Washington Post Magazine: Hidden Hurt
The Remote Area Medical Volunteer Corps Visits Virginia

Mary Otto, Stan Brock and Jean Jolly
Magazine Contributor, RAM Founder and RAM Volunteer Coordinator
Monday, November 10, 2008 12:00 PM

The Remote Area Medical Volunteer Corps brings doctors to impoverished communities around the developing world -- and right here in the United States. Every year, they conduct a three-day free clinic in rural Wise County, Virginia.

Former Washington Post staff writer Mary Otto was online Monday, November 10 to discuss her Washington Post Magazine story, "Hidden Hurt." She was joined by Stan Brock, founder of the Remote Area Medical Volunteer Corps and Jean Jolly, RAM's volunteer coordinator.

Otto is now editor in chief of Street Sense, a biweekly D.C. newspaper largely written and sold by the homeless and formerly homeless. Brock, the former host of the TV show "Mutual of Omaha's Wild Kingdom," founded RAM in 1985.

A transcript follows.


Mary Otto: Hi there, I'm Mary Otto and I was fortunate enough to have the chance to write about the RAM clinic for the Washington Post magazine. The nation's struggle with health care seems to be a defining story for our times. I look forward to your questions, and thanks sincerely for taking the time to participate.


Stan Brock: Hello, this is Stan Brock. I'm joining this chat line from a tributary of the upper Amazon at a place called Lethem. I am here with a RAM team on a Women's Health program for cervical cancer screening and treatment. Due to our limited internet facilities, I have only seen a portion of the excellent article in the Washington Post by Mary Otto. I would be happy to try and answer some of your questions along with my colleague, RAM Volunteer Coordinator Jean Jolly at RAM headquarters in Knoxville TN.


Stan Brock



Portland, Ore.: Dear Mary, Stan and Jean-

Thank you so much for your work and dedication in sharing this information. It is invaluable. This area of Virginia is often neglected and has been neglected for quite some time. One of my goals actually entails providing equal access to care. I am from Virginia and obtained my MPH at MCV and recently finished my naturopathic medical degree in Portland, Ore. at NCNM. I am in my first year of residency and feel my heart being pulled to this area of Virginia. I as well as other naturopathic physicians would like to help in this area at the next RAM project as well as providing long-term medical care in the area. I currently work at a FQHC called Outside In, in Portland, Ore. We serve mostly homeless youth with various medical conditions. We perform minor surgery and prescribe many pharmaceuticals for various acute and chronic illnesses (asthma, STIs, acute infections, diabetes, HTN). We do lifestyle and nutritional counseling to assist individuals in behavioral modification. Some people do not know much about naturopathic medicine/physicians but we work collaboratively and in conjunction with other health professionals. We offer a unique perspective of medical care and we are licensed physicians in 15 states. We are currently working on obtaining licensure within the state of VA so that we can specifically serve SW Virginia. We are waiting to serve this area to provide care for those most needing medical assistance. I know that each of you serve as the voice for many without care and so do I. If you are interested, I think our collaborative efforts, ideas and goals might fuel real change in this area. I think naturopathic medicine can help RAM and more specifically the individuals of Appalachia. It might also be interesting to follow and discuss how MDs, DOs, NDs, DDS, nurses, etc all work together to provide access to those without medical care. It would be inspiring for Virginians, but also other areas throughout the country. Thank you again for your dedication and passion to providing care through RAM. And please let me know how I might best assist in your future efforts.

washingtonpost.com: Note from the producer: I have sent this poster's contact info directly to Jean Jolly, RAM's volunteer coordinator.

Jean Jolly: Thanks so much for your comments. In 2009 during the last full weekend of July, RAM will celebrate its 10th anniversary of holding probably the largest free medical, dental, and vision event in the United States in Wise County, City of Wise, in SW VA. Please contact me at RAM Headquarters and we can discuss how you can best participate in this event.


Shenandoah Valley, Virginia: I am a nurse here in Virginia. How do I get involved with this clinic?

Jean Jolly: Hello -- and thanks for your question! It's easy to get involved. Please contact me at RAM and we can discuss how you can volunteer at one of our two Virginia RAM weekend events. For 2009 the first will be in Wise County in SW VA the last weekend in July, and for Buchannan County in the small town of Grundy VA the second will be the first weekend in October. You can sign up now if you wish. Please see our seb site at www.ramusa.org for contact info.


Ann Arbor, MI: Bless you all for this amazing community service!

What opportunities are there for non-medical volunteers? (I have a Ph.D. in education, but alas no medical training.) How can I find out more about non-medical volunteer opportunities, such as being a line place holder?


Jean Jolly: Hello - and thanks for your question about volunteering! Please contact me and I will provide you with additional information. For contact information, please go to www.ramusa.org or email me at jeanjolly@ramusa.org.


Urban vs. Rural Poverty: Mary, you work with the homeless here in D.C. Can you tell us a little about what problems or advantages they face with getting health care versus the people you saw at the clinic in Virginia?

Mary Otto: That's a great question. The urban poor and homeless of course face big challenges, and life expectancies for the homeless are very low. Still, the people in rural areas such as Western Virginia face enormous challenges urban people don't in that they are living in isolated areas, sometimes hours away from hospitals and doctors who will see them. These people often have very inadequate transportation, and other difficulties getting care.


Cincinnati, Ohio: How do you find your volunteers and is there any training before you go? What professionals do you need the most?

Jean Jolly: Hello Ohio! We hope to be in Cleveland in the Spring of 2009 and we certainly can use you! Professionals that we need the most are ophthalmologists, optometrists, opticians, and optical techs for Vision care -- dentists, dental hygienists, and dental assistants for Dental care -- General Med MDs and Pediatricians for Medical care, Nurses for triage, and support folks to help keep things running smoothly. There is no training beforehand -- the volunteer work is not difficult and is on-the-job. For contact info please go to www.ramusa.org. Or email at ram@ramusa.org. Hope that you volunteer for Cleveland!


Washington, DC: Wow! This was a very powerful story and greatly highlights the current disaster that is our healthcare system.

One of the other things that really stood out to me was also the problems with our education system. So many of the problems that these individuals had were related to un-healthy lifestyles and eating habits. Obviously schools can't do everything but is there any attempt to also influence the school curriculums in this area to include more focus on healthy living and nutrition? Especially with a diabetes rate so high?

Mary Otto: Another sad fact is that bad food is often cheaper and more readily available than nutritious food. Also, in these rural areas, when people get disabled or frail, they are unable to keep up with their gardens or go hunting - two traditional mainstays of nutrition in these places.


Cambridge, Maryland: I am an R.N. with 32+ years of experience in several areas. How do I volunteer to help with this project?

Jean Jolly: Go to our website at www.ramusa.org. lick on "How to Volunteer" (left hand side of the home page.) On that page click on "RAM application." Download it and fill it out. Be sure to fill out the specific domestic clinic that you would like to attend. We will contact you when we are getting ready for that particular RAM clinic.


Burlington, Vermont: Can you make sure a copy of this report, including videos, gets to President-elect Obama's support staff now, while he is compiling his cabinet and circle of advisors? Health Care is a human right - establishing a national health care system should be one of the first priorities of his agenda.

Stan Brock: Passing on the Washington Post article to president-elect Obama would be an excellent idea. Actually several months ago a number of people had contacted both presidential candidates inviting them to the huge RAM medical event in Wise Co. which was the subject of this article. There were thousands of patients and over one thousand medical volunteers at that event. It would have been an ideal opportunity for both candidates to have seen the need and discussed it with those present. Unfortunately, their respective schedules did not allow them to come.

The greatest impediment to RAM's ability to provide this type of free care throughout the United States are the laws that exist in each state that prevent willing Doctors and other medical workers from crossing state lines to provide these much needed services. A change in these laws for charitable purposes would be at no cost to the government or the taxpayer. We changed the law in Tennessee in 1995 and it allows licensed medical practitioners from out of state to provide free care in Tennessee without restriction.


A Reader: Mary Otto, this story is a masterpiece, and I have blogged about it in the hopes of giving it wider exposure.

What you integrated into the story is how critical it is to have professional nurses lead, direct and have professional accountability for nursing care.

Nursing makes a significant contribution to lowering morbidity and mortality and easing suffering, while helping people learn how to make sound health choices.

Nursing is grossly under-represented in health reportage, and your story is a notable exception.

The portrait you paint is the richest and most accurate picture I've seen to date about the state of health care for those who aren't in fully accessible and affordable situations.

Every person who suffers or dies of preventable problems despite using all of their own available resources is OUR failure. Their suffering and deaths are on OUR hands.

Mary Otto: Thanks so much for the kind words. I too was so impressed by the work of these nurses, their dedication and their deep sense of their roots in this community. When I had a chance to spend a couple of days with the Health Wagon ladies about a month before RAM in an effort to get to know the community, people stopped them in restaurants and all along their route, asking questions, getting educated about their health. I think in some places we take advocating for our own health care for granted. But in other places, people are just learning the questions to ask.


Harrisburg, Pa.: Will telehealth and telemedicine help provide access to underserved areas? Could patients be able to show symptoms through web cameras, people monitored by remote devices, etc.? True, there will still be a need for doctors to see patients up close even for periodic reviews, yet not every case needs to see a doctor. Isn't there a good future for telehealth and, if so, how could it best be used?

Jean Jolly: Thanks for this important question! We do use Telemedicine at RAM's largest domestic event each July in Wise VA. Because we move to different areas each month and hold each clinic for a weekend, setting up Telemedicine can be a difficult task. However, as we are invited to return to locations and as we work with our host communities, we would like to see and use more of the benefits which Telemedicine can provide. It certainly can be most useful and perhaps even life-saving for very rural and underserved areas. Being recognized, set up, and used by local communities is the challenge.


Washington, D.C.: One thing that struck me from the article (especially when compared to looking at similar medical problems for the working poor in developing countries) is that most of the pictures showed obese people. How much of a role does obesity play in the health problems of those in Appalachia, and is there anything being done to prevent obesity (and thus hopefully preventing some of the medical problems!)?

Mary Otto: Obesity is a tremendous problem. Many of the doctors, nurses and other experts I interviewed stressed that in many parts of the country, better educated health consumers have been able to learn to take care of themselves, especially when they have access to gyms, etc, money to make good food choices...That isn't always the case in rural places. In addition, disabilities are very common, related to mining, industrial and other accidents... These disabilities can also lead to obesity.


Alexandria, Va.: It's stunning that in there is so much poverty and lack of services in one end of the state of Virginia - and so much wealth on the other. It's like it's a different country or something. Rural poverty seems so much more difficult to combat than urban poverty.

Mary Otto: Mary here. I think you are right. Much of it has to do with the isolation of these areas.


Madison, Wis.: Is this article being sent to President-elect Obama? I'm ashamed of our country for allowing citizens to suffer this way.

Mary Otto: I'm hoping his staff is reading the Post.


Va.: Hello, unfortunately my Post Magazine arrived missing the entire center section... so I only got to read the first and last parts of this compelling story. What kinds of pediatric care do you provide and what do you see as the main challenge for children in this area?

washingtonpost.com: The whole story is available online, with videos and more, so please take a look!

Stan Brock: That is an interesting question. Overseas a medical team of RAM volunteers can expect to see about 43% children. However, in the United States that percentage is less than 6 percent. This means that children under the age of 18 in the US seem to largely be receiving the care they need, while 88% of our patients are 29-65 years of age.

The children we do see at RAM events in the US are generally there to get their teeth taken care of, and get a free pair of eye glasses.


Reston, Va.: Thank you for covering this story. I would have liked a little more information on the patients you profiled, though. A relative with strong opinions seems to think people choose not to have insurance. While I am sure that is true in some cases (i.e., money goes for discretionary items instead of insurance), for many people you profiled, it seems like paying for any form of insurance is simply more than their meager incomes will allow. I hope that health care is one of President Obama's first priorities, despite the economic downturn, because it is shameful that people are going without medical care in a wealthy, developed country.

Mary Otto: Thanks so much for your question. I felt really lucky to have as much space as I did to describe the lives of these patients, but your are right. Maybe it would take a book to provide enough background to fully tell their stories. And you are also right, in the cases of the folks I had a chance to get to know the best, it simply appeared that buying health insurance was out of reach.


So. Md.: I'm just a citizen, lucky to have good health care insurance. I was humbled, to say the least, by your article. Actually, I was SADDENED by your article. To see the number of people lining up, EARLY, to receive the most basic of health care... well, it just should not be the case in THIS COUNTRY. What can people like me do? I'm not a doctor or nurse or dentist... but how can I help????? And I'm serious!

Stan Brock: RAM needs all the volunteers it can get, of all skills - both medical and non-medial alike. For more information see www.ramusa.org


Silver Spring, Md.: Besides Bristol, Va have you been to other parts of the US, such as low income inner cities, to offer your access to health care, or is it mostly in the rural areas of the US where it is needed?

Jean Jolly: Thank you for your thoughtful question. There are underserved and underinsured Americans in every State, city, and rural areas - from coast to coast. We have received calls from many areas throughout the U S asking that we hold a RAM clinic in a particular location. And we would be there -- except for State borders. States have laws which basically say that only health care professionals in that State can provide health care to the citizens of that State. That restricts us from coming in to a State with volunteer doctors, nurses, dentists, Vision specialists and veterinarians. We recruit from all over the US and there are excellent professional health care folks -- medical, dental, vision and vet people -- who want to come and provide free services to people in other States. And it is often quite difficult to recruit enough professionals from the local or regional area that has requested the help. Until those State lines/fences are taken down we cannot go into those areas of the US -- unless we are guaranteed that the local community can recruit the many professionals that are needed to hold a successful RAM clinic. That only too frequently does not happen.


Kensington, Md.: I apologize for posing such a rude political question, but do the people of West Virginia not see ANY connection between the policies of the presidential party they just voted for and the conditions you so eloquently describe in your article? I realize that they also support Democrats for the Senate and House who vote more humanely, but still...

Mary Otto: Mary here. This story was actually about Virginia, not West Virginia. As for folks leanings in the presidential race, I'm not sure if the voting outcomes for the state of Virginia or even the western part of the state provide an accurate reflection of the feelings of the patients at RAM. I did not focus on the presidential race when I was reporting this story, as I was not sure when it would actually be published. But a few people did bring up the need for health care reform and one young man spoke at length about his admiration for Hillary Clinton's plan.


Richmond, Va.: Do the nurses on Health Wagon need help? If so, what and how?

Jean Jolly: The Health Wagon in Clinchco VA may be looking for another FNP to join their group. They also welcome volunteers who can work during the week - M-F. You may call or email -- smhealthwagon@yahoo.com.

They would appreciate hearing from you! And thanks!


Anonymous: Hi, this is Steve Slott, dentist from North Carolina. I know first hand that my good friend Stan Brock and his RAM staff and volunteers are amazing individuals who do remarkable work. I have the utmost admiration for them all. However, I think it is often overlooked in these clinics that the majority of the dental services are the product of the Virginia Dental Association, spearheaded by its Executive Director Dr. Terry Dickinson, which provides the dental volunteers, dental supplies, and major part of the dental equipment, along with the Virginia Commonwealth University School of Dentistry which provides an army of dental students and faculty to provide the dental services which these people so desperately need. Organized dentistry is the driving force behind the Missions of Mercy dental clinics, such as this one in Wise with which RAM partners, that are occuring across the country now in at least 10 states. The American Dental Association, state dental associations, and thousands of volunteer dentists and other dental personnel have seen the need and are rising to meet it. Stan and RAM are to be highly commended and for what they do to help organize and facilitate the clinics in Wise and Grundy but it must not be forgotten that it is organized dentistry and the dental communities in all areas of the country which are stepping up to meet the overwhelming need.

Stan Brock: Well said Steve Slott, you are one of those wonderful dentists that do so much for these folks. I would also like to add that a successful RAM event relies on many volunteer organizations such as the LIONS CLUBS and optometrists from VOSH etc, etc. This incredible support structure allows us to see patients in the thousands totally free of charge.


Anonymous: Steve Slott, dentist from NC, again. I see a great number of folks are asking how they may help. The Missions of Mercy dental clinics are occuring in a number of states including Virginia, North Carolina, Texas, Nebraska, Kansas, West Virginia, and soon to be South Carolina to name a few. A call to the state dental associations of these states can lead anyone to the right contact to offer volunteer services in these free dental clinics. As Stan said has occured in Tennessee and Virginia, many states have now adopted or are in the process of adopting laws which allow non-licensed dentists who are licensed in good standing in another state to work in their respective states to provide free services in volunteer clinics. North Carolina has recently adopted such a change in the law and there are others as well. A call to the American Dental Association or specific state dental associations should be sufficient to find out which states have adopted this change.

washingtonpost.com: Thanks, Steve.


Baltimore, Md.: Hi, I found the magazine story inspiring. Do you have volunteer opportunities for medical students?

Jean Jolly: Hello and thanks for your question. We offer limited volunteer opportunities for medical students. Most medical students want to shadow medical doctors at our clinics. The concern there is patient confidentiality. So while the answer is yes - you can volunteer - you cannot shadow doctors for that reason. Based upon your medical education you may be assigned to counsel patients at our larger clinics or do support activities as non-medical personnel.


The Health Wagon, Clinchco, Virginia: Hi Mary, Stan, and Jean! All from The Health Wagon, the local coordinator for the Wise RAM Event, want to express our gratitude to all for this powerful story. We want to thank all volunteers for their hard work to be able to offer this wonderful act of compassion to others.

Mary Otto: And sincere thanks to you for your endless patience in answering thousands of questions and allowing us so much time with you all.


From the hills myself: I know the uninsured/underinsured situation is a terrible problem, but how much improvement in health would there be with better lifestyle choices? I grew up in an area not unlike Wise Co. I'm sorry, I don't mean to sound harsh, but you eat junk food, never exercise, smoke like a locomotive, and don't brush your teeth, your health will suffer. Don't tell me it's only about money - the locals, despite their finances, seem to be able to find money for tattoos and cigarettes. Toothpaste is cheap, walking a mile a day even cheaper. Improvements in insurance and services can only do so much.

Mary Otto: I think health education is a huge component. In many parts of the country, Americans have managed to cut down on their smoking, manage chronic diseases, etc. But they have not done it without help and education.


Tina in Falls Church: I am a counselor/medical case manager here in Northern Va. I am non-medical. I see from your volunteer app on your web site that non-medical volunteers must get a medical person to sign up too? Please clarify, if I do not have a medical person I can persuade to volunteer am I out of consideration? Thanks.

Jean Jolly: Hi Tina -- For domestic clinics, you do not need to get a medical person to sign up to volunteer with you. If you wish to go on an international expedition and you are non-medical, we ask that you get a medical person to accompany you. That is because our international expeditions are small -- 15-20 people is almost too large -- and could quickly fill up with non-medical volunteers. Because of their size, it is the professionals who are most needed for international trips. Within the US -- you may volunteer. We welcome you! Go to www.ramusa.org and fill out an application -- which you will find at the Home Page under "How to Volunteer" Download the application and be sure to specify which domestic clinic you want to volunteer for. We will contact you when we begin work on that particular clinic.


Georgetown, D.C.: Thank you for what you are doing. More than 60 years ago, my father worked for the UVA Extension Service. As a young child, I sometimes went with him on his rounds through the mountains. Even then I was shocked by the wizened faces and how old even young people looked and how few resources they had. The photographs in your article brought back those memories. How sad that after all these years their hardships endure.

Mary Otto: Thanks for your personal story. It speaks eloquently of the persistence of hardship in these remote areas.


Washington, DC: Do you make any effort to connect people to Medicare, Medicaid and other benefits programs? I realize that access to physicians may still be an obstacle for people living in such rural communities, but linking those who qualify to such programs would seem to be a step towards helping them find and afford care.

Jean Jolly: Hello -- Surprisingly, people who need medical assistance often are very knowledgeable about where they can receive services. First - most folks only become eligible for Medicare when they reach 65 years of age. To become eligible for Medicaid can require being disabled. And there are sometimes State programs for indigent people. We do sometimes have to link people up to the indigent care programs. But it is the very large group of non-indigent people who are falling between very large cracks in receiving health care if they cannot afford it. Those people make up most of the population who we see.


Bee, Va.: My comment is for the person from Harrisburg, Pa. The Health Wagon, a large supporter and Organizer of the Wise County RAM, does see patients in their office for telemedicine through UVA, we just need more volunteer telemedicine doctors, they are greatly needed to do the follow-ups for patients after the RAM clinic is over.

Mary Otto: That's right. When I visited the Health Wagon office, the staff proudly showed off their telemedicine room, where patients can consult with far off experts. They are very hopeful that this high-tech approach is helping conquer the remoteness of this area for some patients.


Clinchco, Virginia: Hi Mary, Stan, and Jean. As a member of the The Health Wagon staff, the organization that spearheads the Wise RAM Event, I would like to address the comment re: people choosing to go without insurance. Most people do have a choice, it is a decision of whether to purchase food, housing, utilities, and medicine. After money is spent for all of the aforementioned items, there is NO money left over to purchase health insurance. This is the case for most of the Health Wagon's patients. If a person only receives $500 a month to live on, where is the money for health insurance? The point is that many people are going without medicines and needed health care due to lack of funding. This leads to untimely death rates.

Stan Brock: Hello HEALTH WAGON and Teresa Gardner and your wonderful team without whom RAM Wise would not be the success that it is.

I hope Mary and Jean can answer more of the great questions from readers today. As you know I am down in the Amazon with a RAM team and we have just received an emergency medical call on the radio from a remote village. So we must dispatch our aircraft to bring in the patient. Love, Stan.


Falls Church: I am a licensed counselor in Virginia and I have always been interested in volunteering for your program in Virginia. I don't think my counseling skills would be of particular use but I have hospital based experience and I have worked as a medical case manager. I'm sure I could help in some way. It is my understanding that non-medical volunteer applicants must recruit a doc, dentist, ophthalmologist,optometrist or other medical professional to be considered... is this correct?

Jean Jolly: Hello. We ask that a non-medical volunteer bring a medical professional along on our international expeditions only. We have need of non-medical volunteers at all of our domestic clinics. You are welcome to volunteer! I am signing support folks up now for Wise 2009! Go to www.ramusa.org. At the home page go to "How to Volunteer." Download the RAM application form and fill it out. Be sure to list the specific RAM clinic that you are interested in -- in this case Wise 2009. Mail it in to me. That's it -- and you have become a RAM volunteer! Thanks!


Washington, D.C.: It seems a big problem contributing to health problems in the area isn't just access to health care, but also health education. The photos and videos show a lot of overweight people (not that it isn't also a problem among the wealthy, but ...), and I was shocked by the guy in the video who said he needed 20 teeth filled. Do you think many of their health problems could be avoided if they were better educated about nutrition and personal care?

Mary Otto: I agree. I think health education is a huge issue. As for the teeth, of coure routine oral health care is a key too. Part of it is taking care of one's teeth and part of it is getting to the dentist on a regular basis, something many poor adults don't do. Even if they are covered for dental care as children through Medicaid, they lose those benefits as adults.


New Orleans, La.: I wonder how many of these people have voted for or against a candidate in part because of that candidate's position on "socialized medicine." I come from an area served by the RAMs (thank you for the work you do!), and the same folks who use its services and who don't blink an eye at a jar on a convenience store counter collecting money so a 3-year-old girl can be treated for leukemia will scream against the possibility of a national health care plan. (I've heard members of my own family do it.) Why the disconnect?

Mary Otto: I think those would be fascinating questions to explore.


Mary Otto: Well, I guess I had better sign off now. But I want to thank everyone for their thoughtful questions. I'm very grateful to have had a chance to be here. Sincerely yours, Mary


Washington, D.C.: The article and the videos mention that eventually you end up having to turn people away because there are just too many and not enough time. This breaks my heart (and I'm sure yours too). What's the greatest hardship or barrier to doing this more frequently -- money? volunteers?

Jean Jolly: The greatest barrier to doing it more frequently has been both dollars and volunteers. First we need two or three core groups of volunteers to organize and go into the field to put together and do the actual weekend clinic. Second -- you are correct - we need dollars to do that. But there is a third reason as to why expansion is slow for us. That barrier is State lines that do not allow health care professionals from one State to do volunteer charity work for a very limited time (3-7days) in another State. Tennessee is the only State which allows free entry for health care professionals to come in without strings. Virginia's law is workable and just went through a revision. Only dentists from out of state have to pay a small fee now ($10.00). Kentucky is working on laws - which currently do have some strings attached. Other states? Check yours. A quick call to your State Boards of Medicine, Optometry, and Dentistry will provide you with the greatest barrier of all. Thanks for this question!


washingtonpost.com: This concludes today's chat. Thanks for all your questions and for reading the story and this discussion.


Editor's Note: washingtonpost.com moderators retain editorial control over Discussions and choose the most relevant questions for guests and hosts; guests and hosts can decline to answer questions. washingtonpost.com is not responsible for any content posted by third parties.

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