This crumbling Delta town, set amid cotton fields, abandoned railroad tracks and cypress-studded bayous, is a hard place.
So hard that the plaintive sound of a local musician drawing a knife blade across the strings of his guitar gave birth to the blues here a century ago. So hard that a Roman Catholic nun named Anne Brooks has struggled for the last 27 years to keep a medical clinic open for the poor.
"It's a pretty hand-to-mouth existence," said Brooks, 71, a physician with a wry sensibility and a profane streak. Brooks earned a medical degree at age 44 before coming to the Mississippi Delta to open the Tutwiler Clinic with the blessing of the Sisters of the Holy Names of Jesus and Mary.
She sees the nation's new healthcare law as a potentially happy turn in a long, hard journey. The measure provides hundreds of billions of dollars to help states expand medical insurance for the poor and pay doctors like Brooks, nearly half of whose patients have no coverage.
But there's a good chance this story will end with another difficult twist in the road for Brooks and for Tutwiler.
Mississippi has the highest poverty rate in the nation and some of the sickest people, with the country's highest rate of heart disease and the second-highest rate of diabetes.
For every dollar the state spends to expand healthcare for the poor, it stands to get as much as $20 from Washington. But state officials have been making it harder, not easier, to enroll in government-backed healthcare programs.
Republican Gov. Haley Barbour campaigned on a promise to cut the healthcare safety net to balance the state budget. Shortly afterward, Mississippi began requiring Medicaid recipients to submit to in-person interviews once a year, making it the only state with such sweeping a rule. In Tutwiler, the closest registration office is in nearby Sumner. It's open one day a week, on Tuesdays, from 9 a.m. to noon and 1 p.m. to 3 p.m., as well as the third Wednesday of month.
Barbour, who said recently that the healthcare overhaul "would prove disastrous" for Mississippi, has joined a lawsuit filed by GOP officials in several states seeking to overturn the law. For the little clinic near the banks of Hobson Bayou, that could mean more challenging days ahead.
Built before desegregation, the Tutwiler Clinic had separate waiting rooms for black and white patients when Brooks took it over in 1983. Many still remember the September day in 1955 when an all-white jury at the county courthouse in Sumner acquitted two white men for killing a 14-year-old black boy named Emmett Till and dumping his body in the nearby Tallahatchie River because he whistled at a white woman.
Brooks was fresh out of osteopathic school when she got here. She had sent letters offering her medical services to mayors up and down the Mississippi Delta. Tutwiler was the only place that answered.
"Catholics are terrible about quoting things," she said. "But there is a place in the gospel of Matthew where it says something like, 'Freely you have received, freely give.'"
For herself, Brooks said, "I have received so much."
It wasn't always clear that would be true.
The only child of a Navy captain and an alcoholic mother, Brooks didn't have much of a family life growing up in the 1940s in Washington, D.C. When she was in sixth grade, her parents divorced and her father sent her to a Catholic boarding school in Key West, Fla.
In her teens, Brooks was stricken with rheumatoid arthritis and confined to a wheelchair. Protected by the sisters who taught at the school, Brooks decided she too would become a nun.
Then, in 1972, Brooks met a doctor at a free clinic in Clearwater, Fla., who changed her life, treating her with a mix of acupuncture, dietary changes and psychotherapy. Within six months, Brooks was walking again.
Six years later, Brooks once more heeded her doctor's advice. With permission from her Catholic order, she enrolled at Michigan State University's College of Osteopathic Medicine. "I never thought I would be a doctor," she said. "I couldn't even pass chemistry."
But become a doctor she did, and she soon found herself with the keys to a dilapidated one-story brick building just off Tutwiler's derelict main street.
"I didn't tell them I was a nun," Brooks said with a chuckle.
Today, Brooks' patients sit together in a single waiting room. They come in search of relief from unexplained aches and pains, prescription drugs they can afford, an X-ray they think they need. The clinic has a staff of 32, including four more nuns and a physician from Nepal who has been here three years.
Brooks and her team see all who come. On a recent morning, she quizzed a young woman with pain in her wrist about her smoking habits after smelling smoke on her patient's breath. "When are you going to quit? Let's pick a day," Brooks commanded firmly.
She helped another woman navigate a garbled notification from her Medicare prescription drug provider. On a house call across the bayou, Brooks visited 82-year-old Johnnie Lane, bedridden after suffering a stroke. Brooks held his hand and gently reminded his wife to make sure she was getting enough rest too.
"When you take care of the person, you take care of the family," Brooks explained after giving Lane's wife a long hug and admiring her roses before heading back to the clinic in her aging white Toyota.
Sometimes, Brooks is able to find a hospital to provide charity care to people like David Kitchens, a 61-year-old farmer who has never had health insurance. Kitchens needed surgery to have a lunch-plate sized tumor removed from his chest.
"I was up a creek without a paddle, and drifting away pretty fast," Kitchens said. "They saved me."
Brooks and her team wish they could do more. But they are up against relentless math.
When they see a patient with private insurance from Blue Cross Blue Shield of Mississippi, the clinic can collect $44.80. For an elderly patient with Medicare, the clinic can bill $61.47.
Medicaid, which in some states pays so little that many doctors have stopped taking poor patients, has higher reimbursements in Mississippi, in part because so many providers rely on it. The program pays $121 for a routine office visit, and $124.01 if the patient is under 18.
Brooks' problem is that 4 in 10 of her patients have no insurance at all. The clinic bills them $15 for an office visit but many never pay.
"When someone brings me a basket of squash, I'm happy," Brooks said.
In 2008, Brooks collected $552,572 for delivering medical care, barely a quarter of the clinic's expenses, according to tax records. Most of the difference had to come from grants and donations.
Even then, there isn't enough money to fix the crack in the ceiling above the X-ray machine or wax the linoleum very often, or upgrade the clinic's aging computer system. The clinic has 24 computers, and seven don't have enough memory to run an electronic records system Brooks wants to install.
"I'm hoping for a little help from Uncle Gates for that one," Brooks joked, plotting the pitch she imagines making to Microsoft founder Bill Gates.
More heartbreaking are the no's that Brooks sometimes has to say to patients. When a woman came to the clinic complaining about pain in her left arm and shoulder, the best Brooks could do was recommend rest. A neurological test might have ruled out something serious, but the woman didn't have insurance — nor the $800 — to pay for the specialized exam.
"There are so many people who need to get help, who go through life in pain because they can't get the tests they need," Brooks noted sadly.
Some of these patients are probably eligible for Medicaid, but they have not enrolled — a fact that many advocates say reflects in no small part the extra hurdles the state has erected.
Mississippi is one of eight states that cut its Medicaid rolls between 2004 and 2008, according to enrollment data analyzed for the Kaiser Commission on Medicaid and the Uninsured. In the same period, the number of Mississippi children living in poverty increased.
Enrollment in Medicaid has begun creeping back up more recently. But the governor has said Mississippi cannot afford to insure any more people, even with the extra help from Washington.
"This new law will ultimately force the state to raise taxes, as hundreds of thousands of new people will be added to our Medicaid rolls," Barbour said.
Mississippi will have to find about $429 million over the next decade, a nearly 5% increase in Medicaid spending, according to an estimate by the Urban Institute, a left-leaning Washington-based think tank. But the federal government has agreed to kick in an estimated $9.9 billion over the same period to help Mississippi, enough to allow the state to cut in half the number of poor adults without insurance.
At the Tutwiler Clinic, Brooks said she's doubtful the state's leaders will take advantage of the federal help. "I just know I have to see my patients," Brooks said, as she reminisced about those she has treated, including the town's former physician who rode through the bayous to see patients with a rifle on his saddle to fend off panthers. "It would be nice if someone could figure out a way to pay us for doing it."