Dental caries, popularly known as tooth decay or cavities, is among the world's most common health problems. When caught early, it is also one of the most easily resolvable. Yet, advanced decay is a trenchant marker of social inequality and a major contributor to the maldistribution of physical pain and psychosocial suffering. Why? Access to dental care within the U.S. model of fee-for-service dental private practice follows existing lines of social stratification. Dental disparities, a term that calls attention to the relationships between maldistributed disease and maldistributed care, reflect deep ontological, moral, and political differences about responsibility for the prevention and treatment of dental disease, the quality and distribution of dental care, and even what constitutes health and well-being. What kinds of sociopolitical and moral negotiations constitute and transpire around dental disparities? How do these negotiations shape the experiences of patients and providers, and how do their experiences shape these negotiations? What can an ethnography of the dental safety net–a complex, fragile, and unpredictable network of treatment opportunities for low-income families–tell us about health governance more broadly? These are some of the questions that drive my research. In this dissertation, I explore how the sociopolitical relations of dental disparities are enacted through the dental safety net. Drawing on fifteen months of ethnographic research in clinical and community settings in central Appalachia, a region that has come to symbolize the dental crisis in the popular imagination, I show how the dental safety net exemplifies health governance in a neoliberal milieu. A fragmented system characterized by a discontinuity that starkly contrasts the model of health care generally advocated in both private and public medical systems, I argue that the dental safety net in far southwest Virginia does not merely fail to relieve the suffering of marginalized people but also can produce it. For example, the constitution of publicly-funded and charitable dental care can serve to routinize and even incentivize excess extractions among low-income adults while exempting preventive or restorative care. In addition to its effects on underserved patients, the dental safety net is a site through the fraught and contradictory relationships of dental providers and the sociopolitical stakes of the pursuit of oral health equity can be understood. For example, the flexible teamwork arrangements prized in private practice, when posited for the dental safety net, are often interpreted by dentists as risks of pluralization and threats to professional hierarchy that must be contained through legislative means. Borrowing from the crude classificatory scheme used to screen teeth quickly, I show how the dental safety net is decayed, as it bears the wear of overuse beyond maintenance; missing, or better described as an absence than a presence; and filled, like a cavitated tooth or a canaled dental root, with manufactured solutions of variable standards and longevity.

This thesis challenges the view that the Republic of Mali is a model of democratization in Africa with the aim of opening the conceptual framework of democratic citizenship inherent in the democratization discourse to greater critical scrutiny. The ‘enthusiastic’ view is held and set forth by various segments of the unity-seeking ruling class (local and foreign, State and NGO) of bringing to Mali a Western-oriented, procedurally minimal democracy, and citizen identity commensurate with international financial institutions’ and donor countries’ vision of democratization as political and economic liberalization. Consequently, this hegemonic project co-opts selected indigenous and Islamic idioms of political and social identity, to reinvent democratization as ‘moral governance.’ Cosmopolitan upper and upper-middle class actors thus apologize for highly personalized politics at the national and local levels, and articulate these more broadly with idioms of recovering rectitude and social cohesion that preserve and reproduce hierarchical social norms. In Malian political culture and in the scholarship of Malian political change, the hegemonic project of citizen identity formation becomes more evident as a construction, as discourses, norms, and practices produced and reproduced by privileged actors. Moreover, the contested character of these constructions becomes evident only as we address the development and deployment of selectively synthesized indigenous, Islamic, and Western-democratic norms, practices, and institutions of citizenship in contemporary Mali. Without a more embedded sense of political membership and identity, the merely procedural democratic project remains vulnerable to challenges from multiple, alternative sites of moral, social, and political authority. / Thesis (Ph.D, Political Studies) -- Queen's University, 2007-10-05 14:29:24.802