For 25 years, Dr. David Avery has been practicing medicine "solo" in West Virginia -- the only state entirely situated in Appalachia, the heart of America's rural poor. Until recently his caseload was 4,000 to 5,000 families across 40 isolated towns.
But today, because of a campaign to recruit new primary care physicians, Avery has more help, working alongside a growing number of foreign doctors at the Ritchie County Primary Health Group in Parkersburg.
Lured by "exchange visitor" visas, these doctors -- hailing from Pakistan to the Philippines -- are often greeted as "rock stars," but in the isolated hollers ofAppalachia, they face a mountain of cultural and medical challenges.
"It's very hard," Avery told ABCNews.com. "These people don't want to trust anyone who hasn't lived here for years. It's hard enough for U.S.-trained physicians to come to a little town. They are very protective, and if you are not one of them, they can chase you out of town. You're not accepted."
With doctors like Avery, 54, who are approaching retirement, and medical students choosing lucrative specialties, the nation as a whole faces a shortage of primary doctors. In Appalachia, a federally declared Health Professionals Shortage Area, the need is particularly acute.
Foreign doctors may obtain a J-1 visa if they relocate to an underserved area for three years. After that, they can practice anywhere in the U.S.
'People Won't Go to Them'
"We find more and more of these places are filling up with foreign doctors who don't have as much debt as the American ones," said Avery. "Doctors come to these small towns, and there are language barriers. The problem is that people won't go to them, even if they are perfectly well-trained."
The new doctors encounter a proud and protective population that is used to "taking care of their own," according to Avery, who serves on the board of the American Academy of Family Physicians.
Nowhere is the need for medical care more striking than in Appalachia -- a 200,000-square-mile swath of mountains that touches on 13 states from New York to Mississippi. The region of 23 million people, which has been vilified in stereotypes, is one of the most historically neglected in the nation.
"They are hardworking people, some of the friendliest in the country, with a strong sense of community and strong sense of purpose," said Louis Segesvary, a spokesman for the Appalachian Regional Commission, which for the last half century has addressed the region's economic depair.
Avery acknowledges some of the stereotypes -- including incest. "Some of that's real," he said. "There are a lot of social issues in small-town families -- domestic abuse and a more isolated redneck attitude."
The region leads the nation in rates of heart disease, cancer and diabetes, as well as the abuse of prescription drugs. Overdoses of the painkiller oxycodone are so common, it's called "hillbilly heroin."
Avery's patients seldom ask for medical help, and when they do, their diseases are more advanced. Mothers shortchange their own health to take a child to the doctor before themselves, and families forgo follow-up visits because of the extra expense for X-rays, lab work and prescriptions.
"The people are generally poorer, eat worse, don't take care of themselves as much and tend to be stoic individuals," Avery said.
Their culture of clannishness encourages Appalachians to avoid mental health professionals and solve crises within the family, according to Avery.
In Sisterville, a poor town of 1,500, a local drunk was "protected" for years until he sexually assaulted a woman from another family and ended up in the emergency room with a skull fracture.
"Things either get very bad before we see them, or someone finds out about it," said Avery. "It's an intra-family thing. The man was supposed to be a contractor but spent most of his time drinking -- until he got drunk at someone else's house and caused major harm to one of the family members.
"He took advantage of a woman and then the family went and beat the daylights out of him," he said. "They protect their own."
'It's a Somewhat Bleak Life'
In some of these small towns, foreign doctors outnumber local doctors 2 to 1, according to Avery, a trend that is seen in other parts of Appalachia, such as Tennessee.
Recruits like Dr. Ryan Guanzon, a native of the Philippines, are attracted to the beauty of the mountains, the "slower pace of life" and the low cost of living.
"I knew I would be a better doctor if I came here," the general practitioner from Tazeville, Tenn., recently told the Knoxville News Sentinel. "They have a lot of problems, both healthwise and their personal situations. Sometimes I have to get both."
Guanzon added, "I always tell [my patients], 'This is something common that I deal with every day, nothing to be ashamed of. And you can tell me everything, because this is a safe place to be. It's a doctor's office. I won't tell anyone about your problems."
Many of those problems have been evoked in both literature and film, but the reality is more nuanced, according to Jeannette Walls, who wrote "The Glass Castle," a memoir of growing up in persistent poverty in the small city of Welch, W.Va., in the 1970s.
"It's a somewhat bleak life, and the employment opportunities and chances for an optimistic outlook are so slim," said Walls, who left Appalachia at 19 to work as a journalist in New York City. "I lived at the bottom."
In her book, Walls described a mountain home with dirt floors and without plumbing. When rainwater poured through the roof into the kitchen, she and her siblings suffered intermittent shocks when brushing against the one modern appliance, the stove.
"The entire time I lived in West Virginia I didn't go to the dentist or the doctor a single time," said Walls. "It's a combination of poverty and living outside the system. I always thought that people who went to hospitals were wusses. You scrape your knee, you take care of it. You get a boil, you pop it and put mercurochrome on it, and you're all set to go."
Economic conditions have improved in the nearly half century since the federal government created the Appalachian Regional Commission to address the precursors to poor health -- low income, limited education and geographic isolation. But new reports show that mortality rates for those under 65 are the worst in the nation.
"The mountains shape people's lives both literally and figuratively," writes Bruce Behringer in the 2006 report "Appalachia: Where Place Matters in Health."
Mortality Rates Highest in Country
Death rates in Appalachia in the 1960s and 1970s were below the national rate, but now the under-65 mortality rate --by both gender and race -- tops the nation, said Behringer, an assistant vice president for the division of health sciences at East Tennessee State University.
Lack of exercise, obesity and smoking all contribute to Appalachia's record as the heart disease capital of the United States. Tobacco is also an entrenched part of the culture, and lung cancer rates among all groups are 20 to 30 percent higher than the rest of the nation.
"Appalachia is a very, very unhealthy place," Behringer told ABCNews.com. "They are dying more frequently at an earlier age."
Mountain families remember tobacco as the "Christmas crop" because payments from auction come at the holidays. Some studies show half of all primary care patients have some connection to the tobacco industry.
It's not unusual to see pregnant women smoke. One-third of all women report they are in abusive relationships and smoking is a "coping skill," Behringer said. "Mama is working. You can't take the baby to the doctor or get a pap smear -- you have to take a day off from work."
Mental health issues exceed the national average but are rarely addressed. "Everybody knows your truck, and if go to that building, everyone knows it's you," he said.
"There's no lack of technology in mountains," Behringer added. But "good, efficient and effective communication" is lacking between doctor and patient. "You don't ask, it's part of the culture, a lack of assertiveness with your own health."
That passive culture makes the job of foreign doctors more difficult, as many patients fear they will not be understood by a non-native speaker.
But finding American-born doctors is difficult because of the rural isolation, said Dr. Don Brady, assistant dean for graduate medical education at Vanderbilt University in Nashville, Tenn.
"If someone wants to have an academic career, they're going to be remote -- too far from a [nearby university] and from discussion," he told ABCNews.com. "There are fewer colleagues to share stories and questions with."
Social isolation is also a problem. "Single doctors are looking for a spouse and want to go where they can meet a partner, marry or raise children," he said. "If they are married, it affects schools and what the environment you raise your kids in."
Doctors Don't Stay Long Enough to Form Relationships
Many foreign doctors stay only the three years and move on to sub-specialty fellowships. "Then the town isn't gaining a primary doctor, but a 'doc-in-the-box,' someone who is there just a short time and they don't really develop a relationship," Brady said.
And for a region with such great medical needs, the loss of primary doctors who are aging and retiring is catastrophic. "We are losing general internists," Brady said. "They are the real quarterbacks of someone's care."
Meanwhile, Dr. Avery relies on his foreign colleagues to help with the "desperate" medical needs at both the Sisterville emergency room and the Ritchie County health center. Those who come with an open heart and no "big city snobbery" are eventually welcome, he said.
Avery said, "It's a really friendly group, and I enjoy working with them."