The clinic – a box perched on wheels and painted with trees and people – sat in the gravel and grass parking lot of a burger and wings joint called VNV Sports Bar and Grill, the only restaurant in Metcalfe, Mississippi. Choosing where to park it in this Delta town of about 1,000 people had not been difficult.
“It’s the main strip in Metcalfe,” said Antoinette Roby, a community health worker and driver at Plan A. The mobile clinic offers pap smears and mammograms, testing for sexually transmitted diseases and COVID-19 vaccines, contraceptives and blood pressure tests– all for free.
Since April 2021, Roby and her colleague Juliet Thomas have criss-crossed the Delta in the clinic, aiming to expand access to primary and reproductive health care in a region where many people hear “clinic” and assume they can’t afford to step inside.
Mississippi has one of the highest rates of uninsured people in the nation, a statistic exacerbated by state leaders’ refusal to expand Medicaid. About 20% of adults in Washington County, where Metcalfe is located, don’t have health insurance.
Family planning is a key part of the clinic’s work, as they counsel patients – especially women – on contraceptive methods and field questions about fertility and pregnancy. And now, with the end of legal abortion in Mississippi, the stakes of that work are rising.
“It’s not going to interrupt what we do,” Thomas said of the ruling in Dobbs v. Jackson Women’s Health Organization, which means abortion will be illegal in almost all cases in Mississippi. But it does spotlight the dire need for contraceptives, pregnancy-related care, and primary care in the poorest part of the poorest country in the United States.
After the leak of the draft opinion showing the U.S. Supreme Court was poised to overturn Roe, Plan A announced plans to distribute emergency contraception and take-home pregnancy tests to patients. The clinic is also adding ultrasounds and pregnancy- and miscarriage-related services.
“Mississippi has one of the highest rates of maternal mortality in the country, and banning abortion will lead to an increase in high-risk pregnancies with no plans to reduce the barriers to care faced by pregnant people,” the clinic said in a press release in May. “Plan A will help to fill that gap.”
In the wake of the overturning of Roe, Republican leaders in Mississippi are touting a “new pro-life agenda.” The leaders of the state House and Senate have established committees to recommend plans to help mothers, children and families.
They have mentioned trying to improve the state’s abysmal foster care, which is the subject of a federal lawsuit, and child support systems. But they have avoided endorsing measures like Medicaid expansion that would make comprehensive health care more affordable and accessible for Mississippians, and that doctors say would make moms, babies and families healthier. Last year the Legislature refused to extend Medicaid coverage for new moms, even as other conservative Deep South states did so.
Attorney General Lynn Fitch, Gov. Tate Reeves, and Speaker Philip Gunn, R-Clinton, have all described the state’s “pregnancy resource centers” as a key way to support pregnant women and new moms. The centers offer ultrasounds and pregnancy tests but generally no other medical services and are not regulated by the health department. And there are only a handful in the Delta; the closest one to Metcalfe is in Cleveland, a 45-minute drive away.
While state leaders hold press conferences celebrating the overturning of Roe v. Wade, Roby and Thomas keep seeing their patients.
Metcalfe is a regular stop on their rotation through the Delta: They visit every fourth Tuesday, rain or shine, at the invitation of Rev. Arthur Thomas, head of the town’s Mayoral Health Council.
On a Tuesday afternoon, Arthur Thomas sat inside Metcalfe’s City Hall, a squat brick building, working the polls for a runoff primary election in which no one so far had voted. Thomas said he had wanted the mobile unit to come to Metcalfe because many residents are low-income, and medical facilities in Greenville aren’t accessible without a car.
“It should be a right for everyone to have it,” Thomas said of health care. “But everyone can’t have it, and that’s where Plan A clinic comes in.”
When Caroline Weinberg – a New Yorker with an M.D. and a background in public health – first conceived of Plan A, the goal was to help meet needs for family planning care in rural, underserved communities.
Mississippi has one of the country’s highest rates of unplanned pregnancy. In 2020, it claimed the highest rate of teen pregnancy. The state has the highest infant mortality rate in the country. It also has a high overall maternal mortality rate, and Black Mississippians are nearly three times likelier than white Mississippians to die of a pregnancy-related complication.
For years, the state’s federally funded family planning offerings have fallen short. Until early 2022, the state health department got the grant to administer the program and used it to provide services at the county health departments. A report commissioned by the department to evaluate its own work found serious problems: Long wait times for appointments, inaccurate information about payment, clinics running out of condoms, and patients being told that they couldn’t choose what contraceptive method they got because “it is up to what the doctor wants.”
Just as reproductive health can’t be separated from health care more generally, barriers to accessing family planning are often the same reasons people struggle to get care at all.
Mississippi has one of the country’s highest rates of people who lack health insurance, at about 12%. The state ranks 49th in primary care doctors per capita, and a 2019 report found that about half of the state’s rural hospitals were at risk of closing. And while Washington County is home to four OB/GYNs, many Delta counties have none.
“We’ve fallen into this trap of making it seem like women’s health is a specialty,” Weinberg said. “That’s part of the issue of rural health care – it’s like, ‘Go talk to your lady doctor about that issue.’ If it’s hard for you to get to the doctor, there’s no reason that everybody shouldn’t be talking about this.”
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So while providing reproductive health care is a priority, Plan A offers as many services as it can. Staff check blood pressure and blood sugar, test for HIV, perform mammograms and pap smears, and provide referrals to providers whose services are as close to free as possible. It costs about $700,000 to run the clinic in Mississippi each year. In the first five months of 2022, the clinic saw 642 patients.
“They come in for one thing, we end up treating them for a whole lot of different things,” Thomas said. “They come in for blood pressure or blood sugar. Then when they start talking, they’re talking about, my feet are swelling, my back hurting. So we have our nurse practitioner come in and go a little bit further.”
About 75% of their patients do not have health insurance.
Roby and Thomas are both Delta natives: Thomas of Greenville, right next to Metcalfe, and Roby of Isola, about an hour away.
The daughter of a teacher and a parks commissioner, Thomas always wanted to stay in the Delta. She worked for the federal government for 15 years.
“I kind of worked my way through the Delta and saw a lot of the problems we have through no fault of the people here,” she said. “A lot of times the trust comes into play – everybody wants to study the Mississippi Delta and everything that goes on, but once the money is gone, people are just left with what they had already.”
Roby initially applied to Plan A as a driver and now serves as a community health worker, too. She spends her free time riding with a motorcycle club; in Metcalfe, she wore a T-shirt from a rally in Perry, Georgia.
Their 230-square-foot mobile clinic consists of two exam rooms, a small bathroom, and a lab space with a minifridge. The walls are decorated with photographs of Delta scenes: cypress lakes and wind-swept fields. The space is efficient, with drawers under the exam tables labeled to indicate they hold patient gowns and speculums. It smells like the citrus disinfectant Thomas and Roby use to wipe everything down at the start and end of each day.
When patients arrive, they climb the stairs to the unit and pick up an intake form listing the clinic’s services.
In Metcalfe, some people take their clipboard over to the grocery store next door to stand in the air conditioning while they fill out the paperwork.
At Frank’s Quick Stop, in business for 37 years, the counter is stacked with pink pickled eggs, pickled pigs’ feet and hot dill pickles. There used to be other places to buy snacks and some groceries in town, but they didn’t last, and now Frank’s is referred to in Metcalfe as “the store.” All day, people walk in and out to chat and buy cold drinks or a $5.89 fish sandwich.
Talk turns to the Delta’s troubles. The region’s population has been falling for decades. Washington County, for example, has lost a third of its residents since 1990. Factories have closed. There are few jobs.
Frank’s was once featured in an Associated Press article about the Delta culinary phenomenon of Kool-Aid pickles, and a print now hangs by the door. The lead photograph shows a young woman, the owner’s niece, smiling behind the counter at Frank’s. She has since moved away.
Metcalfe Alderwoman Etta Christon Washington, whose brother owns VNV Sports Grill, believes her hometown has become less self-sufficient than when she was born in 1964. The Delta can’t depend on the government, she says: Too much red tape, and in recent years the health department closed two of its three clinics in the county.
She describes herself as a resource center, always on the lookout for opportunities to meet needs in Metcalfe, from food to transportation. Plan A is one of those opportunities.
“I was surprised, because I had no idea that there was such services … I had no idea that you could do pap smears and everything on the mobile clinic,” Washington said of the first time she learned about Plan A. “It was mind blowing.”
Down the block from Plan A and Frank’s, 48-year-old Beverly Peterson sat outside her home with a few relatives, sipping sodas in the shade. Everyone had some experience with the clinic, whether they’d gotten a COVID vaccine a few months earlier or, in Peterson’s case, a free mammogram.
Without the mobile clinic, she said, “I probably wouldn’t have taken one, because I couldn’t afford it.”
Peterson, a lifelong resident of Metcalfe, was on Medicaid until her daughter turned 18 about four years ago. Since then, she has gone to the doctor every six months, paying $50 out of pocket to get her thyroid checked, because she knows if she doesn’t, the potential consequences are serious.
Oher needs go unmet. Her anxiety medication isn’t expensive, but the quick doctor’s visit to get the prescription is a cost she can’t justify, so she’s gone without it for months now.
“If I’m not just really hurting, hurting, I get something over the counter,” she said. “After I got off Medicaid, I just stopped going to the doctor.”
She was grateful for Plan A, but it wasn’t a complete solution. Peterson was trying to figure out how she was going to come up with the money to get a tooth pulled.
“Put some dentists in there,” she said. “They need a dentist.”
Thomas and Desiree Norwood, Plan A program coordinator and the mayor of Sunflower, said they’ve talked about adding dental and mental health services.
“There’s always going to be more,” Norwood said.
At 5:48 p.m., nearly an hour after the clinic was supposed to close, Roby and Thomas came outside to walk a patient to her car. A regular at Plan A, she had called to find out where they would be. She made it to Metcalfe a little after 5 p.m., but Roby and Thomas didn’t think of turning her away.
“If they see those stairs, they come up,” Thomas said. “If they come, we’ve got to see ‘em.”
“For instance, here – we won’t be back for another month,” Roby said. “What if their blood pressure is up?”
It’s not uncommon for the Plan A staff to check someone’s blood pressure and send them directly to the emergency room because they’re at risk of a heart attack.
With this patient, they had taken their time “educating and talking,” as Roby put it. It’s common for patients to need more than medical services, and Roby and Thomas are happy to connect them with resources and information, like how to call for free transportation as a Medicaid enrollee. They sometimes give patients their personal cell phone numbers so they can call with questions.
By the time they left Metcalfe, they had seen nine patients and provided every service they offer except for mammograms – a good day, Thomas and Roby agreed.
When the clinic launched in 2021, Plan A staff spent a lot of time meeting with local leaders and trying to find the “movers and shakers” in each Delta town who could help them build relationships. That’s still a key part of their work, but things have changed.
“Last year, we were calling, calling, calling,” Thomas said. “This year, they’re calling us.”