Stuck: a reason writer returns to Appalachia to ask: Why don't people who live in places with no opportunityjust leave?

• Author: Bailey, Ronald
• Position: McDowell County, West Virginia

I LAST VISITED McDowell County, West Virginia, over 40 years ago. Even then, I was already an outsider, a visitor to my family's past.

Sometime around 1950, my grandparents and all six of their grown children pulled up stakes and left McDowell behind. My grandfather bought a dairy farm 100 miles away in Clinchburg, Virginia, and my father joined him after he left the Air Force in the mid-1950s. The house I grew up in didn't have a bathroom until I was 5. My sisters and I bathed in a zinc washtub using water warmed on the chunk burner in our kitchen. Since our house was heated entirely by two wood-burning stoves, I spent a good portion of my summers chopping and stacking cordwood. My upstairs bedroom was unheated, so I slept in a cast-iron bed beneath three heavy unzipped U.S. Army canvas sleeping bags to stay warm. We got a telephone when I was 13 years old; it was a five-party line.

But it was the folks in McDowell-including many of my relatives--whom I thought of as poor. To my eyes, a huge number of the houses we drove past in hamlets like Squire, Cucumber, English, Bradshaw, Beartown, and Iaeger on our way to visit my father's hometown of Panther were little more than shacks. Many were covered with tarpaper. Indoor bathrooms and running water were luxuries. The houses that did have bathrooms more often than not simply ran a pipe from their sinks, tubs, and commodes directly to the nearest stream. My grandparent's old home was a nice and pretty spacious white clapboard house, but they got water from an outside hand pump and resorted to a first-class outhouse to answer nature's call. The water tasted distinctly of iron and sulfur. Except deep inside Panther State Forest, where the Bailey family held our annual Labor Day reunion, coal dust coated most buildings and automobiles.

I do not long for the chilly, dusty, impoverished life I remember--my experience of the past is whatever the opposite of nostalgia is--but in retrospect, I was witnessing the tail end of McDowell's golden era. Mechanization, especially the development of continuous mining machines, enabled coal companies to mine much more coal with many fewer workers. Out of a population of nearly 100,000 in 1950, 15,812 worked as miners. By 1960 that number was just 7,118. Today there are only about 1,000 employees working for coal companies in the county, out of a population of less than 20,000. The county's dwindling economic prospects were further devastated by massive floods in 2001 and 2002 that destroyed hundreds of houses and businesses and killed four people.

In recent years, McDowell has attracted attention for the worst possible reasons. It consistently shows up at the bottom of rankings, with the lowest levels of employment and the worst level of overall health in West Virginia, and the shortest male life expectancy in the nation. But it sits very near the top of lists of counties with the most drug overdoses, obesity, and suicides.

The rather unsentimental question I set out to answer as I made my way back this autumn: Why don't people just leave?

BAD NEWS

ONE SIGN THINGS are not going well in your county is when the kids in the social service programs know to do pre-emptive damage control with the press.

"Don't you focus just on the negative," warned Destiny Robertson, a spunky African-American senior at Mount View High School and a participant in the Broader Horizons program for at-risk kids devised by the Reconnecting McDowell task force. But it's hard not to focus on the negative when it can seem like that's all there is. Asked about their hometown, the kids shout out the usual list of woes with a world-weary attitude: bad schools, no jobs, drug addiction.

They're right to worry: McDowell County has been the iconic symbol of poverty in America ever since the 1960 presidential campaign, during which then-Sen. John F. Kennedy visited the county four times. In his May 3, 1960, speech in the town of Welch, Kennedy cited the collapse of employment in the coal industry and declared that had President Eisenhower "come to McDowell County, he would have seen a once prosperous people--the people of the largest and most important coal-mining county in the world--who were now the victims of poverty, want, and hunger."

Ever since, the unrelenting awfulness of McDowell's problems has drawn the eye of storytellers and researchers alike. In March 2014, The New York Times ran a story comparing affluent Fairfax County, Virginia, with McDowell. Besides noting the fact that average per capita incomes are five times higher in Fairfax, the article reported that average life expectancy in McDowell County was the lowest for males in the United States, at about 64 years. "Poverty is a thief," the Times quoted University of Maryland professor Michael Reich as saying. "Poverty not only diminishes a person's life chances, it steals years from one's life."

Right around when the New York Times writers rediscovered McDowell, Princeton economists Anne Case and Angus Deaton were uncovering an alarming new national trend: The mortality rates of middle-aged white Americans were increasing. In contrast, U.S. mortality rates have been steadily declining and average life expectancy increasing for well over a century. So what is going on with poor white people between the ages of 45 and 54? Case and Deaton reported in a September 2015 paper in Proceedings of the National Academy of Sciences that nearly two-thirds of the increase in the white midlife death rate is the result of drug overdoses. Most of the rest is attributed to increases in suicide and chronic liver diseases like alcoholic cirrhosis.

McDowell fits that pattern: According to 2014 figures from the Centers for Disease Control and Prevention (CDC), it has the highest suicide rate in West Virginia at 22 per 100,000 residents, compared to a national rate of 13 per 100,000. The rate of liver disease in the county, which is the highest in West Virginia, is twice as high as the national rate, at 21 per 100,000 compared to 10 per 100,000. The number of murders per capita--again the highest in the state--is three times the national average.

Debra Elmore, who oversees Destiny's after-school program, backs her kids' generalizations with hard numbers that are hard to hear as well. "Ninety percent of kids in McDowell County schools are below the poverty threshold for free and reduced-price lunches," she says. "Forty-seven percent do not live with their biological parents, often because of incarceration and drug addiction, and 77 percent live in households...