Hidden Hurt
Desperate for medical care, the uninsured flock by the hundreds to a remote corner of Virginia for the chance to see a doctor

By Mary Otto
Sunday, November 9, 2008; W08

Pain hides in these green mountains. Diseased hearts and clouded lungs, aching teeth and anxious minds.

But for three days a year, more than 800 volunteer doctors, dentists, nurses and other health-care workers come from all over Virginia and beyond to this isolated place in Appalachia to provide free medical care to those who cannot afford it. Sick and hurting people by the hundreds gather and wait for the gates of the Wise County Fairgrounds to swing open -- their presence a testament to the country's health-care crisis.

Every year now, it happens like this. On a Thursday afternoon in late July, trucks filled with thousands of dollars' worth of medical supplies and equipment wind through coal country and up the steep roads to the tip of southwest Virginia, just a few miles from the Kentucky border. Then a small army of health-care professionals, along with hundreds of community volunteers, get to work. In tents, in barns, in exhibition halls, they use clotheslines, hospital sheets and medical clamps to separate examination rooms, surgeries, a vast open-air dental clinic, a laboratory, eye and ear clinics and a pharmacy. Moving with swift efficiency, following a model used to respond to natural disasters, they create a vast field hospital out of thin air in just a few hours.

By sunset outside the gates of the fairground, a field that normally serves as the parking lot is filling up with people -- elderly men and women, young laborers, worn-out coal miners, extended families -- setting up camp. "This is a gift from God," says Joyce Waddell as her daughter and small grandchildren settle in for the night.

An elderly woman limps across the field to the row of portable toilets. A young man lights an oil lantern in the darkening sky.

A tall, sinewy, razor-straight man dressed in khaki walks through the campsites, up the dusty road. He's Stan Brock, the British-born adventurer who sets this mammoth effort in motion each year through his nonprofit Remote Area Medical Volunteer Corps. The clinic is now in its ninth year at Wise, and a number of the campers recognize Brock. They wave and nod in gratitude. "The original Crocodile Hunter," says Mike Mullins, a Clintwood, Va., retiree, nearly blind, who is waiting for eye care. "I think the world of him."

Now in his 70s, Brock gained fame four decades ago as the anaconda-wrestling co-star of the popular television series "Mutual of Omaha's Wild Kingdom." But he has spent the last 23 years flying to some of the poorest places on the planet, bringing free medical care to those who desperately need it. And people rely on that care in rural Virginia, just a day's drive from the U.S. Capitol, he says, just as much as they do in Africa or Latin America.

"The need is massive," Brock says. "We pick up everything from brain tumors to lung cancer to cervical cancer to breast cancer."

Brock takes great pride in the economy and efficiency of the Wise clinic, which costs just $26,000 this year because the doctors, dentists, optometrists, nurses and other workers donate their time. But even as the clinic saves lives and alleviates suffering, Brock knows it amounts to slapping a Band-Aid on a gaping wound. There are approximately 47 million Americans who lack health insurance and another 25 million who are underinsured, according to the Commonwealth Fund, a New York-based foundation that supports research on health-care issues. Hospitals on county fairgrounds, Brock says, are not the answer.

Brock found the inspiration for a volunteer medical relief corps dedicated to bringing free care to the isolated and impoverished long before his "Wild Kingdom" days, during a 15-year sojourn in the savannahs and rain forests of South America, running a huge cattle ranch in the former British colony of British Guiana.

Working and living among the Wapishana Indians, Brock says, he witnessed epidemics of influenza, measles and whooping cough sweep through the communities. Common and treatable in the urban areas from which they spread, the diseases devastated the Wapishana, who had no resistance to them and no traditional remedies. When he left South America in 1968 to join "Wild Kingdom," Brock promised himself he would return someday with a volunteer medical corps.

After his stint on the show ended in 1971, Brock continued to work in television and film for more than a decade before founding the Remote Area Medical Volunteer Corps in 1985. Since then, Brock's organization has conducted more than 540 medical relief missions worldwide with little fanfare and limited funds. About a quarter of the group's $300,000 budget for the past year came from grants from private foundations, and the rest from public donations.

Brock often pilots crucial supplies himself in a donated World War II vintage C-47 cargo plane. He and his volunteers brave extreme conditions, civil unrest and piranha-infested waters to bring basic medical treatment, dental and eye care, and even veterinary services to remote towns and villages in Haiti, Guatemala, Nepal and Guyana. He says he can't count the number of nights he's spent away from his home in Knoxville, Tenn., a 90-year-old schoolhouse he rents from Knox County for $1 a year that also serves as the volunteer corps' headquarters.

Because he lives in Tennessee, Brock has become increasingly focused on the plight of the poor in his own back yard -- Appalachia -- where many people in places such as Wise County go for years without seeing a doctor or dentist.

This is coal country, with an economy that has ridden a boom-and-bust cycle from the arrival of the railroads in the 1880s to the passage of the Clean Air Act almost a century later. The richest seams of coal have dwindled, and many of the remaining jobs have been replaced by mechanization. According to the latest figures from the U.S. Census Bureau's American Community Survey, the poverty rate in Wise County is 19.2 percent -- more than twice that of the rest of Virginia. The per capita income is only about $14,000 a year.

Life is tough here. "I don't want to say it's harder here than any place else," says Sister Bernadette Kenny, a nun from the Medical Missionaries of St. Mary, "but it's damned hard. Pain is pain."

Kenny is a registered nurse who has been ministering to the needs of the people in these hills and hollows for years. Her mobile Health Wagon, which treats more than 2,400 people a year with funding from private foundations and patient donations, is a welcome sight as it trundles along the local roads.

It was Kenny and a fellow Health Wagon nurse, Teresa Gardner, who persuaded Brock to bring his volunteer medical corps to Wise after helping him at a clinic in Tennessee in 2000. They told him how badly their patients needed access to specialists, dentists and eye doctors. From the early 1980s to 2000, the Harvard School of Public Health has found, life expectancies in Appalachia have dropped for both sexes.

In Wise County, "there are patients literally dying of diabetes," says Gardner. The specialists who can help them are a two-hour drive away in Kingsport, Tenn., she says, "if you have insurance."

But many don't, which is why the three-day clinic at the county fairground has become such a huge event. On Thursday night, after the volunteers have finished setting up, Gardner peers out of the fairground office command center. Darkness has settled over the mountains. Hundreds of patients have lain down to sleep. Others continue arriving throughout the night.

Linda Yates, a compact woman of 60, gets here at 2 a.m. She's looking for answers.

She's the daughter of a coal miner, the mother of seven children and a grandmother. She is also a day-care provider and foster mother to countless children, who come to her from the Dickenson County social services department, often with special needs, sometimes without even a change of clothing. She feeds them and dresses them and teaches them for however long they stay with her. She speaks of each with a fierce maternal protectiveness. "If they come into my home," she says, "they will be loved."

Yates and her husband, Lonnie, a disabled mine supervisor, left their small house in the tiny community of Birchleaf, Va., at midnight. They wanted to get here before the clinic opened so Linda Yates would be able to see the doctors on Friday. To make the trip, they had to line up two babysitters to care for the 11 children in their house. They rarely go anywhere overnight.

Yates looks around at all the tents and people camping, grateful to be here. Her foster children all have Medicaid. Her husband, a 61-year-old military veteran who has survived two kidney transplants, and who is battling skin cancer, gets much of his care through Veterans Affairs benefits. But she has no health insurance, and three years ago, she was diagnosed with diabetes at a free screening event.

Yates tried to control the disease by carefully watching her diet. But that strategy didn't work. Because the Yateses live on pension, Social Security and day-care income amounting to about $38,000 a year, she worries about the cost of insulin, more than $70 a month, and the test strips for blood sugar, $70 more.

Teresa Gardner and the Health Wagon have helped Yates manage her disease. But her blood sugar has remained dangerously high, in spite of medical counseling, her careful eating habits, and her regular use of insulin.

"I told Teresa: 'I can take five units or 50 units. It doesn't help,' " Yates says. Gardner, too, has been mystified. Yates knows about the terrible toll of diabetes. "There is a lot of diabetes in our family," she explains. "My uncle was a diabetic. He lost his legs; he lost his eyesight."

Then there was one of Lonnie's cousins, Yates says. "She lost her legs, her arms, her eyesight. She just had a torso left."

In the dark moments before dawn, as the three-day torrent of humanity begins, the volunteers prepare themselves. "Please, God, give us the knowledge to help these patients," prays the Health Wagon's operating director, Karen O'Quinn.

Brock is waiting at the gate of the fairground. He begins calling out numbers that people have been given as they have arrived. There are about 1,500 people today, seven or eight abreast, drowsy, almost ghostly, as far as the eye can see.

One of an army of Lions Club volunteers, barrel-chested Greg Hart from Winchester, Va., keeps the line moving with his clear voice: "Don't let anybody charge you for anything. Everything here is free. Ladies, if you are here for the first time, we have a mammogram van. If you haven't had a mammogram, have one. My mother, who is up there," he says, gesturing to the dark sky, "would recommend you have one. She would be down here if she'd had one. If you've got a bump that might be skin cancer, or a pain you don't want to tell anybody about, there is a doctor here who wants to hear about it."

By daybreak, people are moving into a barn to check in at long rows of tables. Volunteers at computers ask questions and take vital signs, creating charts for each patient, determining what tests they will need.

"The object is to diagnose and solve as much as we can, because we only have this one shot at them," says Claudette Dalton, the medical director at Rockingham Memorial Hospital in Harrisonburg, Va., who helps run the Wise event.

Linda Yates sits down at one of the check-in tables.

"Do you see a doctor?"

"The Health Wagon."

"When was the last time you saw a regular doctor?"

"It's probably been 12 years."

She discusses her diabetes and gets a stick test for her blood sugar. She hasn't eaten since the previous night, but at 263, her blood sugar is far above the normal level -- about 100. "It was 400 last night," she says. "I took the insulin, but nothing works."

Last year, the Health Wagon nurses started urging Yates to come to the 2007 clinic, to see specialists and get the tests she needed to better understand her problem. But she had to put off the trip when Lonnie became seriously ill. "I ignored myself for a long time," Yates says. Now she realizes that too many people are counting on her for her to falter. "I've got to be there for my children, my grandchildren and my husband."

When Yates arrives at the medical barn and sees the makeshift examination rooms partitioned off with sheets, a smile of admiration spreads across her face. This is a place after her own heart: "It shows you can make do with less and get it done."

In a surgical tent behind the medical barn, Vincent Voci, a plastic surgeon from Charlotte, removes a disfiguring cyst from a man's cheek.

The cyst is the size of a large egg, but it is not what brought Chester White here from Bristol, Tenn., an hour away. He actually came to see a dentist but learned he could see a dermatologist while he was waiting. The cyst comes cleanly out of the shell of skin where it had been growing for eight years. Then White's adult son comes from the dental tent and also has a cyst removed from his face.

Voci stitches up the torn and bleeding finger of a young man who was working on a tin roof. And he removes what appears to be a slow-growing basal cell carcinoma from a woman's face.

Patients who learn they have cancer, heart disease or diabetes often face major barriers getting the follow-up care they need, even with the ongoing help of the volunteers. Some patients are sent to local doctors who agree to provide the care for free. But area hospitals and health-care providers are already overwhelmed by the number of sick and uninsured people who need treatment but cannot pay, Claudette Dalton says. "We can't stretch resources any thinner," she says. "You can't keep your office or hospital open without some paying patients."

Follow-up care is often available through the University of Virginia Health System in Charlottesville, home to the largest contingent of medical volunteers here. But Charlottesville is about a six-hour drive from Wise.

"These folks still have a lot of large cracks to fall through in getting follow-up care," says Karen Wilson, the executive director of Brock's organization. "Sometimes it's an easy task. Sometimes it's difficult. Sometimes you fail. That's the reality."

Out in the field, Joseph Smiddy, a pulmonologist from Kingsport, is doing chest X-rays in the trailer of a truck he customized to serve as a mobile clinic for the early detection of lung cancer. He went to truck driving school to learn to drive the 18-wheeler. Now he visits remote areas, such as Wise, where he grew up.

Smiddy is studying the X-ray of a patient he just saw. The man's lungs are spotted with granulomas, small areas of inflammation that are benign but can resemble cancer. With its high concentration of major lung diseases, often only recognized in late stages, this region is known as a lung belt. "We're in a lung belt because of the coal work and smoking," says Smiddy, "and histoplasmosis, a soil fungus that causes lung disease." Histoplasmosis is a common cause of granulomas.

The state of health in the region has been historically dismal, with cancers, tuberculosis, black lung and mining accidents. The coal camps had small clinics, though. And mine workers got medical coverage through the United Mine Workers of America.

Then, in 1988, a turn of events rocked the little coal towns through this region. The United Mine Workers contract with the Pittston Coal Co. expired, and widows, pensioners and disabled miners were informed that the company would no longer contribute to their health insurance. The miners' ensuing strike against Pittston and its subsidiaries enveloped southwest Virginia in one of the most searing labor confrontations of the latter 20th century. Hundreds of miners and their families were arrested in sit-down protests and blockades.

During the Pittston Coal strike, Kenny, in her Health Wagon, provided care to the miners whose benefits had lapsed. She was arrested and jailed. "The charges were impeding traffic and giving health care in an unorthodox manner," she recalls. On Kenny's day in court, a group of supporters stood up and sang "Amazing Grace." The charges were dismissed, Kenny says.

The benefits were eventually restored. But the memory of Pittston -- and the impact that the sudden loss of health-care benefits can have on a community -- lingers. It's an impact shared by an increasing number of Americans as companies attempt to control costs by reducing or eliminating health-care coverage.

The number of uninsured Americans has climbed by 12 million since 1990, according to a 2007 report from the U.S. Census Bureau. The number of underinsured Americans has risen 60 percent since 2003, according to the Commonwealth Fund. Those who are uninsured or underinsured can't afford a catastrophic illness or even visits to the dentist or eye doctor, Stan Brock told a congressional subcommittee exploring the nation's health-care crisis in April.

"We could fix this problem," Brock says. "It's just a question of priority."

It's Friday afternoon, and the mammogram van is doing a brisk business. As with the chest X-rays, about one-third of the mammograms done here reveal something that requires further testing.

"Getting each patient to follow-up care is so individually difficult; it can be a real thrash," says Dalton. "It's case by case, and it involves the U-Va. social workers, the Health Wagon nurses and the local health department often scrounging resources locally and just persisting with the patients."

One year, three women from one town all had suspicious lumps in their breasts, but the volunteers could not find a local radiologist who would see them for the follow-up exams.

"We finally scraped up enough money to get them to Charlottesville, but they were so far from home, and it was hard on them," says Dalton. Two had cancer and underwent lumpectomies.

Linda Yates decides she should get a mammogram. "My grandmother died of breast cancer," she tells the volunteer adding to her medical chart outside the van.

"When was your last breast exam by a doctor?"

"Eighteen years ago."

"How many pregnancies?"

"Three."

"How many children?"

"Seven."

The volunteer looks up, puzzled. Some are adopted, Yates explains.

"Are you pregnant?"

"Not so far this morning," the grandmother answers with a chuckle.

Yates spends 12 hours waiting in various lines, getting tests that would have cost thousands of dollars if she were paying for them. When she emerges from the medical barn, it is 6 p.m., and the clinic is closing down for the day. Her husband, Lonnie, her sweetheart since high school, finds her in the crowd.

"Were you worried about me?" she asks him with a smile.

"I haven't seen you since 6 a.m."

"Well, you couldn't have found me," she says. "It was a whole different world back there."

In the half light of Saturday morning, it all begins again, with about 1,000 people waiting at the fairground gates.

Though smoking is forbidden inside the field hospital, many patients are smoking while they wait outside. Along with obesity, smoking is termed a major behavioral risk factor in the area. About 30 percent of adults in the area smoke. Even many of the very poor spend the little money they have on cigarettes. They often started smoking as children.

Patricia Pleasant, 47, from Lee County, Va., is one of them. "I started at 9, rolling for my father," she says between drags. Disabled by a nervous condition, she says, she smokes to try to calm herself. "If I get nervous or anything, I smoke."

"Nerves" are a recurring complaint in this region, according to research by the Southwest Virginia Graduate Medical Education Consortium, based at U-Va.'s College at Wise. "A frequently reported cause of nerves was having too many problems and few solutions," the report observed. According to the consortium, residents of the region are 70 percent more likely to commit suicide than those elsewhere in the state.

Saturday afternoon is hot, and people are getting tired and testy. A brief argument breaks out in one tent over a place in line. Out in the parking lot, a stout woman pauses, then slowly crumples to the earth. Three medics hurry over. One plucks a burning cigarette from between the fingers of the prone woman. Every year, there are "downers," people who collapse from fatigue, hunger, illness. The volunteers gently revive the woman and administer first aid.

In an oral surgery trailer, Melanie Locke, a 31-year-old school custodian from Martinsburg, W.V., gets to smile normally for the first time in her life. She is speechless as she studies herself in a mirror.

She was born with a cleft palate. As a child, she received a series of operations to correct the condition. But as an adult, she has not been able to get proper dental care because of the complexities of her case and her family's lack of insurance.

"We had a tooth pulled once, and it was more than I make in two weeks," says her husband, Kevin Kilmer, a carpenter.

Charlottesville dentist Michael Clark and Roanoke dental technician Greg Gray took Locke's case at one of Brock's clinics in West Virginia, extracting her diseased teeth and tackling the challenging job of designing custom dentures to fit her mouth. The care would have cost thousands of dollars. She and her husband have come to the Wise clinic for the final fitting.

"This is like waking up in heaven" says Kilmer, taking in his wife's smile. She has suffered so much pain and worry, he says. "This is going to change her life."

Yates is also back. Her face is alight as she picks up a small package from the pharmacy tent. "I don't have to take the insulin anymore," she announces. A diabetes specialist has prescribed a medicine that stimulates the pancreas. Yates gets a starter supply from the clinic. In the coming weeks, the Health Wagon will locate more free samples for her. Yates knows the medicine is expensive, but Teresa Gardner won't tell her exactly how much it costs. "I guess she doesn't want to shock me."

Yates's mammogram reveals a possible problem, however. The Health Wagon will work with a Virginia program called Every Woman's Life, which helps provide eligible women with screening and follow-up care for breast and cervical cancer.

Yates's daughter Connie Skeens, 40, is also here today. She's a tall, coltish blonde. "Dad says it takes somebody graceful to be as gawky as I am," Skeens says with a wry smile.

When her health was better, she worked as a waitress. Now she often helps her mother with the foster and day-care children. Skeens has been battling diabetes since she was a little girl. Her parents were told she would probably die young.

"Love her while you can," Skeens said the doctor told them. With vigilance, she has survived, though diabetes has not been easy. She lives daily with dry mouth and confusion, as her blood sugar rises and falls. "It's something I wouldn't wish on my worst enemy," says Skeens.

For eight years, she escaped her troubles through addiction. "I'm a recovering oxycontin addict," she says. "It's a painkiller. They call it the poor man's heroin."

She started taking the medication, like many people in this region, after a doctor recommended it for back pain. She couldn't stop. "Eight years of using and selling," she recalls.

Her parents agonized. They tried to help her stop, but without success. "The way it makes you feel when you are using," says Skeens, "it just makes you giddy."

She finally overcame the addiction in a halfway house after serving 11 months in the local detention center for using her parents' credit card to support her drug habit. "We had to press charges," recalls her mother, the pain audible in her voice. For awhile, Skeens was furious with her parents, but now she is grateful.

Yet she still speaks about "the OC" with a touch of nostalgia, describing the little round pills and the colors that indicate their strength in milligrams:

"The 10s are white.

"The 20s are pink.

"The 40s are gold.

"The 80s are green.

"They had the 160s . . . That was the prettiest blue I have ever seen in my life," she says, "just about the color of that guy's scrubs over there."

Today, her teeth, which have long troubled her, are infected. And her kidneys are infected, she suspects, the infection perhaps spreading from her teeth. She registers at the dental tent and gets a plastic orange bracelet that bears the word "extraction."

She also needs an eye exam, but her blood sugar plays havoc with her plans. She can't have an eye exam until she can get her blood sugar into the normal range. "It's going to be one of those days," she sighs. The volunteers send her to lie down in the medical barn.

A tiny sliver of moon hangs in the dark sky. Then the fog lifts up from the hills, and the long sheets of white paper are lifted from the instruments in the blue dental tent.

It's Sunday morning. Everyone is tired.

In the medical barn, Ross Isaacs, a Charlottesville nephrologist, is still seeing patients, and marveling at the depths of the troubles here. "There are 20 million diabetics in this country. That's about 9 percent of the population. In southwest Virginia, in this clinic, it's 50 percent.

"Then there's hypertension. Fifty million cases in the United States -- about 18 percent. At this clinic in Wise, it's 70 percent."

So much need, so little time.

Meanwhile, Connie Skeens, terrified of the ordeal, gets her 22 remaining teeth, all infected, extracted. Richmond oral surgeon Kimberly Swanson is reassuring as she goes about the difficult work. "You'll never have to do this again -- does that help?" Swanson asks her. "I hope you get some teeth fast."

Skeens steps out into the Sunday sunlight gripping bloody gauze between her gums. She is put on a waiting list to get free dentures next year, when the clinic returns to Wise. She'll have to eat soft food until then.

Meanwhile, this year's clinic is winding down. All over the fairgrounds, volunteers are busy packing up. It's nearly noon, and 2,670 people have received medical treatment worth more than $1.7 million. Hundreds of tests have been administered. More than 1,000 pairs of eyeglasses have been made. More than 4,000 teeth have been extracted.

In the medical barn, medical students are taking down the sheets that divided the examination rooms. Cardiologist Bill Harris, the son of a coal miner, pauses from his work to consider the gap between his own life and those of the patients here. "I'll go home in a nice car," says Harris, who lives in Pikeville, Ky., "and have a glass of chardonnay." The people he cared for will drive winding roads back to hard lives. Harris won't be able to see their pain, but he won't be able to forget it, either.

Mary Otto is a former Washington Post staff writer who is now editor in chief of Street Sense, a biweekly D.C. newspaper largely produced and sold by the homeless and formerly homeless. She can be reached at 20071@washpost.com.