The sun has barely risen over the small Appalachian town of Wise, Virginia, where Virginia Commonwealth University senior Staci Fraley is already two hours into her day preparing for the Remote Area Medical clinic. Soon, the gates will open and more than 2,000 people desperate for medical and dental care will pour through the Wise County Fairgrounds entrance. The patients, many of whom slept in the parking lot overnight to ensure a spot in line, will wait for hours in the dusty heat to be seen for overdue health problems in animal-stalls-turned-exam rooms and behind bedsheets pinned to barn rafters.
“I couldn’t express enough the thanks these people have for us,” Fraley said. “Some of them have never seen a doctor. It is monumental for them to receive this care.”
The 21-year-old nursing student knows firsthand the value that clinics like this provide for medically underserved and impoverished communities. Fraley is from Big Stone Gap, a small southwestern Virginia town about 20 miles from Wise. During her childhood, Fraley’s grandparents would travel to the clinic at Wise every summer for annual doctor and dental visits.
“I am glad I could come back and provide care for people where I’m from,” Fraley said.
For students like Fraley, the clinic is an opportunity to bring the health care expertise she has acquired in school back home. For others, the clinic provides a glimpse of the chronic health conditions faced by millions of Americans who lack insurance and can’t afford basic medical and dental care.
“The goal is to get students out where they are needed most,” said Michelle Whitehurst-Cook, M.D., associate professor of family medicine and population health at VCU School of Medicine. “The more they see how beneficial it is to work in an area of great need, the more likely they are to choose to work in a similar area after graduating.”
Below we share some of the sights, sounds and stories from the three-day event, the largest of its kind in the U.S.
Pamela Sexton arrived at the fairgrounds Thursday afternoon to pick up her ticket for the next morning. The 59-year-old Appalachia resident suffered a series of strokes nine years ago that left the retina in her right eye permanently damaged. “My eyesight gets worse every year,” she said. Sexton’s medical insurance does not include vision benefits, so she comes to the clinic every year to have her eyeglass prescription renewed. On Thursday, she camped at the fairgrounds with her boyfriend and stepfather. They were first to the gate Friday morning.
Wise County resident Rick Colley works with other local volunteers in the weeks leading to the clinic to prepare the fairgrounds for patients. On Friday, he arrived at 2:30 a.m. to direct morning traffic. Colley will work through the following week helping to tear down the clinic.
Clarke County Lions Club Chairman Greg Hart has volunteered at the clinic for 16 years. On Friday morning, he calls ticket numbers admitting patients into the fairgrounds in batches of 25. When their ticket is called, patients go to the horse arena on the right side of the fairground to begin a day of waiting. It is 6 a.m., and Hart has just called the 400th patient.
Rising seniors Staci Fraley and Virginia Slattum woke at 4 a.m. on Friday to get to the fairgrounds before patients were admitted. The two VCU nursing students will volunteer there from pre-dawn Friday through late afternoon Sunday. “I enjoy working within a community,” Slattum said, adding that her nursing school experiences are primarily hospital-based. “Clinics like these provide opportunities for us to experience the other side of health care that is not just the tertiary in-patient setting that we typically are exposed to.”
Stan Brock, 81, founded Remote Area Medical after suffering a near-fatal injury while living among the Wapishana Indians on a cattle ranch in Guyana, South America. A wild horse kicked him in the head while he was working on the ranch, which was 350 miles and a 26-day journey on foot from the nearest medical care. When he recovered, he vowed to find a way to deliver medical aid to people in the world’s most inaccessible regions.
RAM started in 1985 with pop-up clinics overseas in places like the Amazon, Haiti and Uganda. Often, health care providers would parachute into the remote regions where the clinics were held. In 1992 Brock got a call from a resident of Hancock County, Tennessee. The hospital in the small, rural area had recently closed and its only dentist had left town. RAM volunteers treated about 150 people there. Less than a week later, a request came in from residents in the next county over. Soon RAM was so busy in the U.S. that it had to cut back on overseas commitments. Now, more than 90 percent of the clinics RAM hosts are in the U.S. “There is so much need around the world, but you can’t disregard the need right here in the U.S., which is overwhelming,” Brock said.
The largest provider of mobile medical clinics in the U.S., RAM has hosted 869 clinics around the world since the mid-80s, treating more than 700,000 people and providing more than $144 million in free medical care.
Brock has no home and doesn’t take an income from the clinics. He sleeps on a pad on the floor of RAM’s office in Tennessee and stays on-site at the clinics they host around the world. At 5 a.m. on Friday, he opened the gate and welcomed patients to the Wise County clinic.
Larry McKnight visited the clinic Friday and Saturday, first to be seen by a physician for persistent shoulder pain and later to have his teeth cleaned. The 38-year-old makes $18,000 a year as an auto mechanic and welder in Wise. “My shoulder has been bothering me for about eight months and I kept working, but now it’s gotten to the point where I can’t work,” he said.
After witnessing friends overdose on opioids and seeing the devastation the medication caused in his small town, McKnight vowed to manage his pain without prescription painkillers. “We live in the perfect example of opioid addiction,” he said. “Just about every night, especially on the weekends or if it’s a full moon, there is probably going to be some overdoses in this area.”
A physician McKnight saw on Friday tracked the pain in his shoulder to a pinched nerve in his neck. McKnight doesn’t have insurance, but social workers at the clinic connected him with follow-up care at the Health Wagon, a collection of two brick-and-mortar clinics and one mobile clinic that provides free health care to the medically underserved population of Appalachia. The average Health Wagon patient is 38 years old and 98 percent of patients are uninsured. Seventy percent have an income of less than $20,000 annually, despite working multiple jobs, which means they may make too much money to qualify for Medicaid, but not enough to afford private insurance.
“We should all be able to get health care,” McKnight said. “It should be a right, not a privilege.”
Noah Wallace was addicted to opioids for 18 years after being prescribed Oxycodone to treat pain from a wrestling injury he incurred in college. The builder from Castlewood eventually overcame his addiction and now works through his church to help others. “We’re reaching out into our community to try to make an impact on the opioid epidemic,” Wallace said.
At this year’s clinic, VCU students and faculty worked with representatives from the Virginia Department of Behavioral Health and Developmental Services to educate clinic attendees about opioids and provide patients with naloxone, a medication that treats opioid overdoses. According to a 2016 policy brief from VCU School of Medicine’s Department of Health Behavior and Policy, Virginia’s Medicaid program spent $26 million on opioid use and misuse in 2013, with $10 million of this spending occurring in Southwest Virginia.
“I can look back over the past 25 years — and this is a low estimate — I have at least 50 close personal friends who are no longer with us due to opioids,” Wallace said. “The number of people who I know personally who are addicted just in my community is in the hundreds.”
After attending the naloxone information session, Wallace picked up his prescription from the clinic pharmacy. He plans to keep the medication on hand in case he encounters someone during an overdose.
“I’m always trying to help somebody,” he said. “Trying to spread the love.”
Sen. Tim Kaine (D-Va.) registered patients at the clinic on Friday morning. As he listened to patients’ stories and helped volunteer staff, Kaine lamented on Virginia’s Republican-controlled legislature’s vote not to expand Medicaid under the Affordable Care Act, effectively barring more than 400,000 citizens from state-sponsored health coverage.
“Virginia made a huge mistake by not expanding Medicaid,” Kaine said. “The failure to expand Medicaid means people don’t have coverage, but it also means that in places like Southwest Virginia, you have hospitals that are closing.”
The senator referenced Lee County Hospital, a medical center in Pennington Gap, about 40 miles southwest of Wise, which closed in 2013 after 70 years in operation. “That hospital said they would have stayed open if Virginia had expanded Medicaid,” Kaine said.
As with most of Southwest Virginia, about 80 percent of Wise County residents voted for Donald Trump, in part due to the president’s campaign promise to deliver less expensive and more effective medical care nationwide.
Virginia Governor Terry McAuliffe (D) visits the clinic every year. On Friday, he walked through the fairgrounds listening to patients and echoing their sentiments. “We have a moral responsibility to take care of these citizens,” McAuliffe said. “I encourage every legislator to walk through these tents and talk to these people. These are human beings. People are losing their lives. This isn’t about politics. This is about a right. Health care is a right, not a privilege.”
McAuliffe invited Senate Majority Leader Mitch McConnell (R-Ky.) to join him at the clinic, but said he was met with “a polite no.” In addition to McAuliffe and Kaine, Virginia Attorney General Mark Herring (D) visited the clinic. Republican legislators did not attend.
Dental procedures account for more than 65 percent of the services RAM provides at its clinic. At the Wise clinic, dental volunteers work through Mission of Mercy, a Virginia Dental Association Foundation service that provides care in underserved areas of the state where there are not enough dental practitioners to adequately address the oral health needs of the community.
This year, about 450 dental volunteers provided treatment to more than 1,000 patients at the Wise County clinic, amounting to almost $1.25 million in care. In addition to faculty and alumni, VCU School of Dentistry brought 75 students to the 2017 clinic. “We can never take as many students as who apply,” said Kim Isringhausen, department chair of oral health promotion and community outreach at VCU School of Dentistry.
Isringhausen says it is common for patients to expect to have all their teeth pulled at the clinic.
“Extractions are the most common procedure we provide and we see a lot of full mouth extractions,” she said, adding that dentists at this year’s clinic pulled almost 3,000 teeth.
Isringhausen, who serves as faculty advisor for the dental students who volunteer through Mission of Mercy, says the disproportionate number of tooth extractions performed at the Wise County clinic reflects on the poor overall health of that region. “Southwest Virginia is an underserved area with little access to oral health care,” she said. “There are a lot of social determinants of health that factor into the situation.”
In addition to opioid addiction, high levels of methamphetamine addiction contribute to the prevalence of tooth decay in the area. Diabetes, common among patients at the clinic, makes people more susceptible to periodontal disease. Diets high in sugar from soft drinks and processed foods also contribute to oral health issues. For many, simply not having access to regular dentist appointments causes small cavities to rot past the point of repair.
An estimated 3.8 million Virginians — 47 percent of the population — do not have dental insurance, according to the Virginia Health Care Foundation.
“People are in pain and have tooth decay, but they don’t have any means to have it taken care of,” Isringhausen said. “By the time they get to us, their teeth are so grossly decayed that they have to be taken out.”
Sometimes, patients extract their own teeth while waiting to be seen at the clinic because the pain is so severe. “I have been to projects where we numb a patient and the next thing you know, the patient has their tooth in hand,” Isringhausen said. “It is a sad situation.”
While clinics provide students with opportunities to apply dental techniques that they have learned in the classroom, they are more so an opportunity for students to witness the level of need for dental care that exists within Virginia. “The hope is that we are creating awareness and recognition of a problem,” Isringhausen said. “We never created MOM projects to be the solution. We created them to bring awareness to how bad the situation is.”
Daniel Laskin, D.D.S., has taught at VCU School of Dentistry for 32 years. The 92-year-old chairman emeritus of the school’s Department of Oral and Maxillofacial Surgery still teaches four days a week. This is his eighth year volunteering at the MOM clinic in Wise County. “It is a way of giving back, and the patients are so appreciative,” he said. “It really makes you feel good that they care.”
Fatima King traveled to the clinic from Glade Springs to have her dentures repaired. When they broke last year, she couldn’t afford to fix them. The 64-year-old has multiple sclerosis and receives disability benefits through Medicare, but her insurance doesn’t cover dental and vision services. Feeling confident with her new smile, King plans to apply for jobs and maybe enroll in community college classes when she returns home.
“I love them,” she said. “I cried when I got them.”
Genevieve Beaird first visited the Wise County clinic in 2012 before she joined VCU School of Nursing as an assistant professor in the school’s Department of Family and Community Health Nursing. She has brought nursing students to the clinic every year since.
Nursing student Annie Cantrell, 29, works with pharmacy student Mary Beth Bryant, 25, to gather medical histories from patients and record vital signs. “I knew before I started the nursing program that I wanted to get involved in public health and work with underserved populations,” said Cantrell, a rising senior in the school’s accelerated bachelor’s program. “Being here this weekend has solidified that for me.”
For Mary Beth Bryant, whose mother is from Galax in Southwest Virginia, volunteering at the RAM clinic was an opportunity to reconnect with her roots. “All of these people are like my grandparents,” the rising second-year pharmacy student said. “I am very passionate about the patient population here.”
In addition to volunteering at the RAM clinic in Wise, Slattum volunteers at free clinics in Richmond and on construction projects in Appalachia. “Being able to come here and serve is a humbling experience,” the 20-year-old said. “It is a reminder of how much work still needs to be done and an inspiration to remain as advocates for our patients.”
VCU School of Pharmacy associate professor Evan Sisson, Pharm.D., recalls seeing signs for RAM clinics when he would visit his wife’s family in Wise County. “It wasn’t until I joined VCU that one of my students told me her roommate, who was a dental student, volunteered at the clinic in Wise and asked if we could send pharmacy students,” Sisson said. The School of Pharmacy’s first trip to the RAM clinic was in 2007. This year, the school brought 15 pharmacy students, six pharmacy residents and two pharmacy faculty members. “It is organized chaos,” Sisson said. “You take what you know from caring for patients in clinic, where you have a lot of resources, to essentially going camping and providing medical care.”
Whitehurst-Cook started volunteering in Wise during the clinic’s second year. She has accompanied VCU School of Medicine students at the clinic for the past 14 years. This year, nine medical students, five residents and five VCU Health physicians volunteered at the clinic.
Medical students help at the clinic by acting as patient escorts — carrying patients’ medical charts for them and saving their seat in line if they have to leave to use the restroom or be seen by a specialist. “The students learn by observing patients being seen by a physician,” Whitehurst-Cook said.
As with other economically depressed parts of the country, high rates of heart disease and diabetes are common conditions in Southwest Virginia, as well as hypertension, high cholesterol and depression. Wise County ranked 126 in health outcomes out of 133 counties in the 2017 Virginia County Health Rankings, a measure of community health that considers a variety of factors including access to healthy foods, obesity rankings and teen pregnancy rates. According to the survey, issued annually by the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute, 18 percent of Wise County’s population is considered to be in poor or fair health, with 31 percent considered obese and 15 percent uninsured. “In working with underserved populations, you see chronic disease issues surface,” Whitehurst-Cook said.
The family medicine physician plans to continue volunteering at the clinic as long as there is a need, but she wishes she didn’t have to.
“This is not the way health care should be provided,” Whitehurst-Cook said. “It is the way health care needs to be provided right now because it is the best we can do, but we ultimately need a better health care system that will take care of these people all the time.”
Kevin Lee, M.D., practices as a family medicine physician in Herndon and serves as affiliate faculty at VCU School of Medicine’s Department of Family Medicine and Population Health. The VCU School of Medicine graduate has volunteered at the RAM clinic in Wise for seven years. “Having the ability to provide care for a population that doesn’t have access to health care means a lot to us,” Lee said. “There is a lot of gratitude here.”
At the end of the three-day clinic, more than 100 VCU students and faculty packed their medical equipment in vans and drove six hours back to Richmond from Wise County.
“It is eye opening for students to travel to Southwest Virginia, get immersed in this environment and see the true struggle for the working poor,” Isringhausen said. “My hope is that it fosters a sense of civic responsibility within them, so when they become licensed practitioners they are willing to give back a piece of their time to the community.”
For students like Fraley, the journey has just begun.
“Coming to clinics like these inspire me to always give back to the community,” she said. “We have knowledge that needs to be shared.”