The Purple Heart is awarded to members of the military killed or wounded while serving. Mack Kiser of Coeburn, Va., which is located deep in the Appalachian part of the state, earned four of them in Vietnam. He also has a Bronze Star and Army Commendation Medal, among several others. Mack returned to Virginia from Southeast Asia with a host of medical issues caused by exposure to agent orange. Shrapnel has left him legally blind.

Like many men in Appalachia, Mack ended up working in the coal mines. Seventy-two years old, he is a cancer survivor and lives with respiratory problems from his days underground. Mack and his wife are confined to their hillside home now, the same house he grew up in. His war injuries and years in the mines have left him particularly susceptible to the coronavirus.

As the COVID-19 pandemic continues to put a strain on the country’s health-care system, those living in more remote locations like southwestern Virginia, are having to deal with their own special set of circumstances. People who live in rural areas tend to have higher rates of cancer, heart disease, stroke, respiratory illness and obesity, all of which makes them particularly vulnerable to the coronavirus. Seeking treatment is increasingly difficult since more than 120 rural hospitals across the country have been shuttered in the last decade, 18 closing in 2019 alone, the highest yearly total in at least 15 years.

Many of the problems routinely faced by rural communities will make it more difficult to cope with the pandemic and its aftermath. Long-standing deficiencies in transportation systems, employment opportunities, food security and broadband access mean that areas slow to feel the effects of COVID-19 will also be slow to recover.

Mining Declines, but Health Needs Grow

Virginia is a state of economic contrasts. With plentiful, well-paying government jobs and contracts, the northern counties near Washington, D.C., are among the richest in the country. The older, poorer, underemployed residents of the state’s southwest corner are significantly less well off. For decades, mining has been the principal source of work in the region. Geographically isolated by the Appalachian Mountains from the rest of the state, the area’s fortunes have dwindled with the continuing decline of the coal mining industry.

Nationwide, coal mining employment peaked at 862,000 in 1923. Last year, the number had fallen to just 53,000. Ranked 13th among the coal-producing states, Virginia still employs about 2,000 miners but most of those have been laid off due to the coronavirus. Market pressures are expected to further reduce coal production as inexpensive natural gas and renewable energy continue to make gains. The loss of good paying jobs leaves many in the region without health insurance at a time when they need it most.

The levels of poverty here are at odds with the area’s natural beauty and proud people. With hospitals and clinics few and far between, the oldest mobile clinic in the country has been meeting the medical needs of the local population since 1980. Known as the Health Wagon, the free nonprofit clinic on wheels was started by Sister Bernie Kenny in partnership with a local Catholic hospital. Operating on an annual budget of $2.6 million, the clinic receives its funding from the state, as well as gifts and grants from big companies like UnitedHealthcare and AstraZeneca and individual donors.

Initially operating out of the back seat of a Volkswagon Beetle, Sister Kenny dispensed health care and compassion for 25 years before relinquishing control of an expanded operation to current President and CEO Dr. Teresa Tyson, a family nurse practitioner who joined the Health Wagon in 1993. It was Tyson’s first job after college. “I had no idea what it was,” she says. “I took the job and loved it.” Today the coal miner’s daughter oversees an operation that includes a staff of 20, three clinics and three mobile units which make regularly scheduled visits to Lee, Wise, Scott, Dickenson, Russell and Buchanan counties in Central Appalachia. 

Speaking with a strong mountain accent, Tyson rattles off statistics at the speed of a New Yorker. “We’re the medical home to over 4,200 people that would not have access to health care otherwise,” she says. “We do free labs. We’re giving physical exams and treating a lot of chronic disease: diabetes, hypertension, coronary artery disease, mental health, those issues. We’re the largest tele-health provider in the state of Virginia. We did the first FAA [approved] drone delivery in the United States in 2015, delivering medications.”

Clinical Director Dr. Paula Hill-Collins occupies the office next to Tyson and when she’s excited, speaks faster and with an accent that’s even heavier than her colleague's. The two of them have been best friends since the eighth grade. “From 14 years on, we’ve been pretty much each other’s right hand man,” she says. “Or lady.”

Intentionally or not, they followed the same course of study at the same three out-of-state universities, both earning a doctorate-of-nursing practice. “Teresa and I have a running joke that one of these days we’re getting out of here,” Hill-Collins says. “But we’re never getting out of here! No one else would have the passion to take care of these people.”

Health Wagon CEO Teresa Tyson and Clinical Director Paula Hill-Colllins have been best friends since they were 14 years old.

The War Hero

Teresa and Paula have just arrived at Mack Kiser’s house in the hills after a 25-minute trip along winding mountain roads from the clinic. The decorated veteran has been expecting them and steps through the door into the cool but sunny April afternoon, greeting them with a smile and a wave. Donning masks, the two women keep their social distance, staying close to the white Health Wagon SUV. They are here to check in with Mack, to see if he needs any medications and encourage him to continue his isolation. “Mack was very active. Always out and on the go,” Paula says. “Now he’s just staying put here on this mountain.”

Mack has good reason to put his faith in Paula and Teresa, other than the fact that he and Paula are related. Mack had been making repeated trips to the VA hospital in Johnson City. “I kept telling them something’s wrong with my prostate. They kept telling me nothing’s wrong, don’t worry about it.” He told Paula about his concerns when they ran into each other at the local Walmart. She had him come to the clinic for an exam, then referred him to a specialist who confirmed that he did indeed have cancer. “I talked to Paula about what was the best thing to do,” he says. “So, she studied it and I’ve been fine since 2007.”

Perpetually cheerful, Mack is adjusting to a stay-at-home life. But he misses his grandchildren in Kentucky who he hasn’t seen for three months. “It gets boring sometimes, but there’s always something to do around here, take a walk in the woods, something like that.” Mack’s wife has prepared gift bags of fruit, crackers and candy that she hands to the visitors. As she turns to leave, Paula looks around at the surrounding hills. “If I was going to be quarantined, this is the best place,” she says.

   War hero and retired miner Mack Kiser still lives in the house he grew up in. 

The Annual Health-Care Clinic

Every July for 20 years, people with health problems have been coming to Wise, Va., for treatment they could otherwise not afford. Sponsored by the Health Wagon, it is the largest health-care outreach of its kind in the country, and draws thousands of patients and volunteers from Virginia, its neighboring states and beyond. Many arrive at the Wise County fairgrounds the night before the three-day event, lining up early for the 6:00 a.m. start. “I’ve had them fly in on frequent flyer miles and hitchhike to the event,” Teresa says. “We’ve had them camp out weeks in advance to get health care.”

Patients can see specialists in dermatology, dentistry, oral surgery, nutrition and gynecology. Chest X-rays and mammograms as well as vision and dental services are provided free of charge. Teresa is proud of the annual event and the Health Wagon’s role in helping a community deprived of basic care, but also disappointed that there is a need of this magnitude. “It’s something you would truly see in a third-world country,” she says. “It should not be happening in the United States. But it is.”

Teresa is not optimistic about this year’s event because of the coronavirus. “I think that we’re going to end up cancelling it,” she says. “That just breaks my heart.” Back behind the wheel of the Health Wagon SUV, she and Paula are on their way to see another one of their patients.

The Caretaker

Teresa steers onto a level spot after climbing the steep driveway to Dorothy Taulbee’s house, perched high over a sloping green lawn. She and Paula are here to check in on the 83-year-old cancer survivor who not only still drives but also does her own maintenance on her car. “That’s the way women are here,” says Teresa. “They really are self-sufficient.”

Dorothy is waiting and waving, high above on her front porch. Wearing oversize sunglasses, Teresa and Paula put on their masks before climbing the steep steps to see their patient. The only sounds are coming from birds, a barking dog and Dorothy's son mowing the lawn below. A small collection of old cars is visible directly across the road with expansive views of the neighboring hills and mountains just beyond. Dorothy is dressed up, as she is every day, whether or not guests are expected. She has a large, well-worn bible on her lap, one hand resting on an open page. Inside, a 13-year-old great granddaughter is working on her distance learning now that school is closed for the year. “She would be in foster care somewhere if it was not for Dorothy caring for her,” Teresa says.

Dorothy is alive today, thanks to the Health Wagon’s annual event at the fairgrounds. Seeking help for an arthritic finger, she was sent to get a chest X-ray nearby. “She had quit smoking about 15 years prior,” says Teresa. “But knowing her history, we do a lot of X-rays on our smokers, looking for cancer.”

Dorothy Taulbee’s lung cancer was discovered at the annual Wise County Fairgrounds health-care event.

Years later and with one less lung, Dorothy is still going strong. Besides raising her great granddaughter, she volunteers with patients at the clinic and visits nursing homes in the community. Teresa is concerned now because Dorothy is especially vulnerable to COVID-19 and wants her to stay home. “It’s hard with the older people because you can’t tell them what to do.”

Halfway back to the clinic, Teresa pulls off the road and parks in front of a long white mobile home. Her father lives here with his collection of barking dachshunds and a 1962 Ford tractor that still runs. The 79-year-old miner retired with a bad back and black lung. “You see people walking like this,” he says, hunching over. “They’re coal miners probably.” He is understandably proud of his daughter, but that doesn’t stop him from smoking in front of her.

Teresa and her three siblings all went to college, but she is proud to be a coal miner’s daughter. “I can remember when he would come home out of the mines and he dropped out of the car and lay in the grass until he could move,” she says. “What that man went through to get us to this point, I don’t know how he did it.”

Teresa Tyson’s father retired from mining with a bad back and “some black lung.”

Back at the clinic, a gunmetal gray Toyota Corolla has pulled into the parking lot. The driver remains inside, wearing a mask, with the windows up. Teresa and Paula have been expecting him. He is Ethan Collins, a nurse at the clinic, unable to shake a fever and persistent cough for the past several days. He is here to be tested for COVID-19.

Before stepping outside, Teresa and Paula get into their protective gowns, gloves, masks and caps. There are no face shields at the clinic so they will have to do without them. After deciding it best if Ethan gets out of his car, Teresa takes her time inserting a long cotton swab into his nose while Paula observes, making notes on a clipboard. While Ethan retreats to the Corolla, the women review the just-completed procedure and determine that they may not have done it correctly. After coaxing the patient back out of his car, they try again, this time inserting the swab much deeper, prompting Ethan to cough and recoil. He is concerned about the lack of face shields.

With days-long symptoms of coronavirus, Health Wagon nurse Ethan Collins gets tested outside the clinic. 

The Coal Miner

Just like his grandfather, father, six brothers and son-in-law, Reggie Campbell made his living mining coal. His grandfather died in a mine, not four miles from where Reggie and his wife live now. “He was 35 years old, I never got to meet him.” Reggie first went underground when he was 17. “I graduated school on June the 10th, I went underground in the coal mines June 12th.” Even though black lung, a bad back and bad knees forced him to retire after nearly four decades underground, he would do it again. “I loved it,” he says. “The whole time I was in there. If I was able, I’d go back to coal mining today. That’s how I made a life for my family.”

Reggie has a nice home with a detached garage where he built an oversize shower so as not to bring coal dust into the house. He has worked in a number of mines in the area including one inside a mountain visible from his front yard.

One corner of Reggie’s garage is where he keeps a small collection of mining tools and his old helmet. He produces a white board and begins to sketch out a diagram showing how fresh air is circulated underground. “When this miner gets through cutting, he comes back over here and starts again,” he said, tracing a line with an orange marker. “If you’re a coal miner, it gets in your blood.”

Coal miners with black lung, or pneumoconiosis, are much more susceptible to severe pneumonia. Reggie’s wife Rebecca remembers a difficult night back in November. “One night he woke up and he couldn’t get his breath,” she says. “Scared is not the word, it was awful.” It wasn’t the first time he suffered from the lung ailment. It happened in 2012 when he was still working underground. “We were in some dust and I passed out,” he says. “I was in the hospital and they thought I might have had a heart attack or something.” It was pneumonia, but they couldn’t detect it at first. I was off work for a month.”

According to the Department of Labor, coal mining is one of the most dangerous professions in the U.S. with an occupational rate of death six times higher than the average for private industries. Over time, exposure to coal dust destroys lung function, leading to permanent disability and death. Signs of black lung show up in one of every 20 miners.

There is no cure for the disease that has killed more than 76,000 coal miners since 1968.

Reggie wishes he had been told about using a proper mask in the early days of his career. “Back in the 60s and 70s and early 80s we were not taught to wear a mask. They never discussed with the miners what it does to our body,” he says. “It’s the disease you can’t see that kills you.”

He and Rebecca are staying home now since COVID-19 would be especially dangerous for Reggie. They have a collection of masks including a few from the Health Wagon where their daughter works. “We’ve been out one time to get food, in like three weeks,” says Rebecca. “If we have to be where there’s people, we stay six feet away or more.” Reggie is turning an N-95 mask over in his hands. “If you put coal dust in these it would go through them. That’s the way the masks are in the mines.”

Even though he suffers from black lung, retired miner Reggie Campbell wishes he could go back underground.

Telemedicine Fills Some Gaps

Telemedicine has been a regular part of the Health Wagon’s offerings for some time now. “We’re the largest telehealth provider in the state of Virginia with our wonderful partner the University of Virginia Health System,” Teresa says. “We’re able to access a lot of specialty care with the University of Virginia that they would otherwise not be able to access.”

In a region inhospitable to broadband, accessing telemedicine can be problematic. Some 20 percent of the clinic’s patients have no Internet access and must go to a neighbor or relative to get online. A phone will sometimes suffice, but cell service is not universal in the craggy hills and mountains. Since the pandemic, patients are increasingly comfortable accessing health care online while in-person visits are down. Most people have either put off routine lab work or are too nervous to come inside. If a patient must come to the clinic, they are treated outside in their car by a single member of the Health Wagon staff dressed head to toe in PPE (personal protective equipment).

Except for a few stranded international students, the University of Virginia College at Wise, just down the road from the clinic, is nearly empty of people. Christopher Stidham is part of a skeleton crew in place to keep things running until everyone returns. He is calling in for a regular visit with Paula who is monitoring his diabetes. She can see him on her computer, but it takes a few minutes to get the sound working.

“So Chris, how’ve you been doing?”

“I’m doin’ good.”

“How’s your blood sugar?”

“Hmmmm, a little bit high.”

“We may need to adjust your medicine some.”

They talk for several minutes more, interspersing treatment plans with news about their friends and families. “I love ya, and you take care and stay in, OK? Are you wearing a mask at work?

“No, but they’re keeping us all separated.”

Paula Hill-Colllins checks in with one of her regular patients. Since the start of the pandemic, most Health Wagon visits are conducted online. 

The Ballplayer

Hurley Mitchell lives alone. Until three months ago, he shared this home with his mother who lived to be 92. His brother and sister-in-law also recently passed away. Surrounded by generations of family photographs, he settles into a crochet-covered armchair just inside the front door, his left arm propped on a frilly pink pillow. Evidence of his departed mother is everywhere.

Born and raised right here in Coeburn, Hurley was quick to get out, drafted when he was 17 by the Cleveland Indians as a relief pitcher. A short pitching career in the minor leagues was followed by stints as a contractor before ending up a letter carrier. With an increasing number of health problems, he had to leave the post office five years ago. “I had my heart issues and just didn’t have any energy.” Living on Social Security, he is happy that his house is paid for. “It’s a beautiful thing when you don’t have any bills,” he says, laughing.

“I was always blessed with good health.” Hurley says. “I never was one to go to the doctor. If I went, I was in bad shape.” Eventually though, his condition declined enough that a friend insisted he go to the Health Wagon where Paula immediately referred him for an EKG. “I went up there and that guy said ‘Mr. Mitchell, you need to go to the emergency room, your heart’s running crazy.’” He had suffered a small heart attack and received treatment to restore a normal heartbeat. At the time, Hurley didn’t have any insurance. “I was about dead,” he says. “Paula, she nurtured me back to health.”

Hurley Mitchell is sticking to home for the foreseeable future. “I have several heart issues and this, that and the other, so I definitely need to stay away.”

“A Very Resilient People”

As the end of a long day, Teresa is back behind her desk, on a conference call with other health-care providers. The discussion centers on the upcoming health event at the fairgrounds. “It sounds like we feel like the best thing to do with the project is to cancel it this year,” she says to everyone on the phone. The rest of the call is spent going over the process of shutting down something that has been a year in the planning.

COVID-19 is taking its toll on the Appalachian communities of southwest Virginia. An already-isolated population has become even more so. Sue Cantrell is a local district director at the Virginia Department of Health. “Several of the folks we've dealt with have no entertainment at home. Their entertainment is visiting with their neighbors because they don't have TV. They don't have Internet,” she says. “Helping them stay occupied and understanding that they're doing this not only for themselves but for their friends and neighbors is a bit of a challenge.”

Teresa is convinced it’s the ruggedness of the region that gives its people the means to carry on. “We really work to negate those negative stereotypes that are out there and just show people the good things about Appalachian culture,” she says, “We’ve got a very resilient people here and so we’ll definitely overcome this.”

Correction: Coal miner Reggie Campbell's wife was incorrectly identified as Nancy. Her correct name is Rebecca Campbell.