This article first appeared in the St. Louis Beacon, Aug. 14, 2009 - Every Monday morning, primary health care arrives on a bus in Oran, a town of 1,264 in southeast Missouri that hasn't had a doctor for at least 15 years, or maybe 30, depending on who you ask.
From 9:30 a.m. to 3 p.m., the Southeast Health on Wheels (S.H.O.W.) Mobile sets up shop in front of City Hall with a nurse practitioner and registered nurse prepared to treat whoever walks through the door.
They can diagnose everyday ailments, such as sore throats and ear infections, but have also assisted walk-in patients in emergency distress. They perform wellness exams and screenings, take lab samples, monitor cases of chronic diseases such as high blood pressure, diabetes and asthma and, often, throw a lifeline of care to patients who haven't been seen by a physician in years.
Most of the town's residents now find their health care about a half-hour's drive away -- in Sikeston, 16 miles to the south, or Cape Girardeau, 20 miles to the north. But for senior citizens who don't drive, or low-income residents without cars, that distance can seem as daunting as a trip around the world.
Without transportation, the poor and elderly of Oran just can't get there from here, no matter the miles and miles of well-maintained two-laners that slice through the countryside, connecting the small towns of Missouri's Bootheel like so many islands in an ocean.
"In the Bootheel we have no formal transportation. There's no bus service. Most people -- if they don't have a car -- are dependent on others to give them a ride to work or the doctor, or wherever,'' said Rebecca "BJ" Whiffen, the nurse practitioner on the fully equipped mobile health clinic administered through a unique partnership formed in 2008 by Southeast Missouri Hospital and Southeast Missouri State University (SEMO) in Cape Girardeau.
Whiffen said many of her patients either don't have cars or their cars don't work very well.
"This is farmland down here,'' she said. "The land is rich, but the people are not -- and they have no access to care or very limited access to care.''
As health-care providers grapple with ways to improve access to health care in rural areas, the colorfully painted S.H.O.W. Mobile represents one of the more innovative approaches. The specially outfitted bus was purchased with federal funds secured by U.S. Rep. JoAnn Emerson (R-Cape Girardeau) and Sen. Christopher "Kit" Bond and former Sen. Jim Talent.
It is a unique outreach program that targets residents of Emerson's 8th congressional district who have limited access to health care because of geography or low income. The district sprawls across southern Missouri, north from the Arkansas border to just south of St. Louis, and west from the Mississippi River to just east of Springfield. The natural beauty -- from the Ozark Mountains to the fertile Mississippi -- is tempered by economic reality. The sparsely populated district is the 20th poorest in the nation, according to the 2000 U.S. Census.
Emerson said the idea for the mobile clinic grew out of the challenges faced by her district's rural communities in attracting physicians, which is particularly troublesome to the region's senior citizens.
"One of my dreams has been that, if you can't get to health care, we'll bring health care to you,'' she said. "So I've worked really hard over the years to be able to get more funds for rural clinics. And the idea of having a mobile clinic was to go to different communities where they didn't have primary-care doctors because a lot of older people can't drive.''
For now, the S.H.O.W. Mobile operates within a 50-mile range of Cape Girardeau, a limit determined by the requirement that a nurse practitioner must work within that distance of a collaborating physician. In addition to Oran in Scott County, the bus also visits Charleston, population, 4,732, and Bertrand, a hamlet of 740, in neighboring Mississippi County. Patients are billed by the hospital, which uses a sliding scale based on income for the uninsured or underinsured to determine fees.
Mary Coram, 55, a longtime Oran resident who lives four blocks from City Hall, said she and her husband, Larry, 57, regularly visit the clinic-on-wheels.
"We're blessed to have this here,'' she said. "We know we can see them every Monday when we're sick. If it wasn't for this, I don't know. We'd be in bad trouble.''
Welcome aboard: Say, "Ah"
Though the S.H.O.W. Mobile accepts appointments, walk-ins are always welcome. On this hot summer afternoon, the Corams dropped by unannounced and were warmly ushered into the coolness of the air-conditioned bus by Whiffen and registered nurse Lesley O'Daniel who are both employed by Southeast Missouri Hospital. Bus driver Kevin DeArman is a SEMO University employee.
Every inch of the 38-foot bus is put to use, housing medical furnishings, equipment and supplies. Up front, just behind the driver's seat, is a dental chair and equipment, though the program is currently seeking a dentist to use them. In the back of the bus is a fully outfitted medical exam room. Pocket doors close to offer privacy.
"We're limited a little bit by space, but we are fully equipped," said Whiffen. "We have everything here that a clinic normally would have. We have some emergency drugs, as well. It is challenging because you never know what's going to come up the steps into the bus. It might be a laceration that needs suturing. It might be someone having chest pains.''
Whiffen taught nursing and worked in emergency medicine before coming aboard the mobile clinic last summer. She had previously worked in the rural health field.
"The best part is meeting all these people, being a part of their communities," Whiffen said. "We eat at their restaurants. We go to their library and check out books. We go across the street to their store and buy our lunch sometimes."
While her husband consulted with Whiffen in the exam room, Mary Coram chatted with O'Daniel who checked her vital signs. Coram said she battles various health issues, including depression and high blood pressure.
"My heart skips a beat, and my husband's does, too. I'm easily catching pneumonia," Coram said.
Though the Corams both work, they are behind on their rent and have no health insurance or reliable transportation, she said. Until the S.H.O.W. Mobile began coming to Oran, health care was often out of their reach.
"We couldn't afford it, and we couldn't get to Sikeston. We did the best we could. Got medicine over the counter. Whatever we thought would help," Coram said.
She can walk the half-mile to her job as a home health aide in Oran, but getting to work can be a struggle for her husband, who is employed by a restaurant in Sikeston.
"Sometimes when the car's down, he walks. It's an '83, and it's got problems," she said.
To get to work on time, he'll begin the 16-mile trek at 2 a.m., no matter the weather. Sometimes, passing drivers will offer a ride, but often they don't.
Coram said she hadn't heard about the S.H.O.W. Mobile until she saw it parked in front of City Hall and was curious enough to stop in and ask what it was all about.
"This has been a big help," she said, smiling.
A neighborly kind of town
Folks in Oran boast of good schools, a top-notch volunteer fire department, and small town neighborliness.
Originally founded as Sylvania, the town was renamed Oran in 1883 at the suggestion of a resident who had visited the Algerian port of that name during his seafaring days. Landmarks include the striking Guardian Angel Roman Catholic Church, built in 1917 by German immigrants, and the town's old train depot, now a railroading museum.
The basics of daily living can be found along a short stretch of Railroad Street, named for the tracks of a bygone era. There's a grocery store and a post office, a florist, assorted shops and a funeral home.
The S.H.O.W. Mobile has a prominent parking spot in front of City Hall, which draws a steady stream of residents dropping by to pay their water bills. Next door, is the tree-shaded library. And around the corner on Highway W, the O Town Cafe serves a lunch buffet of home cooking: ham and beans, fried chicken strips, pasta -- all you can eat for $5.95 -- including a basket of warm, fluffy melt-in-your-mouth rolls delivered to your table.
For major shopping, though, most residents make the drive to Sikeston or Cape Girardeau. And that's where many of the jobs are, as well.
According to the 2000 U.S. Census, 17 percent of Oran's population is over age 65 and 15 percent are below the poverty level. The median household income is $28,750.
Mayor Tom Urhahn, who is also the town's postmaster until he retires next month, said the S.H.O.W. Mobile has been wonderful for the town's senior citizens.
"We have quite a few elderly in Oran who have no transportation unless someone takes them,'' Urhahn said.
For its part, the town provides an electrical hookup for the bus and allows its staff and patients to use the restroom facilities in City Hall. In return, town residents know that every Monday they can access primary care without a drive or lengthy wait for an appointment.
"It's here if the people want to use it; it's available," Urhahn said.
The mayor, who grew up in Oran, said that it's been a long while since the town had its own doctor, at least 15 years. In the meantime, the county health department provides some services, including shots and health screenings. And he praised Scott County's ambulance district for its ability to respond quickly to emergency calls in town. Still, he says, it probably takes at least 30 minutes to transport cases to the closest emergency medical centers.
Whiffen said the S.H.O.W. Mobile strives to supplement existing health services available to patients -- not compete with them.
"We don't want to take the place of their regular doctor or primary-care provider. But if they need us, we're here," she said. "If they need a primary-care provider we can be that for them. And we try to help them in any way we can, including financially. We have a lot of patients who don't have any insurance and very little money so we have a sliding scale they can apply for through the hospital that will only charge them what they can afford to pay."
Teaching moments and toothaches
O'Daniel, who managed nursing care in an intensive unit before joining the S.H.O.W. Mobile last year, stresses preventive medicine and how important it is to reach patients before chronic conditions, like diabetes or asthma, worsen. As part of its outreach, the mobile clinic participates in health fairs and offers screenings for chronic health conditions.
"Lots of time people just don't truly understand the consequences that their health conditions can have for them down the line," she said.
Some of her patients are people who have stopped seeing their doctors because they have gotten behind on their bills, O'Daniel said.
"Or, they stopped taking their medications because they can't afford them -- or, maybe they started feeling better," she said.
In those cases, the staff tries to get the patients back on a regular health regimen.
O'Daniel says that even though she worked in health care, she didn't understand the limitations to access that Medicaid patients can face.
"I didn't understand before this job, that having Medicaid didn't give you the same access to providers that private or commercial insurance does. I knew that when I went to a new provider they would ask, 'What insurance do you have?' I thought, 'What difference does it make?' " O'Daniel said. "I really thought if you had Medicaid you had insurance, not knowing that providers could decide, flat out, not to take any Medicaid or they might restrict the number of Medicaid patients they had. Then, I didn't understand why that happened, not knowing that, at least in Missouri, Medicaid is slow to pay and that affects the physicians' cash flow and their ability to pay their own employees."
In addition to primary care, the S.H.O.W. Mobile is a teaching facility, both for patients and for students studying health care, said Sandy Ortiz of SEMO University, who serves as the program's director. The goals are twofold: to decrease health-care disparities through education and care and also to provide hands-on experience for the university's students who work with the mobile clinic's staff.
Ortiz said that a current goal is to find a dentist willing to work at least part time on the bus because lack of access to dentistry in some rural areas is even greater than the lack of primary care. In Missouri, Medicaid no longer covers adult dentistry.
"If we go someplace, nine out of 10 people who come to the S.H.O.W. Mobile as walk-ups ask for dental service," she said.