It was a Third World scene with an American setting. Hundreds of tired and desperate people crowded around an aid worker with a bullhorn, straining to hear the instructions and worried they might be left out.

    Some had arrived at the Wise County Fairgrounds in Wise, Virginia, two days before. They slept in cars, tents and the beds of pickup trucks, hoping to be among the first in line when the gate opened Friday before dawn. They drove in from 16 states, anxious to relieve pain, diagnose aches and see and hear better.

    "I came here because of health care - being able to get things that we can't afford to have ordinarily," explained 52-year-old Otis Reece of Gate City, Va., as he waited in a wheelchair beside his red F-150 pickup. "Being on a fixed income, this is a fantastic situation to have things done we ordinarily would put off."

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    For the past 10 years, during late weekends in July, the fairgrounds in Wise have been transformed into a mobile and makeshift field hospital providing free care for those in need. Sanitized horse stalls become draped examination rooms. A poultry barn is fixed with optometry equipment. And a vast, open-air pavilion is crammed with dozens of portable dental chairs and lamps.

    A converted 18-wheeler with a mobile X-ray room makes chest X-rays possible. Technicians grind hundreds of lenses for new eyeglasses in two massive trailers. At a concession stand, dentures are molded and sculpted.

    Desperate for Health Care

    The 2009 Remote Area Medical (RAM) Expedition comes to the Virginia Appalachian mountains as Congress and President Obama wrestle with a health care overhaul. The event graphically illustrates gaps in the existing health care system.

    "We're willing to sleep in pickup trucks or cars and deal with the elements to at least get some kind of health care," Reece adds. He earned a six-figure income working for an international industrial supply firm until an accident five years ago left him disabled. Joining him for dental, vision and medical checks are his wife, daughter, son-in-law and three grandchildren.

    "Tomorrow, I'm going to see the doctor to get my ear and my nose fixed!" grandson Jacob shouts excitedly. His nose appears battered and his ear has an oozing scab.

    Before the gate opened, Loretta Miller, 41, of Honaker, Va., got four hours' sleep behind the wheel of her parked minivan. She was No. 39 in line for her eighth RAM expedition. Her visit last year saved her life.

    "They done an ultrasound and told me that my gallbladder was enlarged and was ready to burst and it could kill me," Miller recalls. "They told me if I hadn't got help when I did, literally I could have died."

    Medical, dental and vision help is often elusive for the 2,700 people seeking treatment during the three-day RAM event. Just over half of the people attending this year have no insurance at all, according to a survey of the patients conducted by RAM. Forty-seven percent could be considered underinsured, given unaffordable copays or gaps in coverage provided by Medicare, Medicaid and conventional insurance plans. Only 11 patients have dental insurance, and just seven have vision coverage.

    "There's no doubt about it. There is a Third World right here in the United States," concludes Stan Brock, RAM's founder. Brock has organized similar medical expeditions in Asia, Africa and South America. "Here in the world's richest country, you have this vast number of people, some say 47 million, 49 million, that don't have access to the system and that's why [this] is necessary."

    About 1,800 volunteers provide the medical, dental and logistical help, including hundreds of doctors, dentists, nurses, assistants and technicians.

    Almost 4,000 Teeth

    Miller is ecstatic when her number is called. The divorced hairdresser and mother of two is uninsured and in pain. But she had taken the time, even with little sleep, to put on makeup, braid her blond hair and dress in a white lace tunic. She walked briskly through the gate for what would turn out to be five hours in dental chairs, given the extraction of an abscessed tooth, three fillings and a root canal.

    More than half of those seeking help sign up for dental exams and procedures. They fill the more than 70 dental chairs while hundreds wait their turn under tents nearby. Hundreds more out in the grassy parking lot hope they'll get their teeth cleaned and fixed before the event ends.

    Dental health greatly affects general health, says Dr. Terry Dickinson, who directs the Virginia Dental Association and the RAM dental effort at the Wise fairgrounds.

    "The infection in the mouth certainly has been shown to have an effect on systemic diseases," Dickinson explains. "So it's really critical that these folks be able to get infected teeth out and infection treated in the mouth because it's going to help them with their overall health."

    The extent of infections is staggering. Dickinson and his team pull 3,857 teeth in 30 hours of work spread over 2 1/2 days. Some patients lose all their teeth. A 4-year-old had cavities filled in every tooth.

    Who Is Responsible for Health Care?

    Terrible teeth, obesity, smoking, high blood pressure and diabetes are common among the people seeking help here. That raises an important question. Are they at fault for their poor health?

    "There's enough blame to go around for everybody. I think patients certainly have to have personal responsibility for what they're putting in their mouth, but we are also trying to create a better access care system. How are you going to get providers, whether it be dentists or physicians or anybody else, into these areas where economically these communities are struggling?" Dickinson asks.

    That's a reference to the costs of medical and dental schools and the debts that graduates incur, which can be $100,000 and more. There's pressure to practice in more lucrative places beyond rural regions like Appalachia.

    "There are areas of the country, and certainly Wise County is one of them, where there just aren't [enough] physicians," says Dr. Susan Kirk, an endocrinologist and diabetes specialist with the University of Virginia Health System, which provides specialists for the Wise RAM event. "We provide indigent care at the University of Virginia, but that's six hours away."

    RAM founder Stan Brock is impatient with those who suggest the people seeking help in Wise are somehow at fault and unworthy of care given poor health habits.

    "The rest of the population is not exactly in the best of shape themselves," Brock asserts. "They're eating well and, therefore, they're putting on weight and, therefore, they've got heart disease and the rate of diabetes in this country is going up. But, in the case of the well-to-do and the well-insured, they can afford to take care of it."

    At the end of her long day with dentists, Loretta Miller was still numb with Novocain but grateful for the care she could not otherwise afford.

    "It's well worth the drive and the wait," Miller said, close to 12 hours after her number was called. "You get tired and stuff. But you think about all the trips and the money it would have cost to have all this done. I couldn't have had it done."

    She then laughs about standing in line again at 5 a.m. the next day so she can get eyeglasses to "see what they've done."

    RAM organizers say they spent about $250,000 providing care worth about $1.5 million. In 10 years in southwest Virginia, they say, they've treated more than 25,000 people. They have eight more expeditions planned this year, from Virginia to California.

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    By the Numbers

    A survey of RAM attendees by the event's organizers provides some insight into who is left out of conventional medical, dental and vision care.

    What: Health care providers saw 2,715 patients and performed 2,671 medical exams, 1,088 eye tests and 1,850 dental exams. They extracted 3,857 teeth and put in 1,628 fillings.

    Who: Patients came from 16 different states; 30 percent were repeat patients.

    Of the patients, 51 percent are uninsured, 40.3 percent are on Medicaid or Medicare, and just 7.3 percent have employer or private insurance. Fewer than 1 percent of patients have dental or vision insurance.

    Twenty-six percent of the people are employed, 40.6 are unemployed, 4.7 percent are retired and 4.8 percent are children.

    Cost: The organizers paid about $250,000 out of pocket to run the event, and they provided an estimated $1.5 million worth of care.

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