The plan was to begin handing out boxes of groceries at 11, but the truck delivering the food blew a tire en route. No one complained.

Perry Hall was among those waiting. His wife, Lilly Hall, volunteers with the distribution team. Perry has been dealing with a form of cancer called multiple myeloma. The Halls get by on around $1,500 a month from his Social Security benefits, plus assistance from the federal , or SNAP. But because of her age, Lilly, 59, recently became subject to new SNAP work requirements and at risk of losing her benefits.

As part of the federal One Big Beautiful Bill Act, all “able-bodied adults” 64 or younger who don’t have dependents and don’t work, volunteer, or participate in job training at least 80 hours a month are now restricted to three months of benefits every three years from SNAP, formerly known as food stamps. Previously, the federal requirement applied to those 54 or younger. The new rule, which went into effect in November, also applies to parents of children 14 or older. And it removed exemptions for veterans, people experiencing homelessness, and young adults who’ve aged out of foster care.

Proponents of work requirements argue that they incentivize people who are “work-ready” to seek and keep jobs, reducing dependence on government assistance and upholding the “.”

Rhonda Rogombé serves as health and safety net policy analyst for the . She and her colleagues have studied the effects of SNAP work rules and found that requiring recipients to work does not lower an area’s unemployment rate.

Previous work requirements were suspended nationwide during the covid pandemic and reinstated in fall 2023. The researchers found that the average number of people employed in Mingo County each month actually went down after the requirement was reimposed.

A 2018 federal research project that examined several data sources, including SNAP data from nine states, found that work requirements “have no impact on labor force participation and the number of hours worked.”

There are a number of possible explanations, Rogombé said, “but when people are hungry, they’re not able to support themselves. When people are hungry, it’s harder to focus at work. It’s harder to engage in work activity, and we think that that’s part of it.”

Jobs are scarce in this southern West Virginia county. Lilly Hall found work at a Delbarton restaurant. But it’s unpaid until a waitress position opens — enough to preserve her benefits, but far from ideal.

On that mild Wednesday in late March, House of Hope provided chicken, eggs, bread, potatoes, fresh fruit and vegetables, and milk.

Among those in line were older residents and “some young people that have lost their way and they can’t get work and they just need help,” said Timothy Treleven, who operates the pantry with his wife, Christine, and Gail Lendearo.

House of Hope’s scheduled distribution day is the last Saturday of each month — supplemented by occasional weekday Facing Hunger visits — as money from monthly checks begins to run out and cupboards go bare.

On a typical Saturday, pantry staff and volunteers hand out up to 400 boxes of food.

“It’s an honor to do this,” Lendearo said. “It’s a blessing.”

Perry Hall’s cancer is now in remission, but for a while his treatment required that he and Lilly travel back and forth, 4½ hours each way, to Morgantown. The couple’s van couldn’t make the trip, so they paid a friend for rides.

Mingo’s population is just under 22,000, down from around 27,000 in 2010. It once flourished, fueled by coal. Williamson, the county seat, was home to an opera house and businesses operated by immigrants from Italy, Russia, and Syria. The region is still referred to as “the coalfields,” but little is mined here these days. .

Rogombé and her colleagues found that Mingo County residents face significant barriers to securing what few jobs are available. These include unreported physical and mental impairments, housing insecurity, and a lack of high school diplomas and identification documents.

Filing the paperwork to receive benefits or to confirm compliance is difficult for many residents. The West Virginia Center on Budget and Policy’s research found that about 1 in 4 lack reliable internet access.

Additional changes lie ahead for the SNAP program. Currently, the federal government and the states share administrative costs equally, but in October states will assume 75% of those costs. And beginning in October 2027, they’ll be required to pay additional costs based on .

Kentucky, like West Virginia, is among the poorer states that will be most affected by the new requirements and costs. The Kentucky Center for Economic Policy estimates that with the expanded work requirements.

Jessica Klein, a researcher with the center, worries about the consequences. “We know SNAP has an impact on health, and not just because it decreases food insecurity,” she said. It worsens blood pressure rates, obesity, medication adherence, and more.

With the additional financial burden placed on states, “I think what we’ll see is some states changing rules that impact participation in order to have a smaller, more affordable program,” Klein said. “My fear is that some states will choose not to operate SNAP at all.”

In Mingo County, folks are stepping up. At least eight food pantries offer groceries to those in need.

Janet Gibson runs the Blessing Barn pantry in the Ben Creek community. “I can go from one end of the creek to the other” and tell you everyone’s name and a little something about them, she said. She takes pride in feeding her people.

Gibson said it can be hard to find even volunteer opportunities in the county, largely because of transportation challenges. A look at a local map can be misleading: A couple of dozen miles into a holler or up a ridge could take an hour or more.

“Whether you’re working full-time or not, you’re still spinning out gas to get to work,” Gibson said, “and gas ain’t cheap now.”

A single mother of three, Trista Shankle of Paducah, Kentucky, isn’t subject to the new SNAP requirements, but she worries about the fragility of the social safety net. She overcame challenges, is earning a master’s degree in social work, and works for an organization that connects community college students with benefits. Her family receives SNAP, Medicaid, housing support, and assistance from the USDA’s . If any one of those is cut, she said, she may have to drop out of school.

Shankle is certain she wouldn’t have advanced to where she is today without the benefits she and her family have received: “They bring a sense of calm and comfort. I know that my kids aren’t going to go hungry.”

The first week in April, Lilly Hall reported for work at Black Bear Trails Restaurant. She’s grateful for the opportunity. And when a waitress slot opens, “I’ll snag that position so quick it’ll make your head flip.”

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Author Barbara Kingsolver opened the facility in January with royalties from her Pulitzer Prize-winning novel, “,” whose plot revolves around Appalachia’s opioid crisis. The home offers a supportive place for people to stay while learning to live without drugs. Kingsolver had asked the women now living there to join her on stage.

Kingsolver, who grew up in Appalachia, suggested the women share with the audience what they were most proud of having gained from their first weeks at Higher Ground. But she learned they were more eager to brag on one another.

Supporters say provides stability and a reentry point after leaving jail, prison, or a treatment center. It offers a range of services and support in an area devastated by addiction to painkilling pills and other types of opioids. Most fundamentally, it’s a true home, with one- and two-person bedrooms, a communal kitchen, and a den. Residents say they have found affirmation from a cohort of women who understand how addiction can demoralize a person and estrange them from family and community.

Ronda Morgan, a resident, said her family has always been in her corner. But while she was serving a jail sentence for drug possession, she told herself, “I’m sick of them having to do time with me.” She was ready for recovery. Her daughter, who’s a nurse, told her about Higher Ground, the first facility of its kind in sprawling, rural Lee County. Morgan learned she could live there for up to two years to gain the footing that had eluded her in three-plus decades of addiction.

What she didn’t anticipate was the kinship she forged with her housemates — among them, Syara Parsell — and with Higher Ground’s staff.

Parsell, 35, one of Higher Ground’s first residents, said that in her time there she’s received help finding employment and enrolling in community college courses.

From the staff and Kingsolver, Parsell said, she has received judgment-free support. “Together,” she said, “we figure it out.”

Traditional treatment facilities typically operate under highly structured medical supervision. Recovery houses, like Higher Ground, offer a more relaxed environment, helping move a resident “toward being an independent, fully functional, self-reliant human being,” said Marvin Ventrell, CEO of the National Association of Addiction Treatment Providers.

“Recovery occurs in the community,” he said. But reentry must be approached delicately. “When addiction occurs with a human being, it also occurs within a family social structure.” If a person in early recovery returns to a family that’s unprepared, that person’s chances of success “are severely diminished.”

For Kingsolver, the opioid crisis became a focal point for what she hoped would be “the great Appalachian novel.” The epidemic “has changed so much of the texture of this place,” devastating families and communities.

Pharmaceutical companies for sales of what they prescription opioids. Kingsolver wanted to “cast my net back over all of the extractive industries that have come to this place, taken out what was good, and left behind a mess.”

“The way I put it is, ‘They came to harvest our pain when there was nothing else left,’” she said.

In research for “Demon Copperhead,” she immersed herself in the stories of people who’ve navigated addiction and those who care and advocate for them.

The novel has been an enormous success, having sold more than 3 million copies and earning far more than her previous works. Kingsolver decided to dedicate hundreds of thousands of dollars to address the crisis that has overwhelmed the region where she was raised — and to which she returned full time in 2004.

Again, she set about listening. Drawing on a wide range of expertise, she determined that a women’s recovery home was the wisest investment.

Joie Cantrell works as a public health nurse in for the Virginia Department of Health, supporting policies and practices to curb the negative effects of drug use, and serves as Higher Ground’s board chair. She had long recognized the need for just such a home.

“That was the part that was missing,” Cantrell said. Too often, when someone would come out of a treatment facility or incarceration, “we lost them. They fell back into the same old patterns.” She said the region sorely needed a safe, stable environment where women could recalibrate.

By August, the home reached its capacity of seven women. It’s right in town, “which is so important,” Kingsolver said, “because in this part of the country we have no public transportation.”

Parsell has long suffered from social anxieties; drugs were her escape. Here, her housemates embraced her. They’ve offered the support she’d never experienced.

“Every two seconds, someone’s like, ‘Syara’s here!’” she said. “I’m very grateful for it.” If there’s an issue in the house, “one of the seven of us has the solution.”

Four residents are employed outside the home, one is enrolled in community college classes, one is completing her GED with plans to continue her education, and everyone volunteers in the community. Crafting classes are offered. Family members visit.

“They’re living life,” said Subrenda Huff, who was filling in while director Liz Brooks took maternity leave.

Morgan said she accomplished more in a month at Higher Ground than she had in years. That includes applying for identification documents, taking budgeting classes, and seeking permanent housing. It includes sharing upkeep duties in the house.

Such was Kingsolver’s vision. But, she said, “here’s what I didn’t expect: The community embraced this with loving arms. I thought maybe people would say, ‘I don’t want this in my backyard.’”

Most of the furniture was donated. Kingsolver’s quarter-million or so social media followers have been instrumental in that. “But it’s not just book clubs in Switzerland or in California; it’s people in Pennington Gap,” she said. Church groups have donated “quilts, bedside lamps, things to hang on the walls just to make it homey.”

Before the facility opened, local folks volunteered to pull weeds, take down an old fence, and put up a new one. Kingsolver said the well of support “has been just endless. It’s been deep, and loving, and a wonder to see.”

Higher Ground, with only one paid staff member, has estimated yearly operating costs of $120,000, Cantrell said. Residents are charged $50 a week. Ventrell said that fees at other recovery houses vary widely but that $2,500 a month is an approximate average.

“We want them to focus on saving money and paying any restitution or fines they may have from past charges,” Cantrell said. “Some may be focused on repaying child support they may owe.”

Higher Ground receives no federal or state funding. Donations continue to pour in. And Kingsolver recently bought the building next door with plans to open a thrift shop, which would be a source of additional income for the home and offer retail work experience for its residents.

Supporters aspire to open more Higher Ground homes elsewhere in the region.

What these women are gaining, Kingsolver said, “is not just sobriety, but belief in themselves.”

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“It’s a very weird time in our lives,” said Kasen, executive director of the .

Last November, a group of people were captured on surveillance video early one morning mocking a “Black Lives Matter” sign in the front window of the center, with one of them vandalizing its free pantry. That same fall, Women’s Center staff reported being harassed.

A couple of blocks down East Michigan Avenue, Strange Matter Coffee, which supports progressive causes in the community, has been confronted by “” outside its storefront. Some toted guns or cameras, sometimes chanting slogans supporting President Donald Trump, generally unnerving customers and staff, Kasen said.

In many cases, throughout the U.S. over the past few years have been driven by the deepening and disinformation-driven rebellion against responses to the covid-19 pandemic. More recently, backlash against immigration and diversity, equity, and inclusion initiatives has heightened tensions.

Last year, the documented nationwide sowing unrest through a wide range of tactics, sometimes violent. Over the last several years, the group writes, the political right has increasingly shifted toward “an authoritarian, patriarchal dedicated to eroding the value of inclusive democracy and public institutions.”

Researchers at American University’s , or PERIL, say that in online spaces, “hate is intersectional.” (For example, Pasha Dashtgard, PERIL’s director of research, explains, platforms dedicated to male supremacy are often also decidedly antisemitic.) Seemingly innocuous discussions erupt into vitriol: The release of “A Minecraft Movie” prompted tirades against an alleged trend toward casting Black women and nonbinary people.

The continued escalations drove staffers at PERIL and the Southern Poverty Law Center to approach the problem from a different angle: Treat extremism as a public health problem. are now operating in Lansing, Michigan, and Athens, Georgia, offering training, support, referrals, and resources to communities affected by hate, discrimination, and supremacist ideologies and to people susceptible to radicalization, with a focus on young people.

The team defines extremism as the belief that one’s group is in direct and bitter conflict with another of a different identity — ideology, race, gender identity or expression — fomenting an us-versus-them mentality mired in the conviction that resolution can come only through separation, domination, or extermination.

Researchers who study extremism say that, as the federal government terminates grants for violence prevention, state governments and local communities are recognizing they’re on their own. (CARE receives no federal funding.)

Aaron Flanagan, the Southern Poverty Law Center’s deputy director of prevention and partnerships, said his organization and PERIL came together about five years ago to examine a shared research question: What would it take to create a nationally scalable model to prevent youth radicalization, one that’s rooted in communities and provides solutions residents trust?

They looked to a decades-old German counterextremism model called mobile advisory centers. The objective is to equip “all levels of civil society with the skills and knowledge to recognize extremism” and to engage in conversations about addressing it, Dashtgard said.

“We’re not about, ‘How do you respond to a group of Patriot Front people marching through your town?’” Pete Kurtz-Glovas, who until June served as PERIL’s deputy director of regional partnerships, explained during a training in January. “Rather, ‘How do you respond when your son or a member of your congregation expresses some of these extremist ideas?’”

Michigan has long been considered . Timothy McVeigh and Terry Nichols, convicted of the bombing of a federal building in Oklahoma City in 1995, were associated with a militia group in the state. Some of the men charged in 2020 in the plot to had ties to a militia group calling itself the Wolverine Watchmen.

The state’s capital city and adjacent East Lansing, where Michigan State University is, are relatively progressive but have seen conflict.

Will Verchereau has a vivid recollection from the early days of the pandemic: a pickup truck speeding down the street in their Lansing neighborhood, a Confederate flag flying from it, music blasting, later joining a rolling protest that clogged streets around the Capitol to protest Whitmer’s covid lockdown directives.

Incrementally, the community has responded to these expressions of extremism. After the confrontations at Strange Matter Coffee, Verchereau, a board member of the , which advocates for and supports the LGBTQ+ community, said people banded together to talk about “how to be safe in those moments; how to de-escalate when and where possible.”

The CARE initiative reinforces such efforts. The centers offer tool kits catered to specific audiences. Among them are a to online radicalization, a , and “.”

Flanagan said the team views this public health model as separate from but complementary to law enforcement interventions. The goal is to have law enforcement as minimally engaged as possible — to detect nascent warning signs and address them before police get involved.

The resources help identify conditions that can make people more susceptible to manipulation by extremists, such as unaddressed behavioral health issues and vulnerabilities, including having experienced trauma or the loss of a loved one.

Lansing resident Erin Buitendorp witnessed protesters, some of them armed, flood the state Capitol building during the pandemic over lockdown and masking orders. She’s a proponent of the public health approach. It’s “providing people with agency and a strategy to move forward,” she said. It’s a way to channel energy “and feel like you can actually create change with community.”

Lansing and Athens were chosen for a number of reasons, including their proximity to universities that could serve as partners — and to rural communities.

In the small town of Howell, 40 miles southeast of Lansing, outside a production of the play “The Diary of Anne Frank” at an American Legion post.

In nearby DeWitt, the local school district proposed a mini lesson on pronouns for a first grade class that involved reading the picture book “They She He Me: Free to Be!” Threats against school staff followed and officials canceled the lesson. Since then, the CARE team has helped provide support to teachers there in holding conversations on contentious topics in classrooms and in dealing with skeptical parents.

“It’s really important that rural communities not be left behind,” Flanagan said. “They persistently are in America, and then they’re often simultaneously demonized for some of the most extreme, or extremist, political problems and challenges.”

The CARE team hopes to expand its program nationwide. Similar public health initiatives have been launched elsewhere, including Boston Children’s Hospital’s and the , run by New York City’s Citizens Crime Commission.

And in June a new tool, the , went live, offering guidance to help prevent violent extremism.

Pete Simi, a professor of sociology at Chapman University and a leading expert on extremism, sees a daunting task ahead, with extremism’s having become more mainstream over the past 25 years. “It’s just devastating,” he said. “It’s really startling.”

Simi said that while there was previously talk of shifts in the Overton window, the range of ideas considered politically acceptable to mainstream society, “I would say now it has been completely shattered.” Violent extremists now feel “unshackled, supported by a new administration that has their back.”

“We are in a more dangerous time now than any other in my lifetime,” Simi said.

The Rev. Pippin Whitaker ministers the Unitarian Universalist Fellowship of Athens in Georgia, which last year received a package of ammunition in the mail with no note included. She embraces framing extremism, and people’s lack of awareness of it, as a public health issue.

“If you have a germ out there,” Whitaker said, “and people aren’t aware that if you wash your hands you can protect yourself, and that it’s an actual problem, you won’t enact basic protective behavior.”

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Trump said he calls it “beautiful, clean” coal. “I tell my people never use the word ‘coal’ unless you put ‘beautiful, clean’ before it.”

That same day, the Trump administration paused implementation of a rule that would help protect coal miners from an aggressive form of black lung disease. Enforcement of the new protections is officially halted until at least mid-August, that came a few days after a federal court agreed to put enforcement on hold to hear an industry challenge. But even if the rule takes full force after the delay, the federal agency tasked with enforcing it in Appalachia and elsewhere may not be up to the task after sweeping layoffs and office closures.

Deaths from black lung — a chronic condition caused by inhaling coal dust — since the introduction of over a half-century ago. But in recent decades, . By 2018, the Centers for Disease Control and Prevention estimated that the lungs of about 1 in 5 coal miners in central Appalachia showed evidence of black lung. It is being diagnosed in younger miners. And the deadliest form, progressive massive fibrosis, has increased tenfold among long-term miners.

Silica is the primary culprit. Exposure to it has increased since mining operations began cutting through more sandstone to reach deeper coal deposits. The stone breaks into sharp particles that, when airborne, can become trapped in lung tissue and cause a debilitating, sometimes fatal condition.

The new rule was set to take effect in April, cutting the allowable level of silica dust in the air inside mines by half — to the limit already in place for other industries — and set stricter guidelines for enforcement.

Years in the making, advocates for miners heralded the new standards as a breakthrough. “It is unconscionable that our nation’s miners have worked without adequate protection from silica dust despite it being a known health hazard for decades,” said when the rule was announced last spring under the Biden administration.

The rule pause came on top of another blow to mine safety oversight. In March, the Department of Government Efficiency, created by a Trump executive order, announced it would end leases for as many as three dozen field offices of the Department of Labor’s Mine Safety and Health Administration, with the future of those employees undetermined. That agency is responsible for enforcing mining safety laws.

Then in April, two-thirds — nearly 900 — of the workers at the National Institute of Occupational Safety and Health, an agency within the Department of Health and Human Services, were fired. As a result, NIOSH’s Coal Workers’ Health Surveillance Program, which offered miners free screenings from a mobile clinic, ceased operations.

An announcement by MSHA of the silica rule delay cited the “unforeseen NIOSH restructuring and other technical reasons” as catalysts for the pause but didn’t mention the federal court decision in the case seeking to rescind the rule.

Separately, on May 7, attorney filed a class-action lawsuit against Health and Human Services and its head, Robert F. Kennedy Jr., to reinstate the program. His client in the case, Harry Wiley, a West Virginia coal miner, was diagnosed with an early stage of black lung and applied to NIOSH for a transfer to an environment with less dust exposure but never received a response. He continues to work underground.

On May 13, U.S. District Judge Irene Berger issued a preliminary injunction to reinstate the surveillance program employees. The next day, Kennedy said the administration would . That day, they were back at work.

“Remaining in a dusty job may reduce the years in which Mr. Wiley can walk and breathe unassisted, in addition to hastening his death,” Berger wrote. “It is difficult to imagine a clearer case of irreparable harm.”

MSHA officials declined to respond to specific questions about the silica rule or plans to implement and enforce it, citing the ongoing litigation.

In an emailed statement, Labor Department spokesperson Courtney Parella said, “The Mine Safety and Health Administration is confident it can enforce all regulations under its purview. MSHA inspectors continue to conduct legally required inspections and remain focused on MSHA’s core mission to prevent death, illness, and injury from mining and promote safe and healthful workplaces for U.S. miners.”

Wes Addington is quick to say a career in the mines isn’t necessarily a death sentence. He comes from generations of miners. One of his great-grandfathers worked 48 years underground and died at 88.

But Addington also said protecting the safety and health of miners requires diligence. He’s executive director of the , a Whitesburg, Kentucky, nonprofit that represents and advocates for miners and their families. A study the center conducted found that staffers at the MSHA offices scheduled to close performed almost from January 2024 through February 2025.

Addington said NIOSH provided the data to document worsening conditions over the past few decades.

Addington’s organization has advocated for the new silica rule for 17 years. “We didn’t think it was perfect,” he said. He would have preferred lower exposure limits and more stringent monitoring requirements. “But, as it was, it was going to save lives.”

The cuts to the agency, Addington said, could affect every American worker who might be exposed to harmful elements in the workplace. NIOSH approves respirators prescribed by Occupational Safety and Health Administration regulations.

With fewer inspectors, miners are “more likely to get hurt on the job and those injuries could be fatal,” he said.

“And if you’re a miner that’s lucky enough to navigate that gantlet and make it through a 20-, 25-year career,” Addington said, “the likelihood that you develop disabling lung disease that ultimately kills you at an early age is much increased.”

The black lung clinic at in southwestern Virginia has diagnosed 75 new cases of progressive massive fibrosis in the past year, according to its medical director, Drew Harris.

“People are dying from a dust-related disease that’s 100% preventable, and we’re not using all the things we could use to help prevent their disease and save their lives,” Harris said. “It’s just all very disheartening.”

He believes it would be a mistake for Kennedy to reorganize NIOSH , shifting the surveillance program team’s responsibilities to other employees.

“It’s a very unique expertise,” Harris said. The agency would be “losing the people that know how to do this well and that have been doing this for decades.”

Rex Fields first went to work in the mines in 1967, a year before an near the small town of Farmington, West Virginia. His wife, Tilda Fields, was aware of the hazards her husband would encounter — the safety issues, the long-term health concerns. Her dad died of black lung when she was 7. But it meant a well-paying job in a region that has forever offered precious few.

Rex, 77, now lives with an advanced stage of black lung disease. He’s still able to mow his lawn but is easily winded when walking uphill. It took him several weeks and two rounds of antibiotics to recover from a bout with bronchitis in March.

Throughout his career, Rex advocated for his fellow miners: He stepped in when he saw someone mistreated; he once tried, unsuccessfully, to help a unionization effort. For these efforts, he said, “I got transferred from the day shift to the third shift a time or two.”

Today, the Fieldses lobby on behalf of miners and share information about occupational dangers. Tilda organized a support group for families and widows. She worries about the next generation. Two of the Fieldses’ sons also went into mining.

“People in the mountains here, we learn to make do,” Tilda said. “But you want better. You want better for your kids than what we had, and you surely want their safety.”

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Infectious disease experts from the Centers for Disease Control and Prevention made a list of recommendations following their visit, including one to launch syringe service programs to stop the spread at its source. But those who’ve spent years striving to protect people who use drugs from overdose and illness say the situation likely hasn’t improved, in part because of politicians who contend that such programs encourage illegal drug use.

Joe Solomon is a Charleston City Council member and co-director of SOAR WV, a group that works to address the health needs of people who use drugs. He’s proud of how his close-knit community has risen to this challenge but frustrated with the restraints on its efforts.

“You see a city and a county willing to get to work at a scale that’s bigger than ever before,” Solomon said, “but we still have one hand tied behind our back.”

The hand he references is easier access to clean syringes.

In April 2021, the CDC came to Charleston — the seat of Kanawha County and the state capital, tucked into the confluence of the Kanawha and Elk rivers — to investigate dozens of newly detected HIV infections. The CDC’s HIV intervention chief “the most concerning HIV outbreak in the United States” and warned that the number of reported diagnoses could be just “the tip of the iceberg.”

Now, despite attention and resources directed toward the outbreak, researchers and health workers say HIV continues to spread. In large part, they say, the outbreak lingers because of restrictions state and local policymakers have placed on syringe exchange efforts.

Research indicates that syringe service programs are associated with an estimated in HIV and hepatitis C, and the CDC to steer a response to the outbreak that emphasized the need for improved access to those services.

That advice has thus far gone unheeded by local officials.

In late 2015, the Kanawha-Charleston Health Department launched a syringe service program but in 2018 under pressure, with then-Mayor Danny Jones calling it a “mini-mall for junkies and drug dealers.”

SOAR stepped in, hosting health fairs at which it distributed naloxone, an opioid overdose reversal drug; offered treatment and referrals; provided HIV testing; and exchanged clean syringes for used ones.

But in April 2021, the limiting the number of syringes people could exchange and made it mandatory to present a West Virginia ID. The Charleston City Council subsequently added guidelines of its own, including requiring individual labeling of syringes.

As a result of these restrictions, SOAR ceased exchanging syringes. now operates an exchange program in the city under the restrictions.

Robin Pollini is a West Virginia University epidemiologist who conducts community-based research on injection drug use. “Anyone I’ve talked to who’s used that program only used it once,” she said. “And the numbers they report to the state bear that out.”

A syringe exchange in nearby Cabell County — home to Huntington, the state’s largest city after Charleston — isn’t so constrained. As Solomon notes, that program for every one exchanged in Kanawha.

A common complaint about syringe programs is that they result in discarded syringes in public spaces. Jan Rader, director of Huntington’s Mayor’s Office of Public Health and Drug Control Policy, is regularly out on the streets and said she seldom encounters discarded syringes, pointing out that it’s necessary to exchange a used syringe for a new one.

In August 2023, the Charleston City Council voted down a proposal from the to operate a syringe exchange in the city’s West Side community, with opponents expressing fears of an increase in drug use and crime.

Pollini said it’s difficult to estimate the number of people in West Virginia with HIV because there’s no coordinated strategy for testing; all efforts are localized.

“You would think that in a state that had the worst HIV outbreak in the country,” she said, “by this time we would have a statewide testing strategy.”

In addition to the testing SOAR conducted in 2021 at its health fairs, there was extensive testing during the CDC’s investigation. Since then, the reported number of HIV cases in Kanawha County , Pollini said, but it’s difficult to know if that’s the result of getting the problem under control or the result of limited testing in high-risk groups.

“My inclination is the latter,” she said, “because never in history has there been an outbreak of injection-related HIV among people who use drugs that was solved without expanding syringe services programs.”

“If you go out and look for infections,” Pollini said, “you will find them.”

Solomon and Pollini praised the ongoing outreach efforts — through riverside encampments, in abandoned houses, down county roads — of the to test those at highest risk: people known to be injecting drugs.

“It’s miracle-level work,” Solomon said.

But Christine Teague, Ryan White Program director at the Charleston Area Medical Center, acknowledged it hasn’t been enough. In addition to HIV, her concerns include the high incidence of hepatitis C and endocarditis, a life-threatening inflammation of the lining of the heart’s chambers and valves, and the cost of hospital resources needed to address them.

“We’ve presented that data to the legislature,” she said, “that it’s not just HIV, it’s all these other lengthy hospital admissions that, essentially, Medicaid is paying for. And nothing seems to penetrate.”

Frank Annie is a researcher at CAMC specializing in cardiovascular diseases, a member of the Charleston City Council, and a proponent of syringe service programs. Research he co-authored in southern West Virginia associated with injection drug use, at a cost to federal, state, and private insurers of more than $17 million, of which less than $4 million was recovered.

Teague is further concerned for West Virginia’s rural counties, most of which don’t have a syringe service program.

Tasha Withrow, a harm reduction advocate in bordering rural Putnam County, said her sense is that HIV numbers aren’t alarmingly high there but said that, with little testing and heightened stigma in a rural community, it’s difficult to know.

In a January 2022 follow-up report, the CDC recommended increasing access to harm reduction services such as syringe service programs through expansion of mobile services, street outreach, and telehealth, using “patient-trusted” individuals, to improve the delivery of essential services to people who use drugs.

Teague would like every rural county to have a mobile unit, like the one operated by her organization, offering harm reduction supplies, medication, behavioral health care, counseling, referrals, and more. That’s an expensive undertaking. She suggested opioid settlement money through the could pay for it.

Pollini said she hopes state and local officials allow the experts to do their jobs.

“I would like to see them allow us to follow the science and operate these programs the way they’re supposed to be run, and in a broader geography,” she said. “Which means that it shouldn’t be a political decision; it should be a public health decision.”

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“I was so scared,” said Morreale, a resident of the small western North Carolina town of Mars Hill. In that moment, her joy about being pregnant was eclipsed by fear she would have to stop taking buprenorphine, a drug used to that had helped counter her addiction.

Morreale’s fear was compounded by the rigidity of the most common approach to treating babies born after being exposed in the womb to opioids or some medications used to treat opioid addiction.

For decades throughout the opioid crisis, most doctors have relied on medication-heavy regimens to treat babies who are born experiencing . Those protocols often meant separating newborns from their mothers, placing them in neonatal intensive care units, and giving them medications to treat their withdrawal.

But research has since indicated that in many, if not most, cases, those extreme measures are unnecessary. A newer, simpler approach that prioritizes keeping babies with their families called Eat, Sleep, Console is being increasingly embraced.

In recent years, doctors and researchers have found that keeping babies with their mothers and ensuring they’re comfortable often works better and gets them out of the hospital faster.

Despite her worst fears, Morreale was never separated from her son. She was able to begin breastfeeding immediately. In fact, she was told, the trace of buprenorphine in her breast milk would help her son withdraw from it.

Her experience was different because she had found her way to , an Asheville, North Carolina-based program, administered through the , that supports pregnant people and parents with substance use disorders. Morreale’s care team assured her she did not need to discontinue buprenorphine and that her baby would be assessed and monitored using the Eat, Sleep, Console approach. The protocol OK to be sent home so long as they’re eating, sleeping, and consolable when upset.

“By the grace of God, he was awesome,” Morreale said of her son.

David Baltierra, former director of West Virginia University’s , chair of WVU’s Department of Family Medicine – Eastern Division, and a family physician, suggests this protocol could simply be called “parenting.”

The method is increasingly being used instead of the long-embraced approach to treating opioid-affected newborns called the Finnegan Neonatal Abstinence Scoring System. That tool includes a list of 21 questions (is the baby crying excessively, sweating, experiencing tremors, sneezing, etc.), the answers to which determine whether the newborn should get medication to counteract withdrawal symptoms, which would then require an extended stay in a neonatal ICU.

Baltierra, though, has issues with the Finnegan method. For example, it often results in a soundly sleeping baby being awakened to be scored. That didn’t make sense to Baltierra. If the baby is sleeping, she’s likely doing fine.

Instead, health professionals should look for the telltale signs of a baby experiencing opioid withdrawal syndrome, he said. “Their body is in tension, they have a high pitch, they don’t calm down.”

Baltierra and his colleagues have been training residents to use an Eat, Sleep, Console approach for a decade, progressively more so in the past six years. The results are persuading more health professionals to adopt the method.

A 2023 study found babies treated this way were discharged from the hospital in and less likely to receive medication than those receiving Finnegan-based care.

Matthew Grossman, an associate professor of pediatrics at the Yale School of Medicine, refers to the introduction of the model of treatment he has helped pioneer as “the least innovative” undertaking imaginable.

that optimal care for pregnant women who’ve experienced opioid use disorder includes treatment with buprenorphine or methadone, which carries the risk their newborn will have withdrawal symptoms. Grossman and colleagues found a non-pharmacological-first approach .

He said the Finnegan tool is useful but often too rigid. Under its scoring, one sneeze too many could send a baby to the NICU for weeks.

Grossman said he observed that some babies receiving medications did well for a few days but began to decline when their mothers were sent home without them. Those observations made him ask, “Did the kid need more medicine, or more mom?”

Research by Leila Elder and Madison Humerick, who each did their residency in WVU’s rural program, found that median stays for newborns in withdrawal dropped from 13 days in 2016 to three in 2020.

Elder said babies born at the 25-bed rural hospital where they performed deliveries received medications to treat their withdrawal symptoms only when unrelated issues sent them to other hospitals for NICU care.

The simpler treatment also means more babies born in rural communities can receive care closer to home and has reduced the likelihood a mother will be released before her baby is cleared to go home.

Grossman suggested that rural hospitals are better suited to employ the Eat, Sleep, Console approach than big-city institutions, given the latter’s generally easier access to a NICU and propensity to choose that option.

Sarah Peiffer recalls the first time, as a medical student, she witnessed a nurse administering the Finnegan protocol, discussing it in clinical terms at a new mother’s bedside.

“And I remember being kind of horrified,” she said. The process was clearly distressing to both mother and child. “I felt like there was almost a punitive feeling to it, like we were telling this mom, ‘Look what you did to your baby.’”

Peiffer is now a Project CARA practitioner and family health physician at in western North Carolina and a vocal proponent of ESC and its approach to partnering with families. “You look at all the nonpharmacologic stuff you’re supposed to be doing — like keeping the lights low in the room, keeping the baby swaddled, doing as much skin-to-skin with mom as possible — and you really treat mom as medicine.”

Research suggests immediate postbirth to short‐ and long‐term health and bonding.

That contact, Elder said, “releases endorphins for mom,” which helps lower the risk of postpartum depression.

Grossman said developing the Eat, Sleep, Console protocol was simply a matter of pausing to reassess.

The original intent of the Finnegan tool wasn’t to render the process so rigid. But “everybody is excited to have a tool, and then this approach calcified around it,” he said.

Grossman said the objective of the simpler approach was to place the family at the core of care, and shorter hospital stays for babies was simply a fortuitous outcome. The shift in approach fits into a wider move toward judgment-free, family-centered care for those who’ve experienced addiction and for their children.

Now, he said, after five days, mothers often say “‘Can we go home? I think I got this,’” and they’re treated “with the same respect as any other mom.”

Peiffer said she has witnessed this mother-centric care counter “that sense of shame that people feel instead of families feeling empowered to care for their infant.” It represents “such a major shift in how we think about neonatal withdrawal both medically and culturally.”

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“Yes, sir. It was a sad day,” Harrison said of the financial collapse of the small rural hospital, where all four of his children were born.

Quorum Health operated the 49-bed facility in this rural eastern North Carolina town of about 5,000 residents until it closed. The hospital had been losing money for some time. The county’s population has slightly declined and is aging; it has experienced incremental economic downturns. Like many rural hospitals, those headwinds drove managers to discontinue labor and delivery services and halt intensive care during the past five years.

Prospects for reopening seemed dim.

But a new hospital designation by the Centers for Medicare & Medicaid Services that took effect last year offered hope. As of August, hospitals in around the country have converted to the to prevent closure. The new program provides a federal financial boost for struggling hospitals that keep offering emergency and outpatient services but halt inpatient care.

The REH model “is not designed to replace existing, well-functioning rural hospitals,” said George Pink, a senior research fellow at the University of North Carolina’s , which has documented 149 rural hospitals that have either closed or no longer provide inpatient care since 2010. “It really is targeted at small rural communities that are at imminent risk of a hospital closing.”

The program hasn’t yet been used to reopen a closed hospital.

With guidance from health consultants, Martin County officials asked federal regulators to explore the possibility of adopting the REH model and were ultimately given the go-ahead.

If successful, Martin County could become one of the a shuttered hospital to this new model.

Ask members of a community that has lost its hospital what they miss most, Pink said, and it’s almost invariably emergency services. Count Harrison among them, especially after a medical crisis nearly killed him.

Harrison, who lives in a smaller crossroads community a few miles south of Williamston, began experiencing leg pain in February. Under normal circumstances, Harrison said, he would have gone to his primary care doctor if his leg began to hurt. This time he couldn’t, because the practice closed when the hospital folded months earlier.

Then, one morning he awoke to find his foot turning black. It took him 45 minutes to drive to the closest hospital, in the town of Washington. There, doctors found blood clots and he was flown by helicopter to East Carolina University Health Medical Center. A doctor there told him that he’d probably had the blood clots for close to a year and that he was lucky to be alive. The medical team was able to save his foot from amputation.

Harrison, like many other community members, now had firsthand experience with the consequences of a shuttered hospital.

The state legislature’s decision last year to has meant fewer North Carolinians are uninsured, which means fewer hospital bills go unpaid. But health care is evolving: Many procedures that once required inpatient care are now performed as outpatient services. Dawn Carter, the founder and a senior partner of Ascendient, a health care consulting firm working with the county, said the inpatient census at Martin General in its last few years ranged from five or six a day to a dozen.

“So you’re talking about a lot of cost, a lot of infrastructure to support that,” she said.

With no emergency care within a half-hour radius, Martin County administrators believe a rural emergency hospital would be a good fit and a viable option. a hospital to collect enhanced Medicare payments, an annual facility payment, and technical assistance.

Carter said the team will present to the state Department of Health and Human Services a set of drawings of the portion of the building they intend to use to see if it meets REH regulations.

“I’m hoping that process is happening in the next several weeks,” she said, “and that will give us a better idea of whether we have a handful of really quick and easy things to do or if it’s going to take a little more effort to reopen.”

Officials then will take proposals from companies interested in running the hospital.

Carter said the expectation is that, initially, the facility will be strictly the emergency room and imaging department, “and then I think the question is, over time, where do you build beyond that?”

And the rebuilding could prove a challenge from the start. Many former staff members have taken positions at nearby health care facilities or left the area. The effects of that exodus will be compounded by the widespread to rural areas.

It’s early yet, Pink said, to assess the success of the rural emergency hospital model. “All we have are armchair anecdotes.” It seems to be working well in some communities, while others “are struggling a little to make it work.”

Pink has a list of questions to assess how an emergency hospital is faring in the long run:

• Is it at least breaking even? And if not, do administrators foresee a solution?
• How is the community responding? If someone believes they have an issue that might require inpatient care, Pink suggested, perhaps they’ll bypass the REH for a hospital that can admit them. And to what extent does bypassing their doors carry over to all services?
• Are patients happy with the care they’re receiving? Are the clinical outcomes good?

The rate of rural hospital closures rose through 2020, then dropped considerably in 2021. Congress had passed the CARES Act, and the Provider Relief Fund offered a financial lifeline, Pink said. That money has now been distributed, and the concern is that “many rural hospitals are returning to pre-covid financial stresses and unprofitability.”

If the trend continues, he said, more rural hospitals may turn to the REH model.

Ben Eisner serves as Martin County’s attorney and interim manager. He acknowledges that the health and well-being of this community require a lot more than a hospital. He cites, for example, a new nonprofit with a mission to address the .

Advancing Community Health Together was created in response to the hospital closure. Composed of community members, its focus is addressing inadequate health care access and poor health outcomes as a consequence of generational poverty, said Vickey Manning, director of Martin-Tyrrell-Washington District Health.

“We can’t address rural health care in a vacuum,” Carter said. Her organization, Ascendient, is part of the , a nonprofit commissioned by the North Carolina General Assembly to study sustainable models of health care for rural communities.

Like most of rural eastern North Carolina, Martin County is in transition, Eisner said. Diminishing family farms, less industry. “And so the question becomes,” he said, “‘What happens for all these communities? What happens next?’ And it’s an answer that is not yet fully written.”

Harrison, still relying on crutches to get around, recently drove 45 minutes north on U.S. 13 to the town of Ahoskie to have a doctor examine his foot. He said a hospital that offers basic emergency care isn’t a perfect solution, but he’ll have some peace of mind once the cover is peeled from that sign and his local hospital reopens.

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“Oh, my word,” said Tawnya Brock, a health care quality manager and a Jellico resident. “That hospital was not only the health care lifeline to this community. Economically and socially, it was the center of the community.”

Since 2010, 149 rural hospitals in the United States have either closed or stopped providing in-patient care, according to the Cecil G. Sheps Center for Health Services Research at the University of North Carolina. Tennessee has recorded the second-most closures of any state, with 15, and the most closures per capita. Texas has the highest number of rural hospital closures, with 25.

Each time a hospital closes there are health care and economic ripples across a community. When Jellico Medical Center closed, some 300 jobs went with it. Restaurants and other small businesses in Jellico also have gone under, said Brock, who is a member of the legislative committee. And the town must contend with the empty husk of a hospital.

Dozens of small communities are grappling with what to do with hospitals that have closed. Sheps Center researchers have found that while a closure negatively affects the local economy, those effects can be softened if the building is converted to another type of health care facility.

In Jellico, the town owns the building that housed the medical center, and Mayor Sandy Terry said it is in decent condition. But the last operator, Indiana-based Boa Vida Healthcare, holds the license to operate a medical facility there and has yet to announce its plans for the building, leaving Jellico in limbo. Terry said local officials are talking with health care providers that have expressed interest in reopening the hospital. That’s their preferred option. Jellico does not have a Plan B.

“We’re just in hopes that maybe someone will take it over,” Terry said. Meanwhile, the nearest emergency rooms are a half-hour drive away in LaFollette, Tennessee, and across the state line in Corbin, Kentucky.

An hour and a half away in Fentress County, the building that once housed Jamestown Regional Medical Center has been empty since June 2019, when Florida-based Rennova Health — which also previously operated Jellico Medical Center — locked it up.

County Executive Jimmy Johnson said Rennova’s exit from Jamestown was so abrupt that “the beds were all made up perfectly” and IV stands and wheelchairs sat in the halls. About 150 jobs evaporated when the center closed.

Rennova still owed Fentress County $207,000 in taxes, Johnson said, and in April the property was put up for auction. A local business owner purchased it for $220,000. But Rennova was granted a year to reacquire the building for what it owed in back taxes, plus interest, and did so within a few days.

Abandoned hospital buildings dot the map in central and east Tennessee. But in the western part of the state, two communities found uses for their empty buildings, albeit not in reopening hospitals.

Somerville, about an hour east of Memphis, lost its hospital, Methodist Fayette, in 2015. Its parent company, Methodist Le Bonheur Healthcare, donated the building to the town and threw in $250,000. The building is now a satellite campus for the University of Tennessee-Martin.

The conversion was pushed along by the town leveraging other funding. Bob Turner, Somerville’s city administrator, said both the town and the county matched Methodist’s quarter-million dollars toward the renovation. In its first year in Somerville, the university raised another $125,000. Tennessee’s governor then matched that $875,000 in his state budget.

Somerville is now in the seventh year of a 10-year agreement with the university, which rents the building from the town.

“We have a building, an asset, that’s probably worth $15 million,” Turner said. “It’s a four-year university right here in the heart of Fayette County.”

Mendi Donnelly, Somerville’s community development director, said the county is still in desperate need of a hospital, but “we’re thrilled that we were able to make lemonade out of our lemons.”

Ninety miles to the northeast, in rural Carroll County, Tennessee, another shuttered hospital found new life.

The closing of McKenzie Regional Hospital in 2018 was a blow to the local economy. But Baptist Memorial Health Care, which operates a hospital in nearby Huntingdon, bought the assets — including the building, land, equipment, and ambulance service — and subsequently donated the building to the town of McKenzie.

Cachengo, a technology company, ultimately took over the space. Because of hospitals’ electrical infrastructure, the site was a perfect fit for a business like his, said Ash Young, Cachengo’s chief executive. Young said Cachengo is now looking into repurposing abandoned hospitals across the country.

Jill Holland, McKenzie’s former mayor and a local-government and special-projects coordinator for the Southwest Tennessee Development District, believes the town can become a technology hub.

“It’s opening a lot of doors of opportunity for the youth in the community,” Holland said.

Back in Jamestown, the vacant hospital is “deteriorating,” said Johnson, the county executive. “It could have been used to save lives.” Rennova did not respond to a request for comment.

The University of Tennessee Medical Center opened a elsewhere in Jamestown, sparing residents a half-hour drive to the closest ER. Johnson believes the old hospital building could serve the community as housing for those who are homeless or as a facility to treat substance use disorder.

Brock, the health care quality manager, thinks things will get better in Jellico, but the community has had its .

Brock believes a freestanding emergency room could be a viable solution. She urges her community to be responsive to “a new day” in rural health in America, one in which a hospital must focus on its community’s most urgent needs and be realistic about what that hospital can provide.

“Maybe it is just the emergency room, a sustainable emergency room, where you could hold patients for a period of time and then transfer them,” Brock said. “And then you build upon that.”

She added, “There are options out there.”

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The arrival of prescription opioids onto seemingly every block of Huntington, a city of about 46,000 people, augured the first wave of an overdose crisis. Heroin followed, then fentanyl.

Residents remember Aug. 15, 2016, as the darkest day because on that afternoon and evening, 28 people overdosed in the city. But Huntington had shouldered collective trauma before.

On Nov. 14, 1970, Southern Airways Flight 932 crashed into a hillside just outside Huntington, killing all 75 on board. The dead included football players, coaches, and boosters from Marshall University, located here.

Residents say the tragedy bonded the community in a way that helped prepare it for crises to come. But now that cohesion is being challenged in a city and county once known as the epicenter of the nation’s opioid epidemic.

This crisis continues to evolve. Cabell County, like other communities, is in the depths of a “fourth wave” of overdoses fueled by mixtures of drugs that often include fentanyl and other powerful synthetic opioids.

Fentanyl is now ubiquitous — heroin is rarely seen anymore — and toxicology results reveal other synthetics, including carfentanil, a drug used to anesthetize elephants that can be 100 times as potent as fentanyl. Also in the mix is another animal tranquilizer that can cause in IV drug users. Increasingly, those drugs are being mixed with stimulants like methamphetamine and cocaine.

Michael Kilkenny, chief executive of the Cabell-Huntington Health Department, recalls coming to the “shocking realization” in 2015 that drug overdose was the third-leading cause of death in the county, after heart disease and cancer.

When the Centers for Disease Control and Prevention in 2016, users turned to heroin. Then came fentanyl. In 2017, Cabell County had the of opioid-related overdose deaths in the state with the — .

Connie Priddy, an emergency medical services nurse, said that after the dark day of Aug. 15, there was initially a sense of relief. “We saved all 28 people,” she said. “Our EMS crews did a wonderful job.”

But Priddy, who now leads the county’s , said the euphoria quickly dissipated when officials learned that none of the 28 people had subsequently been referred to addiction resources or received treatment.

Taylor Wilson, 21, was the first known overdose on that August day. Her parents spent the next 41 days searching for treatment options. On the 42nd day, Wilson overdosed again and died from a mix of drugs that included fentanyl, carfentanil, furanylfentanyl, morphine, and hydrocodone.

“She was enrolled at Marshall,” Wilson’s mother, Leigh Ann Wilson, said. “She was going to be a librarian.” Wilson began taking prescription opioids around the time she entered college but was able to quit them. She was then introduced to heroin by a boyfriend.

Priddy said that later, reflecting on the lessons of Aug. 15, “our community really came together and said, ‘We’ve got to do something different.’”

Huntington now strives to be the “city of solutions.” Establishing the Quick Response Team in 2017 was a significant step. Within 24 to 72 hours after an overdose, the team — consisting of a peer recovery coach, paramedic, police officer, and faith leader — pays a visit to the person who overdosed or to their family. The team also checks on people whose family members fear they may be at risk of an overdose.

The number of ambulance calls to treat an overdose has decreased by 40% since the team was established. Overdose deaths in Cabell County peaked in 2017 with 202. At that time, Cabell had an that was more than double the rate of the next-highest county in West Virginia. According to the CDC, by June 2023 the number of overdose deaths in Cabell had for the previous 12 months, while the numbers statewide continued climbing.

“We’ve expanded over these last few years to provide all kinds of social services along with referral to treatment,” Priddy said.

It is about “letting them know that we care,” said Sue Howland, a peer recovery coach with the Quick Response Team.

But the mixtures of drugs have presented new challenges. Robin Pollini, a substance misuse and infectious disease epidemiologist at West Virginia University, recently conducted studies of injection drug users in several cities in the state, including Huntington. She found that few people are using only opioids; rather, they’re using opioids and methamphetamine.

And the emergence of fentanyl has heightened the risks. Typically administered doses of the opioid withdrawal drug buprenorphine, one of Suboxone’s main ingredients, are less effective against fentanyl than other opioids. While the effects of heroin often last four to five hours, fentanyl’s high lasts a half-hour to an hour. Consequently, people share and reuse syringes more frequently, furthering the risk of HIV, hepatitis B and C, and endocarditis, said Jan Rader, director of Huntington’s Council on Public Health and Drug Control Policy.

Adding stimulants like meth and cocaine to the mix creates another layer of challenges.

Those on the front lines say most stimulant users are unaware they are taking a mix of drugs. That was the case for Jessica Neal, who said she started using methamphetamine in her early 20s, got in trouble with the law, went on the run, became pregnant, and is now in recovery.

Neal, now 33, thought she was using only meth. But a toxicology report from a failed drug test revealed she had also taken heroin, fentanyl, barbiturates, and benzodiazepines.

While some opioid users prefer the contrasting effects of opioids and stimulants, others, particularly people who are homeless, take stimulants to stay awake and safe.

Larrecsa Barker, a paramedic with the Quick Response Team, said regardless of what people report using, she always asks them if they might test positive for heroin or fentanyl. “If so, that means you’re definitely one step closer to getting into treatment,” she said.

There is no equivalent to Suboxone to treat withdrawal from stimulants. “If you’re just using meth, the likelihood of getting into inpatient treatment is slim to none,” Barker said.

In 2020, local government agencies, health providers, and Marshall University assembled a resiliency plan. Short-term goals include expanding outpatient and inpatient care; reducing barriers to treatment and recovery services; and providing more substance use education. They’re also working to address the underlying social determinants of health, including housing and employment.

Rader, the drug control council director, sees incremental gains in caring for the most vulnerable. She said that , a program operated by , has been a godsend. “So many success stories,” she said. Rader also lauded the city’s founding of the and the expansion of its . The low-barrier shelter admits people even if they have recently taken a drug.

Yet Pollini, the epidemiologist, said that too often lawmakers limit how local officials can respond. She cites restrictions, and prohibitions, on harm reduction initiatives at both the state and local levels.

She said that clamping down on syringe exchanges not only restricts the availability of syringes but reduces access to free naloxone, fentanyl test strips, and other lifesaving supplies.

Syringe exchange programs must be approved by both city councils and county commissions, and they can withdraw support at any time. “That’s a pretty precarious way to operate,” Pollini said.

A in the West Virginia Legislature that would ban syringe services programs. Some lawmakers have argued that offering clean syringes in exchange for used ones abets drug use.

“It’s really aggravating what’s happening on the political scene right now, because they’re not deferring to the experts in the field,” Priddy said.

Pollini said: “Let us do the things that we know work.”

Kilkenny, who was of the National Association of County and City Health Officials, said he believes if the will is there, overdose deaths could be reduced by 90%. He said he believes in aiming high, and that a public health department has a critical role to play in getting there.

“We want children to have fewer adverse childhood events,” he said. “We want families to be more resilient.”

As for Neal, she said she made it out of the “madness” and was welcomed into Project Hope. She is raising her baby daughter and working as a Project Hope peer support recovery specialist. Her objective is to help other women get the resources they need to break their addictions.

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Sears was , a sedative used for animal surgeries that has infiltrated the illicit drug supply across the country, contributing to a steady climb in overdose deaths.

Sears divides his time between Burlington and Morrisville, a village an hour to the east. In Burlington, he visits clusters of drug users, offering water, food, and encouragement.

He has been there, been down, done time, struggled to adhere to treatment regimens. But this, he said, is different: — estimated to be as morphine — and now xylazine, and the life-threatening it can cause.

Sears implores those he encounters who suffer the effects of these drugs to look at what they’re doing to themselves. But to little avail.

“They say they’re unable to get out of it — that they don’t have a plan to get out of it.”

Worse, those who seek help breaking their addictions face treatment options rendered less effective by the prevalence of fentanyl, xylazine, and other synthetic drugs. Vermont’s pioneering efforts in establishing a statewide program for medication for opioid use disorder, known as , now face significant new challenges.

Launched in 2012, Hub and Spoke put prescription medicines at the center of the treatment strategy, which many addiction specialists say is the most effective approach. Vermont offers at regional hub sites for those with the most intense needs, while smaller community clinics and doctors’ offices — the “spokes” — provide care such as dispensing the .

Advocates and experts in Vermont honed the model, and today hub-and-spoke systems or variations are in place nationwide, including in , , , , and .

But the rise of fentanyl, xylazine, and stimulants is undercutting the effectiveness of addiction medications.

Commonly administered doses of buprenorphine, better known as Suboxone — the brand name for a combination of buprenorphine — have proved less effective against fentanyl, and commonly used doses can trigger violent, immediate withdrawal. Neither Suboxone nor methadone is designed to treat addiction to xylazine or stimulants.

The Centers for Disease Control and Prevention estimates that of the more than 111,000 drug-overdose deaths in the U.S. in the 12-month period ending in April, more than 77,000 involved fentanyl and other synthetic opioids. The nation has also seen a significant increase in overdose deaths from . Vermont has experienced a spike in the use of cocaine and, .

“There was a time when we couldn’t have pictured things being worse than heroin,” said Jess Kirby, director of client services for , which offers services to counter substance use disorder. “Then we couldn’t picture things being worse than fentanyl. Now we can’t picture things being worse than xylazine. It keeps escalating.”

In Vermont, the Hub and Spoke program is part of the statewide Blueprint for Health, with hubs in relatively populous areas of this largely rural state.

A patient enters the system for assessment and initial induction at one of nine hubs, and then, once stable, is transferred to a spoke. If that patient relapses or needs more intensive care, they can be transferred back to the hub. The spokes typically offer Suboxone — most effective for those with mild to moderate opioid dependence — but not methadone, which is more regulated.

Kirby — who began using opioids in her early teens, has been in recovery for about 15 years, and is Ty Sears’ longtime case manager — said a benefit of the hub-and-spoke model is that it offers support to primary care doctors and other practitioners who might otherwise be hesitant to prescribe medications to treat addiction. (Federal officials recently governing which doctors can prescribe buprenorphine.)

Erin O’Keefe, who runs the Burlington-based program, said the model’s flexibility has been key: from being fully integrated into primary care, whereby addiction is treated like any other chronic disease, to the other end of the spectrum, “making sure that people who are still in chaotic-use cycles receive harm reduction approaches” to keep them alive another day.

Vermont had the 10^th-largest increase in fentanyl deaths for the 12-month period ending in April. Tony Folland, clinical services manager with the Vermont Department of Health’s Division of Substance Use Programs, said fentanyl is now implicated in about 96% of overdose deaths.

Meanwhile, xylazine, commonly called “tranq,” is causing extreme concern. State Department of Health records indicate that almost 1 in 3 opioid overdose deaths so far this year involved xylazine. And those working on the front lines report seeing a marked increase in the extreme wounds it often causes.

The challenges providers now face underscore the need to be prepared to respond in the moment. It’s essential, O’Keefe said, to capitalize on someone’s motivation for change, “and that motivation can be so fleeting — like, ‘I have enough in the tank to make one phone call, and if that phone call doesn’t go well, I’m back in the game.’”

Folland said Vermont now prescribes more medication for opioid use disorder per capita than any other state. He estimates between 45% and 65% of people with opioid use disorder receive medication.

But these challenges are unprecedented. “We have a drug supply that’s contaminated with xylazine, with fentanyl, and we know that people are struggling a lot more and are at a lot higher risk,” Kirby said. “It’s not just overdose to be concerned about anymore. It’s life-threatening wounds and infections.”

In response, advocates have asked state officials to fund more , a treatment approach that provides rewards to patients who refrain from illicit drug use. They also strongly encourage more widespread access to methadone as an alternative to buprenorphine, which is often proving less effective in countering the potency of fentanyl.

According to Folland, eight opioid treatment programs in communities throughout the state offer methadone, with one more soon to come. The goal, he said, is to prevent anyone from having to travel farther than a half-hour or so to access it.

Easier access to methadone would also require loosening .

“Methadone is probably the most regulated medication in the United States. We’ve got to figure out a way to make it more accessible,” said Kelly Peck, director of clinical operations for the . “We’ve got decades worth of data at this point, showing that methadone is safe and efficacious.”

For Kirby, O’Keefe, and their colleagues, more resources can’t come quickly enough.

“People dying — that’s what I’m seeing, every day,” Sears said.

Sears has been fortunate. What has served him in his recovery is the tolerance of those who’ve helped him along the way, and flexibility. There have been times when he was allowed to remain on Suboxone while still using stimulants. He is a recent graduate of a contingency management program administered by Vermonters for Criminal Justice Reform, the organization for which Kirby works.

“She counsels me,” Sears said. “She hears me out.”

Glimpsing a flicker at the end of the tunnel, advocates acknowledge, will require availing an arsenal of options to counter a shifting, and lethal, crisis.

“It’s almost like our understanding is changing from really seeing this, on a social level, as episodic to seeing it as chronic,” O’Keefe said, emphasizing that as the drug-supply landscape shifts, approaches to countering it must evolve as well.

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The plan was to begin handing out boxes of groceries at 11, but the truck delivering the food blew a tire en route. No one complained.

Perry Hall was among those waiting. His wife, Lilly Hall, volunteers with the distribution team. Perry has been dealing with a form of cancer called multiple myeloma. The Halls get by on around $1,500 a month from his Social Security benefits, plus assistance from the federal , or SNAP. But because of her age, Lilly, 59, recently became subject to new SNAP work requirements and at risk of losing her benefits.

As part of the federal One Big Beautiful Bill Act, all “able-bodied adults” 64 or younger who don’t have dependents and don’t work, volunteer, or participate in job training at least 80 hours a month are now restricted to three months of benefits every three years from SNAP, formerly known as food stamps. Previously, the federal requirement applied to those 54 or younger. The new rule, which went into effect in November, also applies to parents of children 14 or older. And it removed exemptions for veterans, people experiencing homelessness, and young adults who’ve aged out of foster care.

Proponents of work requirements argue that they incentivize people who are “work-ready” to seek and keep jobs, reducing dependence on government assistance and upholding the “.”

Rhonda Rogombé serves as health and safety net policy analyst for the . She and her colleagues have studied the effects of SNAP work rules and found that requiring recipients to work does not lower an area’s unemployment rate.

Previous work requirements were suspended nationwide during the covid pandemic and reinstated in fall 2023. The researchers found that the average number of people employed in Mingo County each month actually went down after the requirement was reimposed.

A 2018 federal research project that examined several data sources, including SNAP data from nine states, found that work requirements “have no impact on labor force participation and the number of hours worked.”

There are a number of possible explanations, Rogombé said, “but when people are hungry, they’re not able to support themselves. When people are hungry, it’s harder to focus at work. It’s harder to engage in work activity, and we think that that’s part of it.”

Jobs are scarce in this southern West Virginia county. Lilly Hall found work at a Delbarton restaurant. But it’s unpaid until a waitress position opens — enough to preserve her benefits, but far from ideal.

On that mild Wednesday in late March, House of Hope provided chicken, eggs, bread, potatoes, fresh fruit and vegetables, and milk.

Among those in line were older residents and “some young people that have lost their way and they can’t get work and they just need help,” said Timothy Treleven, who operates the pantry with his wife, Christine, and Gail Lendearo.

House of Hope’s scheduled distribution day is the last Saturday of each month — supplemented by occasional weekday Facing Hunger visits — as money from monthly checks begins to run out and cupboards go bare.

On a typical Saturday, pantry staff and volunteers hand out up to 400 boxes of food.

“It’s an honor to do this,” Lendearo said. “It’s a blessing.”

Perry Hall’s cancer is now in remission, but for a while his treatment required that he and Lilly travel back and forth, 4½ hours each way, to Morgantown. The couple’s van couldn’t make the trip, so they paid a friend for rides.

Mingo’s population is just under 22,000, down from around 27,000 in 2010. It once flourished, fueled by coal. Williamson, the county seat, was home to an opera house and businesses operated by immigrants from Italy, Russia, and Syria. The region is still referred to as “the coalfields,” but little is mined here these days. .

Rogombé and her colleagues found that Mingo County residents face significant barriers to securing what few jobs are available. These include unreported physical and mental impairments, housing insecurity, and a lack of high school diplomas and identification documents.

Filing the paperwork to receive benefits or to confirm compliance is difficult for many residents. The West Virginia Center on Budget and Policy’s research found that about 1 in 4 lack reliable internet access.

Additional changes lie ahead for the SNAP program. Currently, the federal government and the states share administrative costs equally, but in October states will assume 75% of those costs. And beginning in October 2027, they’ll be required to pay additional costs based on .

Kentucky, like West Virginia, is among the poorer states that will be most affected by the new requirements and costs. The Kentucky Center for Economic Policy estimates that with the expanded work requirements.

Jessica Klein, a researcher with the center, worries about the consequences. “We know SNAP has an impact on health, and not just because it decreases food insecurity,” she said. It worsens blood pressure rates, obesity, medication adherence, and more.

With the additional financial burden placed on states, “I think what we’ll see is some states changing rules that impact participation in order to have a smaller, more affordable program,” Klein said. “My fear is that some states will choose not to operate SNAP at all.”

In Mingo County, folks are stepping up. At least eight food pantries offer groceries to those in need.

Janet Gibson runs the Blessing Barn pantry in the Ben Creek community. “I can go from one end of the creek to the other” and tell you everyone’s name and a little something about them, she said. She takes pride in feeding her people.

Gibson said it can be hard to find even volunteer opportunities in the county, largely because of transportation challenges. A look at a local map can be misleading: A couple of dozen miles into a holler or up a ridge could take an hour or more.

“Whether you’re working full-time or not, you’re still spinning out gas to get to work,” Gibson said, “and gas ain’t cheap now.”

A single mother of three, Trista Shankle of Paducah, Kentucky, isn’t subject to the new SNAP requirements, but she worries about the fragility of the social safety net. She overcame challenges, is earning a master’s degree in social work, and works for an organization that connects community college students with benefits. Her family receives SNAP, Medicaid, housing support, and assistance from the USDA’s . If any one of those is cut, she said, she may have to drop out of school.

Shankle is certain she wouldn’t have advanced to where she is today without the benefits she and her family have received: “They bring a sense of calm and comfort. I know that my kids aren’t going to go hungry.”

The first week in April, Lilly Hall reported for work at Black Bear Trails Restaurant. She’s grateful for the opportunity. And when a waitress slot opens, “I’ll snag that position so quick it’ll make your head flip.”

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Author Barbara Kingsolver opened the facility in January with royalties from her Pulitzer Prize-winning novel, “,” whose plot revolves around Appalachia’s opioid crisis. The home offers a supportive place for people to stay while learning to live without drugs. Kingsolver had asked the women now living there to join her on stage.

Kingsolver, who grew up in Appalachia, suggested the women share with the audience what they were most proud of having gained from their first weeks at Higher Ground. But she learned they were more eager to brag on one another.

Supporters say provides stability and a reentry point after leaving jail, prison, or a treatment center. It offers a range of services and support in an area devastated by addiction to painkilling pills and other types of opioids. Most fundamentally, it’s a true home, with one- and two-person bedrooms, a communal kitchen, and a den. Residents say they have found affirmation from a cohort of women who understand how addiction can demoralize a person and estrange them from family and community.

Ronda Morgan, a resident, said her family has always been in her corner. But while she was serving a jail sentence for drug possession, she told herself, “I’m sick of them having to do time with me.” She was ready for recovery. Her daughter, who’s a nurse, told her about Higher Ground, the first facility of its kind in sprawling, rural Lee County. Morgan learned she could live there for up to two years to gain the footing that had eluded her in three-plus decades of addiction.

What she didn’t anticipate was the kinship she forged with her housemates — among them, Syara Parsell — and with Higher Ground’s staff.

Parsell, 35, one of Higher Ground’s first residents, said that in her time there she’s received help finding employment and enrolling in community college courses.

From the staff and Kingsolver, Parsell said, she has received judgment-free support. “Together,” she said, “we figure it out.”

Traditional treatment facilities typically operate under highly structured medical supervision. Recovery houses, like Higher Ground, offer a more relaxed environment, helping move a resident “toward being an independent, fully functional, self-reliant human being,” said Marvin Ventrell, CEO of the National Association of Addiction Treatment Providers.

“Recovery occurs in the community,” he said. But reentry must be approached delicately. “When addiction occurs with a human being, it also occurs within a family social structure.” If a person in early recovery returns to a family that’s unprepared, that person’s chances of success “are severely diminished.”

For Kingsolver, the opioid crisis became a focal point for what she hoped would be “the great Appalachian novel.” The epidemic “has changed so much of the texture of this place,” devastating families and communities.

Pharmaceutical companies for sales of what they prescription opioids. Kingsolver wanted to “cast my net back over all of the extractive industries that have come to this place, taken out what was good, and left behind a mess.”

“The way I put it is, ‘They came to harvest our pain when there was nothing else left,’” she said.

In research for “Demon Copperhead,” she immersed herself in the stories of people who’ve navigated addiction and those who care and advocate for them.

The novel has been an enormous success, having sold more than 3 million copies and earning far more than her previous works. Kingsolver decided to dedicate hundreds of thousands of dollars to address the crisis that has overwhelmed the region where she was raised — and to which she returned full time in 2004.

Again, she set about listening. Drawing on a wide range of expertise, she determined that a women’s recovery home was the wisest investment.

Joie Cantrell works as a public health nurse in for the Virginia Department of Health, supporting policies and practices to curb the negative effects of drug use, and serves as Higher Ground’s board chair. She had long recognized the need for just such a home.

“That was the part that was missing,” Cantrell said. Too often, when someone would come out of a treatment facility or incarceration, “we lost them. They fell back into the same old patterns.” She said the region sorely needed a safe, stable environment where women could recalibrate.

By August, the home reached its capacity of seven women. It’s right in town, “which is so important,” Kingsolver said, “because in this part of the country we have no public transportation.”

Parsell has long suffered from social anxieties; drugs were her escape. Here, her housemates embraced her. They’ve offered the support she’d never experienced.

“Every two seconds, someone’s like, ‘Syara’s here!’” she said. “I’m very grateful for it.” If there’s an issue in the house, “one of the seven of us has the solution.”

Four residents are employed outside the home, one is enrolled in community college classes, one is completing her GED with plans to continue her education, and everyone volunteers in the community. Crafting classes are offered. Family members visit.

“They’re living life,” said Subrenda Huff, who was filling in while director Liz Brooks took maternity leave.

Morgan said she accomplished more in a month at Higher Ground than she had in years. That includes applying for identification documents, taking budgeting classes, and seeking permanent housing. It includes sharing upkeep duties in the house.

Such was Kingsolver’s vision. But, she said, “here’s what I didn’t expect: The community embraced this with loving arms. I thought maybe people would say, ‘I don’t want this in my backyard.’”

Most of the furniture was donated. Kingsolver’s quarter-million or so social media followers have been instrumental in that. “But it’s not just book clubs in Switzerland or in California; it’s people in Pennington Gap,” she said. Church groups have donated “quilts, bedside lamps, things to hang on the walls just to make it homey.”

Before the facility opened, local folks volunteered to pull weeds, take down an old fence, and put up a new one. Kingsolver said the well of support “has been just endless. It’s been deep, and loving, and a wonder to see.”

Higher Ground, with only one paid staff member, has estimated yearly operating costs of $120,000, Cantrell said. Residents are charged $50 a week. Ventrell said that fees at other recovery houses vary widely but that $2,500 a month is an approximate average.

“We want them to focus on saving money and paying any restitution or fines they may have from past charges,” Cantrell said. “Some may be focused on repaying child support they may owe.”

Higher Ground receives no federal or state funding. Donations continue to pour in. And Kingsolver recently bought the building next door with plans to open a thrift shop, which would be a source of additional income for the home and offer retail work experience for its residents.

Supporters aspire to open more Higher Ground homes elsewhere in the region.

What these women are gaining, Kingsolver said, “is not just sobriety, but belief in themselves.”

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“It’s a very weird time in our lives,” said Kasen, executive director of the .

Last November, a group of people were captured on surveillance video early one morning mocking a “Black Lives Matter” sign in the front window of the center, with one of them vandalizing its free pantry. That same fall, Women’s Center staff reported being harassed.

A couple of blocks down East Michigan Avenue, Strange Matter Coffee, which supports progressive causes in the community, has been confronted by “” outside its storefront. Some toted guns or cameras, sometimes chanting slogans supporting President Donald Trump, generally unnerving customers and staff, Kasen said.

In many cases, throughout the U.S. over the past few years have been driven by the deepening and disinformation-driven rebellion against responses to the covid-19 pandemic. More recently, backlash against immigration and diversity, equity, and inclusion initiatives has heightened tensions.

Last year, the documented nationwide sowing unrest through a wide range of tactics, sometimes violent. Over the last several years, the group writes, the political right has increasingly shifted toward “an authoritarian, patriarchal dedicated to eroding the value of inclusive democracy and public institutions.”

Researchers at American University’s , or PERIL, say that in online spaces, “hate is intersectional.” (For example, Pasha Dashtgard, PERIL’s director of research, explains, platforms dedicated to male supremacy are often also decidedly antisemitic.) Seemingly innocuous discussions erupt into vitriol: The release of “A Minecraft Movie” prompted tirades against an alleged trend toward casting Black women and nonbinary people.

The continued escalations drove staffers at PERIL and the Southern Poverty Law Center to approach the problem from a different angle: Treat extremism as a public health problem. are now operating in Lansing, Michigan, and Athens, Georgia, offering training, support, referrals, and resources to communities affected by hate, discrimination, and supremacist ideologies and to people susceptible to radicalization, with a focus on young people.

The team defines extremism as the belief that one’s group is in direct and bitter conflict with another of a different identity — ideology, race, gender identity or expression — fomenting an us-versus-them mentality mired in the conviction that resolution can come only through separation, domination, or extermination.

Researchers who study extremism say that, as the federal government terminates grants for violence prevention, state governments and local communities are recognizing they’re on their own. (CARE receives no federal funding.)

Aaron Flanagan, the Southern Poverty Law Center’s deputy director of prevention and partnerships, said his organization and PERIL came together about five years ago to examine a shared research question: What would it take to create a nationally scalable model to prevent youth radicalization, one that’s rooted in communities and provides solutions residents trust?

They looked to a decades-old German counterextremism model called mobile advisory centers. The objective is to equip “all levels of civil society with the skills and knowledge to recognize extremism” and to engage in conversations about addressing it, Dashtgard said.

“We’re not about, ‘How do you respond to a group of Patriot Front people marching through your town?’” Pete Kurtz-Glovas, who until June served as PERIL’s deputy director of regional partnerships, explained during a training in January. “Rather, ‘How do you respond when your son or a member of your congregation expresses some of these extremist ideas?’”

Michigan has long been considered . Timothy McVeigh and Terry Nichols, convicted of the bombing of a federal building in Oklahoma City in 1995, were associated with a militia group in the state. Some of the men charged in 2020 in the plot to had ties to a militia group calling itself the Wolverine Watchmen.

The state’s capital city and adjacent East Lansing, where Michigan State University is, are relatively progressive but have seen conflict.

Will Verchereau has a vivid recollection from the early days of the pandemic: a pickup truck speeding down the street in their Lansing neighborhood, a Confederate flag flying from it, music blasting, later joining a rolling protest that clogged streets around the Capitol to protest Whitmer’s covid lockdown directives.

Incrementally, the community has responded to these expressions of extremism. After the confrontations at Strange Matter Coffee, Verchereau, a board member of the , which advocates for and supports the LGBTQ+ community, said people banded together to talk about “how to be safe in those moments; how to de-escalate when and where possible.”

The CARE initiative reinforces such efforts. The centers offer tool kits catered to specific audiences. Among them are a to online radicalization, a , and “.”

Flanagan said the team views this public health model as separate from but complementary to law enforcement interventions. The goal is to have law enforcement as minimally engaged as possible — to detect nascent warning signs and address them before police get involved.

The resources help identify conditions that can make people more susceptible to manipulation by extremists, such as unaddressed behavioral health issues and vulnerabilities, including having experienced trauma or the loss of a loved one.

Lansing resident Erin Buitendorp witnessed protesters, some of them armed, flood the state Capitol building during the pandemic over lockdown and masking orders. She’s a proponent of the public health approach. It’s “providing people with agency and a strategy to move forward,” she said. It’s a way to channel energy “and feel like you can actually create change with community.”

Lansing and Athens were chosen for a number of reasons, including their proximity to universities that could serve as partners — and to rural communities.

In the small town of Howell, 40 miles southeast of Lansing, outside a production of the play “The Diary of Anne Frank” at an American Legion post.

In nearby DeWitt, the local school district proposed a mini lesson on pronouns for a first grade class that involved reading the picture book “They She He Me: Free to Be!” Threats against school staff followed and officials canceled the lesson. Since then, the CARE team has helped provide support to teachers there in holding conversations on contentious topics in classrooms and in dealing with skeptical parents.

“It’s really important that rural communities not be left behind,” Flanagan said. “They persistently are in America, and then they’re often simultaneously demonized for some of the most extreme, or extremist, political problems and challenges.”

The CARE team hopes to expand its program nationwide. Similar public health initiatives have been launched elsewhere, including Boston Children’s Hospital’s and the , run by New York City’s Citizens Crime Commission.

And in June a new tool, the , went live, offering guidance to help prevent violent extremism.

Pete Simi, a professor of sociology at Chapman University and a leading expert on extremism, sees a daunting task ahead, with extremism’s having become more mainstream over the past 25 years. “It’s just devastating,” he said. “It’s really startling.”

Simi said that while there was previously talk of shifts in the Overton window, the range of ideas considered politically acceptable to mainstream society, “I would say now it has been completely shattered.” Violent extremists now feel “unshackled, supported by a new administration that has their back.”

“We are in a more dangerous time now than any other in my lifetime,” Simi said.

The Rev. Pippin Whitaker ministers the Unitarian Universalist Fellowship of Athens in Georgia, which last year received a package of ammunition in the mail with no note included. She embraces framing extremism, and people’s lack of awareness of it, as a public health issue.

“If you have a germ out there,” Whitaker said, “and people aren’t aware that if you wash your hands you can protect yourself, and that it’s an actual problem, you won’t enact basic protective behavior.”

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Trump said he calls it “beautiful, clean” coal. “I tell my people never use the word ‘coal’ unless you put ‘beautiful, clean’ before it.”

That same day, the Trump administration paused implementation of a rule that would help protect coal miners from an aggressive form of black lung disease. Enforcement of the new protections is officially halted until at least mid-August, that came a few days after a federal court agreed to put enforcement on hold to hear an industry challenge. But even if the rule takes full force after the delay, the federal agency tasked with enforcing it in Appalachia and elsewhere may not be up to the task after sweeping layoffs and office closures.

Deaths from black lung — a chronic condition caused by inhaling coal dust — since the introduction of over a half-century ago. But in recent decades, . By 2018, the Centers for Disease Control and Prevention estimated that the lungs of about 1 in 5 coal miners in central Appalachia showed evidence of black lung. It is being diagnosed in younger miners. And the deadliest form, progressive massive fibrosis, has increased tenfold among long-term miners.

Silica is the primary culprit. Exposure to it has increased since mining operations began cutting through more sandstone to reach deeper coal deposits. The stone breaks into sharp particles that, when airborne, can become trapped in lung tissue and cause a debilitating, sometimes fatal condition.

The new rule was set to take effect in April, cutting the allowable level of silica dust in the air inside mines by half — to the limit already in place for other industries — and set stricter guidelines for enforcement.

Years in the making, advocates for miners heralded the new standards as a breakthrough. “It is unconscionable that our nation’s miners have worked without adequate protection from silica dust despite it being a known health hazard for decades,” said when the rule was announced last spring under the Biden administration.

The rule pause came on top of another blow to mine safety oversight. In March, the Department of Government Efficiency, created by a Trump executive order, announced it would end leases for as many as three dozen field offices of the Department of Labor’s Mine Safety and Health Administration, with the future of those employees undetermined. That agency is responsible for enforcing mining safety laws.

Then in April, two-thirds — nearly 900 — of the workers at the National Institute of Occupational Safety and Health, an agency within the Department of Health and Human Services, were fired. As a result, NIOSH’s Coal Workers’ Health Surveillance Program, which offered miners free screenings from a mobile clinic, ceased operations.

An announcement by MSHA of the silica rule delay cited the “unforeseen NIOSH restructuring and other technical reasons” as catalysts for the pause but didn’t mention the federal court decision in the case seeking to rescind the rule.

Separately, on May 7, attorney filed a class-action lawsuit against Health and Human Services and its head, Robert F. Kennedy Jr., to reinstate the program. His client in the case, Harry Wiley, a West Virginia coal miner, was diagnosed with an early stage of black lung and applied to NIOSH for a transfer to an environment with less dust exposure but never received a response. He continues to work underground.

On May 13, U.S. District Judge Irene Berger issued a preliminary injunction to reinstate the surveillance program employees. The next day, Kennedy said the administration would . That day, they were back at work.

“Remaining in a dusty job may reduce the years in which Mr. Wiley can walk and breathe unassisted, in addition to hastening his death,” Berger wrote. “It is difficult to imagine a clearer case of irreparable harm.”

MSHA officials declined to respond to specific questions about the silica rule or plans to implement and enforce it, citing the ongoing litigation.

In an emailed statement, Labor Department spokesperson Courtney Parella said, “The Mine Safety and Health Administration is confident it can enforce all regulations under its purview. MSHA inspectors continue to conduct legally required inspections and remain focused on MSHA’s core mission to prevent death, illness, and injury from mining and promote safe and healthful workplaces for U.S. miners.”

Wes Addington is quick to say a career in the mines isn’t necessarily a death sentence. He comes from generations of miners. One of his great-grandfathers worked 48 years underground and died at 88.

But Addington also said protecting the safety and health of miners requires diligence. He’s executive director of the , a Whitesburg, Kentucky, nonprofit that represents and advocates for miners and their families. A study the center conducted found that staffers at the MSHA offices scheduled to close performed almost from January 2024 through February 2025.

Addington said NIOSH provided the data to document worsening conditions over the past few decades.

Addington’s organization has advocated for the new silica rule for 17 years. “We didn’t think it was perfect,” he said. He would have preferred lower exposure limits and more stringent monitoring requirements. “But, as it was, it was going to save lives.”

The cuts to the agency, Addington said, could affect every American worker who might be exposed to harmful elements in the workplace. NIOSH approves respirators prescribed by Occupational Safety and Health Administration regulations.

With fewer inspectors, miners are “more likely to get hurt on the job and those injuries could be fatal,” he said.

“And if you’re a miner that’s lucky enough to navigate that gantlet and make it through a 20-, 25-year career,” Addington said, “the likelihood that you develop disabling lung disease that ultimately kills you at an early age is much increased.”

The black lung clinic at in southwestern Virginia has diagnosed 75 new cases of progressive massive fibrosis in the past year, according to its medical director, Drew Harris.

“People are dying from a dust-related disease that’s 100% preventable, and we’re not using all the things we could use to help prevent their disease and save their lives,” Harris said. “It’s just all very disheartening.”

He believes it would be a mistake for Kennedy to reorganize NIOSH , shifting the surveillance program team’s responsibilities to other employees.

“It’s a very unique expertise,” Harris said. The agency would be “losing the people that know how to do this well and that have been doing this for decades.”

Rex Fields first went to work in the mines in 1967, a year before an near the small town of Farmington, West Virginia. His wife, Tilda Fields, was aware of the hazards her husband would encounter — the safety issues, the long-term health concerns. Her dad died of black lung when she was 7. But it meant a well-paying job in a region that has forever offered precious few.

Rex, 77, now lives with an advanced stage of black lung disease. He’s still able to mow his lawn but is easily winded when walking uphill. It took him several weeks and two rounds of antibiotics to recover from a bout with bronchitis in March.

Throughout his career, Rex advocated for his fellow miners: He stepped in when he saw someone mistreated; he once tried, unsuccessfully, to help a unionization effort. For these efforts, he said, “I got transferred from the day shift to the third shift a time or two.”

Today, the Fieldses lobby on behalf of miners and share information about occupational dangers. Tilda organized a support group for families and widows. She worries about the next generation. Two of the Fieldses’ sons also went into mining.

“People in the mountains here, we learn to make do,” Tilda said. “But you want better. You want better for your kids than what we had, and you surely want their safety.”

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Infectious disease experts from the Centers for Disease Control and Prevention made a list of recommendations following their visit, including one to launch syringe service programs to stop the spread at its source. But those who’ve spent years striving to protect people who use drugs from overdose and illness say the situation likely hasn’t improved, in part because of politicians who contend that such programs encourage illegal drug use.

Joe Solomon is a Charleston City Council member and co-director of SOAR WV, a group that works to address the health needs of people who use drugs. He’s proud of how his close-knit community has risen to this challenge but frustrated with the restraints on its efforts.

“You see a city and a county willing to get to work at a scale that’s bigger than ever before,” Solomon said, “but we still have one hand tied behind our back.”

The hand he references is easier access to clean syringes.

In April 2021, the CDC came to Charleston — the seat of Kanawha County and the state capital, tucked into the confluence of the Kanawha and Elk rivers — to investigate dozens of newly detected HIV infections. The CDC’s HIV intervention chief “the most concerning HIV outbreak in the United States” and warned that the number of reported diagnoses could be just “the tip of the iceberg.”

Now, despite attention and resources directed toward the outbreak, researchers and health workers say HIV continues to spread. In large part, they say, the outbreak lingers because of restrictions state and local policymakers have placed on syringe exchange efforts.

Research indicates that syringe service programs are associated with an estimated in HIV and hepatitis C, and the CDC to steer a response to the outbreak that emphasized the need for improved access to those services.

That advice has thus far gone unheeded by local officials.

In late 2015, the Kanawha-Charleston Health Department launched a syringe service program but in 2018 under pressure, with then-Mayor Danny Jones calling it a “mini-mall for junkies and drug dealers.”

SOAR stepped in, hosting health fairs at which it distributed naloxone, an opioid overdose reversal drug; offered treatment and referrals; provided HIV testing; and exchanged clean syringes for used ones.

But in April 2021, the limiting the number of syringes people could exchange and made it mandatory to present a West Virginia ID. The Charleston City Council subsequently added guidelines of its own, including requiring individual labeling of syringes.

As a result of these restrictions, SOAR ceased exchanging syringes. now operates an exchange program in the city under the restrictions.

Robin Pollini is a West Virginia University epidemiologist who conducts community-based research on injection drug use. “Anyone I’ve talked to who’s used that program only used it once,” she said. “And the numbers they report to the state bear that out.”

A syringe exchange in nearby Cabell County — home to Huntington, the state’s largest city after Charleston — isn’t so constrained. As Solomon notes, that program for every one exchanged in Kanawha.

A common complaint about syringe programs is that they result in discarded syringes in public spaces. Jan Rader, director of Huntington’s Mayor’s Office of Public Health and Drug Control Policy, is regularly out on the streets and said she seldom encounters discarded syringes, pointing out that it’s necessary to exchange a used syringe for a new one.

In August 2023, the Charleston City Council voted down a proposal from the to operate a syringe exchange in the city’s West Side community, with opponents expressing fears of an increase in drug use and crime.

Pollini said it’s difficult to estimate the number of people in West Virginia with HIV because there’s no coordinated strategy for testing; all efforts are localized.

“You would think that in a state that had the worst HIV outbreak in the country,” she said, “by this time we would have a statewide testing strategy.”

In addition to the testing SOAR conducted in 2021 at its health fairs, there was extensive testing during the CDC’s investigation. Since then, the reported number of HIV cases in Kanawha County , Pollini said, but it’s difficult to know if that’s the result of getting the problem under control or the result of limited testing in high-risk groups.

“My inclination is the latter,” she said, “because never in history has there been an outbreak of injection-related HIV among people who use drugs that was solved without expanding syringe services programs.”

“If you go out and look for infections,” Pollini said, “you will find them.”

Solomon and Pollini praised the ongoing outreach efforts — through riverside encampments, in abandoned houses, down county roads — of the to test those at highest risk: people known to be injecting drugs.

“It’s miracle-level work,” Solomon said.

But Christine Teague, Ryan White Program director at the Charleston Area Medical Center, acknowledged it hasn’t been enough. In addition to HIV, her concerns include the high incidence of hepatitis C and endocarditis, a life-threatening inflammation of the lining of the heart’s chambers and valves, and the cost of hospital resources needed to address them.

“We’ve presented that data to the legislature,” she said, “that it’s not just HIV, it’s all these other lengthy hospital admissions that, essentially, Medicaid is paying for. And nothing seems to penetrate.”

Frank Annie is a researcher at CAMC specializing in cardiovascular diseases, a member of the Charleston City Council, and a proponent of syringe service programs. Research he co-authored in southern West Virginia associated with injection drug use, at a cost to federal, state, and private insurers of more than $17 million, of which less than $4 million was recovered.

Teague is further concerned for West Virginia’s rural counties, most of which don’t have a syringe service program.

Tasha Withrow, a harm reduction advocate in bordering rural Putnam County, said her sense is that HIV numbers aren’t alarmingly high there but said that, with little testing and heightened stigma in a rural community, it’s difficult to know.

In a January 2022 follow-up report, the CDC recommended increasing access to harm reduction services such as syringe service programs through expansion of mobile services, street outreach, and telehealth, using “patient-trusted” individuals, to improve the delivery of essential services to people who use drugs.

Teague would like every rural county to have a mobile unit, like the one operated by her organization, offering harm reduction supplies, medication, behavioral health care, counseling, referrals, and more. That’s an expensive undertaking. She suggested opioid settlement money through the could pay for it.

Pollini said she hopes state and local officials allow the experts to do their jobs.

“I would like to see them allow us to follow the science and operate these programs the way they’re supposed to be run, and in a broader geography,” she said. “Which means that it shouldn’t be a political decision; it should be a public health decision.”

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“I was so scared,” said Morreale, a resident of the small western North Carolina town of Mars Hill. In that moment, her joy about being pregnant was eclipsed by fear she would have to stop taking buprenorphine, a drug used to that had helped counter her addiction.

Morreale’s fear was compounded by the rigidity of the most common approach to treating babies born after being exposed in the womb to opioids or some medications used to treat opioid addiction.

For decades throughout the opioid crisis, most doctors have relied on medication-heavy regimens to treat babies who are born experiencing . Those protocols often meant separating newborns from their mothers, placing them in neonatal intensive care units, and giving them medications to treat their withdrawal.

But research has since indicated that in many, if not most, cases, those extreme measures are unnecessary. A newer, simpler approach that prioritizes keeping babies with their families called Eat, Sleep, Console is being increasingly embraced.

In recent years, doctors and researchers have found that keeping babies with their mothers and ensuring they’re comfortable often works better and gets them out of the hospital faster.

Despite her worst fears, Morreale was never separated from her son. She was able to begin breastfeeding immediately. In fact, she was told, the trace of buprenorphine in her breast milk would help her son withdraw from it.

Her experience was different because she had found her way to , an Asheville, North Carolina-based program, administered through the , that supports pregnant people and parents with substance use disorders. Morreale’s care team assured her she did not need to discontinue buprenorphine and that her baby would be assessed and monitored using the Eat, Sleep, Console approach. The protocol OK to be sent home so long as they’re eating, sleeping, and consolable when upset.

“By the grace of God, he was awesome,” Morreale said of her son.

David Baltierra, former director of West Virginia University’s , chair of WVU’s Department of Family Medicine – Eastern Division, and a family physician, suggests this protocol could simply be called “parenting.”

The method is increasingly being used instead of the long-embraced approach to treating opioid-affected newborns called the Finnegan Neonatal Abstinence Scoring System. That tool includes a list of 21 questions (is the baby crying excessively, sweating, experiencing tremors, sneezing, etc.), the answers to which determine whether the newborn should get medication to counteract withdrawal symptoms, which would then require an extended stay in a neonatal ICU.

Baltierra, though, has issues with the Finnegan method. For example, it often results in a soundly sleeping baby being awakened to be scored. That didn’t make sense to Baltierra. If the baby is sleeping, she’s likely doing fine.

Instead, health professionals should look for the telltale signs of a baby experiencing opioid withdrawal syndrome, he said. “Their body is in tension, they have a high pitch, they don’t calm down.”

Baltierra and his colleagues have been training residents to use an Eat, Sleep, Console approach for a decade, progressively more so in the past six years. The results are persuading more health professionals to adopt the method.

A 2023 study found babies treated this way were discharged from the hospital in and less likely to receive medication than those receiving Finnegan-based care.

Matthew Grossman, an associate professor of pediatrics at the Yale School of Medicine, refers to the introduction of the model of treatment he has helped pioneer as “the least innovative” undertaking imaginable.

that optimal care for pregnant women who’ve experienced opioid use disorder includes treatment with buprenorphine or methadone, which carries the risk their newborn will have withdrawal symptoms. Grossman and colleagues found a non-pharmacological-first approach .

He said the Finnegan tool is useful but often too rigid. Under its scoring, one sneeze too many could send a baby to the NICU for weeks.

Grossman said he observed that some babies receiving medications did well for a few days but began to decline when their mothers were sent home without them. Those observations made him ask, “Did the kid need more medicine, or more mom?”

Research by Leila Elder and Madison Humerick, who each did their residency in WVU’s rural program, found that median stays for newborns in withdrawal dropped from 13 days in 2016 to three in 2020.

Elder said babies born at the 25-bed rural hospital where they performed deliveries received medications to treat their withdrawal symptoms only when unrelated issues sent them to other hospitals for NICU care.

The simpler treatment also means more babies born in rural communities can receive care closer to home and has reduced the likelihood a mother will be released before her baby is cleared to go home.

Grossman suggested that rural hospitals are better suited to employ the Eat, Sleep, Console approach than big-city institutions, given the latter’s generally easier access to a NICU and propensity to choose that option.

Sarah Peiffer recalls the first time, as a medical student, she witnessed a nurse administering the Finnegan protocol, discussing it in clinical terms at a new mother’s bedside.

“And I remember being kind of horrified,” she said. The process was clearly distressing to both mother and child. “I felt like there was almost a punitive feeling to it, like we were telling this mom, ‘Look what you did to your baby.’”

Peiffer is now a Project CARA practitioner and family health physician at in western North Carolina and a vocal proponent of ESC and its approach to partnering with families. “You look at all the nonpharmacologic stuff you’re supposed to be doing — like keeping the lights low in the room, keeping the baby swaddled, doing as much skin-to-skin with mom as possible — and you really treat mom as medicine.”

Research suggests immediate postbirth to short‐ and long‐term health and bonding.

That contact, Elder said, “releases endorphins for mom,” which helps lower the risk of postpartum depression.

Grossman said developing the Eat, Sleep, Console protocol was simply a matter of pausing to reassess.

The original intent of the Finnegan tool wasn’t to render the process so rigid. But “everybody is excited to have a tool, and then this approach calcified around it,” he said.

Grossman said the objective of the simpler approach was to place the family at the core of care, and shorter hospital stays for babies was simply a fortuitous outcome. The shift in approach fits into a wider move toward judgment-free, family-centered care for those who’ve experienced addiction and for their children.

Now, he said, after five days, mothers often say “‘Can we go home? I think I got this,’” and they’re treated “with the same respect as any other mom.”

Peiffer said she has witnessed this mother-centric care counter “that sense of shame that people feel instead of families feeling empowered to care for their infant.” It represents “such a major shift in how we think about neonatal withdrawal both medically and culturally.”

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“Yes, sir. It was a sad day,” Harrison said of the financial collapse of the small rural hospital, where all four of his children were born.

Quorum Health operated the 49-bed facility in this rural eastern North Carolina town of about 5,000 residents until it closed. The hospital had been losing money for some time. The county’s population has slightly declined and is aging; it has experienced incremental economic downturns. Like many rural hospitals, those headwinds drove managers to discontinue labor and delivery services and halt intensive care during the past five years.

Prospects for reopening seemed dim.

But a new hospital designation by the Centers for Medicare & Medicaid Services that took effect last year offered hope. As of August, hospitals in around the country have converted to the to prevent closure. The new program provides a federal financial boost for struggling hospitals that keep offering emergency and outpatient services but halt inpatient care.

The REH model “is not designed to replace existing, well-functioning rural hospitals,” said George Pink, a senior research fellow at the University of North Carolina’s , which has documented 149 rural hospitals that have either closed or no longer provide inpatient care since 2010. “It really is targeted at small rural communities that are at imminent risk of a hospital closing.”

The program hasn’t yet been used to reopen a closed hospital.

With guidance from health consultants, Martin County officials asked federal regulators to explore the possibility of adopting the REH model and were ultimately given the go-ahead.

If successful, Martin County could become one of the a shuttered hospital to this new model.

Ask members of a community that has lost its hospital what they miss most, Pink said, and it’s almost invariably emergency services. Count Harrison among them, especially after a medical crisis nearly killed him.

Harrison, who lives in a smaller crossroads community a few miles south of Williamston, began experiencing leg pain in February. Under normal circumstances, Harrison said, he would have gone to his primary care doctor if his leg began to hurt. This time he couldn’t, because the practice closed when the hospital folded months earlier.

Then, one morning he awoke to find his foot turning black. It took him 45 minutes to drive to the closest hospital, in the town of Washington. There, doctors found blood clots and he was flown by helicopter to East Carolina University Health Medical Center. A doctor there told him that he’d probably had the blood clots for close to a year and that he was lucky to be alive. The medical team was able to save his foot from amputation.

Harrison, like many other community members, now had firsthand experience with the consequences of a shuttered hospital.

The state legislature’s decision last year to has meant fewer North Carolinians are uninsured, which means fewer hospital bills go unpaid. But health care is evolving: Many procedures that once required inpatient care are now performed as outpatient services. Dawn Carter, the founder and a senior partner of Ascendient, a health care consulting firm working with the county, said the inpatient census at Martin General in its last few years ranged from five or six a day to a dozen.

“So you’re talking about a lot of cost, a lot of infrastructure to support that,” she said.

With no emergency care within a half-hour radius, Martin County administrators believe a rural emergency hospital would be a good fit and a viable option. a hospital to collect enhanced Medicare payments, an annual facility payment, and technical assistance.

Carter said the team will present to the state Department of Health and Human Services a set of drawings of the portion of the building they intend to use to see if it meets REH regulations.

“I’m hoping that process is happening in the next several weeks,” she said, “and that will give us a better idea of whether we have a handful of really quick and easy things to do or if it’s going to take a little more effort to reopen.”

Officials then will take proposals from companies interested in running the hospital.

Carter said the expectation is that, initially, the facility will be strictly the emergency room and imaging department, “and then I think the question is, over time, where do you build beyond that?”

And the rebuilding could prove a challenge from the start. Many former staff members have taken positions at nearby health care facilities or left the area. The effects of that exodus will be compounded by the widespread to rural areas.

It’s early yet, Pink said, to assess the success of the rural emergency hospital model. “All we have are armchair anecdotes.” It seems to be working well in some communities, while others “are struggling a little to make it work.”

Pink has a list of questions to assess how an emergency hospital is faring in the long run:

• Is it at least breaking even? And if not, do administrators foresee a solution?
• How is the community responding? If someone believes they have an issue that might require inpatient care, Pink suggested, perhaps they’ll bypass the REH for a hospital that can admit them. And to what extent does bypassing their doors carry over to all services?
• Are patients happy with the care they’re receiving? Are the clinical outcomes good?

The rate of rural hospital closures rose through 2020, then dropped considerably in 2021. Congress had passed the CARES Act, and the Provider Relief Fund offered a financial lifeline, Pink said. That money has now been distributed, and the concern is that “many rural hospitals are returning to pre-covid financial stresses and unprofitability.”

If the trend continues, he said, more rural hospitals may turn to the REH model.

Ben Eisner serves as Martin County’s attorney and interim manager. He acknowledges that the health and well-being of this community require a lot more than a hospital. He cites, for example, a new nonprofit with a mission to address the .

Advancing Community Health Together was created in response to the hospital closure. Composed of community members, its focus is addressing inadequate health care access and poor health outcomes as a consequence of generational poverty, said Vickey Manning, director of Martin-Tyrrell-Washington District Health.

“We can’t address rural health care in a vacuum,” Carter said. Her organization, Ascendient, is part of the , a nonprofit commissioned by the North Carolina General Assembly to study sustainable models of health care for rural communities.

Like most of rural eastern North Carolina, Martin County is in transition, Eisner said. Diminishing family farms, less industry. “And so the question becomes,” he said, “‘What happens for all these communities? What happens next?’ And it’s an answer that is not yet fully written.”

Harrison, still relying on crutches to get around, recently drove 45 minutes north on U.S. 13 to the town of Ahoskie to have a doctor examine his foot. He said a hospital that offers basic emergency care isn’t a perfect solution, but he’ll have some peace of mind once the cover is peeled from that sign and his local hospital reopens.

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“Oh, my word,” said Tawnya Brock, a health care quality manager and a Jellico resident. “That hospital was not only the health care lifeline to this community. Economically and socially, it was the center of the community.”

Since 2010, 149 rural hospitals in the United States have either closed or stopped providing in-patient care, according to the Cecil G. Sheps Center for Health Services Research at the University of North Carolina. Tennessee has recorded the second-most closures of any state, with 15, and the most closures per capita. Texas has the highest number of rural hospital closures, with 25.

Each time a hospital closes there are health care and economic ripples across a community. When Jellico Medical Center closed, some 300 jobs went with it. Restaurants and other small businesses in Jellico also have gone under, said Brock, who is a member of the legislative committee. And the town must contend with the empty husk of a hospital.

Dozens of small communities are grappling with what to do with hospitals that have closed. Sheps Center researchers have found that while a closure negatively affects the local economy, those effects can be softened if the building is converted to another type of health care facility.

In Jellico, the town owns the building that housed the medical center, and Mayor Sandy Terry said it is in decent condition. But the last operator, Indiana-based Boa Vida Healthcare, holds the license to operate a medical facility there and has yet to announce its plans for the building, leaving Jellico in limbo. Terry said local officials are talking with health care providers that have expressed interest in reopening the hospital. That’s their preferred option. Jellico does not have a Plan B.

“We’re just in hopes that maybe someone will take it over,” Terry said. Meanwhile, the nearest emergency rooms are a half-hour drive away in LaFollette, Tennessee, and across the state line in Corbin, Kentucky.

An hour and a half away in Fentress County, the building that once housed Jamestown Regional Medical Center has been empty since June 2019, when Florida-based Rennova Health — which also previously operated Jellico Medical Center — locked it up.

County Executive Jimmy Johnson said Rennova’s exit from Jamestown was so abrupt that “the beds were all made up perfectly” and IV stands and wheelchairs sat in the halls. About 150 jobs evaporated when the center closed.

Rennova still owed Fentress County $207,000 in taxes, Johnson said, and in April the property was put up for auction. A local business owner purchased it for $220,000. But Rennova was granted a year to reacquire the building for what it owed in back taxes, plus interest, and did so within a few days.

Abandoned hospital buildings dot the map in central and east Tennessee. But in the western part of the state, two communities found uses for their empty buildings, albeit not in reopening hospitals.

Somerville, about an hour east of Memphis, lost its hospital, Methodist Fayette, in 2015. Its parent company, Methodist Le Bonheur Healthcare, donated the building to the town and threw in $250,000. The building is now a satellite campus for the University of Tennessee-Martin.

The conversion was pushed along by the town leveraging other funding. Bob Turner, Somerville’s city administrator, said both the town and the county matched Methodist’s quarter-million dollars toward the renovation. In its first year in Somerville, the university raised another $125,000. Tennessee’s governor then matched that $875,000 in his state budget.

Somerville is now in the seventh year of a 10-year agreement with the university, which rents the building from the town.

“We have a building, an asset, that’s probably worth $15 million,” Turner said. “It’s a four-year university right here in the heart of Fayette County.”

Mendi Donnelly, Somerville’s community development director, said the county is still in desperate need of a hospital, but “we’re thrilled that we were able to make lemonade out of our lemons.”

Ninety miles to the northeast, in rural Carroll County, Tennessee, another shuttered hospital found new life.

The closing of McKenzie Regional Hospital in 2018 was a blow to the local economy. But Baptist Memorial Health Care, which operates a hospital in nearby Huntingdon, bought the assets — including the building, land, equipment, and ambulance service — and subsequently donated the building to the town of McKenzie.

Cachengo, a technology company, ultimately took over the space. Because of hospitals’ electrical infrastructure, the site was a perfect fit for a business like his, said Ash Young, Cachengo’s chief executive. Young said Cachengo is now looking into repurposing abandoned hospitals across the country.

Jill Holland, McKenzie’s former mayor and a local-government and special-projects coordinator for the Southwest Tennessee Development District, believes the town can become a technology hub.

“It’s opening a lot of doors of opportunity for the youth in the community,” Holland said.

Back in Jamestown, the vacant hospital is “deteriorating,” said Johnson, the county executive. “It could have been used to save lives.” Rennova did not respond to a request for comment.

The University of Tennessee Medical Center opened a elsewhere in Jamestown, sparing residents a half-hour drive to the closest ER. Johnson believes the old hospital building could serve the community as housing for those who are homeless or as a facility to treat substance use disorder.

Brock, the health care quality manager, thinks things will get better in Jellico, but the community has had its .

Brock believes a freestanding emergency room could be a viable solution. She urges her community to be responsive to “a new day” in rural health in America, one in which a hospital must focus on its community’s most urgent needs and be realistic about what that hospital can provide.

“Maybe it is just the emergency room, a sustainable emergency room, where you could hold patients for a period of time and then transfer them,” Brock said. “And then you build upon that.”

She added, “There are options out there.”

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The arrival of prescription opioids onto seemingly every block of Huntington, a city of about 46,000 people, augured the first wave of an overdose crisis. Heroin followed, then fentanyl.

Residents remember Aug. 15, 2016, as the darkest day because on that afternoon and evening, 28 people overdosed in the city. But Huntington had shouldered collective trauma before.

On Nov. 14, 1970, Southern Airways Flight 932 crashed into a hillside just outside Huntington, killing all 75 on board. The dead included football players, coaches, and boosters from Marshall University, located here.

Residents say the tragedy bonded the community in a way that helped prepare it for crises to come. But now that cohesion is being challenged in a city and county once known as the epicenter of the nation’s opioid epidemic.

This crisis continues to evolve. Cabell County, like other communities, is in the depths of a “fourth wave” of overdoses fueled by mixtures of drugs that often include fentanyl and other powerful synthetic opioids.

Fentanyl is now ubiquitous — heroin is rarely seen anymore — and toxicology results reveal other synthetics, including carfentanil, a drug used to anesthetize elephants that can be 100 times as potent as fentanyl. Also in the mix is another animal tranquilizer that can cause in IV drug users. Increasingly, those drugs are being mixed with stimulants like methamphetamine and cocaine.

Michael Kilkenny, chief executive of the Cabell-Huntington Health Department, recalls coming to the “shocking realization” in 2015 that drug overdose was the third-leading cause of death in the county, after heart disease and cancer.

When the Centers for Disease Control and Prevention in 2016, users turned to heroin. Then came fentanyl. In 2017, Cabell County had the of opioid-related overdose deaths in the state with the — .

Connie Priddy, an emergency medical services nurse, said that after the dark day of Aug. 15, there was initially a sense of relief. “We saved all 28 people,” she said. “Our EMS crews did a wonderful job.”

But Priddy, who now leads the county’s , said the euphoria quickly dissipated when officials learned that none of the 28 people had subsequently been referred to addiction resources or received treatment.

Taylor Wilson, 21, was the first known overdose on that August day. Her parents spent the next 41 days searching for treatment options. On the 42nd day, Wilson overdosed again and died from a mix of drugs that included fentanyl, carfentanil, furanylfentanyl, morphine, and hydrocodone.

“She was enrolled at Marshall,” Wilson’s mother, Leigh Ann Wilson, said. “She was going to be a librarian.” Wilson began taking prescription opioids around the time she entered college but was able to quit them. She was then introduced to heroin by a boyfriend.

Priddy said that later, reflecting on the lessons of Aug. 15, “our community really came together and said, ‘We’ve got to do something different.’”

Huntington now strives to be the “city of solutions.” Establishing the Quick Response Team in 2017 was a significant step. Within 24 to 72 hours after an overdose, the team — consisting of a peer recovery coach, paramedic, police officer, and faith leader — pays a visit to the person who overdosed or to their family. The team also checks on people whose family members fear they may be at risk of an overdose.

The number of ambulance calls to treat an overdose has decreased by 40% since the team was established. Overdose deaths in Cabell County peaked in 2017 with 202. At that time, Cabell had an that was more than double the rate of the next-highest county in West Virginia. According to the CDC, by June 2023 the number of overdose deaths in Cabell had for the previous 12 months, while the numbers statewide continued climbing.

“We’ve expanded over these last few years to provide all kinds of social services along with referral to treatment,” Priddy said.

It is about “letting them know that we care,” said Sue Howland, a peer recovery coach with the Quick Response Team.

But the mixtures of drugs have presented new challenges. Robin Pollini, a substance misuse and infectious disease epidemiologist at West Virginia University, recently conducted studies of injection drug users in several cities in the state, including Huntington. She found that few people are using only opioids; rather, they’re using opioids and methamphetamine.

And the emergence of fentanyl has heightened the risks. Typically administered doses of the opioid withdrawal drug buprenorphine, one of Suboxone’s main ingredients, are less effective against fentanyl than other opioids. While the effects of heroin often last four to five hours, fentanyl’s high lasts a half-hour to an hour. Consequently, people share and reuse syringes more frequently, furthering the risk of HIV, hepatitis B and C, and endocarditis, said Jan Rader, director of Huntington’s Council on Public Health and Drug Control Policy.

Adding stimulants like meth and cocaine to the mix creates another layer of challenges.

Those on the front lines say most stimulant users are unaware they are taking a mix of drugs. That was the case for Jessica Neal, who said she started using methamphetamine in her early 20s, got in trouble with the law, went on the run, became pregnant, and is now in recovery.

Neal, now 33, thought she was using only meth. But a toxicology report from a failed drug test revealed she had also taken heroin, fentanyl, barbiturates, and benzodiazepines.

While some opioid users prefer the contrasting effects of opioids and stimulants, others, particularly people who are homeless, take stimulants to stay awake and safe.

Larrecsa Barker, a paramedic with the Quick Response Team, said regardless of what people report using, she always asks them if they might test positive for heroin or fentanyl. “If so, that means you’re definitely one step closer to getting into treatment,” she said.

There is no equivalent to Suboxone to treat withdrawal from stimulants. “If you’re just using meth, the likelihood of getting into inpatient treatment is slim to none,” Barker said.

In 2020, local government agencies, health providers, and Marshall University assembled a resiliency plan. Short-term goals include expanding outpatient and inpatient care; reducing barriers to treatment and recovery services; and providing more substance use education. They’re also working to address the underlying social determinants of health, including housing and employment.

Rader, the drug control council director, sees incremental gains in caring for the most vulnerable. She said that , a program operated by , has been a godsend. “So many success stories,” she said. Rader also lauded the city’s founding of the and the expansion of its . The low-barrier shelter admits people even if they have recently taken a drug.

Yet Pollini, the epidemiologist, said that too often lawmakers limit how local officials can respond. She cites restrictions, and prohibitions, on harm reduction initiatives at both the state and local levels.

She said that clamping down on syringe exchanges not only restricts the availability of syringes but reduces access to free naloxone, fentanyl test strips, and other lifesaving supplies.

Syringe exchange programs must be approved by both city councils and county commissions, and they can withdraw support at any time. “That’s a pretty precarious way to operate,” Pollini said.

A in the West Virginia Legislature that would ban syringe services programs. Some lawmakers have argued that offering clean syringes in exchange for used ones abets drug use.

“It’s really aggravating what’s happening on the political scene right now, because they’re not deferring to the experts in the field,” Priddy said.

Pollini said: “Let us do the things that we know work.”

Kilkenny, who was of the National Association of County and City Health Officials, said he believes if the will is there, overdose deaths could be reduced by 90%. He said he believes in aiming high, and that a public health department has a critical role to play in getting there.

“We want children to have fewer adverse childhood events,” he said. “We want families to be more resilient.”

As for Neal, she said she made it out of the “madness” and was welcomed into Project Hope. She is raising her baby daughter and working as a Project Hope peer support recovery specialist. Her objective is to help other women get the resources they need to break their addictions.

This <a target="_blank" href="/rural-health/west-virginia-opioid-overdoses-fourth-wave/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

Sears was , a sedative used for animal surgeries that has infiltrated the illicit drug supply across the country, contributing to a steady climb in overdose deaths.

Sears divides his time between Burlington and Morrisville, a village an hour to the east. In Burlington, he visits clusters of drug users, offering water, food, and encouragement.

He has been there, been down, done time, struggled to adhere to treatment regimens. But this, he said, is different: — estimated to be as morphine — and now xylazine, and the life-threatening it can cause.

Sears implores those he encounters who suffer the effects of these drugs to look at what they’re doing to themselves. But to little avail.

“They say they’re unable to get out of it — that they don’t have a plan to get out of it.”

Worse, those who seek help breaking their addictions face treatment options rendered less effective by the prevalence of fentanyl, xylazine, and other synthetic drugs. Vermont’s pioneering efforts in establishing a statewide program for medication for opioid use disorder, known as , now face significant new challenges.

Launched in 2012, Hub and Spoke put prescription medicines at the center of the treatment strategy, which many addiction specialists say is the most effective approach. Vermont offers at regional hub sites for those with the most intense needs, while smaller community clinics and doctors’ offices — the “spokes” — provide care such as dispensing the .

Advocates and experts in Vermont honed the model, and today hub-and-spoke systems or variations are in place nationwide, including in , , , , and .

But the rise of fentanyl, xylazine, and stimulants is undercutting the effectiveness of addiction medications.

Commonly administered doses of buprenorphine, better known as Suboxone — the brand name for a combination of buprenorphine — have proved less effective against fentanyl, and commonly used doses can trigger violent, immediate withdrawal. Neither Suboxone nor methadone is designed to treat addiction to xylazine or stimulants.

The Centers for Disease Control and Prevention estimates that of the more than 111,000 drug-overdose deaths in the U.S. in the 12-month period ending in April, more than 77,000 involved fentanyl and other synthetic opioids. The nation has also seen a significant increase in overdose deaths from . Vermont has experienced a spike in the use of cocaine and, .

“There was a time when we couldn’t have pictured things being worse than heroin,” said Jess Kirby, director of client services for , which offers services to counter substance use disorder. “Then we couldn’t picture things being worse than fentanyl. Now we can’t picture things being worse than xylazine. It keeps escalating.”

In Vermont, the Hub and Spoke program is part of the statewide Blueprint for Health, with hubs in relatively populous areas of this largely rural state.

A patient enters the system for assessment and initial induction at one of nine hubs, and then, once stable, is transferred to a spoke. If that patient relapses or needs more intensive care, they can be transferred back to the hub. The spokes typically offer Suboxone — most effective for those with mild to moderate opioid dependence — but not methadone, which is more regulated.

Kirby — who began using opioids in her early teens, has been in recovery for about 15 years, and is Ty Sears’ longtime case manager — said a benefit of the hub-and-spoke model is that it offers support to primary care doctors and other practitioners who might otherwise be hesitant to prescribe medications to treat addiction. (Federal officials recently governing which doctors can prescribe buprenorphine.)

Erin O’Keefe, who runs the Burlington-based program, said the model’s flexibility has been key: from being fully integrated into primary care, whereby addiction is treated like any other chronic disease, to the other end of the spectrum, “making sure that people who are still in chaotic-use cycles receive harm reduction approaches” to keep them alive another day.

Vermont had the 10^th-largest increase in fentanyl deaths for the 12-month period ending in April. Tony Folland, clinical services manager with the Vermont Department of Health’s Division of Substance Use Programs, said fentanyl is now implicated in about 96% of overdose deaths.

Meanwhile, xylazine, commonly called “tranq,” is causing extreme concern. State Department of Health records indicate that almost 1 in 3 opioid overdose deaths so far this year involved xylazine. And those working on the front lines report seeing a marked increase in the extreme wounds it often causes.

The challenges providers now face underscore the need to be prepared to respond in the moment. It’s essential, O’Keefe said, to capitalize on someone’s motivation for change, “and that motivation can be so fleeting — like, ‘I have enough in the tank to make one phone call, and if that phone call doesn’t go well, I’m back in the game.’”

Folland said Vermont now prescribes more medication for opioid use disorder per capita than any other state. He estimates between 45% and 65% of people with opioid use disorder receive medication.

But these challenges are unprecedented. “We have a drug supply that’s contaminated with xylazine, with fentanyl, and we know that people are struggling a lot more and are at a lot higher risk,” Kirby said. “It’s not just overdose to be concerned about anymore. It’s life-threatening wounds and infections.”

In response, advocates have asked state officials to fund more , a treatment approach that provides rewards to patients who refrain from illicit drug use. They also strongly encourage more widespread access to methadone as an alternative to buprenorphine, which is often proving less effective in countering the potency of fentanyl.

According to Folland, eight opioid treatment programs in communities throughout the state offer methadone, with one more soon to come. The goal, he said, is to prevent anyone from having to travel farther than a half-hour or so to access it.

Easier access to methadone would also require loosening .

“Methadone is probably the most regulated medication in the United States. We’ve got to figure out a way to make it more accessible,” said Kelly Peck, director of clinical operations for the . “We’ve got decades worth of data at this point, showing that methadone is safe and efficacious.”

For Kirby, O’Keefe, and their colleagues, more resources can’t come quickly enough.

“People dying — that’s what I’m seeing, every day,” Sears said.

Sears has been fortunate. What has served him in his recovery is the tolerance of those who’ve helped him along the way, and flexibility. There have been times when he was allowed to remain on Suboxone while still using stimulants. He is a recent graduate of a contingency management program administered by Vermonters for Criminal Justice Reform, the organization for which Kirby works.

“She counsels me,” Sears said. “She hears me out.”

Glimpsing a flicker at the end of the tunnel, advocates acknowledge, will require availing an arsenal of options to counter a shifting, and lethal, crisis.

“It’s almost like our understanding is changing from really seeing this, on a social level, as episodic to seeing it as chronic,” O’Keefe said, emphasizing that as the drug-supply landscape shifts, approaches to countering it must evolve as well.

This <a target="_blank" href="/rural-health/overdose-opioid-use-disorder-synthetic-drugs/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">