Closing remote children's dental health gap

The AIHW has recently (26 February 2019) released a report titled Northern Territory Remote Aboriginal Investment: Oral Health Program July 2012 to December 2017 (link here).

I don’t propose to attempt a comprehensive summary the report as it is very accessible and easy to read. A quick scan of the graphs and tables will give any reader a good sense of progress. Not unexpectedly, remote children appear to have higher levels of poor dental health than their mainstream counterparts.

In terms of service delivery, preventative services, primarily involving fluoride varnish treatments, appear to have grown consistently (off an almost non-existent base in 2012) over the past five years (see figure 2.2). In terms of fissure sealant services, numbers have decreased slightly since 2013 (figure 2.4) and in relation to clinical services, numbers of services peaked in 2013, fell dramatically in 2014 and 2015, and are still below the 2013 levels in 2017 (figure 2.6).

In terms of outcomes, while the proportion of Aboriginal children with tooth decay remains extremely high, over time those proportions appear to be reducing. So in the period 2009 to 2017, the proportion of 1-3 year olds with tooth decay went from 73% to 43%; for 8 year olds it went from 93% to 88%; for 11 year olds it went up from 69% to 75%; and for 12 year olds it went from 81% to 68% (see page 16). While this is positive news, it also suggests that it will be decades before we attain parity in dental health outcomes.

Two appendixes discuss a number of data issues and limitations. The report is not based upon a comprehensive survey of all dental services across the remote parts of the NT, and thus there is no guarantee that the data which this report is based on is telling us the full story.

Nevertheless, like most AIHW reports, this report appears to be well researched, thorough, and reasonably accessible notwithstanding a degree of social and bureaucratic complexity.

However, the report raises a number of policy issues that are beyond the AIHW remit, but nevertheless demand consideration and attention.

The program being assessed is a Commonwealth program that is limited to the NT. It is a direct descendant of programs begun as part of the NT intervention and the subsequent Stronger Futures era. This raises the immediate question: what is the state of play in other remote jurisdictions?  The short answer is that we don’t know. My guess is that the outcomes are likely to be similar or worse (unless there is a particular jurisdiction that is delivering outstanding dental services to remote communities).

A second issue that the report fails to mention relates to the causes of high levels of poor dental health. The discussion of preventative health in the report is limited to health related prevention (largely the application of fluoride varnish treatments). Yet it is widely understood that the causal links between consumption of sugar and high sugar drinks and tooth decay are crucial.

These issues thus raise two further significant and related issues for policymakers. First, are governments allocating enough financial resources to both preventative and clinical dental services in remote Australia? In addition, are the programs that exist effective?

Second, are there wider policy responses to poor remote dental outcomes that ought to be pursued, or pursued with greater vigour? For example, should there be tighter regulation or higher taxation on high sugar drinks?  And as a further aside, what are the soft drink manufacturers and retailers doing in terms of their corporate social responsibilities to diminish the impact of poor dental health on children?

These are not simple policy issues, and design of appropriate policy interventions require careful consideration. However, we appear to be in a largely policy free zone at present.

The PMC website includes a number of reports related to dental health of Indigenous Australians. One of the more recent, the Aboriginal and Torres Strait Islander Health Performance Framework 2017 Report (link here) notes inter alia in a section on ‘Implications’:

Implications
Available data indicate that dental health is worse for Indigenous Australians than for other Australians, for both children and adults. Barriers to good oral health include cost of services (see measure 3.14), healthy diets on limited budgets (see measure 2.19), attending services for pain not prevention, insufficient education about oral health and preventing disease, public dental services not meeting demand, lack of fluoridation in some water supplies, and cultural competency issues with some service providers (see measure 3.08)...

Prevalence estimates for oral health conditions for Indigenous Australians are based on out-of-date and incomplete surveys—further data development is a priority for this performance measure.

In the 2018 Closing the Gap statement in the chapter on healthy lives (link here) the Government mentions efforts by Outback Stores (a government owned stores company operating in remote communities) to reduce sales of sugary drinks, and notes also that:

The Australian Government has developed a strategy to reduce the sales of highly sugared products sold in stores in remote Indigenous communities. The store is often the main - or only - source of food and drinks in remote communities, so a reduction the amount of sugared products sold in the store is an effective way of reducing the amount sugar products consumed. The strategy is being implemented in stages through until June 2020, focusing on sugary drinks and expanding to other high-sugar products such as confectionary.

In the 2019 Closing the Gap Report at page 137 (link here), there is mention of Outback Stores operating in 37 remote stores (the Outback Stores website refers to 38 stores), and provides further mention of its store based sugar reduction strategies. But no reference to a wider strategy applicable to all remote community stores, and no mention to widening the strategy to confectionary. Perhaps the reference in the 2018 report was just to the Outback Stores footprint, which is less than a quarter of all remote stores.

The Outback Stores Annual Report for 2017-18 (link here) provides further detail on their sugar reduction strategies, built upon a foundation of price incentives and a support grant from PMC of $500k. What is less clear is whether PMC is doing anything substantive beyond the Outback Stores footprint. The indications are that it is not.

To sum up, we have an excellent report from AIHW addressing only one of the five jurisdictions encompassing remote Australia. It outlines serious dental health issues affecting scores of thousands of children. Its focus on measuring the scale of preventive services is limited to health interventions. There is some indication that Commonwealth policymakers have been focussed on addressing other wider causes of poor dental health in remote communities, but only in an extremely limited way and only in a small proportion of remote communities.

To be blunt, in relation to levels of dental health across remote Australia, the available evidence indicates that we know there is a problem, we don’t know how extensive it is, and we aren’t prepared to do what is necessary to address the wider causes of the problem. Admittedly, probably another twenty health issues across the remote indigenous health domain require focussed attention.

But the question remains, how will we close the gap on remote Indigenous dental health let alone remote Indigenous health status generally when governments are focussed on signalling they are doing something, but are not prepared to devise, develop and implement the substantive policies which might make real inroads?