It was a cool autumn day when the call came into my office.
My staff told me, "You have a new one." In our world, a "new one" meant a home visit, often urgent, often heartbreaking. And this one, they added, was "in the hills." In our region, "in the hills" meant far off the blacktop roads, beyond where GPS was reliable, onto winding gravel paths leading deep into the heart of rural America. A place not just untouched by modern convenience, but often forgotten entirely. Not just rural America, but true American poverty.
Poverty can strike any part of America, from inner city to deeply rural backcountry. According to the Census Bureau from 2023, approximately 37 million people live in poverty in the U.S. and this does not include the so called "working poor." For those of us who care for these people in our nation's health "deserts," the experience can be eye-opening, humbling, and at times traumatic. What I experienced on this particular day was all three.
The referral came from a local home health agency invoking their compassionate care program. The patient was a bedbound elderly matriarch who had recently suffered a large stroke. Her family had no insurance, no income, and no transportation. The agency's own nurses were hesitant to go to that area, fearful of the environment and unknown variables. But I had taken an oath to serve, and these were my people. I had seen these hills, these homes, these hardships before.
After about 30 minutes of driving up and down and around winding roads, I came upon a single wide trailer with two broken down trucks in the front yard, if you could call it a yard. The yard was merely dark clay and rock with no grass in sight, and multiple pieces of trashed metal and countless beer cans. A man in soiled overalls sat drinking a beer on the tailgate. Three children — two young girls in tattered 1950s-style sundresses and a shirtless little boy in stained shorts — were quietly kicking cans. They stopped as l pulled up, watching me like I was the first new face they had seen in months. What caught my eye next was a length of PVC pipe stretching nearly 300 feet from the creek up the hill directly into the trailer window. This, I realized, was their water system. No filtration. No regulation. Just creek water, gravity-fed through a pipe. Unfortunately, even in this day and age, it is not an uncommon occurrence in these areas for people to not be connected to city or county water or have legitimate sewage systems. Unbelievably, many don't even have electricity, using a wood stove for heat with no AC. Forget about the internet.
I took out my stethoscope, a clipboard, and my white coat, and proceeded to the front door. Getting to the door was a feat unto itself, and I ascended eight makeshift wooden steps that were half-rotted and barely holding together. It was just sturdy enough but I felt for the kids and the gentlemen on the truck bed and wondered how they did this every day without injury. I knocked on the door, then waited. And waited. Finally, a young woman came to the door and I explained I was sent by the local home health to visit my patient.
Inside, the reality of rural American poverty enveloped me. The smell — a potent mix of mold, human waste, and rotting flesh — hit me with such force that I instinctively reached for an alcohol swab to place under my nose. To this day, it is still one of the worst smells of my life, except for a decomposed body and GI bleeds I have been unfortunate to experience.
Once inside, I was greeted by an elderly man sitting in a large dirty lounge chair. The room was quite barren with only one small sofa and a very old hospital bed with a frail body in it. The young lady that let me in spoke with a hard lisp and stated the woman in the bed was "Granny."
I nodded and noticed the kitchen, the PVC pipe from earlier coming through the broken window, constantly dripping water at a very slow pace. I immediately explained to the young lady that they must put a filter on that pipe to prevent getting diseases from the water and to keep "Granny" from getting sicker, but she just looked at me with a blank stare.
The trailer was not cold nor warm. I noticed no form of heat as winter was approaching but did not broach that situation at that time. I inspected what served as their bathroom — plywood floors, no toilet, a hole in the ground, and a mildew-covered sink with no water. They were relieving themselves outdoors or directly through that hole in the floor. This was not simply poverty — this was abandonment.
I examined Granny as her granddaughter hovered protectively. My patient was frail and weak and unable to speak. She had left sided contractures and dark sunken eyes with numerous bed sores on her torso. After examining her and reviewing her medicines and scattered hospital notes, I advised her that she had had a large stroke and even with a safer environment and more care, this would likely progress to death. I recommended readmission to the hospital for a safer environment and possibly long-term care but the granddaughter stated they did not have money and that Grandpa would like her to “just stay home until she dies.” It was an answer I heard far too often.
I also gave information and education on hospice but I knew if home health would not visit the patient, then hospice surely wouldn't. And they did not want in-hospital hospice. Unfortunately, many of these rural areas can be seen as unsafe by clinicians due to high rates of alcohol, illicit drug usage, and many of the uneducated that live in these areas having prior bouts of incarceration and mental illness. Many clinicians that provide home care are fearful to accept patients in these areas just for this reason.
As a prior hospice medical director, I advised I would refill her meds, and ordered medications for her bedsores and to ease suffering that would be tolerable and not addictive. I gave the granddaughter a piece of paper with my suggestions on public health for them, including a water filter on their water supply, septic tank with fully functioning bathroom, some type of heat for the upcoming winter, and contacts that may aid the kids with better clothing, health care, and food assistance. I also advised her that when her grandmother passed or seemed to be getting worse, to contact me to come out and I would be there to help with her transition. She thanked me and I got in my car and drove off.
Sadly, I would see my patient again, about 8 days later, when a friend of the family contacted me to come out to pronounce her deceased. Thankfully, I was able to get a local church to volunteer to come to the trailer and put a new set of stairs on the trailer to prevent a tragic accident. The family thanked me for my care and help — and that was the last time I ever saw them.
It is simply unthinkable that in this day and age, some parts of America still live like this. I understand that this is an extreme case, and that many factors including poor knowledge and education led to much of what I encountered, but we simply must do better.
We have to strengthen our physicians in rural areas by paying them appropriately and understanding the bridge they provide for care in these areas. In my county, I am the only physician that is willing to visit patients in such settings due to the physician shortage, decreased reimbursement for difficult patients, and decreased monetary aid to increase access to care and to aid with social safety nets. We need to incentivize more doctors to rural and inner city areas, with full student loan forgiveness and appropriate pay to reimburse the complexity of caring for these patients. We all have to work together to improve those in poverty’s access to health and assistance because by pulling them up, we pull ourselves up. The strength in a nation or a people lies not just in how we provide for our upper and middle class, but how we care for our poor and underserved.
Dr. Christopher Burress is a med/peds physician in Bon Aqua, TN. He enjoys reading, writing, teaching, landscape painting, and spending time with his family and friends. He is a 2025-2026 Doximity Op-Med Fellow.
All names and identifying information have been modified to protect patient privacy.
Illustration by April Brust
