Rural communities often paid the highest price for the consolidation of county schools. It was more difficult for students and their parents to participate in school programs, and the rural community lost a center for community life, pride, and identity. Modern, technical approaches to learning that rewarded individual competition rather than collaborative work; large, impersonal classes; and a school culture that emphasized access to consumer goods rather than traditional values and culture frequently distanced poorer, rural youth from the education system. Rural children, rather than their urban classmates, were among the first to drop out of school after the ninth grade, and those rural students who finished high school were less likely to move on to higher education. Time and again, those who did succeed in the new system were drawn away permanently from their home communities to colleges, universities, and jobs elsewhere. From the perspective of some rural parents, improved educational facilities at the new consolidated schools enhanced the economic opportunities of county officials and their families but only facilitated the exodus of talented students from rural areas.
Many of the young people, especially women, who adapted to the new secondary education system took advantage of the modern community colleges that opened across the region and secured degrees as computer programmers, nurses, accountants, and other mid-level technicians for expanding government agencies in nearby towns. A few attended four-year colleges and universities, but many who did failed to return to the region because of the lack of employment opportunities in their specialty fields. Thus for larger numbers of mountain young people, higher education became a real possibility, but for many it also became another highway out of the mountains. Rather than serving as an economic engine that might power creativity, security, and innovation as it did in other areas of the nation, higher education in Appalachia too often served to sustain the existing system or to drain away the region’s human assets.
Despite the opening of a law school in Grundy, Virginia, and a new medical school at Pikeville College in eastern Kentucky, for example, graduate and professional schools and institutes for scientific and medical research were scarce in central Appalachia, leaving most of the region’s professionals to be educated outside the mountains and denying localities the economic and civic benefits that such institutions provide to dynamic communities. During an era when job creation was often linked to information exchange, knowledge management, and innovation, there was not a single rank-one research university in all of central Appalachia, between Morgantown, West Virginia, and Knoxville, Tennessee, and between Blacksburg, Virginia, and Lexington, Kentucky. Large research institutions on the perimeter of the region and a number of excellent small colleges and regional universities expanded their linkages with the rural interior counties during this period, but the intellectual and economic impact of higher education on Appalachia remained limited.
The mixed benefits of improvements in education were mirrored in health care, which also underwent dramatic change in the last decades of the twentieth century. The expansion of emergency facilities and primary care clinics provided better access to medical care, but income and transportation barriers often limited the use of these facilities by the rural poor. Although primary care facilities were available within thirty miles of almost every Appalachian family by the turn of the century, access to higher-level care usually required travel to a distant university medical center or urban facility. The advent of medical helicopters improved the travel time for emergency treatment, but the economic benefits of advances in health care flowed to the external medical centers rather than expanding the local economy and institutional base. Specialized care, particularly in mental health and obstetrics, was sparse in central Appalachian communities, leaving most rural families to seek advanced services or treatment outside the region.
As a result of federal programs to recruit health professionals to rural counties, the number of primary care physicians serving Appalachia increased between 1965 and 2000, but two-thirds of mountain counties were still listed as “health professional shortage areas” at the turn of the century. The shortage was especially severe in the rural, economically distressed counties of central Appalachia. Those counties were least likely to have full-service hospitals, and the primary health care needs of residents were most often served by federally subsidized community health centers. Many small hospitals in the mountains closed during the 1980s, after the federal government altered the Medicaid-Medicare reimbursement formula to favor larger, urban hospitals, and in the 1990s one in four hospitals in Appalachia was facing severe financial challenges. Rural counties suffered from shortages of dentists, obstetricians, and substance abuse treatment centers as well.28
As in other areas of the United States, life expectancy increased and infant mortality and maternal death rates decreased significantly in Appalachia during the last decades of the century, but such measures, which are often used to assess health status, hid disparities that continued to place mountain residents at greater risk than other Americans. Inadequate health insurance, higher levels of poverty and unemployment, and lack of education and of preventive care led to higher instances of illness and death from some diseases in Appalachia, especially those related to diet and stress. Mountain residents were more likely than other Americans to suffer from heart and other cardiovascular diseases; diabetes; cervical, breast, and lung cancers; and work disability. Moreover, rural Appalachians suffered higher mortality rates from these conditions than did urban Appalachians.29
While the prevalence of a disease among any population group may have complex origins, there is little doubt that poverty contributed to the persistence of these health disparities in Appalachia. As one researcher observed, lower-income people in the mountains experienced “a combination of decreased access to health care, increased risk to occupational and environmental hazards, and a greater tendency toward lifestyle habits that correlate with a low sense of control over one’s destiny.”30 Income uncertainty and the lack of job opportunities, for example, elevated levels of stress, anxiety, and feelings of powerlessness that sometimes resulted in drug dependence, obesity, and depression. The maladies of heart disease, diabetes, and lung cancer in Appalachia were linked to persistently high rates of tobacco consumption, which was in turn associated with stress and with the region’s rural heritage. West Virginia and Kentucky had the highest rates of heart disease in the nation, and eastern Kentucky, where 43 percent of adults smoked, led the country in lung cancer mortality rates.31
Emphysema, asthma, and other lung-related illnesses remained particularly high in coal counties. Within the region, coal mining had always been the most dangerous form of employment. Disability and poor health had gone hand in hand with work in underground mines. The passage of the Federal Coal Mine Health and Safety Act of 1969 and the Black Lung Benefits Act of 1972 increased hopes that the health and survival of miners would improve, but as late as 2007, a national study found severe black lung disease on the rise among younger miners in eastern Kentucky and southwestern Virginia. The report concluded that a lack of enforcement and compliance with dust-control regulations was placing larger numbers of miners at risk. Black lung disease was still listed as the underlying cause of death for an average of more than six hundred former miners each year in Appalachia between 1999 and 2004, more than thirty years after the passage of federal mine safety laws.32
Despite state and federal mine safety legislation and the precipitous decline in coal employment in the last decades of the twentieth century, coal mining remained one of the most hazardous occupations in the United States. Between 1996 and 2005, 320 workers were killed in American coal mines. An even larger number were injured or permanently disabled by mine accidents. Most deaths and injuries occurred in individual incidents of roof falls, equipment misuse, or ventilation problems, most of which, one study claimed, could have been avoided if existing regulations had been followed.33 Only when multiple lives were taken by dramatic mine explosions did the nation’
s attention refocus on mine safety issues. After 16 miners died in unrelated explosions in three mines in West Virginia and eastern Kentucky in the spring of 2006, three separate Labor Department reports accused the Mine Safety and Health Administration of overlooking obvious violations and of failing to take serious enforcement actions against the coal companies involved.34 Critics charged the Mine Safety and Health Administration and state regulators with a long history of failing to enforce legislation, issuing nominal fines, and ignoring unsafe roof conditions, inadequate ventilation, and deficient safety procedures.
Just as coal mining continued to be hazardous to miners’ health, living in the new Appalachia also brought a rise in tobacco, alcohol, and drug abuse usually associated with suburban and inner-city life. High rates of accidents and disease, elevated levels of worker disability, persistent unemployment, income uncertainty, and the growing availability of prescription painkillers contributed to rising levels of drug dependence in many mountain communities. An older population with more chronic disease and more chronic pain increasingly pressured medical providers for pain prescriptions, and more and more young people, lacking hope in the future of their own communities, turned to illegally obtained prescription drugs as a means of escape. According to one study, drugstores, hospitals, and other legal outlets in central Appalachia received more prescription painkillers than did any other area of the country.35
By the 1990s the illegal use of prescription narcotics such as Oxy-Contin and Vicodin had become an epidemic. Marketed by national drug companies as less addictive and less subject to abuse than other drugs and almost casually prescribed by scores of mountain doctors, these narcotics rapidly became the drugs of choice among illegal drug traffickers and users in Appalachia. Possession and sales of these illegal substances jumped 348 percent from 1997 through 2001 in eastern Kentucky, and from 2000 to 2002, more than 1,300 drug-related deaths occurred in the mountains of the Bluegrass State. The Lexington Herald-Leader labeled that area “the prescription-painkiller capital of the United States.” With parts of Appalachia experiencing drug-related deaths at four times the rate of the rest of the country, even the ARC became involved, helping to fund the regional Coalition on Appalachian Substance Abuse Policy and encouraging states to strengthen drug abuse programs and to build more treatment facilities. “Not only is substance abuse a public health problem,” an ARC report pointed out to Appalachian policy makers, “studies show it impacts education, economic development and family life.”36
The rise of the prescription drug culture in rural Appalachia was a tragic symbol of the arrival of modern America in the mountains. The new highways, shopping centers, consolidated schools, and industrial parks had reduced the perceived otherness of Appalachia, but the new economy failed to provide security, hope, and meaning for the lives of many of the region’s residents. Persistent disparities in income, education, and health status limited the life possibilities of young and old alike and hastened the disintegration of the once strong Appalachian family and culture. As the region entered a new century, communities throughout Appalachia again confronted the dilemmas of modernization: how to define progress, how to grow with equity and fairness, and how to change without losing the strengths of identity and tradition.
Debate over growth and development had divided mountain communities for generations. At least since the late nineteenth century, some in Appalachia had advocated growth through industrialization as the way to enhance individual opportunities and wealth, and they looked to the greater connections with mainstream society and markets as the paths to regional progress. Others sought to sustain a more communal way of life that valued stability, security, and independence. After a century of economic change, first as a result of private and corporate investment in the region’s resources and later as a consequence of government initiatives, the old debate remained. Many communities, faced with job losses and the out-migration of youth, searched for alternative ways to survive; a few, confronted with rapid growth, looked to control the process of change and to protect fast-disappearing cultural and natural resources. Most places struggled with conflicting ideas about the good life and with differing notions of the role of government in shaping that life.
The character and strength of that struggle intensified in the new Appalachia, in part because of the consequences of technology and global change and in part because of educational opportunities presented by government programs. The growth of world markets, the shift of manufacturing jobs abroad, and escalating demand for cheap energy added to existing pressure on the economy and the land. The expansion of the professional class, rising numbers of neo-Appalachians who migrated to the mountains in search of alternative lifestyles, and higher education levels among native residents increased the civic capacity and the diversity of critical voices within the region. Greater access to higher education in the 1960s and 1970s, moreover, produced a new generation of cultural and political leaders that was more educated and more willing to challenge existing power structures. A few began to look beyond the old economies of coal and branch plant manufacturing for more sustainable, alternative strategies for development. Coalitions of the new leadership often came together around issues related to the environment, health care, and cultural heritage, but their ideas frequently met resistance from institutions and politicians comfortable with the status quo.
Ironically, the political culture that had evolved with the arrival of industrialization decades earlier now proved to be the greatest barrier to structural change. Mountain residents had always felt a sense of separateness from mainstream society that reinforced their passion for freedom and independence. This pride in things local and familiar was more than just a defensive reaction to outside stereotypes, for it fueled a cooperative community spirit that allowed families to survive during hard times. It also provided a pretext, though, to resist change, and eventually it was utilized by mountain elites to maintain long established political dynasties. A certain deference for authority, for example, sustained by religious traditions and gender roles, strengthened the power of influential local males, who often controlled access to jobs and family security, and it contributed to an acceptance of the political process as an extension of private economic interest. In a world of uncertainty and economic insecurity, challenging existing patriarchy could be especially risky. The good old boys who still dominated much of Appalachian economic, cultural, and political life at the end of the twentieth century disdained criticism, innovation, and wider participation in civic life just as much as those who had controlled the political system on behalf of outside corporate interests decades earlier. They continued to use patronage, fear, and prejudice to maintain privilege and power in their modern little kingdoms.
Most Appalachian families tended to separate public from private life unless some imminent threat challenged their fragile security. As a result, the old cadre of power brokers continued to dominate local governments and institutions, too often utilizing the public sector to achieve personal gain or to reward relatives and friends. Despite increased oversight by state and federal authorities, corruption and election fraud persisted in many mountain counties, and advocates of political and economic reform found their efforts repeatedly frustrated. Programs to improve the quality of leadership and enhance civic participation blossomed in the 1990s and met with some success in bringing women, youth, and minorities into the public process. The ARC even added civic capacity to its list of regional development goals, but these programs were limited and slow to alter the prevailing political culture.
Fraud, corruption, and self-interest were not unique to Appalachia, but in a region plagued with persistent social and economic inequalities, the paucity of honest and creative leadership added an additional barrier to systemic reform. Politicians in some of the most distressed counties of the region were accused regularly of complicity in tolerating poor schools and social services to maintain their control over the local job market, which in turn assured their own poli
tical survival. The consolidation of schools and the growth of federal human service programs provided an ever expanding pool of patronage jobs and government contracts that could be channeled to friends and family, and control of the law enforcement system afforded additional cover for other profitable but illegal activities. Mingo County, West Virginia, for example, attracted national attention in the late 1980s when sixty-two local officials were indicted for corruption within a two-year period. Among those convicted of drug trafficking were two sheriffs, a police chief, and the fire chief. Federal prosecutors charged another local leader, who served as the president of the school board and the director of the poverty program, with drug conspiracy, obstruction of justice, and fraud. The man had personally handed out more than 2,400 jobs in a county where the total number of jobs was 8,700.37
In other mountain counties, elected officials were charged with bribery, the illegal use of public funds to pave private roads, nepotism (including the extension of no-bid contracts for county services to relatives), and theft of public property, but the most frequent indictments were for election fraud. A grand jury in Appalachia, Virginia, in Wise County, indicted the mayor, a council member, and twelve others for buying votes to elect three members of a five-member council. Once in office, the new council members had helped to appoint the head of a police department that trafficked drugs and took money and personal possessions from residents.38 Across the border in Knott County, Kentucky, the county judge executive was convicted of voter fraud and sent to jail. Two years later the county was under new leadership, but the Kentucky state auditor accused the new Knott County fiscal court of gross mismanagement of public funds. An audit found more than $13 million of questionable expenditures for illegal activities ranging from the use of public money to pave private roads to the overpayment of contractors, some of whom were related to county officials.39
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