Nearly 33 million Americans – more than 10% of the country’s population – have no health insurance. While the very poorest are entitled to Medicaid coverage, millions more narrowly fail to qualify, but remain too poor to pay for private health insurance. Among those who do qualify for subsidised plans or manage to pay insurance contributions, paying for minor treatments such as fillings and eye tests is often a problem, as they may not be covered by basic healthcare plans. Even finding local doctors who accept Medicaid can be so challenging that it can seem easier just to work through the pain or to self-medicate.
Virginia is one of 19 states refusing federal dollars to close the healthcare “coverage gap” for people not poor enough for Medicaid, but too poor for anything else. Yet at the Wise County Fairgrounds in Southwest Virginia, for one late-July weekend each year, there is a small glimmer of hope. For three days, a non-profit organisation known as Remote Area Medical (RAM) builds a pop-up clinic – the largest of its kind in the US – from the ground up, and serves more than 2,000 patients from more than 15 different states. These patients come in the hope of getting cavities filled, lungs x-rayed and new pairs of glasses made – for free.
RAM was founded in 1985 by Stan Brock, a British philanthropist, actor, author, naturalist, cowboy and former TV host. The organisation is funded entirely via private donations and – except for a small, paid staff – completely dependent upon thousands of volunteers for everything from performing oral surgery to making up bags of Cheerios to hand out to patients’ toddlers. In addition to international and disaster-relief missions, the group has held more than 800 general health-clinic events across 12 states throughout the southern and south-western United States. In the past five or six years, it has added urban stops such as Los Angeles and Chicago to its regular locations.
As I pull up to the Wise County Fairgrounds clinic this summer, dozens of rows of cars glint in the sun – patients’ vehicles in one field, volunteers’ in another. Those seeking care are given entry numbers based on the order in which they arrive, and cannot leave without forfeiting their place. Many make plans to camp out for up to two days before the gates even open – sleeping in their cars, in tents, or on the ground, to make sure they snag a low number.
By 3.30am on Friday,volunteers with torches are moving from car to tent to car in the patient lot, handing out admission numbers for the day. By the time the sun rises at 6am, they have given out 1,600 tickets to the clinic. On Saturday morning, they will give out about 600 more.
I meet Sheila Harris, a 58-year-old former paralegal, in the early hours of the opening day. Sheila has worked her whole life, but after the birth of the last two of her six children, steady legal work dried up, and she now earns only a small income taking care of children in her home. She is one of the first hundred people allowed through the gates. Hundreds more are packed outside the fairgrounds’ fences, waiting to hear their numbers announced via megaphone.
Sheila, her daughter Amy, her sister Cindy, Cindy’s daughter Elizabeth, and four other family members have travelled for three hours to arrive at Wise two days early. These eight adults and one toddler would end up sleeping in their two cars for four days. During the first couple of nights, they would drape blankets over the windows for privacy, but would take them down after it made the cars too hot to sit in, much less sleep.
It is everyone’s first time at the clinic, except for Cindy, who has been twice before and led the group on this trip. Once, she says, she arrived early enough to be the very first patient served. “It was still a long couple days, though,” she says.
Cindy is here this year to get new glasses and to support her 29-year-old daughter Elizabeth, who also needs glasses, as well as the extraction of two molars. Elizabeth also hopes to get a partial denture plate. She had a bad fall a couple of years ago and broke her top front teeth, most of which have been completely missing for years. At the time of her fall, she had decent health insurance, but still had to pay $ 1,000 from her own pocket, to rebuild just one tooth, which later cracked again anyway. Cindy and Elizabeth now both receive disability benefits – essentially their only source of income. Without RAM, a new pair of glasses with a current prescription would be a luxury item.
Sheila needs glasses, too, but is first set to have six teeth removed – a couple of which are already in pieces – and upper dentures made and fitted. Neither Sheila nor Elizabeth will smile open-mouthed. They haven’t smiled that way for years, out of embarrassment. “I guess I’ve kind of withdrawn from people because of it,” Sheila says. “I used to talk to anyone, anywhere, about anything – real outgoing – but I haven’t been like that in a long time.”
Sheila pulls a roll of Tums antacid tablets from her shorts pocket and says it’s the only thing she’s been able to eat since the day before, on account of her nerves. She’s brought the broken dental crown with her “in case they can use it or something”, and holds it tightly.
It is cool outside before sunrise,but the temperature will reach a humid 35C by late morning, and get even hotter by Saturday. The site has no air-conditioned spaces, apart from the mammogram and radiology trucks. Volunteers drive back and forth across the grounds all day, handing out cold water and chilled neck wraps.
Though traffic through the medical stations is steady, the main attractions of every RAM clinic are the dental and eye-care services. At the Wise County Fairgrounds, the organisation sets up about 80 mobile dental stations under large tents – one section of tents reserved for cleanings by hygienists, a second block for fillings, and, in the back tent, four or five long rows of stations for extractions. The vision and medical services are each delivered in two large barns. The makeshift examination rooms are livestock stalls, with bedsheets hung for privacy.
The full Wise County clinic footprint is immense: one general-support volunteer working as a patient escort could easily walk 15 miles or more in a day. Specialised services such as x-rays, mammograms, and orthopaedics are provided in converted lorries or large camper vans. Other tents, offering treatment for substance abuse, counselling to help smokers quit, and mental healthcare, as well as clothing and book donations and a pharmacy, are scattered wide across the grounds. The only bathrooms – for patients and volunteers – are several dozen portaloos.
Other such RAM clinics may be smaller, but they operate under similar conditions. One in Smyth County, Virginia, is set up on the asphalt and in the emptied hangars of the local airport. Services there must shut down at a particular time so that planes can be moved back inside. One Tennessee clinic is held right on the Bristol Motor Speedway infield, a famous Nascar racing track; Stan Brock can often be seen on the track on his bicycle, vigorously pedalling angled laps.
“Poor teeth, I knew, beget not just shamebut more poorness,” writes Sarah Smarsh in her 2014 Aeon essay on class and dental hygiene. One woman sitting near Sheila and her family in Extraction Row says she has recently been fired from a waitressing job after losing a couple of her front teeth. Her manager didn’t want her in front of customers. Food service has made up the entirety of her employment history, and she is having trouble getting hired permanently elsewhere for similar reasons. Even when she was working, she says, she couldn’t afford the cost or time off necessary to treat her teeth – or anything else, for that matter. The RAM clinic, once a year, is her sole source of healthcare. She now works as a temp in one of the many call centres planted in Southwest Virginia.
Dr Joe Smiddy, one of the long-time volunteer doctors on site, has seen similar scenarios play out for patients here, time and again: “Once they lose their teeth, or they have unsightly teeth, they lose part of their own marketability. They have trouble finding a job,” he says. “Course, when they lose their job, they lose any healthcare they might have had. And then you can have substance issues where people are self‑medicating with tobacco and street drugs for what is real pain and real anxiety.”
Poverty also begets limited choices. Sugar provides a cheap and legal high and caffeine does the same. Both can be used to self-medicate and as an easy way to make your kids happy when you can’t afford much else.
Nearly 100,000 people in Southwest Virginia receive Supplemental Nutrition Assistance Program benefits (formerly known as “food stamps”). A family of four receives $ 115 per week on average for food, or just about $ 16 per day. “The economics of this community,” says Terry Dickinson, executive director of the Virginia Dental Association, “are such that when they go to the grocery store and buy food, it so happens they get a lot more food when they buy highly processed, high-carbohydrate foods, and, instead of water, they pick soda pop or sports drinks, or any of that stuff that’s just as cheap.”
Unhealthy processed foods are not just cheaper: they do not spoil as quickly, and they can take less time and fewer ingredients to prepare. “What you want for everyone is personal responsibility,” says Dickinson, “but you’ve got to give people the education and tools they need to make those decisions.” And, he says, for people living in poverty, “we just haven’t done a good job of that. These are people in survival mode.”
Living in survival mode means prioritising where you spend your limited income. A 2015 survey conducted by the Federal Reserve Board to determine what practical effects, if any, the economic recovery was having on families, found that 46% of Americans did not have enough money on hand to cover an unexpected $ 400 expense. When that expense is a medical emergency, it often leaves only two options: use a credit card if you have one, or forgo care until the pain goes well past emergency and becomes unbearable.
Putting stock in a long-term investment such as one’s health requires hope. Embedded in preventative and rehabilitative care is the presumption of a long, fulfilling life. Health insurance is an invisible protection – it does not fill a hungry stomach, or power a refrigerator, or fill a petrol tank.
Sheila is in Dr Dan Laskin’s dental chair and is about to have her extractions done. There are picks, forceps, syringes and what looks like a hammer and small chisel on the tray beside her. Even when you’re having six teeth pulled, if your dental care is happening under a tent at a fairground, you are given some numbing lidocaine, a few large, well-placed shots of novocaine, and not much more of an anaesthetic cushion than that.
The procedure is probably as smooth as it could be, though Sheila often moans and wriggles from the pressure. The dental assistant gets her to close her eyes and talks her through some visualisation strategies involving her favourite place: the beach. It takes about 30 to 45 minutes before the procedure is finished, and the experts are ready for whoever is next in line. Numbed and frazzled, Sheila says to Laskin through the packed gauze, “You are freaking amazing!” and hugs him.
Elizabeth has already had her two extractions done, and is now at the dentures station, where another dentist has inserted a tray of paste into her mouth that will become the mould used to make her partial plate. The dentist has to keep the tray pressed tight against Elizabeth’s swollen, sore jaw for about a minute. Afterwards, she says she didn’t mind it too much: “It was easier than getting my teeth yanked out!” She heads over to the vision section to get in the long line for glasses.
Observing the makeshift clinic, it sometimes feels more like a carnival than a hospital. Occasionally, in between seeing patients, you can catch Joe Smiddy picking a banjo in the clinic bluegrass band he has pulled together with a few regular volunteers. Smiddy is a 74-year-old retired pulmonary specialist, now a full-time medical volunteer, who grew up in Wise County, the grandson of a coal miner. He got his commercial driver’s licence in order to drive the 18-wheeler that holds his mobile x-ray office to RAM clinics. Smiddy has seen it all: most of what he has to share with me begins with “And I can say this because I’m from here.”
“The people of Southwest Virginia,” he advises me, “are self-reliant, and their self-reliance and their love for their people and their land is such a wonderful thing, but it’s also what holds them here. There’s a social importance to people who are from here being really glued here. So why would we move to another part of Virginia? Why wouldn’t we move to where the jobs are? But we’re totally averse to doing that, and so we have a large population who live in an economically deprived area. The schools are struggling. The churches are struggling. Every time they build a Walmart, it puts several mom-and-pop stores out of business. Your barbershop’s gone because you get your hair cut at Walmart, your beauty salon, your auto-repair – everything Walmart. And then you’ve got people working at Walmart who don’t have health insurance, either.”
People not in poverty often ask those who are to move in various ways – off street corners when they’re homeless, away from their depressed hometowns when they’re unemployed. They are asked to move couches, off front porches and cars, off blocks.Politically, they are usually asked to move out of their own way.
All of the qualities that Smiddy describes, though, are what most people would probably say they want in a healthy community. We want people to love and care about their land and neighbourhoods and to know one another. We want a shared history, vibrant cooperation. These are all characteristics we celebrate, it seems, everywhere but communities of poverty. In places like Southwest Virginia, we do not honour these relationships, or underwrite them – socially or financially – in the same way we do in middle-class or affluent regions. Instead, what we reinforce, as a matter of policy and entertainment, are the rural stereotypes.
In his mobile rig, Smiddy will x-ray “just about anything you can put in front of the machine”. He mostly looks at lungs, though. “We’re a belt of lung disease,” he says. “Southwest Virginia is a belt of asthma, COPD [chronic obstructive pulmonary disease], emphysema, and, of course, heart attacks, strokes, and diabetes. Part of that is smoking – we in Southwest Virginia have a tradition of starting smoking at an early age. There are towns where the average age of starting smoking for current lung patients was age 10.”
But part of it, he says, is the coal dust and environmental allergens. When business was booming, coal workers were paid well and offered decent health insurance, but layoffs and closures have left many in the region with poor health, and poorer prospects for work and the healthcare coverage that used to come with it.
“All of the politicians are singing this little fairytale that coal is coming back,” Smiddy says. “They’re living in that fairytale, and so what they’re not doing is accepting the reality that we could plan, we could think ahead. We could reach broadly to incorporate everybody – schools, churches, civic organisations, mayors, community leaders – that we all pull back together and say, ‘We have a goal, and our goal is that we’re going to try to predict as best as we can the jobs of the future, and we’re going to start now.’ I don’t mean to be ugly when I say that there may be some people who will miss that curve, but we could build for their children.”
Coal is complicated in Appalachia, the mountainous region within which Southwest Virginia sits. The coal industry has torn up pieces of Southwest Virginia and the bodies of those who have mined it, but as it has declined here, the men and women it employed – many of whom have at most graduated high-school – have slipped from relying on steady middle- and upper-income salaries to prospecting for minimum wage. The classified ads in places such as Wise and Coeburn, Virginia, are thin and advertise for such positions as “Customer Service Representative 1” and “Cashier (Part Time)”. We may be able to replace coal with other comparable energy sources, but we have not yet prioritised how to comparably replace coal jobs.
“I mean, how many call centres can you put down here?” Dickinson says. All people want here, he repeats, is a good-paying job.
By Saturday, all eight of Sheila Harris’s family have spent four days and three nights living in two cars. They have had to stay this long to wait for their glasses and partial dentures to be finished.
Cindy and Amy walk over to a large tent where a few thousand brand-new frames – all donated – are set out on long folding tables so that patients can select the styles they like. A few regular volunteers consult on shape and fit.
The barn where the sight tests are given is a touch cooler than outside, mostly because the room has to be kept dark for the testing. The majority of patients here are getting basic checkups and prescriptions written or updated, but occasionally – as with the dentists – the optometrists diagnose more serious health issues: glaucoma, cataracts, macular degeneration, diabetes. Prior to their eye tests, some patients don’t even realise they need glasses.
Dr Victoria Molnar Weiss is the optometrist who runs all the Virginia RAM vision clinics. Weiss and the other eight or nine volunteer optometrists and ophthalmologists will see one third of the 2,200 patients coming through the Wise clinic over the weekend. She explains that the possibility of getting new glasses can be the lure that first brings patients to the clinics, and then, over time, their trust grows. “The patients see us up at 3am too, so it kind of helps them feel like we’re all in this together,” she says.
What also helps is the ability to use the money they might otherwise have spent on frames, lenses, and an eye test on other necessities. People living in poverty are often playing a losing game with whatever limited income they have: skipping a power bill to pay for a visit to the optician might work for a month, but it could put them behind for a year. Much easier to keep using old lenses, squint a little harder, and live through the migraines.
Elizabeth’s partial plate is finally ready. The dental technician is fitting it for her, taking it in and out of her mouth in between filing her teeth down to eventually arrive at the best fit. After a few revisions, they are both satisfied. The technician does not have a mirror, but holds up her iPhone with a forward-facing camera so Elizabeth can see herself. She has front teeth for the first time in years. She smiles and tries not to at the same time. She is now crying. Her mother, Cindy, is crying. The dental technician and I are both crying as we watch mother and daughter cry and hug each other. Elizabeth even hugs me. “It doesn’t feel normal to smile. It feels weird,” she says.
By Saturday evening, the whole family has got just about everything they came for: glasses, extractions, dentures, and even a few bags of clothes and shoes from the donations tent. They are nearly packed up when Sheila discovers her van will not start. She seems much less worried than I would be. This has happened multiple times before – she knows how to fix it herself, she says. She crawls underneath the van and reattaches a loose wire, and when she tries it, the engine turns over.
Late on Sunday morning, I catch up with Sister Bernie Kenny of the Medical Missionaries of Mary just as the clinic is closing down. Sister Bernie is a nurse-practitioner who first persuaded Stan Brock to bring RAM to Virginia back in 1999. “Today we had a young woman, 27 years old, who had all her teeth out,” she says straight away, before I can say a word past “Hello”. “And her hope for dentures is 2018. How can she live? How can her self-esteem, or her nutrition, or her hope of ever getting a job? It saddens me. But the wonder of being here is all these volunteers with one purpose: to help one another. All denominations, all faiths, all colours, everybody together, and we get energy one from another.”
I ask her what she would do if I gave her a magic wand that she could wave and change one thing for the patients here at RAM. She gives a version of the same answer that all the nurses and doctors and most of the patients give when I ask them: “Everybody has the right to healthcare – it’s not a privilege,” she says. “Your neighbour’s health affects you, so you want the best for your neighbour as well as yourself.”
Sister Bernie, like all the nurses and doctors and patients, says that dental and vision coverage need to be included in basic healthcare policies. Consider this: someone living in poverty with no health insurance gets a toothache, but swallows the pain for months. She finally goes to ER when it gets too bad to eat, sleep, or work. She sees a nurse or a doctor, but not a dentist, so the actual cause of the pain stays untreated. The ER doctor gives her some antibiotics and maybe some prescription pain medications. She uses up the prescription and then maybe looks for something cheaper on the street to dull the pain, because the tooth is never fixed. No one I speak to mentions heroin or methamphetamine by name – it’s always just “street drugs”. In the meantime, the abscessed tooth could go septic and turn just as deadly as an overdose.
Sister Bernie sees this repeatedly, across generations of families. “But the people who come to RAM want to be healthy,” she says. “A lot of them don’t take vacations, or can’t. They come here.” One patient I met started off from her house two days before the clinic opened. She had walked 27 miles to Wise just to have a couple teeth pulled. Then walked 27 miles back.
Access to healthcare is about more than just reducing the travel time between patients and doctors – it’s about bringing down those intangible barriers that make a distance seem impossible to cross. The stereotypes that teach that people living in poverty get what they deserve, the employment barriers that leave medical and dental students with a mortgage worth of school debt, such that they cannot afford to treat people who cannot afford to come to them for care. RAM does not solve and will not solve the US healthcare crisis – or poverty, for that matter – but it clears a path. One that starts right in our own backyards.
This article is adapted from an essay published in the autumn 2016 issue of the Virginia Quarterly Review.
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The enormous pop-up clinic trying to bridge America’s health divide | Amy Woolard
