By Chelsea Jack
The annual Remote Area Medical (RAM) clinic at the Wise County Fairgrounds in southwest Virginia has become a sensational representation of the health disparities in America that have built up over the past two decades. Each year, health and policy journalists try to capture the spirit of the event by detailing the desperate patients waiting in fairground horse rings or sleeping out in pickup-truck beds to receive needed medical care — and their grim descriptions aren’t overblown. RAM offers a gut-wrenching sight of what rural poverty and inadequate health coverage still look like in many parts of America. The 17th annual Wise County RAM clinic took place this past July, and on opening day, the clinic took in its daily maximum of 1,600 patients in need of its free medical, dental, and vision health-care services.
As a medical anthropologist, I have attended and followed media coverage of the Wise County clinic since 2012, when the Supreme Court upheld parts of the Affordable Care Act. My interest was heightened once the Virginia General Assembly defeated Medicaid expansion shortly thereafter, a legislative decision that’s been upheld in the years since — and has cost my home state billions in federal funds.
Not only do I study Appalachian health and well-being, but I myself am a “mountain millennial,” concerned when the same headlines appear each year and nothing seems to change. “At a huge free medical clinic in Southwest Virginia, misery that shouldn’t exist,” declared the Washington Post in 2014. Two years later, the same paper came to the very same conclusion: “Return of RAM: Another year without health care for Virginians.” These headlines appear each year at the opening of the clinic, and then, unfortunately, media attention turns elsewhere until the next Wise clinic the following year.
Somewhat bizarrely, last year’s media coverage of the Wise County clinic was dominated by the first U.S. government-approved drone delivery. On the opening day of the weekend-long clinic, an unmanned drone flying from Lonesome Pine Airport delivered 4.5 kilograms of medical supplies to the fairgrounds. The three-minute flight test was meant to demonstrate drone delivery and drop-in capabilities in hard-to-reach areas.
Paramilitary theater aside — and this does seem to have been theater, as serviceable, albeit windy, state roads offer direct access to the clinic site — the drone delivery serves as an unintended yet apt metaphor. The use of such a delivery method is a deeply ironic demonstration of government technologies and resources in an area fighting infrastructural needs unmet by the state.
A nongovernmental organization like RAM prioritizes the provision of immediate care to suffering patients, much as a MASH, or mobile army surgical hospital, unit does. The organization flies in, offers as much free care as possible by utilizing volunteer health professionals, and then flies out. RAM espouses the prevention of pain and the alleviation of suffering among the poor and underserved, and it fulfills this goal in the short run by providing new eyeglasses for people, pulling rotten teeth, and offering preventive screenings.
RAM has served as a stopgap solution for the suffering of those with low access to health care in regions like central Appalachia, but it has not primarily tackled barriers to access. It has never claimed or promised to be devoted to building public health infrastructure by recruiting and training health workers in the communities that it serves. But operating this way admittedly leaves the organization open to a slight criticism: RAM aims to serve patients suffering from systemic inequities, but the organization doesn’t actually allocate resources in a way that facilitates the amelioration of those inequities.
Because it’s a roaming medical clinic, RAM cannot always adequately treat patients with chronic conditions, even though the regions they serve, like central Appalachia, are disproportionately plagued by chronic conditions like diabetes and obesity. One RAM patient, whom I’ll call Jolene, attended the 2015 Wise County clinic. She has suffered from hypothyroidism for over two decades. Uninsured and unemployed without a steady income, she has not been able to consistently afford her thyroid medication or routinely have her condition monitored. For several years she has relied on the medical services offered at the Wise County clinic to obtain medication and to receive current medical information about her condition.
But what does someone like Jolene do to stay on top of her condition for the other 364 days of the year? Hypothyroidism is just one of many chronic conditions that require routine monitoring by a health professional to appropriately adjust the patient’s medication in accordance with his or her response to it. Even if while attending the clinic Jolene received a referral for a pro bono appointment for needed specialty care, that referral cannot serve as a long-term plan for her continued care.
Organizations like RAM serve patients who warrant follow-up care without offering a clear, long-term solution: How can a diabetic with no other access to care manage their diabetes at a RAM clinic once a year? How can a physician help someone suffering from high blood pressure when the physician has only a single snapshot of the patient’s health?
Given the stagnancy that has characterized Medicaid expansion efforts across some central Appalachian states, like Virginia, which has rejected expansion three times, it is unlikely that the needs of RAM patients will change. It is the responsibility of the state to recognize when selfless, extraordinary people have filled a vacuum created by poor governance and respond. RAM has operated with the aim of alleviating immediate physical suffering while awaiting systematic transformation in the surrounding health-care landscape, but if a real dent in the suffering of the patients arriving at RAM’s clinics is to be had, then there needs to be some change in these patients’ access to routine continual care.
There are, to be clear, some real advantages to drop-in aid, and it can sometimes facilitate long-term, positive impacts on patient well-being. In the context of vaccination campaigns, for example, aid workers can drop into a variety of contexts, deliver vaccines, and thereby promote positive long-term health outcomes. However, dropping into southwest Virginia to temporarily relieve a patient presenting with periodontal disease will not necessarily generate a long-term impact on that patient’s ability to navigate rural poverty and the poor health outcomes determined by such poverty.
Globally, organizations like the Academic Model for the Prevention and Treatment of HIV (AMPATH) and Partners in Health (PIH) have collaborated with public health ministries to build infrastructure. These organizations recruit, hire, and train local health providers and engage community members committed to long-term transformation of the health-care landscape. By adopting this kind of approach, the realization of positive and sustainable changes enables these organizations to slowly withdraw from the communities that they serve.
RAM, however, hasn’t been able to withdraw and has become a proxy health-care system serving patients’ continuum of health needs in southwest Virginia. That isn’t sustainable. The reality, as Virginia Governor Terry McAuliffe opined in the Roanoke Times last summer, is that it’s the responsibility of the state and its citizens to choose pathways toward infrastructure building and sustainability. It’s unclear in Virginia what those pathways will be, since the House and Senate failed to support McAuliffe’s push to expand Medicaid for the third year in a row.
Virginia should feel good about a small, albeit effective and noble, group of volunteers dropping in annually to help those who feel abandoned. There are social and political sources behind the suffering of those like RAM patients.
“I feel like we’re living at the bottom of the Earth,” a man told me at the 2014 Wise clinic as he sat with his wife waiting to have an abscessed tooth examined.
I often wonder what patients at the Wise clinic thought of the 2015 drone delivery. Could the painful irony have been lost on anyone there? Patients trust RAM because the organization, though roaming, has returned for 17 years to meet some of the health needs in central Appalachia — the same cannot be said for the government. Underserved people in Virginia and Tennessee cannot afford to have their health needs primarily met by sporadic drop-in aid. Their situation is too dire, and the state’s ability to selectively wrangle resources when it serves a politically advantageous purpose is too obvious.