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Christy Ratliff is sitting in a folding chair in a public school gym in Grundy, Virginia, waiting for her number to be called. She arrived at 4 a.m. on this October Saturday to secure her position in line to have eight teeth pulled. Genetic gum disease, she explains, has left most of them rotten or broken. She hooks a finger to pull down her lip and show me gruesome damage—the kind most dentists see only in textbooks.

Ratliff is 29 years old.

Grundy, the seat of Buchanan County, sits deep in the Appalachian Mountains of Southwest Virginia. This weekend, it’s hosting a free clinic courtesy of Remote Area Medical, a nonprofit like Doctors Without Borders, but for places in the United States where the health ­outcomes are as grim as those in many developing countries. RAM founder Stan Brock once suggested that because Grundy is so inaccessible, his volunteers should literally parachute into town, as he once did while working in rural Africa.

Despite all the faith these locals have put in Trump, his second term is threatening their precarious existence. Few places in America are as reliant on the federal government. According to a recent study, 45 percent of the personal income of ­Buchanan County residents comes from Social Security, Medicaid, and Medicare, the Supplemental Nutrition Assistance Program (SNAP), and government disability programs. Federal dollars also account for about 15 percent of the county budget, subsidizing nearly every aspect of local life—education, economic development, disaster recovery, housing, sewer infrastructure. And Trump has succeeded in jeopardizing or eliminating nearly all of it.

“We live in a remote part of the world,” the driver says, declining to give his name. He’s here for denture work because ­Bradshaw has no dentist. He grew up in a holler, and like generations of his people, worked in the coal industry, including once for a company owned by Sen. Jim Justice (R-W.Va.)—until his paychecks bounced, a chronic problem at Justice’s mines. Now he works in logging. He has no health insurance, he says. Like 80 percent of McDowell County’s voters, he cast his ballot for Trump: “He’s kicking ass and taking names. He’s cleaning up the gangs. He’s doing awesome with the immigrants, too.”