In the heart of the world's only superpower, the poor queue from 3am to see a doctor, writes Denis Stauntonin Virginia
It was only 11am, but it had already been a long day for Shawn Stanley (22) and his wife Stephanie, who had been queuing since 3am for the only medical care they would get all year. There were still a few dozen patients ahead of Shawn, who was perched on a bench in a narrow corridor at the River View Middle School in the Appalachian town of Grundy.
"I got my back wisdom teeth coming on and it hurts bad," he says. "It gets so bad I couldn't sleep." Stephanie has been taking antibiotics for an abscess tooth but the Stanleys decided to endure the pain until now rather than paying up to $1,000 (€700), which is what a regular dentist would charge them.
"We've just had a new baby and we've got to take care of him," Stephanie says.
The Stanleys were among more than 1,000 people who came to the Grundy school for an annual, two-day clinic run by the Remote Area Medical foundation (Ram), a group based in Knoxville, Tennessee, that offers free health care to the rural poor.
When full-time volunteer Ron Brewer opened the doors at 6.30am, there were already almost 300 people waiting outside."These folks today are getting top-of-the-line care," he says, pointing to 40 dental chairs set up in the school assembly hall. "Here in the Appalachian area, you need it. It's got to be happening or people go without."
At the school entrance, a notice explains the purpose of the clinic and urges the better-off to avoid taking the place of someone in need. "These services are provided strictly for the unemployed, uninsured and other needy families, children and adults who cannot afford to pay for medical, dental and eye services. WE CANNOT TREAT EVERYONE. If you are not in need, please do not ask for services," reads the sign.
Brewer says the volunteers never ask anyone about their financial situation but, as he points to the throng of pale, cheaply dressed patients, he says there is no doubt that they need help. "A majority are unemployed or disabled. These folks have a bad need," he says.
AS MICHAEL MOORE highlights in Sicko, which opened in Ireland yesterday, more than 45 million Americans have no health insurance, while many more are underinsured by policies that oblige patients to pay hefty "co-pays", or charges, every time they seek medical treatment. The rural poor in the Appalachians are especially hard hit, but here in Virginia's Buchanan County, where almost one in four of the population lives below the poverty line, there is not a single full-time free health clinic.
"I just saw a gentleman who had retinal surgery. He never got glasses afterwards because he didn't have insurance," says Victoria Weiss, a doctor from Charlottesville who is conducting eye tests in a classroom. "I had done a lot of this work in Nicaragua. It's really scarily similar. That's the sad part."
Next door, a lady called Jean holds up a pair of large, tinted glasses held together by electrical tape. "These glasses are 17 years old," she says as she chooses new frames from a selection laid out on a table. The frames are 2006 designs donated by firms such as Wal-Mart and Target, but Ram conducts the eye tests, fits the frames and provides the lenses, producing hundreds of pairs of glasses in a mobile unit parked outside the school.
"Every time, you've got someone who's had no glasses for five or 10 years and they're on a super-high prescription," Brewer says.
Most of the patients in Grundy come for vision or dental care, but many also take advantage of the general medical services on offer, including flu shots, blood sugar testing, mammograms, smears and blood pressure testing.
Leslie Shephard (25) had taken her mother, father and sister to the Ram clinic in previous years but this time she was here on her own behalf. "I had lab work done for a Carpal Tunnel problem. I didn't know I had a problem with gall bladder but I have a tendency to have high blood pressure. I've had a pain in my stomach for the past week," she says.
Shepherd occasionally sees a doctor at a clinic a few miles away that operates a sliding scale of fees but she says that the annual Ram clinic is essential for people like her. "When you're uninsured, it's pretty important," she says. "Most likely, I wouldn't be able to get it done."
FOUNDED IN 1985, Ram was conceived by Briton Stan Brock, who spent 15 years living among the Wapishana Indians in Guyana, living 28 days away from the nearest doctor. After he was thrown from a horse and had to make the long trek to the doctor in agonising pain, Brock decided to organise a group of medical volunteers to bring health care to remote parts of Guyana.
After the country achieved independence from Britain in the late 1960s, foreign medical volunteers were unable to operate there until the early 1990s and Brock, who had moved to Tennessee, saw a need closer to home.
"Because we weren't allowed to go there, we discovered that there were people here who didn't have access to health care," he says.
Brock has received numerous requests to take Ram clinics to some of America's big cities, and the group has been in New Orleans a number of times since Hurricane Katrina. Restrictions on doctors practising across state lines make operations outside the Appalachians bureaucratically complicated, however. "The other limiting factor is the money. The reason we have no money in this organisation is my fault because I'm the world's worst fundraiser. I don't like asking people for money," Brock says. "We've become so good at doing it without money that nobody gives us any money."
When RAM runs a clinic, the group provides medical volunteers and supplies, but local authorities or volunteers take care of accommodation and food for the volunteers and patients. "They also help us to recruit area doctors," Brock says. "That's very difficult. They'd prefer to be on the golf course."
Many doctors who are willing to travel far away to offer free services are reluctant to volunteer close to home, fearing that potential paying patients will decide to take free treatment - a fear Brock says is groundless. "The people who are prepared to stand in line for eight to 10 hours are not going to go to your office anyway because they can't afford it," he says.
Few of the patients in Grundy were children, partly because poor children can receive free medical care under a federal programme that Democrats want to expand, a move that President George Bush vetoed this month.
Although Ram has run its clinics for more than 20 years, very few Americans know about it, and Brock says that the only people aware of their work are those who benefit from it. "Right in our home town of Knoxville, if I do a talk, invariably nobody has ever heard of what we do. But the poor know about it," he says. "The poor folks appreciate what you do for them."
The biggest event Ram runs each year is an open-air clinic in Wise, Virginia, which attracts up to 20,000 people over two days. Earlier this year, Democratic presidential candidate John Edwards met a 51-year-old former coalminer who had lived with a cleft palate all his life and had never spoken until oral surgeons from Ram treated him.
Local volunteer Sandy Stilner says that, despite its poverty and the loss of many coalmining jobs in recent years, Buchanan County is a strong community.
"I've been here all my life," she says. "This is home. People who live here love it. They have the country feeling. In Buchanan County, everyone loves everyone. We don't shake hands, we hug."
But as she hands out sandwiches to patients while a bluegrass band helps to make the long waiting time pass more quickly, Stilner admits that she is often shocked by the level of deprivation in the heart of the richest country in the world.
"You don't have to go to Costa Rica," she says. "You don't have to go to Africa. You've got your mission right here in your home town."