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. (Article continued below...)
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.
Peter Cunningham, a researcher with the Center for Studying Health System Change in Washington, D.C., agrees: "Yes, in Appalachia, the need is extreme, but this isn't just an isolated problem. This is just where all our national health-care problems converge: high cost, lack of access. This is where the most number of people fall through the cracks." According to a recent study he coauthored, about 20 percent of all Americans reported not getting or delaying needed medical care in the previous 12 months, up from 14 percent in 2003.
Cunningham says that for Medicaid patients, including 29 million children, the dental benefit is really a "phantom" benefit because of the challenge of finding a dentist who will accept Medicaid's low reimbursement rates. The problem is worse in rural areas, where there are too few dentists to begin with.
Governor Kaine points to the fact that two thirds of the 46 million uninsured in the United States have jobs but can't afford health insurance. "This is a matter of political will," he says. "Other nations have a lower GDP than we do, and they've made a political decision that their people are going to have health coverage, but we keep deciding not to."
"We like to believe that everyone can get the care they need," says Diane Rowland, executive vice president of the Kaiser Family Foundation. "But people who are low-income, work hard and don't have coverage through a job have to make harsh economic choices about their health care. That might be to have a tooth pulled instead of getting a crown. Or to go without care at all."
Kaine has gotten funding to set up a small satellite program of the Virginia Commonwealth University Dental School in Wise to serve some of the community year-round. Other programs, such as Save the Children, are setting up nutrition, exercise and health-education programs in schools that they hope will help improve both dental and overall health.
The Virginia Dental Association's Dickinson says that education of the next generation is key in changing the culture in this part of Virginia, where knowledge about dental care and nutrition is poor. The dire dental situation among the low-income populations of southwest Virginia, and parts of Kentucky and West Virginia, is emblematic of the larger health-care crisis—the region has higher rates of tooth loss than almost anywhere in the United States. (Nationally, 108 million people don't have dental insurance.)
"The diet here, which is high in processed, sugary foods because they're cheaper, promotes decay. And when your teeth hurt, you aren't going to be eating salads," he says. "And now we know that there's a suggested link between all kinds of systemic diseases from diabetes to heart disease and oral cancer and the bacteria in the mouth. It's a cascading effect."
Sheila Fowler and her daughter bear out Dickinson's emphasis on education. Martha Hopkins, like her mother, believes teeth are mostly a source of trouble and pain. She wasn't able to have all her teeth removed this year but will come back again next year, she says. Her mom, who wasn't one of the lucky 30 to get dentures fitted, explains why she thinks spending money on your teeth is a bad idea: "I had to have fillings when I was a kid, and that's the worst thing you ever did to your teeth. I really believe that. I'd never have fillings put in my teeth if I knew what I know now. Because when those fillings fall out, stuff gets in there and rots those teeth, and then you have to get them pulled anyway. When they see it, they ought to pull it instead of fooling with it.
"For Dickinson, the philosophical battle will have to come another day. For now, he's thinking about all the patients he had to send home without care on Sunday, the last day of the RAM expedition: "I had to go to the stands, where there were hundreds of people still waiting, and say we could only take 20 more. They rushed me with questions and showed me their teeth. I said they'd have to come see us in October when we go to Grundy, Va.
"In the meantime, he believes many of the patients who were turned away will have to make due with visits to the E.R. for tooth pain, where they'll likely be given antibiotics and a pain pill and sent home. "That'll only calm it down for a couple of weeks. It'll come back," he says.
Thankfully, so will RAM.
How to Help
If you'd like to contribute to or volunteer with the Remote Area Medical Foundation go to their Web site.
To volunteer or contribute to The Health Wagon, whose small staff brings health care to the people of Appalachia all year round, and who will be helping some of this year's RAM patients get follow-up treatment for urgent conditions, go to their Web site.
And, to help with education, nutrition and physical activity programs that help impoverished children in rural communities throughout the United States, go the Save the Children U.S.A. Web site.
To help Mission of Mercy, a nonprofit organization that provides free dental care to underserved populations in Virginia and West Virginia, go to the Virginia Dental Association's Web site and scroll to the bottom of the page for donation and volunteering information.