They took a bus into the center of Cleveland, Tenn., a manufacturing town of 42,000, and slept for a few hours at a budget motel. Then they awoke in the middle of the night and walked toward the first-come, first-served clinic, bringing along a referral from a social worker for what they hoped would be their first doctor’s checkup in more than four years.
“Urgent needs from head to toe,” the social worker had written. “Lacking primary care and basic medication. They have fallen into the gap.”
Only when Stevie and Lisa arrived at the clinic a little after 2 a.m. did it occur to them how large that medical gap has become in parts of rural America. Dozens of people were sprawled out in sleeping bags on the asphalt parking lot. Others had pitched tents on an adjacent lawn. The lot was already filled with more than 300 cars from all over the rural South, where a growing number of people in medical distress wait for hours at emergency clinics in order to receive basic primary care. Tennessee has lost 14 percent of its rural physicians and 18 percent of its rural hospitals in the past decade, leaving an estimated 2.5 million residents with insufficient access to medical care. The federal government now estimates that a record 50 million rural Americans live in what it calls "health care shortage areas," where the number of hospitals, family doctors, surgeons and paramedics has declined to 20-year lows.
What’s arrived in their place are sporadic free clinics such as the one in Cleveland, where a nonprofit agency called Remote Area Medical brought in a group of doctors, nurses and other volunteers for the weekend to transform the local high school into a makeshift hospital. There would be a triage station in the entryway, bloodwork in the science lab, kidney scans in the gym, dental extractions in the cafeteria, and chest X-rays in the parking lot — a range of medical care that would be available for only two days, until the clinic packed up and moved on to Hazard, Ky., and then Weatherford, Okla.
“We’ll do as much as we can for as many as we can,” a clinic volunteer promised as she patrolled the parking lot late at night and handed out numbers to signify each patient’s place in the line. No. 48 went to a woman having panic attacks from adjacent Meigs County, where the last remaining mental-health provider had just moved away to Nashville. No. 207 went to a man with unmanaged heart disease from Polk County, where the only hospital had gone bankrupt and closed in 2017.
“We might not even make it in,” said Lisa, 49, after the volunteer handed her and Stevie Nos. 461 and 462. The muscles in her legs had started to cramp, and she leaned against Stevie for balance. “You really need to hydrate,” he said. He offered her Gatorade, but she shook her head. He handed her a bag of chips, but she pushed it away.
“I don’t feel right,” she said. She gripped her leg and sat down in the grass.
“I’m worried about you,” he said. “I don’t like seeing you like this.”
“Maybe I’m just beat,” she said.
“Probably so,” he said, even though he didn’t believe it. She had been diagnosed with several chronic health conditions in her 20s and 30s, but lately she couldn’t find a primary care doctor and she couldn’t afford to see specialists. For the last several years her only medical treatment had come as a matter of last resort, at the emergency room, and the unpaid bills from those visits had ruined her credit until she began to avoid being treated at all. Now she was trying to manage her leg pain by adding paper towels to cushion the inside of her shoes and buying an herbal extract sold at gas stations. Stevie had seen her lose her balance and fall three times in the past week. Her leg muscles sometimes trembled, and she rarely had an appetite.
He grabbed a blanket from a volunteer and draped it around her as they waited on the far edge of the parking lot with the rest of the 400s. Lisa closed her eyes, and Stevie stayed up and watched her, putting his hand on her forehead every so often to check her temperature.
“It feels like my heart is skipping,” Lisa said, sitting up in the grass as the sun began to rise. Nearby a mother was trying to nurse her crying baby. A woman in a wheelchair was rolling up her sleeping bag and brushing her teeth. The clinic was about to open, and all around them people were beginning to move toward the entrance of the high school.
“I wish we could trade up,” Stevie said, looking at his number. “We might be out here for hours. You need to get seen.”
“Nobody’s trading. They’re all just as desperate as we are,” Lisa said.
The clinic doors opened at 6 a.m., and the director invited the first 100 patients to come inside. “This will take a while, so find some shade, spread out and make yourselves comfortable,” the director told the rest of the crowd, but Lisa and Stevie continued to stand and wait at the door along with everyone else. The 100s streamed in a few hours later, followed by the 200s, and by midmorning some patients had begun exiting the building still slack-jawed from Novocain and carrying to-go packages of bandages, gauze, nasal strips and hand sanitizer. The line was moving at a steady pace, but Lisa had begun moaning and holding onto Stevie for support as the temperature rose toward 90 degrees.
“We need to get you into the shade or inside,” Stevie said. There were still at least a hundred people in front of them in line. Maybe Lisa was suffering from extreme fatigue, Stevie thought. Maybe it was high blood pressure or dehydration.
“My wife needs to get indoors,” Stevie told people in line, and some of them looked at Lisa and began moving out of the way, until Stevie and Lisa were entering the building and sitting down at a table for medical check in. A volunteer handed Lisa a bottle of cold water, and she pressed it to her forehead.
“How are you today?” the volunteer asked.
“We’re blessed to be here,” Lisa said.
“We’re going to take good care of you,” the volunteer said, and she typed into a laptop as she began asking questions about their medical histories, prompting Stevie to go first. He had been born with a cleft palate and two holes in the lower chamber of his heart that required annual monitoring, but he hadn’t seen a cardiologist since high school. He had an abscess in his mouth, arthritic knees and a damaged kidney, none of which were his priority now.
“She’s really sick,” he said, placing his hand on Lisa’s shoulder. “Can you help her?”
“What’s been bothering you?” the volunteer asked, turning to Lisa, and she wondered where to start. With the neuropathy in her feet? Or her digestive disorder? Or her heart murmur? Or her anxiety and depression that often led to panic attacks? Together she and Stevie had spent two decades accumulating pain, cycling in and out of homelessness and addiction. They’d lost a baby to stillbirth; another child to the foster care system; a house to foreclosure; a series of menial jobs at Cracker Barrel, Hardees and Walmart; and the private insurance that had come with those jobs. Now Stevie was on disability insurance, and Lisa was uninsured in part because Tennessee had chosen not to expand Medicaid.
They’d also lost their car, which forced them to rely on doctors who practiced nearby, but many of those rural doctors were aging out and retiring. The ones who remained were deluged with patients, which meant they often chose not to take on people like Stevie and Lisa, who couldn’t afford even minimal co-pays.
“I’ve got pain in my muscles, my feet, my stomach,” Lisa told the volunteer. “Some days I hurt so bad I don’t get out of bed.”
“How long have you been managing like this?” the volunteer asked, and Lisa shrugged.
“A while. Some days I manage and some days I don’t.”
“We’ve been through hell and high water,” Stevie said. “We’ve breathed life back into each other. She saves me and I save her.”
“You know some couples break up over stupid stuff,” the volunteer said. “Like toothpaste. Or laundry.”
“In sickness and health,” Lisa said.
“In sickness,” Stevie repeated. He reached for Lisa’s hand as the volunteer led them to a different room to take basic measurements. Lisa’s weight was too low. Her blood pressure was too high. Another volunteer checked her heart rate and couldn’t get an accurate reading. “I need to sit down,” Lisa said, as the volunteer tried checking her pulse again. It felt faint. It felt like it was jumping.
“We better to get you back to see a doctor,” the volunteer said. She spoke into her walkie-talkie and then helped Lisa out of her chair.
They hurried through the gym, where 40 dentists were working side by side to extract teeth. They rushed through a darkened room, where dozens of patients were lined up to take vision exams. The hallways were crowded and chaotic, and somewhere between a consultation room for urologists and a sign-up station for lung cancer exams, Stevie got separated and fell behind.
“Wait. Where’s Stevie?” Lisa said. She stopped and looked backward down the hallway, but she couldn’t find him.
“We need to get you looked at,” the volunteer said, and she led Lisa into a science classroom with five cots positioned at the back of the room, partitioned off by black drapes. A dozen patients were seated in the waiting area. One woman paced the classroom on crutches. A teenager with a gash on his forehead was sprawled out and sleeping across two chairs. Lisa slumped down against the wall and closed her eyes, until a nurse practitioner came over to her.
“You must be Lisa,” Corry Paul said. She had a stethoscope dangling around her neck, and she asked Lisa to follow her to one of the cots in the back of the room.
“But my husband,” Lisa said, her voice beginning to falter. She looked out down the hallway again but didn’t see him. “I need him,” she said. “Where is he?”
“We’ll find him,” Corry said. She sent two volunteers to search the school and then led Lisa back to a cot.
Corry had driven to the clinic from Kentucky to volunteer for the weekend along with a team of five other doctors and nurse practitioners, and they had already treated more than 70 patients during the clinic’s first hours. They had diagnosed six new cases of Type 2 diabetes and distributed more than 40 doses of medication for high blood pressure. A 21-year-old had come in with dangerously high blood sugar and splotchy patches forming on her neck and her legs. A 62-year-old had arrived in the waiting room holding a murky lung scan that revealed, among other things, a lighter and a pack of cigarettes still tucked inside his chest pocket. There had been precancerous tumors, open wounds, unmanaged heart conditions, and more than a dozen people with chronic obstructive pulmonary disease (COPD) who kept wheezing for air.
During a meeting for doctors before the clinic, one medic had compared the job to operating a highway checkpoint. For a few moments, they could slow the spread of a rural health epidemic and bring people’s pain under control, but after that everyone went rushing back onto the freeway toward what seemed like an inevitable crash: Newly diagnosed diabetics with limited access to healthier food. Asthmatics who couldn’t afford a $200 inhaler. Patients in the final stages of heart failure who had no primary care and few nearby hospitals.
“You do the best you can in the limited time you have, but then you have to move on to the next patient,” one of the doctors had said.
And now that next patient was Lisa: crying about Stevie and then calm again, complaining of exhaustion before delivering a nonlinear monologue that lasted a few minutes. She told Corry she had cramps, heart palpitations and digestive problems. She said her muscles ached and her feet sometimes tingled.
Corry suspected Lisa was hypokalemic, dangerously low on potassium. If she was right, there was a risk Lisa’s condition could worsen and paralyze her muscles or cause sudden cardiac arrest. The temporary clinic had neither the facilities to perform complete blood tests nor the medications necessary to bring Lisa’s potassium levels back under control.
“We need to send you to the hospital,” Corry said. “Do you have a car?”
“No,” Lisa said. “I don’t have insurance. I don’t —”
“We’ll call an ambulance,” Corry said. “This can be quite serious.”
“We’ll find him,” Corry said again, and a few minutes later Stevie came hurrying down the hallway. He hugged Lisa, and she leaned into him for support as they walked down the hallway.
“Where were you?” she asked, and he said he’d gotten lost on the way to medical, and when he couldn’t find Lisa, a volunteer had persuaded him to spend a few minutes addressing some of his own medical needs. He’d gotten a blood pressure check for his heart and stopped to do a urine test for his kidneys.
“Did you pass?” Lisa asked, and Stevie shook his head.
“I guess we’re both doing bad,” he said.
They sat together on the curb as the ambulance pulled up, and three paramedics helped Lisa onto the gurney. “What does this cost?” she asked. When nobody answered, she tried to sit up and ask again, but Stevie put his hand gently on her shoulder.
“It’s okay,” he said. “You need help. Let them help you.”
The paramedics drove her two miles to the hospital. A radiologist performed an ultrasound on her leg and an X-ray on her heart. A lab technician ran a series of blood and urine tests, which confirmed Lisa was severely lacking in potassium. A nurse gave her six potassium supplement pills and an injection for muscular pain, and within 90 minutes Lisa and Stevie were back in the front lobby.
“How much was that?” Lisa asked again, and this time a receptionist in billing estimated it would be about $3,000.
“Sorry,” Lisa said, because she already knew she could never afford to pay it. She had no savings and no bank account. She and Stevie had just used most of his monthly disability check to move out of a tent behind Food Lion and into a bedroom in a shared apartment. The cost of her care would become more bad debt for a struggling hospital. It would become another mark against her credit score, or a lien against the car or house she hoped to someday own.
“If you prepay in full, we take 40 percent off,” the receptionist offered.
“Just bill me,” Lisa said, and she followed Stevie outside. The hospital helped call them a cab, and they rode back to the two-bedroom apartment they shared with five roommates. They went upstairs to a small bedroom with a blow-up mattress on the floor, and Stevie tried to sleep while Lisa kept getting out of bed with an upset stomach. She rationed out a few ounces of Gatorade every 20 minutes but couldn’t keep it down.
“I feel worse than before,” she said the next morning, and Stevie had an idea.
“The clinic is still open,” he said, and a few hours later they were back at the front of the line for check-in. A nurse took Lisa’s vitals. This time her blood sugar was low and her blood pressure was high. Lisa told the nurse she wanted to get another checkup with a doctor, a mammogram, a lung scan and a prescription for new glasses.
“Pick what you need most, because we’re getting ready to close,” the nurse said.
“What do you think?” Lisa asked, turning to Stevie, and together they ran through the calculations. The doctor’s checkup would possibly result in some temporary relief from her chronic symptoms, but after that the volunteer doctor would go back to another state and she would probably go back to being sick. The mammogram and the lung scan were basic preventive care, but she didn’t want to use her only doctor’s appointment to discover new problems she couldn’t afford to fix. That left vision. Lisa was nearsighted and farsighted, and she hadn’t gotten a new prescription for glasses in 31 years. The bifocal lenses she needed cost more than $400, but at the clinic she could get them for free.
“It’s a problem you can actually take care of,” Stevie said, so Lisa went to see an optometrist and picked out new bifocals as Stevie stood nearby.
“No more headaches,” he said.
“Or tripping because I can’t see right,” she said.
Volunteers had begun packing up around them and carrying boxes of medical equipment out to a truck headed for the next clinic in rural Kentucky. Lisa and Stevie exited the high school with the last remaining patients and stopped by a diner for lunch. “I’ve finally got an appetite,” Lisa said, ordering a Coke and a hamburger, and Stevie leaned across the booth and reached for her hand.
“If you can get something down, you’ll get your energy back,” he said. “Things will start turning around.”
“It all starts with feeling good,” she said. She reached for her hamburger and took a few bites, but a moment later she grimaced and pushed her plate away. She put her hand on her stomach and leaned back in the booth. “Oh, no,” she said.
“You okay?” Steve asked. Lisa shook her head and ran to the bathroom, and when she returned a few minutes later she was holding onto the wall for balance.
“My muscles are cramping up,” she said. “I’m worried it was more than the potassium.”
“You don’t look right,” Stevie said. He touched her forehead and it was sweaty. “I hate this,” he said. “You’re all pale. You’ve been hurting too long.”
“I know,” she said, staring back at him, searching his face for answers. “What would you have me do about it?”
He reached over to steady her while he considered their choices. She didn’t have a doctor. She couldn’t afford the emergency room. The temporary clinic had already disappeared behind them. He could think of only one option. He slipped his arms under Lisa’s shoulders and helped her out of the booth.
“Let’s get home,” he said. “I’ll take care of you.”