Chapter seven
On weekday mornings just before seven, a crowd gathers at the back entrance of the Friendship House, a drop-in center in Morgantown, West Virginia, that offers services and support for people dealing with mental health concerns and recovery from what it calls drug “misuse” in a state with a raging opioid drug crisis. On a rainy Tuesday in November 2020, about a dozen men and women—all white—wait at the door, which is situated in a parking lot across from Milan Puskar Health Right, the free health-care clinic for low-income uninsured or underinsured patients that runs the center. Another knot of people sit together on the pavement in front of a mural of Charlene Marshall, who became the first Black woman mayor in West Virginia when she won her election in Morgantown in 1991. The group huddles against the cold, swirls of cigarette smoke floating above them. They look gray and ground down, a sharp contrast to the brightly colored likeness of a full-bodied, smiling Marshall, who was barred from attending West Virginia University in the 1950s because the college banned Black students, but went on to serve seven years as mayor and another fourteen years in the West Virginia House of Delegates.
At seven on the nose, they are allowed to enter, and about a dozen people walk in. Some arrive empty-handed; others are freighted with their belongings, stuffed into suitcases and duffel bags they drag up the splintered stairs or in backpacks slung over their arms. One by one, they take a turn at the mustard-colored coffee urn, which looks like a relic from several decades ago. Morgan Anne Wood, a peer support specialist at the Friendship House, keeps up a stream of friendly chatter at the front desk, handing masks to those who aren’t wearing them. Contracting COVID would make their fragile lives so much more tenuous. They cradle Styrofoam cups, clutching them like lifelines as they pull down their masks to take a sip of the strong coffee. Many of the visitors know each other, though others have just stumbled in from off the street, happy to find someplace warm and safe to sit for the next hour and a half, to get out of the cold and use the bathroom. They also come to Coffee Club to talk and exchange information, seeking out others who understand what it feels like to lose a job, a car, a home, and a family and end up on the street. And perhaps most important, others who understand the crater that psychiatric illness opens up, the pull of pills, meth, and heroin, and the downward spiral that often follows either.
Ashley and Jason turn their chairs to face each other. The two have just met and have become fast friends. Leaning in, their heads almost touching, they sit under a series of colorful paintings created by other Friendship House clients as part of an art therapy project. The piece directly above them reads, “Love Is Like a Flower. It Will Never Bloom Without Care,” next to a bright orange tulip. Ashley’s blond hair is cut in a neat bob. She’s wearing a purple Champion sweat suit, the pants tucked into suede boots. A sturdy wool coat hangs on the back of her chair. She looks like Felicity Huffman, a star of the TV show Desperate Housewives. Jason wears glasses, sneakers, and dad jeans; he’s clean-shaven, his hair also neatly cut. Together, they could be a suburban couple, volunteers, rather than clients.
Ashley, who is thirty-eight, has just landed in Morgantown, a city she liked when she was stationed there in 2006 while serving in the U.S. Army. She left the military the following year, returning to her hometown in western New York. There, she bought a house where she could raise her two young daughters. But then the trouble started. At first, she felt as if her home were getting sick. She describes it as vibrating. Then she worried that someone was following her, casing her home. At night, she could hear someone digging a tunnel under her house. She was diagnosed with PTSD, the result of being raped by several other soldiers while stationed at a base in Missouri. Eventually, her fears became overwhelming, and she felt so unsafe that she decided to run, leaving one daughter with her parents, the other with the girl’s father. Ashley flew to Florida, bought a 2017 Toyota Highlander, and hit the road, staying in motels and shelters or sleeping in her car as she hopscotched between towns, cities, and states, living off her pension and military benefits. When she wrecked the car, she switched to the bus. She had landed in Morgantown the night before and secured a room in a motel but had a feeling she was being watched. So, she took a cab to another motel, where she ended up sleeping on a couch in the lobby until 5:00 a.m., when guests started waking up. Then she sat outside in the gazebo, until the doors of the Friendship House opened.
Jason is eager to help. He had a job as a carpenter earlier in the year, until an accident disabled his car and he could no longer get to work. He slept in his vehicle in the parking lot of a Walmart until it got too cold and he had spent the last of the $180 he had earned as a carpenter. The night before he joined Ashley and the others at Coffee Club, he slept at Bartlett House, a nonprofit shelter in Morgantown, funded by United Way. But because he got an emergency bed last night, he explains to Ashley, chances were slim he could get one again tonight. He pushes his glasses up with his index finger, looking like a roughed-up version of the college student he was ten years ago, before he dropped out.
People begin lining up in front of the Bartlett House emergency triage shelter just after sunset. When the doors open at 8:00 p.m., the crowd outside will jostle for one of about two dozen beds, and the rest are turned away. Those who don’t get beds may head to Diamond Village, an encampment for the homeless in the Greenmont section of town, or curl up in an alley, under scaffolding, or on a bench. The other options that the Bartlett House offers, transitional and bridge housing, are reserved for families with children and young people aged eighteen to twenty-four. Many of the Bartlett House clients are working poor in a town with an unemployment rate of 5.3 percent when I visited, which was lower than the state average. But the census points to a poverty rate of 33 percent. That means that most have jobs but are still too poor to survive on the state’s $8.75 minimum wage. And it’s even harder for people like Ashley, who struggles with mental illness, and Jason, who brings a criminal record left over from his younger days with him every time he applies for a job.
Jason isn’t sure what he’s going to do; Ashley either. She prefers sleeping in a shelter around other people who can protect her from her demons. But once she understands that Bartlett House isn’t an option, she pulls a smartphone out of her orange leather purse and begins googling for a motel. As it nears the end of Coffee Club, the two leave together. Later, I see them walking from Trinity Episcopal Church, which serves free lunch to the homeless and hungry from its back door on Willey Street. They are part of a line of people shuffling the streets between the Friendship House and the church, like so many gray ghosts from a Dorothea Lange photograph.
The local government’s annual Point-in-Time survey in January 2020 revealed that sixty-eight homeless individuals resided in Monongalia, the county that houses Morgantown, pre-COVID. But I have seen more than that between the Coffee Club, the free lunch program, and Diamond Village, though not every one of them is technically without a home. I pass Ashley and Jason again, still trying to figure out their sleeping arrangements, as they walk up Spruce Street carrying empty Styrofoam lunch containers. Across the street, the Alpha Phi house still has a sign announcing homecoming 2020. About a block up a steep hill, the University of West Virginia, a research institution with more than twenty-six thousand students and national-class sports teams, seems a world away. Improbably, Ashley has made up her face—foundation, blue eye shadow, mascara, and pink lipstick. She throws her lunch container in a trash bin and waves when I pass.
—
At its most basic, racism is defined as discrimination against a person or group of people because of race, resulting in harm and disadvantage. Its most pervasive and profound form, systemic or structural racism, is a set of power dynamics, braided into our country’s history, culture, politics, and institutions, that reward white people while disadvantaging people of color, particularly African Americans. The system, which is invisible to most because it is so thoroughly baked into our experience, has created inequality in power, access, opportunity, treatment, policy, and outcomes.
Worst off are those at the intersection of race and poverty, and America punishes disadvantaged Black people with the least empathy, the most harm, and the fewest options. But our country judges all of the poor, including white people. U.S. culture overemphasizes personal responsibility, creating the false notion that poor Americans are largely to blame for their own poverty, with little interrogation of an unequal system that is beyond the control of the individual. People are poor as a result of their own laziness, immorality, and irresponsibility, the stereotype goes, and could turn their lives around by making better choices. America shames them by glorifying the privileged rich as well as Horatio Alger–esque examples of individuals who have overcome the odds, ignoring the societal barriers that create obstacles to health, wealth, well-being, and safety for many.
We have slowly been coming to grips with the bodily harm that discrimination has caused to Black people, who have struggled against mistreatment in various potent forms for centuries, across multiple generations. But discrimination is discrimination, and when sustained, it can cause harm to anybody, including white bodies. What if Black people are simply the canaries in the coal mine? In other words, what if the health disparities they have experienced aren’t particular to the culture’s view of Blackness, but are a result of the harm that oppression, neglect, and erasure can cause any body? The effects of discrimination may not look the same in white people from Appalachia as they do in Black women or other populations. But what if the wear and tear that comes with feeling that their world is collapsing and with battling against social and educational inequality is creating a similar outcome—homelessness, poor health, and early death?
That question sent me to West Virginia, where 93 percent of the population is white. West Virginia is part of Appalachia, the more than 200,000-square-mile region of the country made up of thirteen states—from southern New York to northern Mississippi. In the American imagination, the twenty-five million people of this region are all poor, white, uneducated, and backwoods, and like every stereotype this one is untrue. Still, the region is much less diverse than the country as a whole, and the economic distress is real: in the past several decades Appalachians have seen their wages stagnate, their jobs become obsolete, and their communities decay as a result of desertion or disinvestment by the companies that mined away their natural resources.
West Virginia is one of the whitest of all states and one of the most impoverished in the nation. It has among the country’s highest unemployment and poverty rates for white people, as well as the overall lowest rate of labor force participation, 54 percent of working-age adults. Yet even that scorched-earth statistic understates the depth of the state’s economic woes: it hides the large number of working poor who are barely scraping by on minimum wage, as well as the fact that many of the 46 percent who aren’t currently part of the labor force would like to work but can’t find jobs. It also leaves out people who want to work but have given up looking altogether. The coal industry, long the backbone of the economy, has extracted natural resources while leaving behind abandoned mines, shuttered businesses, depleted government coffers, black lungs, polluted land and water, and lost hopes and dreams. Mining jobs peaked at 125,000 in West Virginia in the 1940s, when the mines and the jobs they brought in paid enough to support families and scaffold the state’s economy. When they began to close, as the industry became more automated and coal was replaced by other forms of energy produced in other states, the well-paying jobs left with them. By 2021, coal mining directly employed only about 13,000 West Virginians. Ironically, one of the poorest states has one of the richest governors: Jim Justice, himself a coal baron, who amassed billions. Along with Donald Trump, he promised to bring back coal and to loosen environmental and other regulations to make mining more profitable. That did little except to pile on dirty air, water, and soil into areas already overburdened with long-term pollution. In reality, the parts of West Virginia that for generations produced the most coal are now among the poorest communities in the state.
West Virginians have paid with their bodies. The state had the lowest life expectancy of any in the country when I was there; the average West Virginian could expect to live 74.4 years, according to 2018 data, compared with Hawaiians, the longest-lived Americans, at 81.3 years, or with the national average, which is 78.7 years. Racial health disparities still bubble up in a state with a Black population of less than 4 percent; on average Black West Virginians live several years less than white residents. Still, it is worth examining why early death in this overwhelmingly white state inched upward between 2010 and 2017, outstripping a broader downturn in life expectancy among white Americans. This, even though West Virginia expanded Medicaid in 2014, making access to health-care coverage more common for West Virginians than for Americans as a whole.
West Virginia is plagued by some of the same diseases that shorten the lives of Black Americans; poor physical health and mental health and the limitations in activity that result from those conditions are more prevalent in West Virginia than anywhere else in the nation. The obesity rate in West Virginia is nearly 40 percent, the highest in the nation. More than two-thirds of West Virginia adults are overweight or obese, raising the risk of heart disease, which is higher in the state than almost any place else in the United States. These health problems have been compounded by the slow drip of alcoholism, drug overdose, and suicide, which have reached crisis proportions, primarily among white Americans, in the past decade.
As with Black people, poor whites are generally blamed for their circumstances with little acknowledgment of the structural forces that stack the odds against so many. That conversation was raised a number of decibels by the author J. D. Vance, who used many of the same stereotypes usually foisted on Black Americans to describe the “broken” Appalachia that he fled. His 2016 best seller, Hillbilly Elegy, a bootstrapping story of the author’s escape from rural Rust Belt Ohio into the arms of the coastal elite, zeroes in on welfare recipients gaming the government the same way Black so-called welfare queens have been accused of leeching off government largesse. The book—which came out in the middle of Donald Trump’s frenzied run for president—became an explainer to understand poor and working-class whites, with Vance portraying the hillbilly culture as pathological, its members suffering from learned helplessness and appearing undeserving of sympathy.
In West Virginia, I am struck by the similarity to what W. E. B. Du Bois described when discussing the plight of Black people in the 1890s: the peculiar indifference to human suffering. When I meet Scott at the Friendship House, it takes a minute for him to stop shivering after spending the night on the street. Like Ashley, Jason, and the others, he has come to the Friendship House for a respite from the cold and rain, for the coffee, the company, and a bite to eat. He is hunkered down in a folding chair, alternately sipping coffee and slurping down a cup of ramen noodles, the noodles still hard because he’s too hungry to wait for the hot water to soften them up. As is the case with many of the now two dozen people who will shuffle in and out of the room over the next hour and a half, his clothes are soiled and baggy, his oversized jeans pooling at his feet. He has a bushy gray beard, flecked with bits of noodle, and as he pulls down the hood of his sweatshirt, he rakes his long dirty nails through his matted hair. “I need a haircut,” he says. His speech sounds slow and draggy. His left eye droops into a half-opened slit, making his right eye look wide with surprise. His left arm hangs limply at his side, and he keeps that hand stuffed in his pocket. We smile at each other and he tells me my hair is pretty, and I tell him his is too. He pulls down his mask to show me a snaggletoothed smile. Sizing up his eye and arm, the stiffness of his movements and pattern of speech, I guess he’s had a stroke. “No,” he explains. “An accident.”
Scott, or Mr. Scotty as some of the others call him, is an Appalachia native, born and raised in Greene County, Pennsylvania, just over the northern border of West Virginia. In 1993, he was working at a tire shop when he was involved in a car accident that killed a friend and put Scott in a coma for three months. After he regained consciousness, his injuries were so severe that he required a wheelchair and later physical therapy to relearn to walk and talk. Once mobile and partially recovered, Scott was arrested for the role he played in his friend’s death. His memories are hazy, and the sequence of his life after the accident and release from prison remains jumbled because of the permanent effects of the head injury. As he struggles to recount where he has lived and how he has survived in the more than twenty-five years since the accident, I interrupt to ask him his age, sizing him up to be about seventy. “I’m forty-eight,” he says.
Immediately I think of weathering. Though most of her research has centered on Black-white health disparities, more recently Arline Geronimus has expanded her theory of weathering to other disadvantaged groups who are the targets of sustained discrimination. Several years ago, Nicole Novak, one of her doctoral students, led her to Postville, Iowa. There, in May 2008, about 900 federal immigration officials in SWAT gear stormed onto the factory floor of a large meat processing plant to arrest 389 employees, most from Guatemala. Suspected of being undocumented, the men and women were handcuffed, linked by chains at the waist, herded into buses with blacked-out windows, and held in detention centers. Families were ripped apart, and some people, including children without their parents, sought refuge in the local Catholic church.
Novak, who is from Iowa, took Geronimus’s class Structural Influences on Health and Social Behavior at the University of Michigan School of Public Health in 2012. As a final assignment, Geronimus asked her students to describe a public health issue and think about it through a structural lens. Novak wrote about the Postville raid. Geronimus was both outraged and intrigued and asked Novak to work with her to examine birth outcomes in the years before and after the raid. The two spent more than a year nudging the Iowa Department of Public Health for data from all 209,389 births in Iowa from 2006 to 2010. They also combed Spanish-language newspapers, collecting articles about the raid and its aftermath. These included alarming eyewitness accounts and frightening images from Postville that spread throughout Latinx communities in Iowa via the press. Rumors of impending raids and ICE going door to door panicked people throughout the state.
Ultimately, Geronimus, Novak, and another colleague, Aresha M. Martinez-Cardoso, found that for the nine months after the Postville incident, Latinx mothers—both U.S.-born and immigrant—had a 24 percent higher risk of delivering a low-birth-weight baby than before the raid. Most of these Latinx mothers across Iowa who gave birth to underweight babies weren’t directly connected to the Postville crackdown and most lived far away from the town. Yet many of them still experienced enough fear, anxiety, and trauma to create a weathering effect on their bodies. This was associated with lower birth weight, even after controlling for age, smoking, and other factors. The study, published in 2017 in the International Journal of Epidemiology, served as a dangerous omen of the toll on the health of Americans that could be taken by the cruel methods of Donald Trump’s immigration policies.
If Black and Latinx people can have their health eroded by stress caused by ill-treatment, what about white people like Scott? His Sisyphean coping in the face of dire life circumstances seemed to age him. Those circumstances went beyond the consequences of his accident. A high school dropout, Scott grew up in an area of Appalachia where secure jobs dried up and the poverty rate crept to 20 percent. He was already hanging by a thread before disability and incarceration derailed his life. Scott’s circumstances are clearly extreme. But many of the people shuffling up and down the streets of Morgantown between the Friendship House, the back door of Trinity Church, Bartlett House, and Diamond Village seemed weathered by life’s headwinds. Though the experiences of Blacks and Latinx Iowans don’t match exactly with white West Virginians, the people I see in Morgantown are suffering because the bottom has fallen out of their lives and their tenacious efforts to hang on have made them look and seem older than their biological ages would suggest.
Caitlin Sussman, the Friendship House’s program director, keeps a scrapbook of clients who haven’t managed to weather life’s storms. The front of the white binder reads, “In Loving Memory of Our Past Loved Ones,” with rainbows splashed to the sides. Sussman, who was raised in rural Maryland an hour east of Morgantown and graduated from the University of West Virginia’s social work school, thumbs through page after page of mostly young and middle-aged white men and a few women. Charles Ray Cress died in 2014 at age forty. He loved fishing and hunting; in his tribute photo, he poses with his hands wrapped around the antlers of a deer he has just shot. Charles Lee Shultz stares directly into the camera; he looks tired and slightly annoyed. He loved country music and karaoke before he passed away in 2016 at the age of fifty-six. Charles Ellis Everett died the same year at fifty-three. He smiles in a snapshot taken at sunset, his fishing rod extending over a favorite lake. Jason Allen Smith died the same year at age thirty, leaving behind two daughters and a son. The following year, Kenny Allen Johnson passed away at fifty-one; his father and two brothers had proceeded him in death. In 2019, Etta Pearl Saint, a big-boned redhead, died just before her fiftieth birthday. Her boyfriend, Clay, wrote in the book, “She was my partner, friend and lover. She will always be my angel.” Sussman explains that these people have died from a variety of causes—heart disease, diabetes, cancer, suicide, alcoholism, and drug addiction. She pauses when she lands on a picture of Phil McCarty, a volunteer at the Friendship House who had died a few months before. He’s wearing a mask and foggy horn-rimmed glasses and holding a certificate celebrating his volunteer work with the homeless during the pandemic. A few months later, after being clean for a year and a half, he relapsed and died of a heroin overdose at age forty-one.
Each of these men and women adds to the grim accounting of what have been labeled deaths of despair. Nearly every U.S. media outlet covered the 2015 study by Anne Case and Angus Deaton that pointed to the rising rate of deaths among white Americans in their mid-forties to mid-fifties between 1999 and 2013. The married Princeton economists blamed this death rate among whites—not seen since the height of the AIDS epidemic—on suicide, drug overdoses, and alcoholic liver disease, particularly in states such as Arkansas, Kentucky, Mississippi, and West Virginia. The researchers noted declines in self-reported health, mental health, and ability to work, increased reports of pain, and deteriorating liver function, which they believed pointed to growing midlife distress almost entirely among white Americans without four-year college degrees.
The drug overdose numbers are most alarming. The rate of opioid overdose has drastically increased nationally, and West Virginia is at the epicenter with the country’s highest rate of overdose deaths. The sad statistics of West Virginia and Appalachia as a whole have been clouded by the belief that poverty and unemployment stem from laziness and bad personal choices and that the addiction that can follow results from weakness and lack of willpower. This contradicts the reality that pharmaceutical companies aggressively marketed OxyContin as a safe pain pill. Between 1997, just after Purdue Pharma released OxyContin to the market, and 2007, prescriptions for opioid medication skyrocketed 402 percent in the United States. But in 2007, the government cracked down on Purdue Pharma, which meant that buying opioid medication on the street became more difficult and much more expensive. Those who had gotten hooked on prescription medication filled the void with cheaper and more dangerous heroin and fentanyl, a synthetic opioid. The vast majority of heroin users, studies show, first used prescription medication. Though Purdue Pharma pleaded guilty to charges of misleading regulators, doctors, and patients about the drug’s risk of addiction and potential for abuse, the personal responsibility narrative remains stubbornly alive.
Race runs through this problem in complicated ways. Some in the field believe Blacks have avoided the brunt of the opioid crisis because physicians, falsely believing African Americans have superhuman pain tolerance, prescribed pain medication to them less frequently. This myth, left over from slavery, might have inadvertently prevented tens of thousands of Black overdose deaths, though it also might have resulted in undocumented suffering for those who were undermedicated for a variety of health concerns—from broken bones to cesarean sections. Other myths about Black people—that they were more likely to become addicted to drugs or to sell them—might have also led to fewer prescriptions written for pain medication.
The opioid epidemic is drenched in the kind of shame and judgment that leads to deaths and diseases of despair. Geronimus, while acknowledging the numbers and the problem, warns away from the term “of despair,” which suggests passivity and a kind of giving up. Instead, similar to the way she describes how weathering affects the bodies of Black and brown people, Geronimus connects the falling life expectancy in white Americans to high-effort coping that is softly killing those who are working doggedly against barriers and difficulties to survive. These are people who believed that hard work was enough to create good lives and also internalized the opposite: that those who failed didn’t work hard enough or suffered from a character defect. There is not enough acknowledgment in their communities that the economy had changed in ways that make it more difficult than in the past for people with the least education to find and keep jobs. This disconnect creates emotional distress and erodes physical health.
Despite Geronimus’s dislike of the term, despair seems etched into the faces of those people who live in Diamond Village, an encampment that has turned into a shelter of last resort for people in Morgantown. Many of those who have made their homes in the chaotic jumble of tents, situated on a parcel of public land down the hill from Pennsylvania Avenue next to Deckers Creek, seem to have gotten tired of battling life’s barriers and have sunk into hopelessness. Many are the Americans whom Case and Deaton describe as “drinking themselves to death, or poisoning themselves with drugs,” or, at rock bottom, “shooting or hanging themselves.” Their belongings, strewn on the ground among the tents, tell the stories of lost lives: yellowed storage bins, a rake and mop stuck in a shopping cart, a wheelchair tipped on its side, a milk crate full of rusted pots and pans, a yoga mat, a cracked kiddie pool, a printer, a space heater, a brown velour pullout couch, and a Persian rug draped over a sagging clothesline.
Dani Ludwig, a peer recovery coach at the Friendship House, walks comfortably through Diamond Village. She steps around a fire pit, making her way to the back of the collection of tents, calling out, “Who’s here?” She stops to point to a makeshift garden, vegetables planted in blue, green, and red storage bins. Over the summer, it produced peppers, carrots, cucumbers, and squash, but as winter approaches, one lone green tomato clings to a tangle of vines. Ludwig, who has three piercings in her nose, a fuzzy buzz cut, and a tattoo of Maleficent on her leg, feels at home in what seems like human chaos. She connects with the people who live inside the tents because she’s been there: Seventeen years of active drug addiction—except for the nine months she was pregnant with her daughter, Olivia—meant that she spent several years, off and on, living in a tent city like this one in another part of West Virginia. She stripped and did sex work to survive and dug through dumpsters at the back door of Little Caesars and Food Lion to eat. Her mother was so alarmed by her daughter’s descent that she bought her a cemetery plot and told her, “This is where I’m going to put you.”
In December 2017, she was both using and selling heroin when an acquaintance called and asked her if he could buy from her. Ludwig met her friend in the parking lot of a 7-Eleven and sold him $90 worth of heroin; that fix killed him three days before Christmas. Ludwig was arrested on felony charges and incarcerated for six months. She refused bond—too afraid of either catching another charge on the outside or dying of an overdose. Eventually, she was able to persuade a social worker to help her into rehab, and her sentence was reduced. In 2018 she ended up in Sober Living, a program in Morgantown that provides housing and support for people dealing with addiction as they reintegrate back into the community. In 2019, drug-free, she began working for the Friendship House, and a year later she was reunited with Olivia.
Her eyes sweep over the back end of the encampment, several yards from a three-story house with dirty siding and boarded-up windows, where Daniel is sitting on his haunches in front of his tent eating what looks like cereal out of a paper bowl. He is wearing an oversized Drippin Swag T-shirt stained with old food and is surrounded by a dolly, a portable storage bin containing three onions, a pile of empty plastic soft drink bottles, and, improbably, a Christmas tea towel. He moved into Diamond Village four months ago, from an abandoned house up the street where he had been squatting. Raised in Morgantown, he dropped out of school in ninth grade and got a job as a welder. He lost that job and struggled to find another. As is the case for many of the least educated Americans, his opportunities were few. He started buying pills off the street, grinding them up, and snorting them to feel the high faster. Though prescriptions for pain meds began to fall across the country that year, some areas of West Virginia continued to be inundated with them. But after a big bust in Morgantown about five years later, supplies dried up. The price of Perc 30s—Daniel’s drug of choice, which contain a thirty-milligram dose of oxycodone—went from $15 a piece to $50. So he switched to heroin, which was much cheaper. His long-standing addiction shows: his body is covered with scabs where he injects drugs, even on his face and ears, some of them bloody. He has a girlfriend who is incarcerated and a son and daughter he hasn’t seen in years. If he closes his eyes very tight, he can remember his children’s faces, but otherwise he doesn’t think about them—or his life or his future.
Paula, a friendly blonde wearing a blue sweatshirt and turquoise jewelry, walks by with a black garbage bag, picking up trash. She has a leather tote slung over her arm and shifts it slightly as she leans down to feed a Vienna sausage to Pedro, the camp cat, before she continues tidying up. Paula grew up in Morgantown and graduated from the University of West Virginia, just up the hill, with a degree in psychology, a minor in criminal justice. Now forty-nine, she was married for twelve years and has two adult children and a grandchild. Before she ended up in Diamond Village, she was running her own business, doing remote customer service for companies like Quicken. She looks up from her hands. “I know you’re wondering what the hell happened, right?
“I’m bipolar,” she explains. “I love the manic phases but hate the lows. It’s not like being depressed or sad. It’s a deep hopelessness like nothing you could ever imagine.”
Medication never worked for her. It made her feel dead inside. To avoid the crushing lows, she self-medicates with crystal meth. Even while using “ice,” she managed to maintain her business, living in a house in Morgantown with friends. But in March her computer was hacked, and she couldn’t get her files back up, which meant the end of her business. About a month later, someone died in the apartment below them, and the landlord evicted anybody whose name wasn’t on a lease. She had only a few hours to pack up before a sheriff came to the property. After bouncing around, couch surfing, for a few months, she claimed a tent in Diamond Village.
“At first to me, it just looked like tents on top of each other,” she says. “But now it feels more like home.” She describes family meals and sitting around the fire pit with other Diamond Village residents. Unlike Daniel, Paula can see a future for herself. Eventually, she’d like to restart her business or renew her social work license and find a job as a caseworker of some sort. A thick paperback with a light blue cover is sticking out of the top of her bag. She’s reading Broken Open: How Difficult Times Can Help Us Grow.
Ludwig gives Paula and Daniel each a bottle of water and several doses of Narcan, a nasal spray containing naloxone, a drug used to counteract the life-threatening effects of an opioid overdose. In the nine months Diamond Village had been open, a hundred overdoses had been reversed there using the drug, and no one had died. Several hours after I walk through, however, the first person does die at the encampment. On October 27, 2020, police found Rebecca Colgan, a young Black woman I didn’t see when I visited with Ludwig, lying on her back with a used needle filled with fresh blood next to her body. A month later, the City of Morgantown shut down Diamond Village.
The day after Rebecca Colgan was found dead, I was scheduled to meet with volunteers from SOAR (Solutions Oriented Addiction Response), a harm-reduction group in Charleston, West Virginia’s capital and largest city. Charleston has been in the grip of a raging opioid addiction crisis since pharmaceutical companies began inundating the area with prescription pain meds. Between 2007 and 2012, drug wholesalers flooded West Virginia with 780 million hydrocodone and oxycodone pills, according to the Pulitzer Prize–winning reporting of Eric Eyre of the Charleston Gazette-Mail. All told, these shipments—mainly to counties in the southern part of the state surrounding the capital—amounted to 433 pain pills for every man, woman, and child in West Virginia, according to Eyre’s reporting. In response, law enforcement cracked down on pain management clinics, doctors, and “pill mill” pharmacies. As prescription opioids dried up, people turned to injecting heroin and fentanyl, often using and sharing needles and syringes. This led to an outbreak of HIV in southern West Virginia, similar to a well-documented cluster of cases tied to IV drug use in rural Scott County, Indiana, in 2014 and 2015. West Virginia has historically had low rates of HIV cases, but parts of the state have turned into HIV epicenters.
In 2015, worried officials at the Kanawha-Charleston Health Department brought a syringe exchange to Charleston. Several decades of research from all over the United States and the world provides crystal-clear evidence that syringe exchange programs are safe and effective. These programs have also been shown both to save money and to create opportunities for people to get into treatment and care.
Despite the abundance of data about the benefits of this kind of harm reduction, syringe exchange advocates are often met with suspicion, accused of encouraging drug use and promoting crime. Those fears mounted in Charleston and came to a head in 2018 when the program could not meet the needs of the number of people looking to exchange dirty syringes and “points” or “sharps,” words that describe needles, for clean ones. At its peak, nearly five hundred drug users passed through the exchange in just eight hours—in a city of fewer than fifty thousand people. The mayor at the time, Danny Jones, called the syringe exchange program a “mini-mall for junkies and drug dealers.” The city shut it down that year, leaving Charleston with only a much smaller exchange run by a private clinic.
As HIV and overdoses spiked among injection drug users, SOAR was created to fill the void of government response. Largely under the radar, harm-reduction volunteers launched a DIY street outreach syringe exchange project in the parking lot of Unitarian Universalist Congregation (UUC), a progressive church at the corner of Vine Street and Kanawha Boulevard. Every other Wednesday evening, they collect used needles and syringes and exchange them for clean, sterile ones. They also offer food, water, HIV tests, condoms, and hundreds of doses of Narcan to as many as three hundred people who come through each night. As I was packing for the two-and-a-half-hour drive south from Morgantown to Charleston to observe the work, Joe Solomon, one of SOAR’s organizers, emailed me. The group was considering canceling the week’s Wednesday night event after a local television reporter called attention to its work with a lurid, tabloid-style story. The spot included hazy video recorded on the sly by an unnamed woman who said she had received sixty needles from SOAR over two visits without turning in any needles or syringes. The “exclusive investigation” takes credit for alerting the police to SOAR’s activities. In the end, Solomon and the other volunteers decided to lie low and not hand out syringes but still conduct HIV testing and distribute Narcan and other supplies.
By the time I arrive, the sun is setting and people are beginning to stream into the parking lot at UUC. Solomon, wearing foggy glasses and a black mask that says, “I Save Lives,” stands in front of a table groaning with supplies. He spends most of his time apologizing as he breaks the bad news that there are no syringes and points tonight. Behind him an assembly line of volunteers, including two ministers from the church, collect “returns,” or syringes, in white plastic canisters and sharps in a red medical waste container. Hands sheathed in blue surgical gloves, they also distribute masks, hygiene wipes, water, Pop-Tarts, snack bags of Goldfish, granola bars, tampons, condoms, and blankets donated by another church. At another table, a nurse hands out naloxone and offers wound care. A young couple—a man in baggy fatigues pushing a woman in a wheelchair—approaches Solomon. Her head is slumped over, stringy blond hair brushing a dirty backpack on her lap. Joe shakes his head and says he’s sorry. Their faces show less despair than desperation. Before he wheels her away, the man grabs a snowy-white blanket from the pile and stuffs it in the backpack. Another couple approaches Solomon, this time older, although I’ve learned to stop guessing anyone’s age anymore. Their eyes are flinty, their hands jittery as they inquire about “sharps.” When Solomon apologizes—again—and suggests HIV testing and counseling offered by the city’s Ryan White program, they stomp off. They pass a woman pushing a shopping cart full of her belongings; the man catches her eye. “They ain’t got nothing here. Just for HIV,” he spits at her over his shoulder. She turns, puts her feet on the shopping cart, and rides it out of the lot. Another man, wearing a Pittsburgh Steelers cap and matching yellow and black hoodie, approaches the table. “So, you don’t have any needles?” “No, I’m sorry,” Solomon tells him, and offers him Narcan. “You sure you don’t have any clean ones?” the man insists, grabbing Solomon’s sleeve. He shakes his head. “I need some bad, man,” the man says.
I go to the back and sign up for an HIV test so that I can see how the process works and talk to a provider. After my OraQuick blood test, as I wait for my results, a woman with hair dyed the color of dark cherries sits down next to me. She’s in line behind me for results. She looks agitated, her leg is shaking erratically, and the cigarette in her hand is quivering. Between puffs, she gnaws at the Band-Aid on her fingertip. “You are waiting for your test?” she asks me. I tell her yes. “You, too?” “Yeah,” she says.
She explains that she used to get points from the health department, but once the exchange ended, clean syringes and needles became hit-or-miss. A friend told her about SOAR, but when she showed up tonight, she learned that the exchange had been disabled. “To be honest, I been sharing, had no choice,” she explains. “I’m scared I got it,” she says, and I understand that she means HIV. As we wait, Chrissy, a peer recovery support specialist, approaches us. She asks if we want cigarettes; the woman with the burgundy hair takes one from her. Chrissy hands her a business card from a local drug recovery program and explains that she was an active user for half her life. “You can get help,” she says. The woman stuffs the card into the pocket of her jacket, takes a drag on the cigarette, and says thank you. Chrissy moves on, approaching two young women on Sting-Ray bicycles who look like sisters, pulling more business cards out of her fanny pack.
When my number is called, the burgundy-haired woman wishes me luck. I come out of the tent and give her a thumbs-up and hand her the $10 gift card and $5 Kroger card I received in exchange for testing. I ask her to let me know how it goes as her number is called and she stands up. On this evening, many fewer people come by SOAR. Solomon explains that news spread fast about the TV report and people were afraid the police would raid the event. He estimates that only about seventy have come through, down from several hundred on an average night. At one point, a blond woman wearing sunglasses and spotless white workout clothes climbs out of a Jeep SUV. Another organizer, Brooke Parker, points her head toward the woman and whispers something to Solomon. They both watch her, worried that she’s a television reporter, as she walks across the parking lot with her head down, carrying a white canister. She leaves the used points and syringes at the returns table. “She’s just dropping off for family, I guess,” says Parker as the woman gets back in the Jeep and drives away.
That evening, the Ryan White providers administered thirty-four HIV tests. Three people test positive; usually they record one, two at most. I think about the woman with the burgundy hair. About twenty minutes after she snubs out her cigarette to learn her test results, I see her rush out of one of the three HIV counseling tents. She’s moving too fast for me to catch her. The sun is almost completely set, and under a streetlight I see her shove her hands into her jacket pockets and walk hurriedly into the night.