Thursday, October 29, 2009

The uninsured and underinsured of rural America

A story from AARP's Bulletin Today is entitled "The Doctor Is In - in the Heart of Appalachia." It details the latest efforts of a wonderful program called Remote Area Medical to provide desperately needed medical and dental services to the many needy uninsured and underinsured people in rural areas. Scroll down or click here to watch AARP's video clip about one of the program's recent health fairs in Wise, Virginia, population 3,255.

Remote Area Medical (RAM), based in Knoxville, Tennessee, began as a program intended to provide emergency medical services to the world's remote areas. RAM's founder, Stan Brock, created the program after spending 15 years in the Amazon rain forest with the Wapishana Indians, where he personally witnessed the devastation caused by the inaccessibility of medical services to people residing in spatially isolated areas.

The program's focus has shifted, however, and most of RAM's efforts are now focused in rural America because so many rural Americans lack health insurance or are spatially isolated from medical facilities. As founder Stan Brock says in the video, "What's sad about it really, of course, is that it's required in the first place - but the situation in the United States for many, many years now has been requiring us to concentrate our efforts here in America..."

These efforts include large-scale organized health "expeditions," which usually provide free vision, dental, and health services in a field-hospital type setting. In conjunction with a local organization from the host community, RAM coordinates local logistics and recruits as many volunteers and health professionals as possible to provide services usually over 2-3 days. The day before the expedition starts, RAM brings in all the necessary medical equipment and sets up camp.

In July, RAM's health expedition took place in Wise, Virginia. Approximately 1,000 medical professionals came to volunteer their time. Volunteers spent the day before the expedition setting up equipment under tents at the Kentucky-Virginia Fairgrounds. Thousands of people needing services came from all over (one woman came from New Jersey, a 10+ hour drive!) and waited in line for days before the expedition began providing services on Friday, July 24, 2009. The patient who nabbed the first spot in line had been camped out since Tuesday. Others, many with young children, slept in their cars to get a spot in line.

The expedition provided a wide array of services: dental services such as treating tooth decay and making dentures, minor surgeries such as tumor removal, complete eye exams, x-rays, pap smears, and just about everything in between. Patients who needed more complicated surgeries were taken to local medical facilities. No payment or identification was necessary to receive services.

I highly recommend watching the video - it is truly awe-inspiring to see such a large-scale coordination of so many dedicated and compassionate people volunteering their time, expertise, hard work, and long hours to provide such desperately needed services. The video also briefly and tangentially touches on some other issues we've discussed in class so far, such as how many people who leave rural areas for education tend to not return to settle in their hometowns. One dentist in the video, Dr. Scott Miller explains his reasoning for volunteering with RAM:

"I'm from this area so, these are people I'd see at a family reunion, some of them. My dad was a coal miner, a hard worker, and I have a lot in common with these people. I just went to dental school and they didn't."
I think this program is particularly interesting to learn about in light of the big national debate on universal health care that's currently going on. Of course, if we move to a universal health care type of system, a lot of RAM's services would no longer be needed. But the article and video clip mostly focus on the problem of uninsured and underinsured people in rural areas - they don't really discuss the problems created by spatial isolation, which was the founder's original concern. Mr. Brock created RAM because the Wapishana Indians were spatially isolated from medical facilities/services, not because they lacked health insurance. And yet the article and video clip fixate on the health insurance issue, which is a problem that plagues the urban poor as well as the rural poor. Spatial isolation, on the other hand, is a problem that's particular to rural communities. Recognizing that the health insurance issue is a problem in urban communities as well, RAM actually recently held their very first urban health expedition in Los Angeles, where they saw approximately 6,000 patients over one week and unfortunately had to turn many people away.

Incidentally, each University of California medical school includes a "Programs in Medical Education" (PRIME) curriculum, which is a combined degree program meant to "produce physician leaders who are trained in and committed to helping California's underserved communities." Each school selects different emphases for their PRIME curriculum and the UC Davis School of Medicine's PRIME curriculum, called Rural-PRIME, just so happens to focus on training its students for careers in rural communities.

1 comment:

rachel said...

The RAP program in rural areas reminds me of the use of temporary medical clinics in the developing world. One issue that is concerning in the context of the developing world that may be worth considering in rural areas as well is what happens in the aftermath of these temporary medical clinics. While they undoubtedly do great work and meet people's immediate needs, there is also concern that they leave people without access to follow-up services. Whether this means lack of post-operation care or unanticipated questions about prescription medications, the post-clinic issues are worth considering. I've also heard people voice concern about sharing of medications that had been distributed by a clinic. These issues are certainly more acute in the rural than urban context, where spatial isolation may mean lack of access to information and doctors.