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I would like to sort out a few additional thoughts, having had some time to reflect last night, to work during a torrential down pour this morning, and then to ponder it all on the long drive back.

va dare will, when she is ready, post something I expect will add greatly to our understanding.  After our long conversations yesterday evening, and a shared conversation we had with Stan Brock, who founded the Remote Area Medical mission effort - and yes, that is the same Stan Brock as in Mutual of Omaha's Wild Kingdom - I know the valuable insight and commentary she will offer.  

This will not be a formally organized essay.  It is the experience and perspective of one person who now has a commitment to two things

  1.  returning to Wise and perhaps going to other sites
  1.  giving this issue all the attention I can.  It is a precondition to my normal passion of education, because a child suffering from malnutrition, bad health, dental pain cannot be expected to learn effectively.

Below the fold I will briefly explain how I will approach this.

I invite you to continue reading.

I am going to begin by describing this morning.  And then try to put some of this into a broader context.  I will include parts of conversations with Stan Brock, with a number of the key dentists, with some of the patients we encountered.  And I will offer my own personal perspective.

We had really seriously bad weather in the mountains of Southwest Virginia.  It started last night, and throughout the morning we had periods of heavy rain, occasional periods of lightning and thunder.

Much of the set-up is under tents.  Some have metal poles.  While a good chunk of the electrical setup did have the GFCI (Ground Fault Circuit Interrupter) setups that could prevent problems should they get wet, some did not and had to be abandoned.  For most of the morning we could only get panographic x-rays, which lack the detail available on other kinds.  The dentists in triage (where I was working) and providing services adapted as they could.

We started early this morning.  Yesterday we had done some triaging of people we could not serve then so that we could begin on them right away.  In some cases we already had their x-rays done.  We started early.

We did have to cut off processing new people some time after 8:30, because we had already filled the capacity we had to treat people, even though several dentists who had planned to leave last night had stayed over - at their own expense, remember - in order to try to serve as many people as possible.

We were largely limited to providing one service -  reconstruction/filling/rootcanal (a few); extraction;  cleaning.  This meant that in triage the dentists had to ask people to choose between getting fillings to save some teeth versus having painful teeth extracted.  That sounds cruel.  We had no choice.  We wanted to be able to do something for everyone there, and we were running out of time.

One case stands out in my mind.  The woman had first been diagnosed with a small tumor in her mouth about 7 years ago when she lived in Texas.  She never had dental insurance, could not afford to have it addressed.  Recently it had started to grow.  She was desperate, because she was risking her jaw locking, or being so damaged that she would lose all her teeth.  Remember, we were in somewhat primitive settings.  And today we could not get as detailed x-rays as we might have wanted for such a situation.  Through the cooperation of a number of people, a top oral surgeon agreed to remove the tumor.  

My work in triage was done shortly after 10.  Originally one of the dentists with whom I worked had planned to move down and do some extractions - he told me I could learn how to do suction and continue as his assistant.  As it turned out, perhaps due to the restricted space we could use, that didn't happen. I am sure the patients upon whom I would have been performing suction are grateful without even knowing it.

There is another event in Grundy VA on October 3-4.  I listened to dentists urge patients to try to get there so they could perform more services.  The driving distance from Wise to Grundy is less than 60 miles, but much of it is over twisting mountain roads, and in good conditions it would take a good 90 minutes.  But that assumes two things

  1.  you are able to travel on that weekend
  1.  you have some means of transportation

Many of the patients we saw cannot meet one or the other of those assumptions.  Remember, in this part of the country there is almost no public transportation.  And not all of the people we saw were from the immediate area - some had traveled several hundred miles to receive care.  According to Stan Brock, there were at least two patients from Florida -  why, you might ask?   Because the cost of traveling, including in part by air, was far less than paying for the necessary dental care in Florida.   Ponder that for a moment.  If you are having trouble understanding, perhaps you could check the cost of a single extraction where you live.  Now imagine that you are getting a dozen, or more, teeth extracted.  

Of course, it should not have reached this point.  But then ask yourself, how much it costs to get a regular cleaning and checkup?

It is not as if the people coming to RAM did not try to take care of themselves.  Some were on multiple medications, often through Medicaid or if they were older through Medicare.  But if you are taking 4-5 meds just to stay alive, you do not really have any money for basic dental.  And remember that many people who do have some health insurance are not covered for dental, and in some cases have no or limited coverage for the prescriptions necessary for the diagnoses they receive.

Because several people had on my diary on Friday suggested that Congress Critters needed to see this, perhaps by having an event in DC, va dare and I approached Stan Brock on that specific point.   We found out that he has been trying for a number of years.  I won't go into all the details, because va dare is likely to cover some.  There is a small event in Alexandria, that somehow does not get the coverage that could make a difference.

One issue is that many states will not allow out of state doctors to offer free medical services.  Another issue is one of liability.  Here I think the Congress could step in and condition some federal funds that go for medical services on lifting the restrictions.  TN has, in part because Brock is based there.  Virginia has some flexibility.  But if my wife's sister, who is a licensed Physician's Assistant, wanted to volunteer at such an event, because her license is in a Northeastern state she could only offer those professional services in TN and in VA.  

One of my acquaintances also volunteering has been involved in health policy, first at the state level in Virginia and now on the Hill.  I included her in the conversations with Brock, and she is going to try to help facilitate doing something.

Being able to serve people in more parts of the country is of benefit to those additional people whom we can serve.  And if we can continue to raise awareness, then perhaps we might realize something -  we cannot appropriate address the medical needs of the people of this nation by expanding what already happens at Wise and elsewhere.  Stan Brock would really like to focus on the needs of developing nations that do not have the health care infrastructure that we do.  Of course, that infrastructure is inequitably distributed around the nation:  I remember that when I lived on the Upper East Side of Manhattan in the late 1960s something like 1/4 of the nation's psychiatrists live and/or practiced there.  

Those people who have access to primary healthcare providers in rural areas often are served by immigrant doctors.  One should read about Abraham Verghese, who has written about the years when he was in Eastern TN, not that far from Wise County VA.  His original training as a doctor was in India.  Many doctors in rural areas in this nation are foreign trained, and/or foreign born, because too many of our American doctors have been unwilling to work in those communities.  After all, one incurs huge bills in medical training, which are far easier to pay off as a specialist in a metropolitan area.  

We have forgotten how many people live outside the metropolitan areas.  Some are living in communities that have been largely economically abandoned.  They lack skills that would make them employable elsewhere, and besides, the only support systems the have are familial, or communal, in the communities where they have spent most of their lives.  They lack skills because in many cases they lack education, and our recent approach to educational policy has apparently been oblivious to the different needs of rural communities.  

The medical and health problems are not limited to rural Appalachia.  Were you to go into meatpacking plants in Iowa, Nebraska or North Carolina, you will find many of the workers were not born in this nation.  If you saw "Food, Inc." you got a sense of how many are undocumented - makes for a compliant and cheap work force, doesn't it?  Some companies in the food industry do provide some health insurance, others do not.

And in our cities there are often sections with huge numbers of unemployed.  Because most health care in this country has been provide through an employer-based insurance system, those communities often have large numbers of people not receiving medical or dental care on a regular basis.  

Several of the dentists with whom I worked at Wise County read my Friday diary.  That led to some extended conversations, especially when we had to cease triaging because we had no place to put anyone else in the xray or service areas.  These medical professionals are as frustrated as some of us in the blogosphere on those politicians and journalists and pundits who simply do not "get" it, that we are mistreating a large group of people and that becomes very expensive, not merely in the emergency services they were providing for free, but in the human cost.  

I mentioned the diary commenting about serving people in animal stalls.  One dentist noted that those stalls were used just as much for medical/dental during this weekend as they are for animals for the county fair, which is the only time they are animal stalls. And in that conversation I found myself saying that if I thought of animals inside I might think also of another term, a manger, and perhaps that might bring up some associations for a few people?

I almost did not go to Wise this weekend.  A number of my classmates from my Political Leaders Program class at the Sorensen Institute did have to cancel.  My wife and I talked about it, and I decided that if I had to skip one planned event this summer it was more important to go to Wise for this than to Pittsburgh for Netroots Nation.  I still do not know if I will do the latter.  I do know that I am glad I went to the Southwestern part of Virginia.

Yesterday va dare gave me a tour, including driving to the top of Black Mountain, on the border with Harlan County KY (and at the border, at 4411 feet, it is the highest point in the Bluegrass state).  From the top one could look at at multiple sites of mountaintop removal.  Or one could simply look nearby at a huge sheer expanse of white - bare, naked rockface.  Not something you would see naturally among these ancient green mountains.  It stretched over half a mile, and perhaps 1,500 from bottom to top.  The rest of the mountainside has been sheared away to get the coal, dumping the rest as valley fill.  

That image has stuck in my mind, because it is applicable to my reaction to the Remote Area Medical / Missions of Mercy event at which I volunteered.  We have people who care deeply about the place in which they live, in which their families live.  They care deeply for one another.  We saw husbands and wives come together, some older, some only in their late teens or early twenties.  Some were missing parts of legs - perhaps mining accidents for the men, almost certainly diabetes for the women.  We tried to serve as many as we could.  I saw the dentists, the dental assistants, the ordinary volunteers, trying to treat each person with respect and dignity.  These are our fellow citizens.  They are not their dental conditions.  They are not the situation of economic distress to which somehow our society has allowed them to be stripped, almost like that naked expanse of rock.  Some just wanted to stop the pain - take out all the teeth.  Others desperately wanted to save their front teeth, to be able to smile, at least partially.  

This connects with much of what I feel about educational policy.  Our President has supported his Secretary of Education in insisting that states evaluate teachers by the test scors of their students.  My students are not merely their test scores.  That is like seeing only the coal in the ancient mountain, and that approach winds up with the naked, white rock face appearing as a huge scar across an otherwise beautiful - and ecologically rich - landscape.

Many of the mountains were previously raped for the lumber.  Now they are being raped for their coal.  In neither case does the extraction benefit the people who live there.  And to have so many of those people subject to the indignity of massive dental extraction with no immediate followup for dentures speaks loudly - we as a nation do not care.  About our landscape which we value only for the resources we extract, about our school children whom we reduce to numbers on tests that really do not indicate what a child knows or can learn and do, about those of our people who are in so many ways shunted aside.

I could quote Matthew 25, which given how religious many of those patients I encountered this weekend are, is appropriate, about whatsoever we do to these the least of the brethren of Jesus...  I could again quote Hubert Humphrey, noting that here we are truly dealing with people who except when we again provide media focus on the RAM event are in the shadows of American life, and what that says about the moral test of this nation.

I mention both.  I hammer on neither.

It is insufficient that I volunteered, although for me it was important, and I expect to go back so long as I am physically able.  That is, so long as we have this shame in our nation that the Wise health fair is necessary.  I need to be reminded, because it is my shame, that the nation in which I live, in which I pay taxes, can allow this scar upon the soul of the nation.

There is another passage from the Gospel that comes to mind.  How can you love God whom you cannot see when you hate your brother whom you can see.  

Perhaps some will argue that they do not hate. I will agree.  They do worse.  They ignore, they deliberately turn away, they find occasion to blame.  I unfortunately heard that this weekend from someone I know and like, who simply does not understand that this falls on all of us.

When I consume electricity unnecessarily, as a Virginian I contribute to the mountaintop removal that left that scarring of the mountainside that is now ingrained into my memory.  

When I insist on buying the cheapest food or the cheapest clothes because I am trying to stretch my dollars, do I consider the economic impact on those in this nation, or in the other nations upon which manufacturers and food producers depend in order to supply us at the lowest cost possible while they still make obscene profits?  

I am ashamed.  I am embarrassed.  By myself, by the obtuseness and obliviousness that has been so much a part of my own living, even recently.

Perhaps I am now Wise-r as a result of this weekend?  Or to put it another way, since the beginning of wisdom is to admit what one does not know, I have begun to learn how little about my state, about my nation, I really know.

I am of an age to have seen Harvest of Shame when it first came out.  That is almost half a century ago.  That was one window into the hidden places in this nation that too often we pretended were not there.  We saw others through the Civil Rights movement, through the organizing of the farm workers by Cesar Chavez and Delores Huerta.  

I think I have learned one thing this weekend, or perhaps finally understood something about which I had an inkling.  Here I speak only for myself.  I cannot compartmentalize.  I am too interconnected with all of humanity, and with all of the world.  To compartmentalize is to risk turning away.

I cannot fix the world.  I cannot carry all of its pain.  But perhaps now, after this weekend, an important parable makes sense to me.  It is the tale of the small boy on the seashore, with the water having receded, reaching down, picking up one star fish after another, and throwing them back.  A man tells him he cannot save all the starfish.  The boy with the wisdom of a child acknowledges that, but also points out that he is still saving some.

My friends the dentists, the dental assistants, the ordinary volunteers, me -  we were like that little boy.  We were saving star fish -  one at at time, only a few of the vast number stranded on the beach.

We might not be able to prevent the waters from receding.  With a star fish perhaps all we can do is pick it up and throw it back.

With our fellow human beings, cannot we do more?  Yes, we must continue to help where we can.  For some that will be the limit of what we can do.

For others?  Cannot we reconnect ourselves with what it means to be part of community, part of common humanity.

". . .and secure the Blessings of Liberty to ourselves and our Posterity . . "

Might not being able to smile be one of the blessings of liberty?  Do we not owe that to one another?

I will carry this weekend with me for the rest of my life.  If I do not, if it has not meaningfully changed me, then I have neither conscience nor soul.


Originally posted to teacherken on Sun Jul 26, 2009 at 04:55 PM PDT.

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