By Alex McEllistrem-Evenson
Dr. Douglas Cross, a public health dentist in New Orleans, doesn’t mince words when asked about the reality of the situation for the working poor in his city who need dental care.
“Very bad,” he states.
For a moment, those words hang in the air as he tries to come up with statistics that can accurately convey the magnitude of the problem he and his few remaining colleagues have faced since Hurricane Katrina decimated much of the city in 2005. “There are very few options. The clinic that I work at most of the time is the only fixed dental clinic that serves the working poor. A lot of folks have lost their jobs; I see very few people with dental insurance. We are booked with new patients into March right now, and we don’t advertise our clinic because we can’t handle anybody else.”
The city of New Orleans has received millions of dollars in federal disaster money to rebuild its infrastructure and provide essential services to residents. Dental care, however, is one area that has yet to recover. Principally, this is due to the utter lack of public health dentists.
“Many dentists left after Katrina,” clarifies Cross, “and a disproportionate number of dentists that provided services to poor neighborhoods left. In New Orleans east, there was at least fifteen to twenty dentists. After Katrina? Virtually no one.”
The reasons for this are multifaceted. “Every dentist has their own story,” states Cross, “but when your office is damaged and your house is damaged and most of your personal possessions are gone and your practice – or your former practice – most of those people are as well, you don’t have a lot to stay for. You know it’s going to be a while before you’re going to have a steady income.”
A complicating factor is that dental offices are expensive to establish. “They’re different from medical practices,” states Cross. “They involve a lot more leaseholder improvements; you need to do a lot more plumbing and a lot more wiring.” This made things particularly difficult in post-Katrina New Orleans, as plumbers and electricians were in high demand. “They were like celebrities, and you saw them just a little bit less” Cross muses. “They made a tremendous amount of money and they were in such demand. Even if you decided two weeks after the storm that you were going to rebuild your practice, it would have been very difficult to get electricians and plumbers.”
For others, financial recovery from Katrina’s damage was impossible, even with federal disaster money in hand. According to Cross, many dentists did not maintain insurance coverage for “all perils,” and weren’t aware of this gap when Katrina hit. “If your policy wasn’t all perils and you didn’t have flood insurance, you were out of luck. I knew quite a few dentists like that,” he states.
Even beyond that, leaseholder improvements are rarely covered under any insurance policy. “Those improvements could have cost you 100,000 dollars but you don’t get any insurance compensation for that,” laments Cross, “and the building may have had to be torn down.”
A few different things enabled Cross to remain in New Orleans. For starters, he served as the city’s antemortem and postmortem dentist in the hurricane’s immediate aftermath. “I realized there was going to be a need for dental records to identify the victims, and that probably quite a few victims were patients of the city clinics and so I volunteered my services.” He ended up working on the lower ninth ward – the area of the city where the damage was most catastrophic.
This work led Cross to help establish temporary dental services for returning and remaining residents of the city, using donated equipment and relying on assistance from the Council on Aging and the American Dental Association, as well as funding through the Primary Care Access and Stabilization Grant. He quickly found, however, that demand for care greatly outpaced his capacity.
Cross believes that more dentists would have stayed if the federal government had offered immediate financial incentives for those willing to provide services, but there was no word. “It was quite a while before they came up with the [Primary Care Access and Stabilization] grant,” he states. “After Katrina, they opened a network of primary care clinics—I think there may be 90 of them—but I think because of the cost to set up dental clinics and the difficulty, [dental care] was kind of passed over.” Dr. Cross notes that two FEMA-funded mobile dental units have just begun operating in the last few months, more than four years after Katrina.
The situation in New Orleans raises difficult questions about the overall strength of our oral health workforce and its capacity to recover from systematic trauma. It also illustrates the degree to which dental care is critical to overall public health and often under-addressed by health insurance. “In this state we have a lot of poor people and we don’t have a lot of money,” Cross clarifies. “Our fees are very low, you know. Forty dollars for an extraction, thirty dollars for an occlusal amalgam [a filling]. We’re kind of it. But a lot of people with dental insurance can’t even afford that right now.”
“The disparities are tremendous,” he continues. “In Louisiana, after you’re twenty-one you can’t get dental coverage [under Medicaid] unless you’re pregnant, other than dentures. That means you can’t even get extractions, so if you have a toothache, you’re out of luck. A lot of people can’t afford to get their teeth taken out so they can get the free dentures.”
Dr. Cross, who began part-time work for the city immediately following his graduation in 1982, laments the lack of funding for public health dentistry and wishes it were emphasized more in dental schools. “I was working with the state board because they were putting restrictions on mobile dental units and somebody I know was saying ‘you’re a public health dentist?’ like they’ve never heard of it before. But you know, there is such a thing.”
“We have a lot more demand than we have capacity right now,” Cross continues. “In order to get more capacity, we would have to get some sort of grant money. We’re running at a deficit now, a big deficit.” With his time at a premium, however, preparing grant applications must necessarily take a back seat to providing patient care. “We don’t have a lot of staff, that’s the problem, so nobody has time to write the grants.”
Concludes Cross: “We do what we can, and I feel good about that, but it would be nice to be able to help more people. Particularly the working poor, because these folks worked hard all their lives, you know? I mean, hard-hard jobs, you know? They’re struggling when they get older and it’s hard to imagine somebody sitting there with a toothache and not enough money to get it taken care of.”