FILLING A GAP
Dental clinic treats patients from the Downtown Eastside who have nowhere else to turn
From her tiny desk in the corner of the crowded waiting room, Maria Rempel is part social worker, part traffic cop as she manages the steady flow of vulnerable patients coming into the non-profit dental office in the Downtown Eastside.
“We see anybody who is in desperate need of dental work. A lot of people that come here have either been rejected by other offices, or they've been traumatized from something in their childhood. We get a lot of people who have a mental health disorder. So in that case, we're not just a dental office ... it's almost like triage in an emergency department,” Rempel said.
“But we're financially sitting at the precipice all the time that goes: Can we make the payroll?
“And if this clinic didn't happen any more, where do these people go?”
The Vancouver Aboriginal Health Society opened this clinic on East Hastings Street 16 years ago, staffing it with volunteers who helped walk-in patients with dental emergencies.
But in the spring of 2020, when pandemic restrictions led to most dental offices closing and overburdened hospitals cutting back on emergency dental work, officials with the B.C. Dental Association asked the clinic to boost its number of patients and treatments so vulnerable people still had a place to go, said manager Lex Vides.
In 2020, it grew from 1,300 patients annually to more than 3,500, which includes some First Nations people but also others on social assistance or with a low income.
For the first time, the clinic hired a few staff members and increased services, offering advanced procedures such as fillings, root canals and complicated extractions, instead of just dental care.
The larger size and scope of the clinic continues today, but it is struggling to keep up with rising demand from residents trying to cope with the high cost of living. Vides said his pleas for more funding have gone unheeded by every level of government, including Ottawa, which has promised a universal dental care system.
“We need money. And I have done everything that is in the normal channels,” he said. “It feels like you're alone. You're doing something for the community, everybody's talking about it, but nobody is helping.”
In 2022, about 750 people — a combination of paid staff and locums, volunteer dentists and hygienists, and students — provided more than 9,300 dental services to 3,500 patients. Since 2020, the clinic has done about $1 million in free work for low-income patients in dire need of treatment.
It collects about $1 million in annual revenue from social assistance benefits, government coverage for some Indigenous people, and private insurance plans — which covers some, but not all, of the patients' treatments. The clinic also receives some money from patients who can afford to pay for the uncovered portion of treatments, and from a handful of private donors.
To balance his books and keep the lights on, Vides needs about $200,000 more a year.
Patient Diana Gustafson has been in the clinic about 10 times in the last few months, getting a new crown, a cavity fixed, two root canals and, most importantly, a bridge that fills the gaps left behind by teeth removed by other practitioners. Before she got the bridge, it had been hard to chew and speak clearly.
“They fixed everything,” the grateful woman said. “It's made a huge difference.”
The clinic covered some of her dental work by accessing money from the National Sixties Scoop Healing Foundation, as the Dene woman was born in Saskatchewan but adopted by a B.C. couple as part of a mass removal of Indigenous children from their families in the 1960s and '70s.
The staff in the clinic, Gustafson said, made her feel like “they really care about us,” noting Vides and Rempel came in on a Saturday during her root canal, a dental hygienist calmed her during a painful procedure by rubbing her shoulders, and a locum dentist texted her after her root canal to check on her well-being.
There is a plan to expand the clinic in 2025 so that it can help more patients like Gustafson and offer more services. The Vancouver Aboriginal Health Society has partnered with other agencies to build a “healing centre” in the Downtown Eastside, which would contain housing, a tipi and sweat house, and expanded medical and dental clinics.
But project manager Leonard Laboucan, a former society board member, recently delivered bad news to Vides about the project: “Vancouver Coastal Health will fund the medical clinic, but not for the dental . ... Unfortunately, we just don't have the funding for Lex's wish list.”
The society has a charity number and hopes to do a fundraising campaign to find the money for new dental equipment and supplies to fill the larger space, which Vides estimates will cost $2.6 million. That includes money for a unique dentistry chair for people with disabilities, something he said is badly needed in the Downtown Eastside.
Laboucan said he is optimistic that by the time the building is finished, estimated to be in 2025, the money will be found. “I think that what we're doing really is something that resonates with a lot of people,” he said.
But it's not just the startup money Vides needs for the new clinic. He'll need an extra $1.4 million or so a year to operate the bigger space and care for additional patients.
There is hope at the society that the clinic's financial woes may ease if there is less free work in the future as a result of a new federal dental insurance program that will subsidize care for eligible Canadians without coverage, applying to households making up to $90,000 a year.
Right now, children qualify for $260, $390 or $650 in annual coverage, depending on their family's income, and Ottawa hopes to expand the $13-billion program by the end of this year to cover teens, seniors and people with disabilities.
While the payments will eventually be helpful to most of Vides's patients, he said it is unlikely they will cover all the services many people need, especially those who have neglected oral care due to poverty and other challenges. He argues a truly universal dental system should include direct funding for non-profit clinics that treat vulnerable citizens.
Vides does not speak in angry outbursts but in frustrated resignation after years of being rebuffed by various health authorities, all levels of government and charities.
“It's an Indigenous clinic, (but) First Nations Health doesn't help me. Vancouver Coastal Health doesn't help me. Provincial Health Services Authority doesn't help me. Minister of Health doesn't help me. But I'm here providing services as a dental not-for-profit,” he said.
B.C.'s Social Development and Poverty Reduction Ministry last year pledged $2.8 million to be split among 21 non-profit dental clinics to help offset costs. Vides said the money is helpful, but it will be spread over three years so the small amount each will get won't balance his books.
These non-profit clinics typically provide services at lower fees than private offices, and Vides said his is the only Indigenous-run clinic. It has never turned anyone away, “but we will reach that point” without additional funding, he said.
Vides received a dentistry degree from the University of El Salvador, his home country, where he got experience doing community dental work until he moved to Canada in 2009.
He is not licensed to practice in Canada, but found a good fit for his skills in managing the dental clinic, a job he took over a decade ago when it was open only two days a week for emergency drop-ins. Today it runs full-time with five exam rooms, each with a dental chair and other donated equipment. It has a mobile dental van and a small non-profit clinic for children in another Downtown Eastside location. It also offers some counselling for issues such as substance use and trauma.
The clinic will not turn away patients whose coverage has been depleted or who cannot afford to pay the difference between the dental fees and what their benefits will cover.
This “kindness act” makes the clinic the last place that will treat these patients, said Vides, who jokingly refers to himself as Robin Hood.
“If a person does not have any dental coverage, a donation will be suggested at the time of screening, but no one is refused care because of an inability to provide the donation,” Vides said in a fundraising letter he's sent to potential donors.
“The need is always exceeding our capacity (manpower and financially), which leads us to be in a constant search for new volunteers and resources to satisfy the increasing demand and continue our operations.”
From her perch at the clinic's front desk, Rempel brokers the best deals that she can with the patients: What can you pay? Can you pay in small instalments? Can you pay when your insurance turns over to the next year's benefits? Sometimes, when the person is in extreme pain, she tells them the clinic will pay.
“We just go ahead and do what we need to do and hope and pray that things will get covered,” she said.
There are federal programs that will pay for some dental work for certain groups, such as Indigenous people and refugees, but the reality, she said, is they can take a long time to approve work and pay the bills.
Rempel, who is Métis, said the low-barrier clinic does more than fix people's teeth. If patients are struggling with another health issue, such as high blood pressure or anxiety, staff will ensure they get assistance.
“The more people we help, the less likely that they're going to fall through the cracks,” she said.
There are rough days trying to negotiate with clients who are angry or high. She also has sympathy, knowing these behaviours are often a self-preservation mechanism against trauma.
“They have smashed the front door. They have tried to smash the windows,” said Rempel, an experienced medical office worker who joined the clinic as it was ramping up in April 2020.
She is close to retirement, but is committed to the clinic because of Vides's fierce determination to make it succeed.
“He will do anything for anybody at any time of the day,” she said, wiping away tears of admiration.
What keeps her going is witnessing the transformation in patients, like a man who recently came into the office with his head hanging low but walked out smiling with new dentures.
“He can't even make eye contact with you because he's so degraded because he has no teeth in his mouth. But when he walks out the door, he goes, `Look at my mouth, look how good it looks,'” Rempel said, becoming emotional again.
“That's the reward.”