind you, but one of a geopolitical nature. Gregg L. Lage, DDS Denver 1. United Nations Development Programme. Human Development Report 2007/2008. Fighting climate change: human solidarity in a divided world. New York City: United Nations Development Programme; 2007. “http://hdr.undp.org/en/reports/global/ hdr2007-2008/”. Accessed Jan. 4, 2010. 2. Labonté R, Schrecker T. Globalization and social determinants of health: promoting health equity in global governance (part 3 of 3). Global Health 2007;3:7.
SOCIAL ENGINEERING
I read with interest Dr. Eduardo Bernabé and Dr. Martin Hobdell’s February JADA cover story, “Is Income Inequality Related to Childhood Dental Caries in Rich Countries?” (JADA 2010;141[2]:143-149). The reported aim of the article was to assess the correlates of income and income inequality with dental caries in the various countries studied. As such, it was a study worthy of space in the scientific journal representing organized dentistry. What I found odd and out of place was the section on “reducing inequalities.” While reading through the statistical data, I wasn’t aware that the authors planned to go beyond their stated aims, which did not include advocating some sort of social engineering. After examining their list of references, it became obvious that more than a little bit of political editorializing was an unstated goal. Reference No. 16 by Wilkinson and Pickett, “The Spirit Level: Why More Equal Societies Almost Always Do Better,”1 and reference No. 23, “United Nations Development Programme. Human 500
JADA, Vol. 141
http://jada.ada.org
Development Report 2007/2008. Fighting Climate Change: Human Solidarity in a Divided World,”2 are meant to point out that greater income equality should be a goal. These two articles cite Nordic countries, which achieve greater income equality through progressive taxation or through legislating earnings and redistributive taxes and benefits. Wrapping up their admonition, the authors point out that a society with a strong political commitment to achieving a more equal society would more likely reduce the inequities reported in their study. I’m sure somewhere in their research, cultural differences and dietary habits came into play along with relative income, although it is not clear what emphasis was attached to these. Perhaps their next study could be to analyze obesity among America’s welfare class. I’m guessing no link to income will be found. When I look for sources of political commentary, I must say the last source I would turn to is JADA. Peter Muehleis, DDS Sheboygan, Wis. 1. Wilkinson RG, Pickett KE. The Spirit Level: Why More Equal Societies Almost Always Do Better. London: Penguin Books; 2009. 2. United Nations Development Programme. Human Development Report 2007/2008. Fighting climate change: human solidarity in a divided world. New York City: United Nations Development Programme; 2007. “http://hdr.undp.org/en/reports/global/ hdr2007-2008/”. Accessed March 29, 2010.
Authors’ response: We welcome the opportunity to respond to the comments raised in relation to our recent publication. As both dentists and epidemiologists, we believe that debate and interchange of ideas always are relevant and useful. The aim of our study was to
provide evidence, from the dental field, on the income inequality hypothesis about health that, beyond a certain level of economic development, income inequality is more strongly related to population health than is national income.l The original income inequality hypothesis was developed after examining variations in mortality rates between countries.2 Later, the importance of income inequality to health was found to hold true for several other health and social problems, both between countries and within the same countries.2,3 Using obesity as an example (as mentioned by one of the letter writers), prior research has shown that more adults are obese and children overweight in more unequal countries2,4 as well as in more unequal U.S. states.2,5 Within the limitations of our data, we found that the income inequality hypothesis also applies to childhood dental caries (that is, decay of primary teeth). As highlighted at the end of our discussion, it would be interesting to explore whether similar patterns exist for other oral diseases, such as chronic destructive periodontal disease and oral cancer, and for different age groups. Our preliminary assumption is that they do and we are conducting further analyses to determine if this really is the case. The question remains: “Why is it that so many health problems (including childhood dental caries) are related to such a broad macroeconomic indicator as income inequality?” This begs a further question: “Is this association spurious?” By using sophisticated statistical multilevel modeling, which allows the disentanglement of the influ-
May 2010
Copyright © 2010 American Dental Association. All rights reserved. Reprinted by permission.