The Virginia Forum is
is an annual conference that brings together historians, teachers, writers, archivists, museum curators, historic site interpreters, librarians, and others engaged in the study and interpretation of Virginia history to share their knowledge, research, and experiences. Accordingly, the Forum is interdisciplinary in nature and welcomes proposals on all aspects of Virginia life, society, history, and culture.
That quotation is from this link about this year’s forum, held this past weekend at Emory and Henry College in Washington County Virginia. Founded in 2006, this was the 13th such gathering, and the first under the new status of being incorporated as a non-profit Virginia corporation. My wife, Leaves on the Current, has been involved in the Forum since its founding, and has been maintaining the listserv. At times in the past she has presented at the Forum, which includes a number of notable scholars.
We did not stay for the final event, a gathering at a local brew pub in nearby Abingdon, where our hotels were, at dinner time on Saturday, because we had to get back home in Northern Virginia that evening. You can see what that was like by visiting the Facebook page of the Forum.
The Forum travels around the state, as you can see by the list of locations at this website.
I serve as the guinea pig for the listserv — my wife asks me to be sure blast emails and announcements reach me so that she knows they have successfully gone out. While I have attended several events with her in previous years, largely because she needed me to serve as her driver, this year’s location intrigued me: as many here know I volunteer in free dental clinics in Far Southwest Virginia, most notably in Wise and in Grundy, in two of the three coal counties (Wise and Buchanan respectively, the other being Dickinson, which is between them). I decided to offer a paper on the history of health care in that region, and it was accepted.
My paper was the first in a group of three, before one on Midwives in Virginia, which practice continue in the more mountainous parts of the state even when it was officially illegally, and one on gun violence, specifically looking at the impact of the tragic shooting at Virginia Tech, offered by a man who at that time was an editor at the Richmond Times Dispatch.
Below the fold I offer the text as prepared for my paper. I had a few photos as well, one of which is included in this diary.
Our moderator was Joan C. Browning, herself a notable figure in Civil Rights, as a white woman heavily involved in things like the Freedom Rides. As it happens, each our papers in some way connected with her life.
Enjoy the paper.
Peace.
Everything below this is the text of my paper
The Historical Importance of Free Health and Dental Care Events in Southwest Virginia
She slept in her car starting Tuesday. Friday, she had all her teeth pulled, although she had no hope for dentures for at least a year. She was not yet 40.
I wrote those words in 2009.. They describe PART of my first experience of volunteering at a free medical and dental event in Wise Virginia the previous summer, sponsored jointly by Remote Area Medical and by the Mission of Mercy of the Virginia Dental Association Foundation. I have continued to volunteer ever since, at Wise, at Grundy, and occasionally elsewhere, and that is why I am offering this paper. I volunteer in dental.
This paper is titled “The Historical Importance of Free Health and Dental Care Events in Southwest Virginia.” It should more properly be titled “The continuing crisis of health care in Far Southwest Virginia.”
Let me be clear. I am neither a medical nor dental professional.
I am a high school social studies teacher who in 2008 was in a political leadership program through the University of Virginia where my cohort decided to volunteer at Wise the following July. That day the lead story in the Washington Post Magazine was about Wise.
When the following July I went to Wise I thought I knew what I was going to see. I was very wrong. I stayed with an acquaintance who lives close to the Fairgrounds where the event was held, and who over the next few days filled me in on the history of the event and the culture of the region.
Even more, what I encountered then, and what I have continued to encounter in my volunteering since, is largely what motivated me to give this paper.
I live in the wealthiest part of the Commonwealth, less than two blocks from a hospital that has played a major role in the lives of both my wife and myself.
When I first went to Wise I might have been in the same Commonwealth, but I was in a totally different world. Most of my time volunteering since 2009, I have worked in dental triage. The term triage comes from French military doctors in the Great War, and is appropriate, because what I saw represented then - and still represents today - a crisis as severe as war, one in which without the non-profit organizations would be far worse.
I will cover the history of medical - and dental - care in the Mountains of Virginia, something that cannot fully be described in 20 minutes, but I lack the time to fully set the stage on which this history has played out. I also reference my own experiences and observations.
Early in the history of coal, many mining companies provided company doctors to address the needs of the miners and their families. These services were paid for by check-offs from the miners, early on $1/month for single miners and perhaps $1.50 for families. The doctors might charge more for dealing with a pregnancy, and sometimes the companies kept the “excess” beyond what was necessary to pay the doctors.
By the time of the Coal Commission Report in 1922, a survey of 167 towns in coal country across the nation found that 147 had resident physicians and 44 had hospitals, although neither necessarily provided specialized care, for which miners and their families might have to travel and pay out of pocket. Some doctors, serving a number of mines, were able to accumulate enough money to themselves own coal mines!
This was the primary source of medical care in coal country, including Virginia, for quite some time. After World War II the leader of the United Mine Workers of America, John Lewis, got aggressive about trying to get better medical care for the miners and their families. He led a nationwide strike in 1946, which led to President Harry Truman taking over the mines, but this was key to getting better health care. Lewis was adamant about addressing the needs not only of current miners, but also those and their families who had lost medical coverage as a result of disabling injuries.
Truman commissioned Navy Doctor Rear Admiral Joel T. Boone to do a survey of the medical care available to miners. Much of the Boone report reaffirmed what had already been learned from the 1922 Survey. But was critical to the role the Federal government played in helping move to a new system established and to some degree financially supported by the government until fully implemented as a result of the 1947 contract with the Bituminous Coal Operators Association.
The first phase was an agreement between Secretary of the Interior Julius Krug and Lewis that ended the strike, and led to the creation of benefit funds financed by royalties on coal produced and on payroll deductions.
The coal industry was booming at this time, which made the mine owners far more willing to listen to the demands of Lewis. Thus in 1947 and 1950, the National Bituminous Coal Wage Agreements established benefit trusts modeled on that of Krug-Lewis, and led to the establishment of the United Mine Workers of America Welfare and Retirement Fund.
The various agreements also addressed the needs of disabled miners, who after they could no longer work had not been provided with the medical care funded by the royalties on coal. The Funds, beginning in 1949, started covering some 50,000 disabled miners with their families. It is worth noting that this care enabled some 23,000 miners to return to work, either in the mines or elsewhere by the end of 1955.
By this time the plan through the UMWA was as comprehensive as anything in the US, providing hospital care, including some specialists; physician services, including in hospitals and some mental health service; drugs (but not long term); and appliances and prostheses.
Having the “card” was key to health care. A miner could walk into a doctor’s office and simply show the card, and the doctor would bill the fund. If hospitalization was needed, the doctor simply signed for it, and the hospital billed the fund. When there was some abuse by some doctors, a 2nd opinion was required for surgery and an approved list of doctors was established.
- another problem occurred - during the 50s and 60s many miners loaned their cards to friends and extended families as the fund became the primary source of health care payments for almost entire communities. The system became overloaded, and there is evidence of miners overusing the easy access. Further, there were diminished royalties as a result of wild-cat strikes during which operators would not pay into the funds. By the mid-70s the system was financially overburdened and collapsing. The old system was replaced with individual contracts with standard medical insurers like Aetna & Blue Cross, with each operator negotiating a separate contract, although payment into the funds continued for outstanding obligations to older miners. By the time of the 1980 report on The American Coal Miner, the ratio of doctors in most coal producing communities was less than half the national average. Most care was by General Practitioners, although there had been an increase in specialists in the previous decade.
- key issue was hospitals. Many local hospitals in the mining communities, including in the states around Cumberland Cap, were of very low quality. In the mid 1950s the UMWA Welfare and Retirement Fund established the Miners Memorial Hospital Association facilities, which were state of the art. These were totally free to miners with the “card.” Of the ten established, one was in Wise VA, but many of the others were in counties in Kentucky and West Virginia that bordered Virginia coal country. However, by the early 1960s most of these hospitals were in dire financial straights, as they had lost $40 million in 5 years. The Kennedy administration intervened, in part to avoid violence from the miners who had come to depend upon these institutions. The Presbyterian Church’s Board of National Missions was willing to take the chain over for $9.6 million, but was unable to provide the financial resources to do so. Ultimately the federal government financially enabled the transition. What is left of the original ten, plus several other institutions, are now part of Appalachian Regional Healthcare, although the hospital in Wise has closed (there are now several hospitals in Norton, an independent city in Wise County).
It is important to note that full dental coverage was not always a part of what the miners got. This was in keeping with the ridiculous separation in the US between medical and dental, even though dental issues can if unaddressed regularly contribute to serious medical problems.
Let’s jump ahead to our time. First, the coal industry has been dying for some time, and along with it employment in coal, which has been a significant economic driver in the 7 counties of Far Southwest Virginia. Coal production in Virginia, which was 46 million short tons in 1990, was in 2016 down to 12.2 million. Production is far more mechanized, meaning far fewer jobs, with only around 3,000 actual miners state wide in 2016, fewer jobs than in solar energy. This is not surprising given that nation-wide coal employment has dropped more than 80% since its peak in the 1920s.
- of Virginia’s coal is mined in Buchanan, Dickinson and Wise counties. These all have depressed economies, as do other counties of Far Southwest. Buchanan and Dickinson had 6.6% of their people unemployed as of December - compare this to Arlington, where I live, which was just over 2%. Similarly, income in Southwest- whether measured by per capita, median family, or median household - pales to the better off parts of the state. Arlington has a median household income of 94.8k. Compare that to Buchanan at 29.1K and Dickenson at 29.0. Buchanan has about 1 in 5 people on Social Security Disability Insurance as a primary source of income - one can see this in some of the people who show up in the events at Wise and Grundy.
Despite multiple health programs, including Medicare, Medicaid, SCHIP, and ACA, there is still a shortage of medical and dental practitioners and a large groups of people who do not get regular health care. The percentage has gone up even as the population base of the counties in question has either shrunk or gone static. Wise, with 39,000 people, has more on SSDI than does Arlington with 230,000.
It is in this context that we can best understand the role of non-profit groups providing free health and dental services.
We start with the Health Wagon. In 1980 Sister Bernadette Kenny, who had been a medical missionary, began providing free health services out of her Volkswagen Beetle. Over time this has expanded into a large organization, now headed by Teresa Gardner Tyson, like Sister Bernie a nurse practitioner, that provides service both in two fixed clinics and through mobile vans in 6 of the 7 counties of Far Southwest (not Tazewell) as well as the city of Norton. In 2016, the mobile vans and clinics provided over $1.7 million in medical services, as well as another 1.7 in pharmacy and laboratory services.
Of greater importance, it was Sister Bernie and Teresa Gardner who persuaded Stan Brock to bring his Remote Area Medical to Virginia, beginning at Lonesome Pine Airport in 1980 then moving to the Wise County Fairgrounds. These events were done in partnership with the Mission of Mercy, founded under the auspices of the Virginia Dental Association and its executive director Dr. Terry Dickinson through their foundation.
- give some idea of the impact of these events, the total value of patient care in 2017 for just the Wise event in July was $1,471,828. In the 18 years at Wise the total amount is over S26 million. Wise saw hundreds for various medical procedures and over 1,000 for dental procedures, the latter with a value of more tan $1.2 million. For Grundy, by comparison, dental saw just under 400 people with a value of more than $400,000.
But money and people do not tell the whole story. In the 18 years beginning with the first event 124,464 teeth have been extracted. I can recall too many times of the only service we could provide in dental was a full mouth extraction - for someone still in his 30s. Or because we could give only one service, asking a woman if she wanted to end the pain by extracting all her molars or to try to save her smile by filling the cavities in her front teeth.
It is worth noting that Health Wagon continues to expand its services. It now offers telemedicine with specialists, and is from its fixed clinic in Wise able to provide for remote diagnoses in most specialties. It is also piloting delivery of medicines by drone, which given the number of medicines some locals need is expected to contribute to better health.
Over the years since I first volunteered, the numbers coming for general medical purpose have come down at Wise, although dental has not decreased that much. Yet despite the implementation of the Affordable Care Act, there are still major problems.
First, Virginia has not YET expanded Medicaid.
Ad even with ACA, many people cannot afford the co-pays that could be part of their plan or coverage even under Medicaid: remember the unemployment, SSDI, and income figures I cited.
Even those with Medicaid have the problem of finding medical and dental professionals willing to take patients for what most view as a totally inadequate reimbursement rate. Of the more than 4,000 licensed dentists in Virginia, only 1/3 accept Medicaid patients. 14 localities statewide have NO Medicaid Dental providers.
And even though SCHIP and Medicaid both provide for a lot of dental, access to pediatric dentists is pretty much non-existent in most of Far Southwest.
When I first volunteered in Grundy in 2009, there were 4 dentists practicing, of whom 3 were over 70, and only one of the 4 took Medicaid.
Doctors and dentists come to these events in coal country from elsewhere in Virginia and from out of state - Virginia is a state that allows that. That means those volunteering can treat more people. But it is not enough. It is not unusual to see people turned away - lack of the necessary specialist, lack of time. Some people need medical and vision and dental, and have to go through separate lines for each. In dental we usually have to give them a choice among three services - cleaning, fillings, and extractions.
There are other services. The Commonwealth now sends hygienists to some schools to provide basic cleaning and education. The Dental Association runs other events to help. The Virginia Department of Health has established the Southwest Virginia Medical Reserve Corps that covers all 7 counties of Far Southwest. However, the primary purpose of this group is to cover public health and local emergencies, although members of the Corps may participate in volunteer events as well.
I began by telling you that I often work in dental triage, and why i thought such terminology was warranted. We are very unequal as a Commonwealth when it comes to health issues, even more so with dental - after all, dental services are not part of most medical plans, even though dental issues can easily spread throughout the body with serious consequences.
Historically much of the health care in Far Southwest came through the coal industry. But that industry is a shadow of what it was. That has huge financial impacts in the region, and equally strong effects on medical care.
Coal Country has many problems. Rates of things like cancer and obesity and diabetes and depression tend to be far higher than in the rest of the Commonwealth, as does the increase in opioid issues. The medical and dental issues would be far worse were it not for things like the Health fairs and the Health Wagon. They are necessary. They provide valuable services. But they are not enough.
Given the low income in the region, it is worth noting that there is either inexpensive or free public transportation through buses that run variable fixed routes. In Buchanan, Dicksenson, Russell and Tazewell this is provided by Four County Transit. In the rest of the region, including Norton, it is provided by Mountain Empire Opportunity Center. This enables people to make regular medical and dental appointments, if they can afford the co-pays. There is not, however, any transportation to specialists outside the region.
The history of health care in Far Southwest has been uneven. The communities still need assistance in providing it to all of the people. With uncertainty over the future of the ACA, and the proposed cuts to Medicaid in the current budget proposals, it is not even clear that things won’t become worse.
Meanwhile I am now 71. I began volunteering when I was 63. I will continue to volunteer in Coal Country as long as my own health allows.
Why?
You have all your teeth, smile. You can.
Now think of all the people in Far Southwest for whom such a smile is not possible.
Thank you for letting me present to you today.