volunteer fire department and a community center... that helped revitalize the community. And St. Charles, in Lee County, Virginia, needed revitalization. This part of the southern Appalachian Mountains was once Daniel Boone country: ridge after ridge forested with oak, sycamore and ash. There are more wild flowering plants in southern Appalachia than in any other region of the U.S., and the land's original inhabitants, the Cherokee Indians, developed sophisticated medicinal uses for them. After thousands of Cherokee were herded in mid-winter marches to an Ok- lat]oma reservation, most dying enroute, the area was settled by whites. The descendants of those original pioneers didn’t continue west in the same pattern, however, but simply moved farther up the hollows. Preferring to remain in the mountains and near their kin, they soon became isolated from a rapidly changing America. “What is it about this country that people like the most?” I asked an old miner who had been born just down the road. “The hills,” he answered simply. “They like the hills.” But the country’s new inhabitants didn’t hold those hills for long. First they sold the timber, then the mineral rights, and stories about farm families losing their land to coal companies became a part of the region’s tradition. Today, 40 percent of the land and 70 percent of the mineral rights are held by corporations; nearly three-quarters of the surface acres and four-fifths of the minerals are absentee-owned. This in large part accounts for southern Appalachia’s lack of public services, economic development, housing and agricultural land. In many of these rural counties, unemployment runs between 20 and 50 percent. Lee County is soft coal country, the dirty burning, high sulphur content coal whose use is increasingly restricted. This is also a “low’coal” area, where seams are 24 inches to 36 inches high, mine shafts often only 42 inches, and miners work on their knees. “What kind of protection did you wear?” I asked an old miner who Art was treating for lung disease. “Oh, the new men would wear pads,” he laughed, “but after a couple of years you would build up a big callus. You could just crush a lump of coal with your knee and not feel a thing.” An anomalous- country, this industrialized rural area. Lee County’s streams are either dark and dingy or glittering with golden acids from the coal mines. All of them are littered with trash that has been washed down in floods that plague the area because of strip mines on the hills. There are abandoned cars in the brush and garbage scattered everywhere. Roads follow streams that are often lined with shacks crowded cheek to jowl along a narrow strip of level land; many end at coal mines. The Bonnie Blue Mine outside St. Charles, for instance, had 2000 men underground every day during the 1950s. But now the country has been used up, coal production is down, and during the 1978 strike the companies broke the union. Most of Art’s patients are old people, chronically ill, hanging on in a land that cannot support its children. His work consists primarily of treatment that eases suffering and prolongs life. There are few cures in Lee County. “This region has so many myths surrounding it that it’s hard to get to the substance, even after living here a while,” Art says. He’s dressed as you would expect an unmarried country doctor to be, in hurried purchases from the county’s only department store: Penney’s indestructible double knit slacks, black shoes, a tie and white shirt with sleeves rolled up. His front pocket bulges with pens and note pads. “But if I see 30 patients a day and just listen, they should tell me what I need to know.” What they reveal is a litany of problems stemming in large part from the area’s position as an economic colony: alcoholism, black lung, internal parasites, teenage pregnancies, lack of money for medicine, lack of dental care, and scores of bodily injuries that occur in the mines. “It's hard to find even one family that hasn’t been affected by some tragedy,” Art explains, “like a husband or a son or a brother seriously injured or killed in the mines.” Unfortunately, the real challenge for physicians like Art Van Zee isn’t fighting the environmental and social forces responsible for those conditions, but the sheer hours of work necessary to simply care for the sick. “Working 70 to 80 hours a week and being on call so much is not good for me; it doesn’t make me a better person at all,” he says with a rare show of emotion. “All of us in clinics like this would like to expand our treatment, but I’d like to pursue music and reading and writing, too. And how many Jx>oks have I read in the last five years? You start off with all these visions of the kind of person you want to grow into, and then you find yourself in an occupation where that’s going to be impossible. You just set yourself up for disappointment and depression. When I was starting out, I didn’t really understand burn out, I didn’t realize that I was in fact more susceptible to it than other people because I was more idealistic and had higher expectations. But the point has finally come home to me. “The times I enjoyed most,” he remembers fondly, “were my first couple of years, when there were fewer patients and I had time to talk to people and wasn’t always rushed. I wrote longer notes for my charts, “I didn't really understand burnout. I didn’t realize thatI was in fact more susceptible to it than other people because I was more idealistic and had higher expectations. ” information about their families that would remind me of the important things about the patient, the interesting things they would say...I’m not able to do that now,” he says sadly, his great listening head crowded with the day’s buzzing rush. “I always thought I’d be a moral hero someday,” he smiles thinly. “But not now.” Independence, Virginia: Old Dreams Die “I left Arkansas to practice somewhere for just a couple of years,” Art’s friend Tommy Townsend explains while gesturing with a laugh toward ten years’ accumulation of books and jazz records that fill his home. He runs a hand through thinning black hair and sighs. “I felt pretty adamant and pretty strong about the National Health Service Corps then.” The National Health Service Corps was the first federal program designed to distribute health care and train people as salaried physicians. The goal was to actually put doctors where there were none, and to pay for the program with tax monies. Both Art’s and Tommy’s salaries were paid for years through the NHSC. Begun in 1972, it grew rapidly, from 75 to 150 to 550 physicians, and was projected to maintain 17,50(5 health providers by 1990. As its potential became apparent, however, the initially favorable American Medical Association began to see it as a threat, and its budget was frozen during the Carter Administration. Then the Reagan Administration effectively sealed its demise by cutting off the scholarship program that had guaranteed a continuing supply of Corps physicians. Last year, Tommy left the Corps and is now paid by his community board, just like Art. “The end of the National Health Service Corps,” Tommy says glumly, “took away any chance for participating physicians to feel like they were part of a great continuing program that was going to establish a system of fair health care in this country.” And so on Labor Day of 1984, ten years after he first settled there, Tommy Townsend threw a party at his place in the farm country near the American River, a sloping-floored house with a tiny bathroom and a view of forever. “My Old Dreams Die party,” he called it, and friends and colleagues came from 300 miles around. There was a lot of heavy drinking and a big bonfire. “It’s real hard to talk about this," Tommy explains in a gravelly drawl. “I almost want to cry.... It’s not just that the idea of the provision of funds for these dreams is over, but that you could educate people to have a similar dream or anything—it’s pretty close to over. “Ten years ago, it was felt that medicine would eventually progress to some nationalized program. In 1978, Kennedy came out with his National Health Plan, Califano came out with a plan, even the Republicans had a program. But now it’s not even on the damn Democratic Party Platform! “We believed that these community- oriented programs were going to be able to show—through the preventitive nature of their care, through their totality of care, through their ’cosmicness’ or whatever—that something was different and that people were getting better care and that this was the way to do it, and that it was acutally cheaper.... Now we just have to wonder how to keep it alive. Are you really gonna continue a labor of honesty and loyalty toward people that you came here in the first place for? Because that’s the last straw, that you’re gonna stay with them. “And how do you keep it alive? You have to compete, you have to play the game. That means making enough money so you can get another partner so you don’t work yourself to death and die when you’re forty, instead of thinking about what you're gonna do over five years in a true community program. You've got to just suck it up, tighten your belt, really be an efficient little business—you become Mr. Reagan at the lowest level possible. You just become a small business, a typical, old-time country practice: over-worked, our own creativity lost.... We’re not different from country practices 25 years ago, when traditionally about a quarter of the work was charity." Tommy sighs. “That’s the reason the National Health Service Corps was the biggest deal in American medicine,” he continues, frequently running a hand through his hair in frustration. “Charity, they say, is the flower grown on the graves of the poor by the middle-class. Charity is for you to feel good and sleep better at night as a member of the world's highest-paid profession.” He pauses, a million things on his mind. “We used to feel that the door was maybe opening on the whole community concept of health care. Now we re trying to be happy because there’s a little glimmer of light still coming under the door. But the door is closed. And yet Tommy Townsend remains at the clinic in Independence. “I’m not ever going to do private practice,” he explains,” and I can’t put the reason into a sentence because it’s not simple. I used to say, ‘Because it’s evil for a physician to make money off sick people.’ And the moral angle is still strong...to sacrifice yourself for the community. But it’s not that simple.... Why do I do it? Because there is still a light under the door, because it’s going to change. “A national health system is going to happen,” he says, sitting up a little straighter. “Even if Reagan has set everything back 40 years, he may still only be able to keep health care costs to less than 15% of GNP by 1990 by nationalizing the program! Because you could save money that way. For instance, in 1950, less than 10% of the people died in hospitals or institutions. -Today it’s 85%. It costs an average of a million dollars to add a year to a person’s life. But in rural areas, less than half the people die in hospitals or institutions. That’s because tha family ties are stronger, and because they don’t know that staying hooked up to a bunch of tubes just to be sick and die in their last year of life is really that important. They’d rather be home, with the comfort and respect they get there. That may be something even a Republican can see.... Those are the hopes,” he ’ concludes, his enthusiasm running down. “But it really hurts to see all this,” he says, looking across the hills,” because personally our clinic is losing out. The horror is, you never sit still in the water. Programs like this are tethered with only one cord-length of anchor chain, so you sink as the water rises. If you’ve only got one cord-length, you’ll drown. Rhodell, West Virginia: Patron Saint of the Hopeless Dr. Joanna Roberts, who was Art Van Zee’s mentor in his student days, didn’t attend Tommy’s Old Dreams Die party. Tethered to her clinic in Rhodell with less than his metaphoric cord-length, she has simply learned to survive underwater. “St. Jude’s Health Clinic” the sign on the two-story building reads; St. Jude is the Patron Saint of the Hopeless. I came here after having worked in Mississippi for eight years at one of the original Poverty Program clinics set up in the 1960s,” Joanna explains. “At that time, the politicians said, ‘Let’s give them something that looks like health care.’ They had no desire to set up a health facility that would compete with professionals in private practice. So the structure of those clinics was designed to make you non-competitive, they were inefficient and wasteful because they were designed to fail. “But here at Rhodell,” she says with a kind of bravado, “we aren’t really dependent on federal funds. They are about one-third of our income, and I want to move us out entirely. But even if we got no grant funds today we could probably continue operating in the same fashion. Everybody would just take a one-third cut in pay.” Joanna Roberts does not look or act like a physician, not even an eccentric country doctor. In her 40s, she is dressed for one of the many home visits she makes each week, in jeans with a plaid shirt over a t-shirt. She laughs like a much younger person while pulling nervously on a cigarette, and takes her time to form her thoughts, then delivers them 24 Clinton St. Quarterly
RkJQdWJsaXNoZXIy NTc4NTAz