MAYNARDVILLE, Tenn. — The two-hour drive is done, but Hannah and Jack Hurst leave the Honda's engine running.
Hannah's prayers have brought them here. Now there's little to do but turn up the car's heat, get some sleep and wait for morning — and a set of glass and metal doors to open.
Still, Hannah doesn't complain. The 26-year-old mother of three has waited "pretty much as long as I can remember" to escape the pain throbbing through her jaws. Jack lost his road construction job a year ago and health insurance is out of the question. If the answer to Hannah's misery lays behind those doors, what's 10 hours more?
Out in the dark, the Hursts have plenty of company. Even before 10 p.m. on this Friday in late fall, nearly 50 cars ring the lot. By 6 a.m. Saturday, more than 400 men and women stand tightlipped and bleary-eyed under the Big Dipper.
By day's end, as long as they keep tempers in check and sleep from their eyes, they will win the privilege of care from a dentist or a doctor.
In a country convulsed over health care, the scene is alarming. But it is always the same, Stan Brock says. For 17 years, Brock has piloted a nonprofit called Remote Area Medical, offering free health care to the uninsured, the underinsured and the desperate.
Brock has seen so many crowds like the one outside Union County High School he chides himself for losing track of whether this is RAM's 578th expedition or its 587th. Yet in every crowd, there are hundreds of Hannah Hursts, each a unique testament to the nation's ragged pursuit of health care answers.
Over the next two days, RAM's volunteers will examine, extract and prescribe hundreds of solutions for individual aches and afflictions. They will, in the few moments left, attempt to convince patients they'll probably never see again of the virtues of healthier living and continuous care. They will try to answer Hannah Hurst's prayers.
Lawmakers debating reform could almost certainly learn something here in the trenches.
But the most striking lesson might also be the most daunting: To fix health care inequities, expanding insurance alone may not be enough.
'How do you talk to a doctor?'
"Good morning folks," Brock booms in an accent crisp with authority. "We're going to get started on time."
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It is precisely 6 a.m. and Brock has just pushed open the high school's doors, questions ready.
"Who's here to see a dentist?"
More than half raise their hands. Who needs an eye doctor? Almost as many. Who needs a medical doctor? Scattered hands go up, but Brock expects that, too.
"Really, they all need to see a doctor," he says. "They just don't want to lose their place on line."
Ronnie and Debbie Erwin have driven 2½ hours from Johnson City. Insurance from her job covers his care for spinal stenosis. But the prescriptions caused his teeth to disintegrate and infection followed. Insurance doesn't cover that.
"My doctor said you've got to do something or it's going to kill you," Ronnie says.
Melissa Hayes, a home health aide from nearby Luttrell, has waited since 11:30 p.m. with her daughters, aged 5, 7 and 10. Her oldest, Brittney Prince, can't see the board at school, but the family can't afford glasses.
Joe Mason is anxious about a broken molar, but if there's time, he's thinking about seeing a doctor, too. The idea, though, leaves him uncertain.
"How do you go in there and talk to a doctor? I probably haven't been to one in 20 years," says Mason, 31.
"I mean, what are you supposed to say to one?"
"Who's got No. 1?"
The day's first patients are waved in to "triage" — the school cafeteria. Decide which need is today's priority, volunteers urge. There won't be enough time or doctors to deal with them all.
"Dental?" Go to the gym.
"General medical?" In the classrooms down the hall.
It's just 45 minutes from RAM's base in Knoxville to Maynardville, the center of a county of 19,000 set amid corduroy ridges. But the volunteers' arrival is the product of a long and convoluted journey.
It began in the Amazon. Brock, a British boarding school dropout, landed there more than 50 years ago and turned himself into a South American cowboy. He left in the 1960s to wrestle anacondas and rope giraffes on a popular U.S. television show, "Wild Kingdom."
But in 1985, settled in Knoxville, he began organizing medical relief flights back to the region. Seven years later, he got a call. The only hospital in Hancock County, Tenn., had closed and the sole dentist had moved away.
"We literally loaded a couple of 400-pound dental chairs that we borrowed into the back of a pickup truck and we went up there with a couple of dentists," Brock says. "It wasn't long before another county called and on and on and on and on."
Hundreds of expeditions later, Americans have become the group's main mission.
For all their planning, RAM's people never know entirely what to expect. Neither do their patients.
Although the Hursts got to Maynardville early, they lost their place in line when police cleared the parking lot because of shots from nearby woods. It turned out to be just some teenagers hunting.
By the time the couple reaches the gym, dentists clustered around 38 portable dental chairs fill the Union County Patriot's home court. Patients pack the bleachers.
Finally, Hannah Hurst is called to a chair and explains why she's come.
In pregnancy, her mother suffered from a calcium deficiency. Hannah's baby teeth decayed fast. It was even worse with her permanent teeth and disease filled her gums, swollen with abscesses. Insurance either wasn't enough or dental wasn't covered. Four years ago, Hannah saved enough to reach a dentist's chair, when her phone rang. Her aunt, hospitalized with cancer, had taken a turn for the worse. She rushed out, even though a spring breeze can trigger pain that knocks her to her knees.
Back home in Campbell County, worshippers at Sled Creek Holiness Community Church have prayed, even fasted, to help Hannah heal.
Today Hannah is ready to embrace the answer.
Please, she asks, pull them all out.
It's calmer in the classrooms reserved for medical doctors, but the patients' stories are at least as telling.
"I went to college. I'm a graduate. I just never thought I'd ever be here," Earleen Black says.
Until losing her job eight months ago, Black was a radiology technologist. She's embarrassed to ask for help. But bursitis has attacked her hip like a baseball bat. She's relieved when a doctor administers a shot without charge, but mystified there was almost no wait.
The truth is, many are here only because their blood pressure registered too high to undergo the dentist's drill.
Daniel Drake's blood pressure came in at an eye-popping 200/120. He chalks it up to an energy drink and leaves happy when a pill brings it down enough to get his tooth fixed. But Dr. Alan Weder, a Michigan researcher volunteering for the weekend, shakes his head.
"If that's the way he's walking around, his risk of having a heart attack or a stroke in the next five years is probably 20 to 30 percent," Weder says. "And that's for want of 30 cents in medicine."
Comprehensive insurance could resolve the patient cost dilemma, Weder says. But the problems go beyond that.
Weder notices many patients who say they can't afford basic prescriptions — now carried by discounters for as little as $4 a month — have cigarettes in their shirt pockets that cost more than the pills.
When Kevin D'Angelo, a dentist from upstate New York who's volunteered at more than 20 RAM expeditions, asks patients what they drink, the most common answer is Mountain Dew, often five or six cans a day. The only way to get teeth as bad as some he sees, D'Angelo says, is almost never to have brushed at all.
While some of those waiting speak glowingly of their regular physicians, others recount the difficulty of getting in to see a doctor or a dentist in rural areas where providers and openings for people without insurance are in short supply.
There's only so much a weekend's barrage of free care can solve.
RAM, says Bruce Behringer, an expert on Appalachia's public health needs at Eastern Tennessee State University, "is a symptom of the problems in the health care system, not a solution."
Praying for strength
Hannah Hurst is back for Day 2.
Yesterday, RAM's dentists pulled 16 of her teeth. In the gym, Trey Parker, a University of Louisville dental student, welcomes her return. But before reaching for his tools, Parker honors Hannah's request, linking hands with Jack and two other volunteers.
"Lord," Parker says, "let Hannah have the strength to bear through getting all her teeth pulled; that she can hold up; that her jaw will be made whole and that she can live a happier life being a mother. In the name of Jesus Christ."
Today is a bit of a gift. By 9 a.m., just 260 patients have come through the door. RAM's volunteers may get to everybody. But patients still fill the bleachers and line a hallway, a case study in needs health care reform may not answer.
Take Hannah Hurst's teeth. Proposals by Congressional Democrats, while they would greatly expand traditional medical coverage, won't cover dental care, except for children.
It's no better for vision care, not covered for adults under either the House or Senate bills.
Changing the economics, though, is just the start.
"There's a culture that sort of surrounds the problem," Brock says.
All the high blood pressure readings aren't a coincidence. Heart disease, hypertension and diabetes are serious problems throughout Appalachia. That is the result of smoking, lack of exercise, unhealthy diets and obesity, as well as relationships with the health care system, Behringer says.
It can be hard reaching a doctor in thinly populated counties with few roads and mountains. Many people don't see a doctor regularly and many doctors are unable to build the continuous relationships with patients to help ensure care.
The challenges are all too real to Eddie Graham, the local school health coordinator, who lobbied RAM to come to Maynardville. He recounts trying to foster health in an area where some families send children to class sick and tell them to go see the school nurse. Kids arrive at elementary schools carrying chewing tobacco.
Making health care affordable only partly solves problems like these, he says.
"It's changing beliefs," Graham says. "It's educating people about what is health."
Solution or symptom?
When the numbers are totaled, Expedition No. 587 into America's health care jungle will be recorded as followed:
Over 1½ days, 701 patients have come through RAM's doors.
Its dentists have extracted 852 teeth and filled 234 others; 345 pairs of eyes have been tested; 87 people have been examined by a medical doctor.
If RAM was going to send out a bill, it would total $138,370.
Does that make it a solution to a crisis or a symptom? The answer may lie beyond the bottom line.
When Brittney Prince goes back to school Monday, she'll be wearing her first pair of eyeglasses.
"Momma," she says, gazing outside, "the grass is not fuzzy any more."
And when Hannah Hurst — her toothless mouth stuffed with gauze — is helped from the chair, she hugs her caregivers. At church, raising money for dentures may have to wait until spring. But, at last, her prayers have been heard.
"There is no other answer for it but God and it just makes me so much more thankful," she says. "It truly is my testimony now. You keep praying, you keep asking, and your answer will be there sooner or later."
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