WISE -- Universal health care comes to this coal-mining corner of Southwest Virginia once a year, and 1,200 or so people waited anxiously for it in the pre-dawn chill Friday.
From as far away as Indiana came the uninsured poor seeking the help of about 1,400 volunteers, including doctors, dentists, nurses, optometrists and medical technicians. The annual Remote Area Medical Health Expedition, or RAM, is being held for the ninth time at the Wise County Fairgrounds.
The grape-sized cyst that bulged from Brian White's right cheek brought him from Bristol, Tenn., an hour's drive. "I hate living with this, but my only income is about $600 a month in government disability benefits," said White, 28, who said he has been unemployed for many years. "I can't even think about getting together enough money to see a doctor back home."
But at the fairgrounds, in a tent, Dr. Vincent Voci, a plastic surgeon from Charlotte, N.C., slices into White's cheek, pulls the cyst out with a plierslike instrument and puts in 15 stitches -- all in less than an hour. "That's normally a $1,000 procedure," said Voci, wearing a black T-shirt and combat fatigue pants.
"God bless you," said White.
"You, too. You're a nice man," said Voci. An assistant brought him the next patient's chart; six more waited outside the tent.
The RAM clinic in Wise County is supported largely by volunteers from the University of Virginia Health System, an arm of UVa that also donated 1.5 tons of supplies, ranging from blankets to glucometers.
The RAM organization itself is based in Knoxville, Tenn., and it also organizes free clinics in its home state, Kentucky and Louisiana, as well as internationally.
"We go where we think the need is greatest and where we can get cooperation," said Jean Jolly, a part-time employee who coordinates volunteer activities.
But in some states where RAM has offered to start clinics, Jolly said, certain medical specialties oppose the effort.
"It's turf protection. You'll find optometrists' groups that want to charge each volunteer eye doctor $700 for the right to come and give their time for free."
No such resistance exists in Virginia, and the medical team has found a home in Wise County, where Roanoke dentist Steve Alouf brings a 30-foot tag-along trailer equipped with two chairs for oral surgery.
"It makes me feel just great to do this. Dentistry has been very good to me," said Alouf, who along with Greg Gray, a Roanoke dental lab technician, has spent more than $15,000 creating the traveling facility.
By noon Friday, the two had treated 20 patients, and they planned to work until 6 p.m. or so -- then return for similar efforts today and Sunday.
The clinic has come to the right place to find many in need. According to the 2000 U.S. census, about 20.2 percent of Wise County's population come from families below the poverty level, with incomes of less than $21,200. That rate is about one-third higher than the rest of Appalachia Virginia and twice as high as the state overall.
To be sure, the impoverished in the Wise County area have other benevolent medical sources to which they may turn. Norton Community Hospital, a 129-bed nonprofit institution, wrote off about $3 million in charitable care in 2007, according to Barbara Hale, the chief financial officer.
"We see an increase every year in the need. We've had a 381 percent increase in charity write-offs since 2001," she said.
"It's all about insurance. Our unemployment here is high and many of our patients who do have insurance either have insufficient coverage or such large deductibles that they're still afraid to seek care," said Hale, who has regularly volunteered at RAM to register patients.
To some area residents, RAM's very existence is an embarrassment and an indictment of the medical system.
"We need to put RAM out of business -- to fix what's wrong down here instead of having hundreds of people come in to rescue us once a year," said Elizabeth McGarvey, associate professor of public health sciences at the University of Virginia School of Medicine who is researching health issues in Appalachia Virginia.
She recoils at the long lines of RAM patients, including many children and people in wheelchairs, who camp out, often sleeping in their cars, during the three nights of the clinic in order to be among the first admitted.
"It's like something out of the Third World," McGarvey said.
Indeed, Loretta Casstevens, 29, from Kingsport, Tenn., complained that there were only six portable toilets in the parking lot. By 9 p.m. Thursday, about 900 patients were already there.
"The toilets are a mess," she said. "They're wet, so you can't sit -- and most of them are out of paper."
Jolly later acknowledged that there weren't enough toilets and vowed to increase the number by Friday night. Virginia Department of Health guidelines recommend one portable toilet for each 100 people at public gatherings -- about half the capacity provided by RAM during the first night and morning of this year's clinic.
The gates opened at 5:30 a.m. Friday. Kaiden Benton, 2, had been with her mother, Wendy, in the fairgrounds' grassy parking lot since late Thursday afternoon. They sought out roaming RAM volunteers who handed out registration numbers that gave them places in line: 59 and 60.
Once through the fairground gate, the Bentons walked about 200 yards across a gravel-strewn field to the registration building, normally used as a barn for agricultural events.
After waiting in another line until just after 9 a.m., they were ushered into the dental tent, where more than 30 chairs at a time were filled and the whine of drills was nearly constant. Kaiden was welcomed into the chair attended by Peggy Carwile, a dental hygienist from Prospect.
"It's her very first cleaning," said Wendy, who added that Kaiden had been practicing "open wide" at home. She's calm about Carwile's probing, a mood enhanced by a big red stuffed hound dog she hugged that was among many toys donated by the Lion's Club of Alexandria and the Virginia Dental Association.
"Good job. Not a single cavity," pronounced Carwile, who also gave Kaiden a professional toothbrushing lesson.
Many patients saw doctors or nurses in several specialties, depending on the lines. Judy Rodriguez, a 56-year-old Kingsport waitress and grandmother, went from having a bicuspid and molar filled to getting her first mammogram in three years. She was interviewed about her medical history before the cancer test by Danielle Gong, a second year medical student at UVa.
"Is there any history of cancer in your family?" Gong asked.
Two of Rodriguez's aunts died of breast cancer, she responded, and added, "Our family is cursed."
Gong, working on her bedside manner, struck a cheerful tone: "Well, every family has its problems."
And while almost any medical procedure can encounter complications, RAM seemed to serve most of the patients with skill and speed Friday. Jolly said that by Sunday the clinic will likely have exceeded its 2007 totals of 2,506 patients served and rendering care valued at $1.6 million.
Still, those numbers aren't enough for Jolly, who noted that every year, the clinic is forced to turn away nearly as many patients as it helps.
"There just isn't enough time. It brings tears to my eyes."