Pulling teeth in Appalachia
The patients gathered before an Appalachian sunrise. Some had traveled from nearby states and slept in cars at the muddied fairgrounds. Others came on foot from miles away.
All had unmet medical needs — and the most urgent was dental.
On this morning, they were willing to suffer a little bit longer, if it meant some relief from their pain at the sprawling clinic rising here.
Founded in 1985, Remote Area Medical — known as RAM — is an all-volunteer organization that provides free health care to some of the most remote and medically underserved areas in the United States and the world. It offers a portfolio of health care services, including dental care, and all its events are supported through donations or partnerships with other charitable organizations.
The care was free for the 2,292 patients seen over the course of three days. The medical equivalent of winning the lottery in a region where health care is often a gamble and dental care is often out of reach. This time, few were turned away.
“It doesn’t matter where it is in the United States — it can be California or it can be here — 65 percent of the patients that walk through the door are for dental care,” RAM founder Stan Brock said during an interview with POLITICO. “And about the same percentage are here for vision and eyeglasses. In other words, they need both.”
But both they can’t have, at least not during the same three-day event now in its 14th year in Wise County. They must pick, and about half, more than 1,000, elect for dental care. In the future, some may have many of their health care needs taken care of under the new health law — although some could still be left out if they live in states that aren’t choosing to expand Medicaid to low-income adults.
But conversations with several of the waiting patients here indicated they didn’t know too much about the president’s health law, the Affordable Care Act, or what it might mean for them and their families. But for those here with toothaches, it may not make much of a difference. The new health law may cover a lot of services, but most adult dental care won’t be part of it.
As the gates opened precisely at 5:30 a.m., the crowd filtered in according to pre-assigned numbers. The grounds cultivated for vegetables and livestock were transformed into a military-style surgical hospital, complete with a small army of surgeons, physicians and volunteers. Open-sided tents protected dozens of dental chairs placed neatly in rows. PVC pipe snaking along the edge of tents and tarp-lined shelter carried the mixed remains of cleanser, spit and blood. The smell of antiseptic — not farm — filled the morning air. Nervous student volunteers insist it is a sterile enough environment.
The waiting patients, many clearly in pain, did not seem to notice the austere conditions. By the end of the three days, 3,926 adult teeth would be extracted, and an additional 70 from children. Some 1,635 cavities would be filled. As patients walked away, relieved of pain, their smiles pierced through mouths crammed with bloodstained gauze.
“All these years later, people are still losing teeth in these mountains,” said Carole Pratt, a volunteer dentist for Mission of Mercy, which partners with RAM here at Wise.
“I would have loved to have seen the Affordable Care Act include dentistry for adults, but it didn’t,” said Pratt. And state cutbacks mean public health dentists are vanishing across the country. Pratt said that 70 dental chairs are going unused not far from Wise County Fairgrounds because public dentists are not available to provide needed care.
“Charity is not a solution long term,” said American Dental Association President Robert Faiella, who was volunteering at the fairgrounds. But charity is what many dentists offer, pro bono care without state reimbursement, he said. “Most dentists do it silently because they feel the need to do the right thing,” Faiella said.
It isn’t only dentists volunteering. Sen. Tim Kaine (D-Va.) was on hand, helping register patients and chatting with them. They may only know that their teeth hurt; he knows the policy gaps that make their problems hard to solve.
“Even if you expand Medicaid for medical care dentistry access, the number of dentists we train, the number of dentists that are in communities like this, it’s not enough,” Kaine said. “So we ought to be looking at reforms to Medicaid to expand dentistry, and we ought to be training more dentists.”
A few bills have been introduced to enhance access to dental care. Given the gridlock in Congress and the divisiveness around the health law, it’s unlikely anything will change in the near future.
But, for now, Brock has stepped up to fill this unmet need at his U.S. clinics. Brock is a fit 77 years old with energy twice that of many of the younger volunteers. He expertly commands his organization with a gentle voice, thick with a British accent. A nearby volunteer and former U.S. Army officer quips, “There are no colonels in Stan’s army, just privates.”
Brock also serves as chief advocate against anything that stands in the way of his mission. He has testified before Congress twice. He has invited lawmakers to visit these mammoth moving clinics, although only a dozen or so have taken him up on the offer. One big obstacle he cites is state-enacted legal barriers against doctors providing free care across state lines.
“We just want access,” Brock said. “We’ve tested this in 700 expeditions. If you let doctors cross state lines, you’re going to be able to see many, many more patients. And … it’s at no cost to the government or the taxpayer. So why not let them do it?”
Only 10 states — Virginia, California, Colorado, Connecticut, Illinois, Missouri, Nevada, North Carolina, Oklahoma and Tennessee — have enacted laws that provide a path for doctors to volunteer their services across states lines. At Wise, doctors from Illinois, New York and elsewhere travel on their own dime to come here to care for the people of Appalachia.
Kaine’s office was open to talking to Brock about how Congress might help. Brock also had a chance to discuss the matter with Rep. Morgan Griffith (R-Va.), who represents the Wise County area in Congress and who visited the RAM site.
While legislation moves at barely a slow crawl in Washington, RAM made a difference immediately — as Virginia resident Earl Compton can attest.
Compton was hit in the mouth while traveling with a carnival years ago. The injury knocked loose a tooth and started a chain reaction of gradual tooth decay. Weary of pain, with no access to dental care at the time, Compton tried to solve the problem himself, attacking the painful tooth with a pair of pliers.
“Just get mad and jerk it real quick,” he said. “If you hurt bad enough, you’ll pull ’em.”
Compton would repeat that painful process several times. Eight years ago, he started coming to RAM clinics. After years of pro bono care, Compton finally received a full set of dentures. Thanks to the volunteers at the muddy fairground, he could once again bite into an apple.
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