*
I found hope in the stories of Tyson’s staff and patients as I set out, in multiple visits, to discern what happened after the volunteer doctors departed for their urban enclaves, and the politicians and pundits went home. I felt hope as I witnessed Tyson, a bubbly, every-curl-in-place blonde, manage her workaday free clinic as she seamlessly steered her rattling 2001 Winnebago through southwest Virginia’s serpentine roads, juggling phone calls from nurses, patients, and the media alike—in high-heeled, rhinestone-studded sandals. With her sorghum-thick accent, Tyson was camera-ready and thoroughly put together each time we met, except once, when mascara smudged her doctor’s coat.
I would find out soon enough why she’d been crying for days, and it wasn’t because the battery on her Winnebago had just conked out. (The nonprofit’s marketing manager was dispatched with the battery booster to give us a jump, while Tyson’s husband offered real-time jump-starting counsel via FaceTime.)
It was a fitting state of affairs for what happens after the out-of-state RAM do-gooders depart and Tyson’s grant-funded Health Wagon staff of twenty is left to tend to the health needs of the region’s uninsured. The program is called the Health Wagon because it was founded in 1980 by a Catholic nun and medical missionary named Sister Bernie Kenny, now retired, who first provided care out of the back of her red Volkswagen Beetle.
At our first stop, Tyson treated the swollen wrist of a substitute teacher whose pay had just been reduced from $70 to $56 a day. She was a casualty of school district depopulation and austerity, measures that included closing two schools in the town of Appalachia, one of which was now a food bank. In St. Paul, where our RV was presently stalled, the middle-school roof had become so tattered that buzzards had descended on it a few months earlier to eat the rotting tiles. With no money for repairs, school administrators resorted to temporary measures to divert the vultures, erecting giant inflatable tube men, the silly beacons you see waving from car dealerships.
The fifty-four-year-old teacher hadn’t had insurance in decades, not since she was pregnant and qualified for Medicaid; her husband, a former Walmart worker disabled by a series of strokes, was on Medicare. Because Virginia hadn’t approved the Affordable Care Act Medicaid expansion, she patched together free coverage at RAM events and occasional visits to Tyson’s mobile unit when it came to town. She had to be practically dying before she went to see her family doctor, who accepted cash at a discount rate of $63 per visit.
*
In a state with an increasingly flimsy safety net, people like Tyson had been left to clean up the politicians’ mess. As the health care debate over repeated attempts to repeal the ACA raged in Washington and opioid activists waited for President Trump to declare the epidemic an official national emergency—to free up immediate federal disaster relief funds for cities and states—between patients Tyson followed the machinations on her phone, fuming as she scrolled.
A devoutly religious wife and mother from nearby Coeburn, she was finding it hard to remain optimistic. In our first interview, she’d been distraught over the recent death of a forty-two-year-old patient caused by untreated hepatitis C. Though he hadn’t used or injected drugs for eight years, he could not afford to see a specialist. And by the time treatment could be arranged, “the damage was already done, and he couldn’t overcome it,” said his father, who owns a twenty-seven-acre cemetery.
The man buried his son near his office so he could visit him daily, he said. He invited me to tour the Wise County graveyard, where he offered to point out the scores of people he’d personally buried thanks to “OxyCoffin,” as the pills are now known here.
Months later, Tyson found herself crushed by a repeat in the continuing tragedy: In spite of 24/7 news cycles and a dense web of interconnectedness, here was one more death that gained no media traction and inspired zero public action. She could give all the interviews she wanted during the month of RAM, but the truth was that the extent of the suffering here garnered very little attention outside the spectacle of the annual health care event.
Unremarked on were the slow-simmering and increasingly common stories of people for whom no treatment could be secured. This time Tyson was crying about Reggie Stanley, forty-five, who died in a Charlottesville hospital while awaiting a liver transplant, after twelve years of untreated hepatitis C. “This patient was such a good person. He did make the wrong decisions initially,” Tyson said of Stanley’s IV drug use, but he’d been sober for several years. She’d tried desperately to get him into treatment, but like 90 percent of her patients, he was uninsured, and Tyson could not persuade a gastroenterologist to take him on as charity care. (She has since had success dispensing free medication provided by the company that makes Harvoni, the expensive hepatitis-curing drug.) By the time Stanley made it to a liver-transplant list, his disease was too advanced.
“You can fix it upstream, when it’s affordable, or you can wait till they present back in the ER with stage-four cancer or cirrhosis, and they still need extended hospital stays,” Tyson said. “It’s a drain on the system no matter what, so why can’t we fix it upstream?”
Tyson kept looking at Stanley’s obituary on her phone, which included a photo of him beaming in his Clintwood High graduation gown. “He was a great guitar player, great singer, and a good soul who was loved by many,” one of the guest-book mourners wrote.
*
The region’s health-department director, Dr. Sue Cantrell—the same one who’d warned state supervisors about the epidemic two decades before, only to have her pleas dismissed as “a regional problem”—was slowly making inroads. With the Scott County, Indiana, HIV epidemic still in mind, Cantrell had been holding town-hall meetings in the coalfield counties throughout the summer of 2017 to sound the alarm. Though Virginia had recently passed legislation paving the way for syringe exchange programs, every legislator in the coalfields had voted against the bill, citing widespread local law enforcement concerns, even though crime historically has not risen in communities with access to clean needles. Across the border in West Virginia, a 2015 syringe exchange had resulted in lowered overdose deaths and five-times-greater access to treatment and disease prevention services. Cantrell was hoping to arrange a visit from a West Virginia police chief to talk to local authorities, and her staff was already teaching users to clean their syringes between injections, giving out Clorox packets and plastic cups. She sometimes offered free food to entice patients both to be tested and to return for their results.
The RAM clinic offered free hepatitis C testing for the first time—a pharmacy professor estimated that 75 percent of IV drug users in the region have contracted it “and have no idea”—and handed out take-home naloxone kits with training to almost four hundred people. “In a rural area like this, just trying to get people to their appointments is huge,” Cantrell told me. Two patients in the MAT clinic she runs in nearby Lee County, Virginia, either hitchhike or walk to their appointments, some from a distance of more than five miles.
She’d floated the idea of turning some of the area’s subsidized housing units into “clean living facilities,” with wraparound services and support group offerings, not unlike substance-free college dorms. “We need to support this as a chronic disease the same as we support cancer and other diseases,” Cantrell said. “Not just evidence-based treatment and drug prevention programs but broadening it to meaningful education that leads to jobs with a living wage so there are options to stay in the area—or to leave.”