Doctors Within Borders

Sheila Fowler is 43. She has short brown hair, a soft, girlish voice and three grandchildren. What she does not have is teeth, or a way to pay for dentures. But Fowler is stoic; she jokes that she's got tough gums, adding that she can even eat pretzels if she sucks on them for a bit.

Fowler has made the hourlong journey from her home in Cleveland, Va., to the small town of Wise to take advantage of a huge annual medical and dental expedition set up by Remote Area Medical, a nonprofit organization that provides basic medical and dental care to people in the world's most inaccessible regions. This year, more than 1,800 volunteer doctors, dentists, nurses and assistants descended on the small town near the Kentucky border, setting up enormous field-hospital-style tents in which they saw roughly 2,500 patients over the course of two and a half days in late July. The Wise operation is coordinated locally by a team of nurses with the Health Wagon, a tiny health-care outreach program.

By the end of the weekend, the medical team, had extracted 3,857 painfully decayed teeth, administered 156 mammograms, screened hundreds of people for diabetes and heart disease, and given out 1,003 pairs of eyeglasses. About 30 people, chosen by lottery, were fitted for free dentures. Hundreds of people were turned away by volunteers who headed off cars at the main intersection when the clinic reached capacity.

RAM events such as the one in Wise—the Knoxville, Tenn.-based group runs about 15 similar clinics around the world every year, from Guyana to East Africa and rural parts of Appalachia—underscore the health-care dilemmas of the poorest Americans. Fowler's case is a prime example: She has almost no income after an auto accident left her unable to do her restaurant job. She's covered by the state Medicaid program, but Medicaid doesn't cover any preventive or routine dental care for adults. It will pay for emergency extractions, but, for Fowler, as for
many others in areas where dentists are scarce, finding one that will take Medicaid payments isn't easy. That's why she came to Wise in 2003 to have her teeth pulled for free.

When she got her lower teeth out, volunteer dentists told Fowler that she had a few that could be saved, but she begged them to take every single one. "I said, 'Do it now while I'm here so that a week from now, after you're all gone, I don't have an infected tooth'," she remembers.

She has come back to Wise this year to see if she can get dentures and have some questions answered about diabetes, which she suffers from, along with arthritis from the auto accident. It's a hot Thursday evening, and the clinic, which is held at the county fairgrounds, won't open till the next morning. But Fowler, her 28-year-old daughter and her daughter's husband, both of whom say they also urgently need painful teeth pulled, are camping to be sure they get a good spot in line.

They aren't the only ones. By 8 p.m. on Thursday, the parking lot is jammed with people hoping to be among the lucky patients who make it in to see the volunteer medical staff. At least 200 are turned away. Those who have gotten there early enough have their numbered blue admission tickets in hand. They don't even flinch when they're told that they're in for yet another six-hour wait.

"We see people waiting in those long lines, and I simply don't know how they tolerate the pain they must be in because of infection and bleeding in their mouth," says Terry Dickinson, executive director of the Virginia Dental Association. And, says Dickinson, patients still are amazed that they don't have to pay for their care here: "I told a young lady here that we could remove her teeth, she was in her 20s, and she just started crying. 'You mean, I don't have to pay for that?' she asked."

Virginia's governor, Tim Kaine, visited this year's RAM expedition with five of his staff members on its first and busiest day and met patients like these as he worked the lines of people waiting for care. Later he said that he finds the event "both depressing and inspiring at the same time." Southwest Virginia's coal-mining region lags behind much of the rest of the country and the state in health care—residents have vastly higher rates of diabetes, obesity and lung disease and lower income levels than the rest of Virginia—but Kaine says that the need for more comprehensive care goes far beyond these rural communities, and his is not the only state facing the double bind of a tightening economy and increasing health-care costs.