Neil Shea

writer | photographer | story consultant

This story was commissioned by The Virginia Quarterly Review for the Fall 2009 issue. Photo by Andrew Cutraro.

Out Yonder

Sick and Unseen in America

I watch Billie, her slimness, her eyes large and swimming from the drugs. Dried blood flakes from the corners of her mouth. Someone curls an arm around her waist. She is so slender she is almost nothing, those stranger’s fingers pulling at nothing but fabric. She has always been this close to vanishing. I am filling in a past for her because I know very little of her past. The mind does this, fills in spaces. Still, some things are true beyond asking. She cannot tell me more because her mouth is all blood and holes.

“Nothing, honey,” the man says, smiling and tugging too hard at her waist. She loses her balance. Like she is high again and stumbling around the living room. “It ain’t gonna cost you a thing. We got you covered.”

Her eyes roll around the circle of people, her gaze slipping off the faces. This morning, while choirs gathered in small churches hidden in the hollows, Billie sat in a chair in a trailer, the kind used to haul stock cars, while all of her upper teeth were ripped out. What was left of them. Stumps mostly. There was a wet sound to it, a sodden pop. Beside her on a tray sat a pile of dead teeth. She wouldn’t look at them. I wonder what it felt like to have bones unsocketed from your skull. Where does the mind go? Did she think of the tooth fairy? I am fairly certain the tooth fairy never visited her. It was the meth fairy who came and stayed for many years.

In the chair, blood draining from her mouth, her brown-blonde hair had been damp with sweat. In her eyes had been a wild, fierce light. I was drawn to it, and then shamed by it. In pain we are all animals.

The guy has released Billie’s waist. He is somehow responsible, a volunteer or an organizer at this clinic. I notice her slimness again as she wobbles in his American-sized gravity. Outside, light is retreating up the sides of the ravines. Her boyfriend comes to her side and guides her self-consciously away. They will probably not sleep in the car again tonight but instead will drive all the way home, him smoking and eating Funyuns or the peanut butter balls I bought at a church bake sale and gave to them.

In the middle of the night I will wake with her face in my mind. Wads of blood-flecked cotton had been billowing from her mouth, as though she had been biting clouds to death. I was supposed to know that it was really tragic. That she was once so beautiful.

Scenes from Appalachia, late 2008. The autumn of Yes We Can. The economy is worsening and everyone is talking about change. I have come with photographer Andy Cutraro to look at rural healthcare, specifically to visit mobile health clinics that provide free services to those who cannot afford them. You can’t call it journalism, really, because what we are building is a collection of images and impressions, but some things are undeniable. On the coasts and in the capitals things that once appeared solid are crumbling; it is not the end, but it is loud. Andy and I are not searching for signs of novel phenomena or symptoms of the looming recession. In a way we are heading in the opposite direction, trying to escape those obsessions. The people we meet are not newsworthy, because for them there is no sudden collapse or calamitous fall. They did not plummet from penthouses or even subdivisions. They were already here, unseen.

To enter Appalachia is to descend. We drive down the spine of the Blue Ridge and find beautiful and unfamiliar shapes and shadows. The way light drains away, the suddenness of dusk. The hills crest and fall sharply across these parts of Virginia and Tennessee. Waves of rock and soil rise into the sun then plunge into dark troughs. Rivers glint in the ravine bottoms, reflecting slivers of sky, and houses, shops, and roads cram into flat spots beside the water. Where there is no room for moving or living, men have hewn space out of the stone, forcing flatness where it has never been. In wet times water has nowhere to go but up, rumbling toward the foundations of the houses.

Past the cemeteries and the woods and the expired coal trains wrapped in weeds. Tumbled-down barns. In certain places, a sadness rises from the ground. It is distinct from that suggested by a solitary tree in an empty mall parking lot, or a face peering from the window of a small apartment. It is old memories and unfinished work, the struggles of others, shaped and pooled by the land.

The hills are partly to blame for what escapes or is trapped here, but they bear no burden save dirt and the fossils of animals that died before the hills were, when Earth was not Earth and north was not north and even the stars were unfixed. So long ago that it is easier to believe the lives of those fossil creatures were unreal or possibly a lie. At night, when our bearings disappear, the little glowing houses and double-wides resemble ships vanishing into the sea, and the election signs along the road seem the only things mooring this place to the rest of the country.

I met Billie outside an elementary school where a clinic would be held as she sat in the car with her boyfriend Tommy, smoking cigarettes and eating junk food. I introduced myself through the window. Katydids wheezed in the trees. It was a slow sound, as if made by lazy insects, but that is how they sing when it’s growing cold, before they die.

Tommy and Billie had driven a few hours from their home to take advantage of a clinic. They arrived early so they could be among the first in line in the morning and thereby raise the chances of seeing a dentist. There would be a lot of other people in the line. Not all of them would get care. First Come First Served must be the rule guiding this form of generosity.
In a few weeks, when I am laid off from my job, my own health insurance will disappear. Not long after that, in my apartment, I will cut myself deeply on broken glass. I will be mesmerized by the easy stupidity of this accident, how simple it is for blood to be inside, where it is supposed to be, and then suddenly outside, all over the floor and spreading. I will run around looking for duct tape. I cannot afford a trip to the emergency room, so I will use tape to try to keep the edges of the wound closed. The experience alters my perspective.

But when I met Billie I had a health care plan and I was not afraid of bad health or accidents. In that moment I wanted just to meet people and hear their stories and see the land. Obama was rising. Billie would vote for Obama, Tommy would not. Neither of them was registered to vote.

I told a joke through the car window, trying to make Billie laugh. A girl’s laughter is a prize worth winning every time.

She laughed and turned away and her hand rose to her mouth, covering it. The reaction is reflex, learned through years of watching people’s faces change at the sight of her mouth. But she did not hide it before I saw the brown ruin of what was there or before my mind without thinking mapped the causes and effects, the contours of the path along which that ruin came.

A clinic near Unicoi, Tennessee. People waiting in line to see eye doctors, GPs. But mostly to see dentists. You can measure the enormity of America’s health depression in teeth. Teeth are a tell, they reveal economic class. When people feel like they’re dying, they go to the emergency room, even poor people. But dental visits are a luxury. Rotten teeth, like certain deep, protracted illnesses, can be endured for a long time if there is no other choice. It costs, what, several hundred bucks to have a tooth extracted? What else costs that much? A flat-screen TV. A computer. Art. Jewelry.

Billie suffered for years while her mouth dissolved. She finally chose to deal with it the only way she and Tommy could afford to: by buying a tank of gas and driving to the clinic.

They should make a roving exhibit out of it—Billie’s and all the other teeth pulled from the heads of people in invisible parts of the country. A giant tank of rotten teeth. Put it on a flatbed, haul it around. Like the AIDS quilt. Park it out front of Wal-Marts, but also Pottery Barns. Finish up in Atlanta, where you could donate it to the Coca-Cola Company. Or enshrine it on these very ridgelines, near the town where Mountain Dew was invented.

At the end of the day, a small Indian dentist named Mehta, who volunteers at many of these clinics, wipes sweat from his brow and tells me proudly that he has pulled one hundred teeth. His arms are thin as straws, but I notice his right arm looks slightly stronger. Must be from gripping that evil silver tool, the Extractor. Gets his back into it, he says. Fights them out. They don’t want to go; a tooth’s roots sink deep into the jaw. I know this because I was once married to a dentist’s daughter. He was a kind man with strong hands, but even he went violent dislodging teeth. They are like trees of bone. A stump grinder would not be inappropriate. Mehta cussed silently in Hindi as he tugged and tugged. He says he is giving back to America by taking its teeth.

In the late afternoon the day before the clinic opened, I spoke with the man who runs these operations, Stan Brock. An Briton who left home to become a cowboy in the Amazon, then a minor anaconda-wrestling television star, Brock is now a rural savior. His nonprofit, Remote Area Medical (RAM), brings mobile care to communities throughout Appalachia and parts of South America. Brock would like to take his services to other areas in the U.S., and plenty have requested his help. But he is limited to Appalachia largely because many states do not recognize out-of-state doctors or dentists, which means Brock’s volunteers from, say, Virginia might not be able to legally work in a state like Georgia. So he sets up where the laws accommodate and invites people, anyone, to come to him for care.

Brock’s hair is perfect, windswept. His outfit all khaki in the way of colonial officials and legendary aviators. He loves aircraft, and prefers, when he can, to parachute his teams into the hollows. It’s a little dramatic, but why not? You’ve got to love doing work like this, lace it with small pleasures. Because mostly it is ugly. I believe Brock bears this better than other people partly because, like many savior types, there are no other characters in his life. At this thin end of his life. He sleeps alone in a dilapidated schoolhouse in Knoxville where RAM has its offices and stores its equipment.

“It’s rather fallen to me,” he says, his accent charming.

All night the cars arrive in the freshly mowed field beside the ancient schoolhouse where the clinic will be housed. People travel from next door and hours away for this. Dented, rusting wrecks roll in, as well as new, unblemished vehicles. Some giant SUVs arrive, and this puzzles me.

I ask one man, “How can you afford that ride but not health insurance?”

“I just want one thing that isn’t shit,” he says.

There is no accounting for health, as there is none for taste. There are only individual measures of what we ourselves are willing to endure balanced against what we must.

People sleep behind steering wheels. Some have brought tents and bed down like deer amid their children. Some stay up through the night, visiting strangers in the little neighborhoods of parked cars and listing their ailments and how many years they have borne them. They also list their hopes. New teeth or new glasses; for this to stop hurting or for that strange illness to be identified. Good Lord for the pain to stop! They bear it calmly and politely and share stories easily.

In the field there is the whirr of crickets and the thump of car doors. Occasionally an uncomfortable groan as night deepens into the coldest hours. Shooting stars flare over mountains that are suggested only by a hulking blackness in the distance that is blacker than the sky. In the morning there will be fog thick as cotton. Through this field and this fog, stiff people with blurry faces will come limping and coughing toward the clinic. They will be silhouetted by car headlights and they will look like zombies roaming a dream.

Before dawn, cigarettes glow in the darkness as shawled people shiver and stand in line waiting for the clinic to open. As though by the pool called Bethesda, waiting for the angel to trouble the water. Jesus knew this scene. The angels have not yet appeared because the doors are closed. It is not quite 5 a.m. and probably they are still asleep.

Later, as the fog clears, foreign television reporters cruise the crowds asking questions. This story fascinates Europeans. Theirs seem to be the only media who cover the clinic. Other than Andy and me—but I am not sure we count. A Dutch journalist is asking how so many Americans can be in such a miserable state. Some of the patients are offended that foreigners are poking around like nosy neighbors. I think it’s just that everybody is embarrassed, ashamed perhaps, that their own countrymen are not interested. That some problems seem to require the mystical aid of saviors rather than the gathered concern of citizens. There is, after all, only one honest reply to the tall Dutch woman.

Q: How is it possible, in the world’s richest, most powerful nation, that so many people cannot get medical care?

A: Fuck if I know.

A man wearing a baseball cap and an eye patch begins telling me jokes. I had watched him coming, zeroing in on me. A warning light had gone off in my head. Some people you can just tell. He is here for a checkup or something. His jokes are not funny, but not so awful that I won’t be polite. The eye patch is kind of intriguing. And then he says, “Mind if I tell a nigger joke?”

I feel dazed. It is hot in the sun and I have been awake for a long time. My eyes slide over the crowd. I wonder if anyone is listening, if many more deformed hicks are wandering around.

“You shouldn’t,” I say. “Don’t.”

“How do you get a nigger out of a tree?”


“You cut the rope.”

“I’m leaving.”

The man tracks down Andy and tells him the same jokes. Nearly all the patients at these clinics are working-class or working-poor white people. Perhaps that gives him courage. Or perhaps he locked his eye on us because we were new arrivals, and everyone in his hometown had stopped paying attention to him long ago. He was that kind of man, would be even to other racists. The kind of man you ignore. That means, living where he does, that he is invisible twice—first to his nation, and then to his neighbors. A person barely there.

I seek escape in Robert, a man I met before One Eye found me. He is waiting under a small tent for a dental checkup; his wife is waiting to have several teeth removed. Their four young children, three girls and a boy, cartwheel through the field beside the clinic. Robert’s face is tired but handsome, with deep circles under the eyes and Sean Connery’s wraparound eyebrows.

Three months ago he lost his job as a logger. After a century of cutting, the small logging plots gave out and the small companies followed. It was too expensive to go after the trees that remained, high on the steep ravines and in the craggy hollows. He had worked logging since he was about fourteen, but he never had insurance. Now he is twenty-nine. We sit talking about his garden and the spring that provides his household water, vital things for his family. About “Tradio,” a local radio program where callers talk on the air about something they want to sell or something they want to buy. Like eBay for the hollow country.

He could find no other work when he lost his job. So he went to school in Dallas to learn how to drive freight trucks. The school paid for a bus ticket to Texas and for the motel where he lived for a month while he attended classes. He brought two duffel bags stuffed with canned food and preserves from his garden, so he wouldn’t spend money eating out. He must now hope for work so he can afford the school’s repayment plan and chip away his debt. It is not the kind of credit problem you hear about.

“Right now I’m not gettin’ any miles because there’s no freight,” Robert says. “Prices are higher, fuel’s higher. Stores aren’t orderin’.”

His hand finds a cigarette but he does not light it.

“Seems like the work never stops. If you don’t work every day in this part of the country you won’t make it.”

His wife comes over again and again to check in on him. But really it is because she is very nervous about her own appointment with the Extractor. Her green eyes reveal it. She kisses him.

“I love you.”

“I love you, too.”

When she is gone Robert says, “I just want to fix her up. For her to feel pretty again.”

It is a gift he thinks he cannot afford to give.

Teeth. Prettiness. Kissing. Children. The sex lives of poor people. I wonder about it. I am tired from all-nighters in fields and warm beer. My mind drifts. There is a strange tension in all this that I did not notice before. It is obscured by more graphic details. It seems entirely reasonable now to wonder how obese people get laid. Maybe they don’t. Do you kiss someone with meth mouth, with all those dead teeth?

The people here have been molded by poverty and disregard into thin or obese or seeping things that seem utterly asexual. Bodies that have spent years decaying and that spent last night farting beneath blankets in the parking lot. But sexuality is always there, revealing itself, as it does in America, in contrasts. The patients are not generally beautiful. At these clinics, however, beauty surrounds them— in the young, freshly-washed dental students and hygienists who have come from a nearby university. All are volunteers; many are women. One or two are pageant contestants.

These strangers are tireless and fearless, even enamored of the grossness and weirdness of biology. They do not remove their jewelry as they work, drilling and scraping while wearing silver watches and bracelets. Large rings bulge on their fingers beneath the latex gloves. Their earrings flash in the fluorescent light, gleaming like the rows of steel tools lying on trays throughout the room. The patients, most of them, do not wear any jewelry at all.
Students and assistants lean over the patients, breasts inches away, perfume like spring. Bodies that have known no hardship. College bodies sweated over and fitted into scrubs. The women with their slender arms, faces masked, hair tied back in swinging ponytails. The men with finely rounded biceps, fruits of discipline and nutrition. There is no stoop in their shoulders. Mascara and manicured hands. Strong jaws.

After a while the nature of my tiredness changes and I am no longer thinking about sex but abduction. Nightmare. Out-of-body experiences. All the ingredients are there—tables heavy with alien tools. Bright lights, hoses, and motors. Suction. Blood on the floor, masked faces, terrified patients, their knuckles white along the edges of the chairs. This is no antiseptic dental office; there is no lobby stocked with magazines. The chairs are packed closely together. As you wait in line you can plainly see what you are in for. You can ponder whether you will squirm or remain deathly still.

In the chair now. A voice whispers you’re doing fine, everything will be okay, try to sit still. Eyes smiling down as the suction hose enters your mouth.

You will feel a slight pressure.

The wrinkles beside those eyes will disappear when the smile fades, not like your wrinkles, which remain forever.

Tongue to the left, please.

Some of the men, patients, make feeble passes at the hygienists, who dismiss them, dismiss this world, with tight laughter. The room is filled with this laughter and the whine of drills.

Okay, sit up and spit that out for me.

My last images. A classroom turned examination room that is crowded with miniature desks. The walls are covered with visions of a world coming into focus for the first time. Children’s paintings, all blobs of color and misspelled names. Rows of enormous numerals, pictures of animals and objects, competing sets of rules. Use Your Inside Voice. No Slapping, Touching, Poking, or Kicking. Raise Your Hand. No Talking.

An old woman stands in a corner, reluctantly letting a doctor examine her. She arrived alone and tells him she lives in the hills. Her hair is the color of vanishing smoke, her skin so pale it is translucent. She is stooped and dressed oddly, wearing a skirt and bright yellow socks. Some kind of sweater. Dogs have gnawed at her shoes, or maybe they are supposed to look like that, with her toes and heels poking out.

It is the day Billie had her teeth out. Or perhaps it is decades later. I am deliriously tired. I decide I am seeing the future. The arc of it will be the same. Billie has returned, years later, to another clinic. Perhaps she has visited several in her life. I met people who did that, who became clinic groupies, getting eyeglasses at one, root canals at the next.  Billie became like them.

She has been losing weight, losing energy, her body melting away. She has her own theories but she came down for someone else to say what is what. The doctor is far younger and from a different dimension. He touches her softly. Cautious investigations. There is a sponginess to her fingertips where there should be firmness. A lump on her neck. Muscle wasting. Other signs.

The doctor circles with questions and processes her responses. He decides it’s probably all through her. Vines of cancer. He never delivers his diagnosis directly.

“You know what I’m getting at, right? I don’t want to say the word, but . . . you understand?”

A silent minute passes.

“Your body is trying to tell us something,” he continues. “What do you think it is?”

“An infection,” she says, touching her neck. Her hands are shaking.

“Well, it could be. But your infection was on the other side.”

She speaks very softly, mumbling. He offers to write her a prescription, but both know it will change nothing.

“I have faith in God,” she says, as if in defense. “He heals.”

“I can write prescriptions,” the doctor says gently. “But He does the work.”

Her eyes flick along the rows of childish paintings. Grapes Are PURPLE. Apples Are RED.

A lifetime has elapsed. Choices made and unmade long ago and in other places. She shuffles out of the classroom past the paintings and the rules and the thicket of desks, past help and all else but God, and she goes up into the hills. Katydids are singing in the trees.