The light of a Friday morning in autumn gently touched the little town: the Farmers and Miners Bank, the grocery store with the hand-lettered signboard advertising sugar on sale, the squat yellow brick courthouse. It was Jonesville, the county seat of Lee County, by many measures the poorest county in Virginia, and the farthest flung, here, in Appalachia. On this day, all attention was focused upon the outskirts, where at the small airport, preparations were under way for a free health clinic, to be held over the weekend.

In a few hours, the first of the patients would start arriving. They would come from the roads and the highways, the nearby towns and the more distant hollows, from southwestern Virginia and Kentucky and farther away. Some barely had the gas money to get to Jonesville. One woman was driving from Tennessee holding her broken glasses to her eyes. The truck with the chest x-ray machine was already parked at one end of the runway. And when the sky cleared a little more, an old airplane would be flying over the mountains, bringing in folding dental chairs and medical equipment and crates of surgical gauze and gloves from Knoxville.

The free clinic was organized by the Remote Area Medical Volunteer Corps (RAM), a nonprofit that, since its beginnings in 1985, had headed hundreds of missions and brought medical relief to some of the poorest places on the planet. This would be RAM’s first visit to Jonesville. But the health problems in this pocket of Appalachia—the cancers, the diabetes, the ruined joints—were nothing new. The rotten teeth were nothing new. The toothaches were nothing new. In Lee County—remote, isolated, poor—the shortages of all kinds of health care had been a chronic problem. There were not enough primary and mental health care workers. And the shortage of dental providers was most acute.

By federal estimates, roughly 49 million Americans live in communities that have been designated dental professional shortage areas—Lee County is one of them.

And if dentists are in short supply in places such as Lee County, so is the money to pay them. “These are not forgotten people,” explained RAM dental director John Osborn, a Knoxville dentist. “The system has passed them up.”

Hundreds, sometimes thousands of aching teeth are extracted at these free weekend clinics.

The loss of a tooth to disease may prefigure other losses in life quality. In terms of oral health, complete tooth loss, or edentulism, has been called the “final marker of disease burden.” An extraction is emblematic of defeat. The extracted tooth will not grow back. But when routine care is long deferred, when more complex procedures are out of reach or not an option, the extractions serve the urgent need of relieving infection and relieving pain.

The news of the plans for the RAM clinic in Lee County claimed top headlines in the local paper. People talked about it for days in church and at the gas station and in the coffee shop out on the U.S. 58 bypass. On this Friday, at the airport, there was excitement in the air as volunteers worked to set up a sort of field hospital with tents and folding tables. Volunteer doctors and nurses, dentists and hygienists were coming from “out of town.” A man with a “Friends of Coal” bumper sticker on his truck arrived with pizzas. Members of the high school football team, the Lee County Generals, who were waiting in their red numbered jerseys to help unload the plane, ate the pizza quietly and hungrily, out by the runway. Then a great deep-throated roar could be heard and everyone looked up to the pale clearing sky.

“Here’s the plane!” someone shouted.

The World War II–vintage C-47 cargo plane landed smoothly, then stood there shimmering on the narrow landing strip at the foot of the mountains. RAM’s founder, Stan Brock, a lean, charismatic British-born adventurer, greeted the small crowd in his calm, serious way. He was, as always, tan and, as always, dressed in a khaki shirt and pants.

Brock became famous in the 1960s as the anaconda-wrestling co-star of the television program Mutual of Omaha’s Wild Kingdom. When he started RAM, his original goal was to get health care to the people living in the far-flung, third world places he had visited in his travels. But when he discovered that there were people in desperate need right in the United States, he began organizing clinics much closer to home. (Brock passed away on August 29, 2018, after the publication of this book. He was 82. Remote Area Medical, the organization he founded, is continuing his work.)

Brock told the football players the plane they were seeing was used for the invasion on D-day, that young men about their own age had parachuted out of this very plane on June 6, 1944. “A lot of those young guys didn’t make it back,” he explained, as the football players listened with a kind of shy attention. Then it was time to get to work. There was a military precision to these operations that Brock had honed over the years that helped convey their urgency. At Brock’s direction, the football players began hauling carefully organized crates of supplies out of the plane.

Slowly, methodically, the weekend hospital took shape. Areas were set up for medical tests and exams. Eyeglasses would be provided free of charge. The airport waiting room was transformed into a six-chair dental clinic. By the time the chill of evening fell upon the mountains, a line of cars and pickup trucks had formed on the road coming up to the airport. In the predawn darkness of Saturday, about four hundred people were waiting. Worn-out miners, old farmers, tired homemakers, unemployed workers took their numbers at the gate, wrapped in coats and blankets. Charlton Strader, a retired construction superintendent with tremors and chronic obstructive pulmonary disease, said he used to have dental benefits but that he lost them. He said his teeth had started “snapping off and breaking.”

“I’ve got one that bothers me all the time,” he said.

Randy Peters, a former miner and mattress factory worker with multiple sclerosis, was also troubled by his teeth. “I’ve got a couple broken ones and a couple of bad cavities,” he said. “It’s getting so I can’t eat.”

Ernest Holdway, a disabled miner, said he came to get a tooth extracted. “It ain’t hurting but it will,” he predicted. His dental insurance ended when he had to leave the coal mine. Now his teeth were starting to fail him. “I always had good teeth until I started the arthritis medicine,” he explained. “Nobody wants to lose their teeth. I’ve heard it takes years off your life.” He said he just finished paying off the $1,500 he’d owed for the extraction of three bad molars, which he was told to get removed before a knee surgery. He was still fighting to save his leg. He showed it. It was fearfully swollen.

“I’m a good person, but I sure have been tested,” he said.

By the time the sun was fully up, Jonesville’s small downtown was empty. “Everybody is down at RAM getting their teeth pulled,” said the waitress at the coffee shop.

Throughout the day, patients emerged from the dental clinic with gauze clenched between their remaining teeth. They took seats in folding chairs underneath a tent to recover, or waited for friends and relatives still receiving services. “I had two pulled,” said Emma Marsee, an unemployed nurse. “One had an infection underneath the filling.” Marsee’s daughter, a waitress, was also in the tent waiting for care. She depended on her smile for her economic security, Marsee said. “It’s all about appearance,” said Marsee, a striking woman, strawberry blonde with golden eyes. Who wanted a waitress with bad teeth? “If you are not a healthy-looking individual, [customers] don’t want that person taking care of [them].”

Everyone in that big tent was struggling.

“It’s tough in this area because there are no jobs,” said Marsee. Even as people sat in their folding chairs, the behavior of some suggested fatalism, weary self-destruction: the girl with the deeply decaying teeth taking another drink of Coke. A baby with a sippy cup of sweet juice in the arms of a gaunt mother waiting to see a dentist. The woman with the rasping cough, taking a drag from a cigarette.

“Nerves” are a common complaint in this region, research by the Southwest Virginia Graduate Medical Education Consortium found.

“A frequently reported cause of nerves was having too many problems and too few solutions,” the authors of a study on the problem found (Southwest Virginia Graduate Medical Education Consortium, “Report to the Virginia State Assembly,” January 2008). The consortium concluded that residents of the area were 70 percent more likely to commit suicide than people living elsewhere in the state.

Marsee, too, was familiar with the dark side. “Drug abuse in this area is horrible,” she said. It showed in some of the hopeless, drug-blackened teeth.

The area has been poor for a long time, yet people hate to move on. “All your roots are here,” said Marsee. “It’s hard to leave it.” There was the old beauty of the mist-shrouded mountains, the green woods. The love of family, the kindness of neighbors, of strangers.

The teeth flame out when they die. That is a very old kind of pain. The human fossil record bears mute testimony: the ancient Egyptian mummy unearthed with packing in the jaw. The Alaskan incisor, bored with a simple tool sometime between 1300 and 1700 A.D., apparently to relieve an abscess. The tooth of a medieval Dane, with a rosary bead tucked into a cavity (Charlotte Roberts and Keith Manchester, Archaeology of Disease, 82).

Decay is a progressive disease and, unchecked, it results in excruciating pain and tooth loss. Many factors contribute; diet plays a major role. In the very old days, when refined foods were rarer, the toothache was a curse of privilege. When sugar became cheaper, tooth decay, the main cause of toothaches, became more widespread. The habit of sipping sweet sodas has been widely implicated. The steady bath of sugar never allows the teeth to repair and remineralize themselves.

These days, too, hundreds of common over-the-counter and prescription medications taken by millions of Americans make teeth more susceptible to disease.

One of their side effects is dry mouth, a condition that reduces the natural flow of saliva that cleanses and buffers the teeth, helping to protect them from decay. Without fluoride to strengthen the teeth, without enough routine home care, without timely professional care, the disease process progresses.

The excruciating pain of toothache is not rare. Millions of Americans experience toothaches.

Financial factors are the main reason Americans delay getting needed professional dental care, a study by the American Dental Association found.

Private and even public dental benefits can help defray the cost of services.

But in 2014, an estimated 114 million Americans lacked them entirely. While the national health care reform program signed into law in 2010 took significant steps to broaden access to dental services for children, it did less to address the broken system for adults. Even many working adults with private health insurance lack adequate coverage for dental care. While routine preventive visits may be covered, beneficiaries are typically required to pay a percentage of the cost of procedures such as fillings, crowns, root canals, and implants, which can run to hundreds and thousands of dollars. Among U.S. adults who struggled with unpaid medical bills, 12 percent reported dental bills made up the largest share of the bills they had problems paying, a 2015 survey found. “Insurance is not a panacea against these problems,” the researchers concluded.

And most people who have dental benefits lose them when they retire. Medicare, the nation’s health care program covering roughly 55 million elderly and disabled Americans, does not cover routine dental services.

The dental suffering among many of the more than one million residents of American nursing homes is particularly acute. Since 1987, when federal law set new standards for institutions receiving Medicare and Medicaid funding, nursing homes have been required to provide oral health services. Yet amid the daily cycle of washing, turning, and changing bedridden and disabled patients, simple tooth brushing and denture care have often been overlooked. “Most clinical studies of nursing home residents report widespread inadequate oral hygiene and associated dental, gingival and periodontal conditions,” noted the authors of one survey. “Medical and nursing services were almost uniformly provided while dental and mental health services were provided much more infrequently.”

Visits by dental professionals are also rare in many institutions. Many of the patients Louisiana dentist Gregory Folse said he has visited on his rounds of nursing homes have not had care in years. When he looks into a new patient’s mouth, he is not surprised to find decay, rampant infection, the broken stumps of teeth, and even oral cancers. He is paid a stipend to serve as the dental director for the homes. Most of the patients are covered by Medicaid, but adult dental benefits in the state are extremely scant. Folse estimated he has donated more services than he has billed to Medicaid. He said he travels forty to fifty thousand miles a year through the backwoods and bayous, driving a pickup truck, carrying portable tools and instruments, setting up in nursing home community rooms and beauty parlors, repairing dentures, pulling teeth. “Nine hundred patients with severe gum disease or abscess. Half of my patients. I take everybody that has swelling. Everybody in pain. Everybody that’s got loose teeth. And I help them as best I can. With funding, without funding. The family pays some, the nursing homes. Sometimes no one pays. I do it.”

Some of the patients suffer from dementia and getting them to open their mouths is a challenge. The work is rewarding, just the same, he said. “I had a patient in a wheelchair. She had a stroke. She was so happy to get her dentures. She reached down and grabbed her purse. She reached inside. She found a piece of bread. ‘Here doc. Take it.’ I didn’t want to take her last piece of bread,” said Folse, with a laugh. “No telling how long it had been at the bottom of her purse. We have to give out of being wealthy. She gave to me out of her poverty.”

The rate of dental suffering is a grim kind of economic indicator. The poor are more likely to suffer from toothaches. Their oral health is worse and it can be hard to find a dentist who will treat them. The lack of money to pay for care is a major barrier: roughly one in five Americans is covered by Medicaid, the enormous federal-state health care program for the poor. But coverage is no guarantee of access to treatment, as only a minority of dentists see Medicaid patients.

Children are entitled to dental care under Medicaid but often face difficulties obtaining services. Fewer than half of dentists saw any Medicaid patients in the majority of states included in a 2010 study by the U.S. Government Accountability Office.

A 2016 study by the American Dental Association found that 42 percent of the nation’s dentists had registered as Medicaid providers on the program’s Insure Kids Now database. But the percentage did not necessarily reflect the percentage of dentists actually participating in the program. “It does not mean you are seeing Medicaid kids. It does not mean you have open appointments,” said economist Marko Vujicic, who helped lead the study. “Take it for what it is. It is the best data we have.”

The situation is harder for Medicaid’s adult beneficiaries. Dental benefits for adults are an optional part of state Medicaid programs. They are among the first line items to end up on budget chopping blocks in times of fiscal austerity.

Toothaches are destroyers of sleep. They make eating painful, working and parenting overwhelming. It is the poor who are most likely to pray to heaven for relief. They turn to drugs, both legal and illegal, and folk remedies. In desperation, some even pull out their own teeth.

Out at the free clinic in Lee County, among the solid, stoic mountain people, Tabitha Hay, with her fragile face and darkly mascaraed eyes, looked like a lost tropical bird, blown off course by a storm. She and her mother-in-law and husband arrived at the clinic after a thirteen-hour drive from Belleview, Florida. They were self-employed. They cleaned houses and took care of pets for well-off retirees. They left after work on Friday evening and drove all night to get to Jonesville. All three of them needed care, but Tabitha, twenty-six, needed it most. She was tormented by a molar, decayed beneath a filling.

“I feel like my jaw is being crushed,” she said. “Sometimes the pressure is like it is going to explode. I’m hungry but I can’t eat. To sleep I have to put a heating pad on it and nothing takes the pain away.” After missing a week of work she tried to get back to the job on the day before the trip.

“I tried to work. I couldn’t do anything. I sat in the back seat and cried.”

She said a Florida dentist told her the extraction would cost $500. It was money she did not have. She arrived too late to get care at the free clinic on Saturday. She was told she would need to wait until Sunday. As night fell upon the mountains, she bedded down in the red Kia with her husband and mother-in-law to face another night of pain.

Mary Otto is the author of Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America. She is the oral health topic leader for the Association of Health Care Journalists. She began writing about oral health at the Washington Post, where she worked for eight years covering social issues including health care and poverty.

Copyright © 2017 by Mary Otto. This excerpt originally appeared in Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America by Mary Otto. Published by The New Press. Reprinted here with permission. The excerpt was produced by Economy for All, a project of the Independent Media Institute.