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A Weekend Providing Healthcare In Rural Appalachia

Photo by Wes Hicks on Unsplash

By: Deanna Altomara

When I signed up for the job, I did not envision myself toting buckets of blood across a middle school gym. Yet this was the least of the challenges I encountered while planning and executing a five-day service trip in Rutledge, Tennessee. Along with my co-lead Alyssa, I led a group of Emory undergraduates into an immersive experience studying environmental health in rural Appalachia. Over the course of our fall break, we learned about the different factors influencing health and healthcare in Appalachia, and got hands-on experience with one organization’s solution to the problem: pop-up medical clinics in rural areas, free of charge. We worked at one such clinic that sprung up at a middle school in Grainger County, Tennessee.

A group of college students wearing matching t-shirts smile at the camera. One girl sits in a dental chair, one boy sits in the dentist's chair. They are in a school gym with blue tarpaulin on the floors.
Emory students volunteering at the RAM clinic. Photo credits: Alyssa Milton

The clinic’s organization, Remote Area Medical, was founded in 1985 by noted actor Stan Brock. After suffering an injury while riding a horse in Guyana, South America, Brock had to be carried for 26 days to the closest clinic. Following his recovery, he vowed to increase healthcare access in rural areas around the globe. The idea for Remote Area Medical (RAM) was born.

Since then, RAM has treated more than 785,000 patients and provided over 135 million dollars worth of free care in the US and around the world. Many of their clinics take place in rural Tennessee and neighboring Appalachian states, serving some of the poorest areas of the country. Doctors fly in from across the country to volunteer on their weekends off. Their services are desperately needed.

At 6 am, we welcomed in the first patients of the chilly October day–people who had waited all night in the parking lot. Some said they would have arrived even earlier if they hadn’t had work the afternoon before, work as truck drivers or factory workers. The patients came in shivering, wrapped in blankets and several pairs of gloves. As I guided them to the triage station, they answered my questions in short breaths, rubbing their hands to their mouths. By 6:30, there was a steady flow of people pushing at the blue double doors and check-in table. 

6:30am, Rutledge Middle School

Another coat pushes open the door.

Knit hat, pink ears, pink fingers, pink face. Blue fleece and slippers.

Medical, dental, or vision care, ma’am?

You slept in the car?

I’m sorry, we’re out of hot chocolate.

You drove four hours?

Here, ma’am, take your seat. Doctor is busy.

Another coat pushes open the door.

The economic history of these states has played a significant role in shaping the poverty that plagues much of Kentucky, West Virginia, and Tennessee. These areas are rich in natural resources, and some of their main economic outputs are from mining and agriculture.

In Grainger County, where 18.7% of people live below the poverty line, a significant portion of the population is employed in factories and other blue-collar production facilities. All too often, these jobs do not come with sufficient health insurance, forcing workers to pay for care out-of-pocket. An alarming 10.7% of people are uninsured. As a result, many people choose to ignore symptoms for as long as possible, delaying treatment and giving rise to more severe illness.

Unable to afford proper nutrition or medical care, these individuals are particularly susceptible to long-term, chronic diseases like hypertension and diabetes.[1] At the RAM clinic, many patients were diagnosed and treated for these chronic diseases, outfitted for a pair of glasses, and received dental work, some for the first time after years of suffering.

Map of the Rutledge Clinic

Long, straight road.

Churches. Barns. Tomato fields. Beef pastures. Churches.

Drive back to middle school.

Wait in back of parking lot overnight. Bring blankets. 

Blue double doors. Baskets of blue pocket Bibles. 

Escort to computer lab for triage. 

Blood pressure, blood sugar, medical history. Hablas español? 

Forms.

Escort.

Forms.

Slumped at desks, waiting for doctors.

Lining the halls, waiting for glasses.

Packed into bleachers, waiting for dentist.

Waiting, forms, waiting. 

These chronic illnesses are also fueled by a dearth of nutritious food. Although located in the heart of farmland, many rural Tennesseans do not have regular access to a grocery store. At the church we stayed at for most of our trip, we were more than fifteen minutes away from the nearest grocery store. While this may not initially seem like a problem, this distance becomes a large barrier for families who might struggle to put gas in their car or for seniors who are unable to drive.

Furthermore, produce and other healthy ingredients often cost significantly more than their less-healthy counterparts. Families on a tight budget are sometimes forced to rely on prepackaged and processed foods, such as ramen, frozen meals, and potato chips. These foods do not supply sufficient nutrients, hampering important bodily processes like bone development and immune strength. Even though people may get enough calories from this kind of diet, they often do not have enough vitamins, fueling a crisis of invisible malnourishment that contributes to inflammation and a variety of chronic health conditions.

Poor diet drives many of the most common health conditions in Grainger County, where 14.3% of adults have diabetes and almost a third are obese. Many of the patients at the clinic were overweight, and some carried visible markers of chronic disease or disability, like canes or oxygen tanks. In addition to contributing to chronic disease, sugary foods and beverages also contribute to tooth decay. 

The most commonly-requested service at the RAM clinic was dental work. Given that the county has less than one dentist for every 7,691 patients, this is unsurprising. The dentistry area was set up in the middle school gym, where the ground had been completely carpeted with blue tarpaulin. A long table flanked by a dozen dental chairs on each side stretched from one basketball hoop to the other. On one side of the gym, there was a sterilization station and a table with bins of silver instruments and vials of lidocaine. On the other side, the bleachers were pulled out to accommodate the crowds of patients waiting their turn.

Waiting for the Dentist

Middle school bleachers stretched into stairs.

Row after row, stair after stair, seat after seat.

A sea of white beards, white faces, whiskers, wrinkles, canes, jackets. 

One woman, long face, with a Dear America book.

Children crawling over each other.

Bald man, silent. Tattoo on arm. Won’t answer questions.

Sound of drills. No screams. Just drills.

Voices. Swapped weed.

“I need a cigarette.”

Students work at a long table filled with dental supplies.
The dental supply table at the RAM clinic. Photo credits: Nicole Pan

I sat in the bleachers and spoke to some of the patients, who told me their stories. Due to a lack of insurance, many had not been to the dentist in years. Some had been ignoring toothaches for months or longer, until they could no longer bear the pain. Multiple people had to get over eight teeth pulled—all in one sitting, under the harsh lights of a middle school gym, in front of an anxious audience, with only minimal pain medication. Anesthesia or pain-dulling opiates were out of the question, both because of cost and concerns of addiction. 

How to Clean Blood from a Dental Station. 

First. Goggles, mask, gloves, coat.

Second. Pick up bucket sloshing by handle.

Third. Tote across school gym, canvassed floor crackles beneath boots. Slosh slosh slop bucket.

Fourth. Set down bucket by dental chair in middle of gym. Wipe down station. 

Fifth. Connect tubing from slosh bucket into dental station’s fluid collection flask. Press button.

Sixth. Vacuum blood, spit, water, and pus from flask. Red bubbles froth and swirl through tube. Fill up bucket.

Seventh. Unhook tube. Clean. Disinfectant.

Eighth. Pick up bucket sloshing by handle.

Ninth. Return to gym sidelines, canvassed floor crackles beneath boots. Slosh slosh slop bucket. 

Many of the people I spoke to had either dealt with addiction themselves or had known, or even lost, people to it. Tennessee is one of the states at the center of the opioid epidemic.  In 2017, there were 94.4 opioid prescriptions for every 100 people living in Tennessee, contributing to a rate of 19.6 opioid overdose deaths per 100,000 inhabitants.

Disenfranchised and impoverished, in a community with little racial diversity and where only 26% of students were considered proficient at math in 2016-2017, the outlook is bleak. Many people turn to drugs as a source of income, comfort, and escape. Drug use not only robs the county of some of its most valuable workers, but destroys what the community finds most precious: the lives of its members. Locals told us that Grainger County is known for “[to]matos and meth.” 

Legal drugs also play a central role in this pictures: nicotine, medical marijuana, and alcohol. In Grainger County, 23.1% of adults smoke. The high rates of smoking have fueled cases of lung cancer, heart disease, and other chronic illnesses. It has also contributed to gum disease and tooth decay—a fact that wasn’t lost on the multiple people who huddled in the cold morning air to smoke a cigarette. The patients shared knowing looks with one another, held each other’s spots on line, and gave recommendations about where to get the best brands and sales. One man flashed a ziploc packet of medical marijuana from his coat pocket, explaining to his neighbor how important it is to get the drug from a reputable source. Others nodded, sharing stories about their own battles with chronic pain, cancers, and gastrointestinal disease so powerful that only a few certain substances—be it marijuana, painkillers, or even the mind-numbing effects of alcohol—seemed to alleviate.

Snippets of Stories

“See that dentist over there? I’ve been watching him. He hurts people.”

Big smile, hollow mouth. 

“I never did drugs, but they all think I did.”

Leans against a silver wolf-tipped cane.

“Used to work a forklift. ‘Til it took out my foot.”

Pass a cigarette lighter.

“I’m getting nine teeth pulled. How ‘bout you?

Rolls back sleeves.

“Got four tattoos. One for dead mom, two for dead nephews, one for God.”

Our work at the RAM clinic helped to serve over three hundred people in the course of two days. That weekend, over three hundred people returned home with newfound pieces of hope—new dental fillings, a new pair of glasses, phone numbers of local doctors who might be willing to work with them.

That being said, much work remains undone. A disease like diabetes requires much more than a one-time diagnosis: it requires careful follow-up, daily access to insulin and other medications, and long-term monitoring. Heart disease cannot be prevented by one doctor’s explanation of the importance of fruits and vegetables; it requires lifelong education, supports for smoking cessation, and affordable access to a healthy diet. While clinics like RAM can change lives, they are just the beginning of the change that is needed to truly alleviate the health crises engulfing rural Appalachia. But before long-term change can happen, one thing is certain: people need to care about the poverty in America’s own backyard.

References:

  1. Herath Bandara, S. J., & Brown, C. (2013). An analysis of adult obesity and hypertension in appalachia. Global journal of health science5(3), 127–138. doi:10.5539/gjhs.v5n3p127