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Hidden Hurt: Desperate for medical care, the uninsured flock by the hundreds to a remote corner of Virginia for the chance to see a doctor

Smiddy is studying the X-ray of a patient he just saw. The man's lungs are spotted with granulomas, small areas of inflammation that are benign but can resemble cancer. With its high concentration of major lung diseases, often only recognized in late stages, this region is known as a lung belt. "We're in a lung belt because of the coal work and smoking," says Smiddy, "and histoplasmosis, a soil fungus that causes lung disease." Histoplasmosis is a common cause of granulomas.

The state of health in the region has been historically dismal, with cancers, tuberculosis, black lung and mining accidents. The coal camps had small clinics, though. And mine workers got medical coverage through the United Mine Workers of America.

Then, in 1988, a turn of events rocked the little coal towns through this region. The United Mine Workers contract with the Pittston Coal Co. expired, and widows, pensioners and disabled miners were informed that the company would no longer contribute to their health insurance. The miners' ensuing strike against Pittston and its subsidiaries enveloped southwest Virginia in one of the most searing labor confrontations of the latter 20th century. Hundreds of miners and their families were arrested in sit-down protests and blockades.

During the Pittston Coal strike, Kenny, in her Health Wagon, provided care to the miners whose benefits had lapsed. She was arrested and jailed. "The charges were impeding traffic and giving health care in an unorthodox manner," she recalls. On Kenny's day in court, a group of supporters stood up and sang "Amazing Grace." The charges were dismissed, Kenny says.

The benefits were eventually restored. But the memory of Pittston -- and the impact that the sudden loss of health-care benefits can have on a community -- lingers. It's an impact shared by an increasing number of Americans as companies attempt to control costs by reducing or eliminating health-care coverage.

The number of uninsured Americans has climbed by 12 million since 1990, according to a 2007 report from the U.S. Census Bureau. The number of underinsured Americans has risen 60 percent since 2003, according to the Commonwealth Fund. Those who are uninsured or underinsured can't afford a catastrophic illness or even visits to the dentist or eye doctor, Stan Brock told a congressional subcommittee exploring the nation's health-care crisis in April.

"We could fix this problem," Brock says. "It's just a question of priority."

It's Friday afternoon, and the mammogram van is doing a brisk business. As with the chest X-rays, about one-third of the mammograms done here reveal something that requires further testing.

"Getting each patient to follow-up care is so individually difficult; it can be a real thrash," says Dalton. "It's case by case, and it involves the U-Va. social workers, the Health Wagon nurses and the local health department often scrounging resources locally and just persisting with the patients."

One year, three women from one town all had suspicious lumps in their breasts, but the volunteers could not find a local radiologist who would see them for the follow-up exams.

"We finally scraped up enough money to get them to Charlottesville, but they were so far from home, and it was hard on them," says Dalton. Two had cancer and underwent lumpectomies.

Linda Yates decides she should get a mammogram. "My grandmother died of breast cancer," she tells the volunteer adding to her medical chart outside the van.

"When was your last breast exam by a doctor?"

"Eighteen years ago."

"How many pregnancies?"


"How many children?"


The volunteer looks up, puzzled. Some are adopted, Yates explains.

"Are you pregnant?"

"Not so far this morning," the grandmother answers with a chuckle.

Yates spends 12 hours waiting in various lines, getting tests that would have cost thousands of dollars if she were paying for them. When she emerges from the medical barn, it is 6 p.m., and the clinic is closing down for the day. Her husband, Lonnie, her sweetheart since high school, finds her in the crowd.

"Were you worried about me?" she asks him with a smile.

"I haven't seen you since 6 a.m."

"Well, you couldn't have found me," she says. "It was a whole different world back there."

In the half light of Saturday morning, it all begins again, with about 1,000 people waiting at the fairground gates.

Though smoking is forbidden inside the field hospital, many patients are smoking while they wait outside. Along with obesity, smoking is termed a major behavioral risk factor in the area. About 30 percent of adults in the area smoke. Even many of the very poor spend the little money they have on cigarettes. They often started smoking as children.

Patricia Pleasant, 47, from Lee County, Va., is one of them. "I started at 9, rolling for my father," she says between drags. Disabled by a nervous condition, she says, she smokes to try to calm herself. "If I get nervous or anything, I smoke."

"Nerves" are a recurring complaint in this region, according to research by the Southwest Virginia Graduate Medical Education Consortium, based at U-Va.'s College at Wise. "A frequently reported cause of nerves was having too many problems and few solutions," the report observed. According to the consortium, residents of the region are 70 percent more likely to commit suicide than those elsewhere in the state.

Saturday afternoon is hot, and people are getting tired and testy. A brief argument breaks out in one tent over a place in line. Out in the parking lot, a stout woman pauses, then slowly crumples to the earth. Three medics hurry over. One plucks a burning cigarette from between the fingers of the prone woman. Every year, there are "downers," people who collapse from fatigue, hunger, illness. The volunteers gently revive the woman and administer first aid.

In an oral surgery trailer, Melanie Locke, a 31-year-old school custodian from Martinsburg, W.V., gets to smile normally for the first time in her life. She is speechless as she studies herself in a mirror.

She was born with a cleft palate. As a child, she received a series of operations to correct the condition. But as an adult, she has not been able to get proper dental care because of the complexities of her case and her family's lack of insurance.

"We had a tooth pulled once, and it was more than I make in two weeks," says her husband, Kevin Kilmer, a carpenter.

Charlottesville dentist Michael Clark and Roanoke dental technician Greg Gray took Locke's case at one of Brock's clinics in West Virginia, extracting her diseased teeth and tackling the challenging job of designing custom dentures to fit her mouth. The care would have cost thousands of dollars. She and her husband have come to the Wise clinic for the final fitting.

"This is like waking up in heaven" says Kilmer, taking in his wife's smile. She has suffered so much pain and worry, he says. "This is going to change her life."

Yates is also back. Her face is alight as she picks up a small package from the pharmacy tent. "I don't have to take the insulin anymore," she announces. A diabetes specialist has prescribed a medicine that stimulates the pancreas. Yates gets a starter supply from the clinic. In the coming weeks, the Health Wagon will locate more free samples for her. Yates knows the medicine is expensive, but Teresa Gardner won't tell her exactly how much it costs. "I guess she doesn't want to shock me."

Yates's mammogram reveals a possible problem, however. The Health Wagon will work with a Virginia program called Every Woman's Life, which helps provide eligible women with screening and follow-up care for breast and cervical cancer.

Yates's daughter Connie Skeens, 40, is also here today. She's a tall, coltish blonde. "Dad says it takes somebody graceful to be as gawky as I am," Skeens says with a wry smile.

When her health was better, she worked as a waitress. Now she often helps her mother with the foster and day-care children. Skeens has been battling diabetes since she was a little girl. Her parents were told she would probably die young.

"Love her while you can," Skeens said the doctor told them. With vigilance, she has survived, though diabetes has not been easy. She lives daily with dry mouth and confusion, as her blood sugar rises and falls. "It's something I wouldn't wish on my worst enemy," says Skeens.

For eight years, she escaped her troubles through addiction. "I'm a recovering oxycontin addict," she says. "It's a painkiller. They call it the poor man's heroin."

She started taking the medication, like many people in this region, after a doctor recommended it for back pain. She couldn't stop. "Eight years of using and selling," she recalls.

Her parents agonized. They tried to help her stop, but without success. "The way it makes you feel when you are using," says Skeens, "it just makes you giddy."

She finally overcame the addiction in a halfway house after serving 11 months in the local detention center for using her parents' credit card to support her drug habit. "We had to press charges," recalls her mother, the pain audible in her voice. For awhile, Skeens was furious with her parents, but now she is grateful.

Yet she still speaks about "the OC" with a touch of nostalgia, describing the little round pills and the colors that indicate their strength in milligrams:

"The 10s are white.

"The 20s are pink.

"The 40s are gold.

"The 80s are green.

"They had the 160s . . . That was the prettiest blue I have ever seen in my life," she says, "just about the color of that guy's scrubs over there."

Today, her teeth, which have long troubled her, are infected. And her kidneys are infected, she suspects, the infection perhaps spreading from her teeth. She registers at the dental tent and gets a plastic orange bracelet that bears the word "extraction."

She also needs an eye exam, but her blood sugar plays havoc with her plans. She can't have an eye exam until she can get her blood sugar into the normal range. "It's going to be one of those days," she sighs. The volunteers send her to lie down in the medical barn.

A tiny sliver of moon hangs in the dark sky. Then the fog lifts up from the hills, and the long sheets of white paper are lifted from the instruments in the blue dental tent.

It's Sunday morning. Everyone is tired.

In the medical barn, Ross Isaacs, a Charlottesville nephrologist, is still seeing patients, and marveling at the depths of the troubles here. "There are 20 million diabetics in this country. That's about 9 percent of the population. In southwest Virginia, in this clinic, it's 50 percent.

"Then there's hypertension. Fifty million cases in the United States -- about 18 percent. At this clinic in Wise, it's 70 percent."

So much need, so little time.

Meanwhile, Connie Skeens, terrified of the ordeal, gets her 22 remaining teeth, all infected, extracted. Richmond oral surgeon Kimberly Swanson is reassuring as she goes about the difficult work. "You'll never have to do this again -- does that help?" Swanson asks her. "I hope you get some teeth fast."

Skeens steps out into the Sunday sunlight gripping bloody gauze between her gums. She is put on a waiting list to get free dentures next year, when the clinic returns to Wise. She'll have to eat soft food until then.

Meanwhile, this year's clinic is winding down. All over the fairgrounds, volunteers are busy packing up. It's nearly noon, and 2,670 people have received medical treatment worth more than $1.7 million. Hundreds of tests have been administered. More than 1,000 pairs of eyeglasses have been made. More than 4,000 teeth have been extracted.

In the medical barn, medical students are taking down the sheets that divided the examination rooms. Cardiologist Bill Harris, the son of a coal miner, pauses from his work to consider the gap between his own life and those of the patients here. "I'll go home in a nice car," says Harris, who lives in Pikeville, Ky., "and have a glass of chardonnay." The people he cared for will drive winding roads back to hard lives. Harris won't be able to see their pain, but he won't be able to forget it, either.

Mary Otto is a former Washington Post staff writer who is now editor in chief of Street Sense, a biweekly D.C. newspaper largely produced and sold by the homeless and formerly homeless. She can be reached at

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