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To find out more about the Beersheba Springs Medical Clinic, visit www.beershebaclinic.org.
There's the diabetic woman who has a kit to test her blood sugar — but can't afford the strips.
The 23-year-old mother with severe knee pain she's put up with for several years without knowing what's causing the ache.
The man with crippling headaches who carried on with his day-to-day work, never suspecting that a tumor was swelling in his brain.
The unemployed woman who lived for years with a ruptured eardrum without ever having a doctor check it.
For many people in Grundy County, Tenn., the health care strategy is to bite the bullet. Learn to live with pain and sickness. There just isn't a more realistic option, they say.
About 17 percent of the county's population doesn't have health insurance. More than a third is on TennCare. You can count the number of primary care doctors on one hand.
Grundy is the unhealthiest among Tennessee's 95 counties, according to a national survey released this year.
The premature death rate -- which measures the years of potential life lost to preventable deaths -- is nearly twice the state average.
Grundy is not the only Southeast Tennessee county in the bottom bracket. It's joined by Sequatchie, 91st, and Marion, 90th, according to the 2013 County Health Rankings, which measure health according to life expectancy, chronic illness, access to health care, socioeconomic factors and overall health habits.
The dynamics at play in Grundy are common in rural communities across America, according to a study by the Henry J. Kaiser Family Foundation.
The chief obstacle is income. Rural Americans typically have lower incomes than those in urban settings, with a declining population and the loss of key rural industries. After the coal mines shut down in Grundy in the '80s, local industry never really recovered. Median household income in the county is $25,600. The unemployment rate is 9.6 percent.
Residents of rural communities also have the lowest rates of private health insurance, largely because they are more likely to work jobs that do not offer benefits, the study shows.
On average, residents in these areas tend to report poorer health and less access to preventive care.
They show a lot of the same negative health trends seen in inner-city areas. But rural residents don't have the same proximity and level of access to social services.
The sheer physical geography of rural areas can be a barrier. Seeing a specialist means an hour drive or longer. Trips to the grocery store are fewer and farther between.
Despite the discouraging report and staggering disparities, some medical providers say they are more motivated than ever to find cures -- even small ones -- for the chronically ill.
The county has already hit bottom. It can only stay there -- or go up.
A STARTING POINT
On Thursday morning, 23-year-old Tiffany Anderson sat in front of the old hearth at the Beersheba Springs Clinic, filling out paperwork and cooing to her 5-month-old baby as she waited her turn to be examined.
Lace curtains drape the clinic's waiting room windows. The walls are dotted with medical posters, but also with family pictures and plaques. The receptionist sits behind a desk in the kitchen.
The clinic feels homey because that's what it once was. For generations, the house in the Beersheba Springs community of Grundy County was the gathering place for physician assistant Norma Sparks' kin.
It was turned into a free clinic just a few years ago.
On Thursday, Anderson's husband was being examined for congestion, and she needed to have Sparks check her knee. It has been bothering Anderson for a couple of years now, but has escalated to a constant pain.
Both of the Andersons, who live in nearby Coalmont, Tenn., work. But their jobs don't provide health insurance.
It's the same plight for many in the county, say clinic staff members. While the county is plagued with high unemployment, many of those who do work have jobs without benefits: seasonal work; growing shrubs and trees in nurseries; part-time labor.
The lack of health access increasingly disturbed Dr. Garrett Adams, a pediatric specialist from Louisville, Ky., who has summered in Beersheba Springs his entire life.
"I realized just how desperate the need is among mountain people for health care," Adams said. "They couldn't afford the daily, timely attention of just regular visits, labs, or the education that goes with that."
He decided to create a free clinic through the state. Sparks not only agreed to lease her house for the clinic, but came out of retirement to resume her job as physician assistant for the community. The clinic opened in 2010.
Most patients are seen by Sparks and another nurse practitioner. Adams comes in on a monthly basis.
The clinic has some grant money but mainly operates off of private giving. A jar sits on one side of the waiting room, with a sign requesting donations for labs. But patients don't have to pay a dime to be seen or to be given certain medications.
"Without this, we'd probably just have to go without," said Anderson. "There's just so many other bills you have to pay first."
The clinic has managed to forge relationships with specialists in the area, to which they can refer patients who need further treatment -- but they haven't found an orthopedist. So for now, Sparks gives Anderson anti-inflammatory medicine, wraps her knee and recommends an X-ray at an imaging center that offers a reduced rate.
Sparks and the other staff stay busy the rest of the morning.
They prescribe antibiotics for Constance Bradford, an Altamont, Tenn., resident who has lived with a ruptured eardrum for years. It had never been examined or treated before she came to the clinic.
She has also been directed to a surgeon who is willing to perform a long-overdue hysterectomy pro bono.
"I would have never been able to see a doctor if I had had to pay for it," she said. "I just suffered with whatever was wrong with me."
It's the same story for Linda Nelson, who long struggled with frequent "spells" where her heart raced -- until Sparks agreed to see her around midnight during one of the spells and began prescribing blood pressure medication.
The spells have stopped. But the clinic's help hasn't. Last year, Nelson's husband, Jerry, had been having headaches for some time. During one agonizing episode, Nelson again picked up the phone in the middle of the night and called Sparks -- who insisted the couple go to the hospital.
Scans later showed Jerry had a cancerous tumor growing in his brain. They had caught it in time to get approved for free surgery at Vanderbilt Hospital in Nashville, saving Jerry's life.
While the clinic cannot always provide the needed treatment, it offers a starting point and a steady guiding hand to the next step.
"She'll help you, or she'll lead you in the right direction to get you some help," Linda Nelson said of Sparks. "Without her ... I wouldn't know which way to go."
To a large extent, improving the county's health care rankings hinges on improving the economic climate.
But there are cultural factors that need to be addressed, too, said Caleb Rae, a local physician assistant. He sees patients at the Grundy County Primary Care Center in Coalmont -- many of whom are on a sliding scale payment system.
"There is the poverty issue. But there is also the cultural factor -- just the habits people get into," Rae said. "Just how you eat, which is to a large extent determined by who your parents were and your education level."
The most common medical problems the local doctors recite are the same: hypertension and diabetes. About 30 percent of the county population is classified as obese and inactive.
"These diseases are silent illnesses until things get far advanced. And then it's hard to change habits," said Adams.
A big habit is unhealthy eating, as fats and starches are cheaper and a larger part of the local diet, said Rae.
"You go into most of the restaurants around here that have plate lunches, and they'll have a meat, they'll have a roll, and then there'll be mashed potatoes and then corn or a salad," explained Rae. "If you're a diabetic, this is going to run your blood sugar through the roof."
Education is a constant part of Rae's work. Give up soft drinks, he urges patients. Eat off smaller plates and don't go back for seconds. Drink water. Do something active every day.
The Grundy Health Department offers classes on managing chronic illnesses and diabetes, along with family runs and healthy cooking classes, said Beth Delaney, spokeswoman for the Southeast Regional Health Office.
"We're working really hard on ways to improve health in the county," she said.
Other cultural mindsets also affect rural residents' attitudes toward health, both Adams and Rae say. Some people don't want to ask for help. Some people simply don't trust doctors.
"There is a level of pride," said Adams. "I don't want to overgeneralize, but I think many of our friends have been used to getting by without the latest in medical care or frequent medical care. They're used to toughing it out."
Some have grown used to staving off chronic pain with high doses of ibuprofen and Tylenol. Others have sunk into a painkiller addiction -- another chronic struggle for Southeast Tennessee.
"There are a lot of people that work tough physical jobs who have back injuries or shoulder injuries that they can't get fixed," said Rae. "They start taking something every now and then, and the next thing you know, you've lost your house and your kids."
Rae's clinic maintains a strict policy on prescribing painkillers. The Beersheba clinic stays away from them altogether.
GETTING MORE DOCTORS
Another threat to rural health is a doctor shortage that is reaching crisis levels, experts say. There is already a dearth of primary care doctors nationwide. In rural areas, the problem is compounded by the fact that positions in clinics there just aren't popular.
It's not uncommon for it to take months -- even years -- to fill a vacancy at a rural clinic.
That's where the Tennessee Rural Partnership steps in. The organization works with rural-based providers to help bring more doctors, physician assistants and nurse practitioners to areas like Grundy County.
"The basic intent [of the program] is to look at increasing access to rural and underserved areas in the state and help recruit primary care providers in these areas," said Bill Jolley, vice president of Rural Health Issues for the Tennessee Hospital Association, which oversees the initiative.
It takes a special kind of personality to work in these communities, explained Denise Primm, operations manager for the program.
"It takes a mission-minded person, because they don't have the amenities of a larger community," she said.
It may also take some incentive. Since 2006, the TRP has run an incentive program, giving stipends to medical residents and other nursing students through their training. Once that is completed, recipients must honor a three-year commitment with a rural-based provider.
"We've seen a large increase in applicants," said Primm. "We're way above our expectations this year."
While the group hopes it can begin to fill in the chasm of primary care access with doctors, they noted that the gap will be increasingly filled with physician assistants like Rae and Sparks.
"With the shortage, there will be greater reliance on nurse practitioners and physician assistants," said Jolley.
Doctors like Adams know that they may not be able to turn the tide of health trends in Grundy County. But he knows that doing anything is better than doing nothing.
"A lot of times it feels like a drop in the ocean," said Adams. "But still -- it's good to be able to do even that."
Contact staff writer Kate Harrison at firstname.lastname@example.org or 423-757-6673.