ALEXANDER C L HOLDEN and CARLOS R QUIONEZ. What should our health professional associations be in the 21st Ce ntury?

Health professionals form professional associations to facilitate collective action and advocacy on relevant and pertinent issues. What should the guiding values and principles be behind these organisations and what should their role be in our society in the 21st Century?

In this post, we explore these questions through examining how health professional associations have evolved and how their current and past behaviour both fits and contrasts with their raison d’être and individual members’ professional obligations. Whilst many of the examples given are specific to the context of dentistry, many of the principles explored are widely applicable to other health professions. We challenge all health professional associations to ensure that their activities overtly serve and support the wider interests of society, not just those of their membership. This blog post in inspired by a recent article written by the authors for the International Dental Journal which explored many of these issues in depth.

What is the purpose of a health professional association? Traditionally speaking, the formation of a professional association has been driven by two main goals; the protection of jurisdiction and the besting of professional rivals. Given that at the dawn of most professions, practitioners with training and experience might have often found themselves working (or competing) with untrained and unskilled ‘charlatans’, this protectionist motive for forming an association might be well justified.

Fast-forward into the 21st Century, most health professions have enjoyed relative protection of their jurisdiction for some time. Although squabbles over professional role and ‘turf’ can still be common, these typically are provoked by public attempts to enhance access to care through skill-mix, rather than being a case of unqualified practitioners seeking to provide care in an unsafe manner.

If you ask any health professional what the most important part of their role is, their answer would most likely revolve around their obligation to place the interests of those that they care for in a position of primacy. However, when health professionals gather under the umbrella of a professional association, is observance of this professional duty maintained? Many health professional associations operate as corporate entities, employing large numbers of staff with the continued success of the corporation hinging on retention and recruitment of members. In the business of professional associations, the customers are the members who pay their subscription fees. There is therefore a commercial imperative that drives many of the activities of health professional associations to justify value and relevance.

Many health professionals practice in a relative state of isolation. Research in dentistry, for instance, shows that community-based practitioners often do not have the capacity to engage in wider population-focused activities. Thus, health professional associations represent the ability to connect their individual members, as part of a collective, to advance advocacy efforts at a population-level. Health professional associations should ensure that their collective actions as organisations are congruent with the professional duties that their individual members are bound to observe by the expectations of society. Where associations are viewed as being self-serving, there is a risk that they damage their legitimacy when interacting with the public through discourse with the media, politicians and other community groups. Another way of viewing this is that membership of a health professional association for an individual health practitioner should be less about what they might be able to get out of the organisation, but a way of being able to amplify one’s own ability to contribute to the work of that health profession at a population-level.

The obligation that health professional associations have to promote health at a community-level should also be understood through the context of the commercial determinants of health. The consequences for health professional associations failing to take a strong stance and leadership on this issue can be illustrated by the case of the American Academy of Pediatric Dentistry (AAPD). In 2003 the AAPD announced that they had accepted a USD$1,000,000 donation from the Coca-Cola Foundation to fund research. Amidst public criticism, the then-AAPD executive found themselves having to defend sugar-sweetened beverages even making the arguably unbelievable statement; “Scientific evidence is certainly not clear on the exact role that soft drinks play in terms of children’s oral disease.” The AAPD also tried to justify accepting the donation by drawing attention to the potential good for health research the money might do. In reality, the result of the donation was that a group of health professionals overtly supported a commercial product that is well known as having detrimental effects upon health.

Over 15 years later, the dental profession has still not addressed its collective conflict of interest relating to relationships with commercial entities whose activities are damaging to health. Dental professional associations world-wide accept funding from Wrigley to endorse the beneficial effects of chewing sugar-free gum on oral health. Wrigley, which since 2008 has been owned by Mars, produces sugar-free gum, which is only a small part of a global portfolio that is dominated by high-sugar confectionary brands. As well as allowing Wrigley to place endorsements by dental professional associations on the back of gum packets, they also run a community grants program that provides money towards community-based oral health projects. Unhealthy sponsorship is also prevalent in sport, and perhaps of even greater concern is that many of these sponsorship activities target children. It is alarming that dental professional associations are willing to collaborate and endorse the products of a multi-national company that markets and sells unhealthy food ubiquitously. The argument that this relationship is justified by the benefits of sugar-free gum is similar to arguing that a fast-food chain is a healthy choice because one of their options in a child’s meal is apple slices.

Clearly, there is a huge amount of good that health professional associations can do through their efforts of advocacy and collective engagement. Many of these associations have been established to ensure and safeguard the interests of the health professionals who sustain the association through their subscription fees. And, in some instances, the public might be tolerant or even sympathetic to advocacy issues that are self-interested, but which are also aligned to wider societal interests. For example, the 2016 junior doctors’ strike in the UK provoked by proposed changes to the junior doctor contact had broad public support and provides a clear example of when the direct interests of a professional group and the public might align.

Activities that support health professionals to deliver optimal clinical care should be separated distinctly from those that are more obviously self-interested, with health professional associations distancing themselves from activities that have no wider public interest. Failure to acknowledge a collective duty to the public interest will ultimately encourage the erosion of public trust in health professional associations and health professionals themselves. Ultimately, it is likely that this would attenuate the ability of health professional associations and health professionals to advocate for and affect important matters that impact health.

Declarations

ACLH is a Director and Federal Councillor of the Australian Dental Association Inc., a Director and Councillor of the Australasian College of Legal Medicine and is member of the New South Wales Registrations Committee of the Dental Board of Australia. He is also an external consultant to the College of Dental Surgeons of British Columbia and has received research funding from the Australian Dental Council and the Dental Council of NSW.

CQ is incoming president of the Canadian Dental Specialties Association, former president of the Canadian Association of Public Health Dentistry, and past-chair of the Canadian Dental Association’s Committee on Clinical and Scientific Affairs. He is Editor of the Ontario Dental Association’s professional journal, an external consultant to the College of Dental Surgeons of British Columbia, and has received research funding from the Canadian Dental Association, Ontario Dental Association, and Royal College of Dental Surgeons of Ontario.

Dr Alexander C L Holden is a Senior Lecturer in Dental Ethics, Law and Professionalism and Head of Subject Area – Professional Practice at the University of Sydney School of Dentistry, Professor Carlos Quiñonez is Associate Professor and Director, Graduate Program in Dental Public Health at the Faculty of Dentistry, University of Toronto.

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