Sam Runyon navigated to the house by memory as she reviewed her patient’s file, a “problem list” of medications and chronic diseases that went on for several pages. Sam, a 45-year-old nurse, had already seen Cora Perkins survive two types of cancer. During previous appointments, she had found Cora’s arms turning blue from diabetes, or her ankles swollen from congestive heart failure, or her stomach cramping from hunger with no fresh food left in the house. It had been a week since Sam’s last visit, and she wondered if anyone had come or gone through the front door since.
She knocked, but nobody answered. She walked across the porch to a hole in the window and called into the house. “Cora, honey? Are you OK?” A light flickered inside. A dog began to bark. Sam pushed open the door and walked into the living room, where she found Cora wrapped under a blanket.
“Sam. Thank God you’re here,” said Cora, 64. She tried to stand, but she lost her balance and sat back down in a recliner.
“It looks like you’re wobbly this morning,” Sam said. “Are you feeling really bad or just normal bad?”
It was the same question she asked her patients dozens of times each week as she made home visits across West Virginia, traveling from one impending emergency to the next in a country where feeling bad had become the new normal. All 31 patients in her caseload for the Williamson Health and Wellness Center were under 65 years old, and yet each had at least one of the chronic diseases that had become endemic in the United States over the last two decades: death rates up 25 percent nationally from diabetes, 40 percent from liver disease, 60 percent from kidney disease, 80 percent from hypertension and more than 95 percent from obesity, according to data from the Centers for Disease Control and Prevention.
Americans now spend more years living with chronic disease than people in 183 other countries in the World Health Organization — a reality that Robert F. Kennedy Jr. framed as a “national crisis” in his first weeks as health secretary. “We will reverse the chronic disease epidemic and make America healthy again,” he was promising members of Congress that same morning, while Sam confronted the challenges of that work in Mingo County, where the average life expectancy had been dropping steadily for a decade to 67 years old.
“Are we calling that your breakfast?” Sam asked, pointing to Cora’s side table, where two bottles of sugar-free Dr Pepper sat next to a bag of pepperoni-flavored Combos.
“It’s the end of the month,” Cora said. “It’s whatever’s left. I got the pops on sale at Dollar Tree.”
“You know Dollar Tree isn’t a good place to buy real groceries,” Sam said.
“How am I supposed to get to the grocery store if I don’t have a car?” Cora said.
Sam had been visiting Cora every week for almost two years, helping her to lose 40 pounds, stabilize her blood sugar levels and lower her cholesterol back into the normal range, but each problem they solved revealed another. Cora and her live-in boyfriend regularly had less than $100 in their joint bank account, so she needed help applying for government assistance. She finally qualified for food stamps, but she had no way to go shopping. She occasionally managed to buy meat and vegetables, but her oven was usually broken, so instead she relied on the cheap, ultraprocessed foods that make up 73 percent of the U.S. food supply. Those foods made her sick. Her illnesses made her anxious and depressed. Anxiety raised her blood pressure and complicated her ability to manage diabetes.
“I don’t mean to nag you,” Sam said. “I know it feels impossible. I can see how hard you’re trying.”
She took out a blood pressure cuff and started her examination while two dogs crawled over her lap and nipped at her neck. She had been offered an extra $8 an hour to work as a nurse at a nearby hospital, with a sterile office and a support staff, but she preferred the messy intimacy of home visits, where she could spend an hour with her patients and see the systemic decay behind their conditions. She’d grown up nearby in another drafty rental home, and she knew how to spot the empty jar of cooking oil in Cora’s kitchen, the collection notice on the refrigerator for an electric bill of $766, and the pill box on the counter with several outdated prescription medications.
Many of Sam’s patients stabilized and even got well. They were more likely to take their medications and less likely to visit the emergency room while under her care. More than half lowered their average blood sugar levels or improved their kidney function. But in other cases, no amount of intervention was enough to stop the progression of chronic disease, and Sam ended up listed among the survivors in her patients’ obituaries.
“We’ve still got work to do,” she told Cora. Her blood pressure was high. Her resting pulse rate was 93. Her legs were swollen from eating too much salt. Sam went back to her car and brought in a box from a nearby pantry that had some canned goods, noodles and a bag of potatoes.
“I’m sorry it’s not more nutritious,” Sam said, as she packed her nursing bag and gave Cora a hug.
“I’m pretty much used to the junk,” Cora said.
“You and everyone else,” Sam said.
She had worn out five cars while visiting patients on the back roads of Mingo County, and over time she had come to recognize every pothole, every scar on the hillsides left from logging, deep mining and mountaintop removal. It was a place where every resource, including the residents, had been exploited for a profit. Sam turned into Williamson, population 3,042, where two local pharmacies had distributed more than 20 million opioid painkillers over the course of a decade, though the drugs didn’t so much numb people’s pain as exacerbate it. Now the downtown was largely vacant except for rehab centers, budget law offices and a methadone clinic. She drove by a liquor store offering three-for-one shooters of vodka and a gas station advertising two-liter bottles of soda for a dollar each. “Every business is either trying to kill you or selling a cure,” she said.
She pulled up to a house on the edge of downtown to check on another diabetic patient, Joe Miller, 48, who was lying shirtless on his bed, immobilized from hip pain as his pit bull chewed his socks. On his night stand was a bowl of Kraft macaroni and cheese, a box of salt and a photograph of him from a few years earlier — thin and smiling in a button-down shirt, his arm wrapped around his wife. Now she was dead of a heart attack in her 40s, and he was struggling with depression and closing in on 300 pounds with dangerously high cholesterol. He told Sam he’d kept having a recurring nightmare in which he found dynamite stuffed inside his chest.
She reached for his wrist to take his pulse and measured his heart rate at 130 beats per minute.
“Geez, Joe,” she said. “Are you sneaking out to ride roller coasters on me?”
He pointed to a portable toilet in the corner of the room. “That’s about as far as I’ve moved from this bed in two weeks,” he said. “It’s so sad I can’t help but laugh.”
“Well, we might as well try to bring some light to the situation,” Sam said. “But I can tell you’re in pain, and I hate that. Let’s set you up to talk with a counselor.”
She got back into her car and followed the Tug River into the mountains as she opened her second energy drink of the day. “You have to cope with the stress somehow,” she said. “If there are any saints around here, I haven’t found them.” About half of the county’s 22,000 residents were obese, a quarter of them smoked cigarettes and almost 20 percent were diabetic — numbers that had become increasingly typical in rural America, where working-age adults were dying at higher rates than they were 20 years earlier, according to data from the C.D.C. People in the country’s poorest places were now almost twice as likely to develop chronic disease as those who lived in wealthy, urban centers on the coasts, helping to create a political climate of resentment. Mingo County had been solidly Democratic for much of its history, but more than 85 percent of voters supported Donald J. Trump in the 2024 presidential election.
Sam passed one of the only fresh grocery stores within 30 miles, where inflation had driven up the cost of produce. She slowed next to a roadside stand and saw a couple reselling off-brand soda, charging $3 for 12-packs containing 500 grams of sugar each. “Fill up for cheap,” their sign read.
The road twisted up a creek bed, and Sam stopped to check on a 43-year-old patient. She had cut her average blood sugar in half with Sam’s help, but her diabetes was still causing hemorrhaging in her eyes. “I brought you some exercise bands,” Sam said. “We’re going to get all Jane Fonda up in here.”
She went back to her car and opened another energy drink. “This job is like fighting gravity,” she said. Her younger brother had died in his early 40s of heart and liver failure. Her father was a diabetic who loved Wendy’s and drank several sodas a day. The father of Sam’s two children was prescribed opioids after a work injury, and then he spiraled into addiction. Sam had raised the children mostly by herself, worked three jobs and put herself through nursing school at night while driving her relatives back and forth to the methadone clinic. “I keep thinking I can fix people,” she said.
She pulled up to see her last patient of the day, Harry Ray, who lived with his brother in a single-wide trailer tucked against an icy hillside. Next to the house were two gravestones: one for their mother, who died from kidney disease at 56; the other for their father, killed by diabetes at 61. Harry had lost his leg to diabetes in 2009, but with Sam’s help, he’d dropped almost 75 pounds in the last two years. She taught him how to organize his medications and manage his diseases. He took notes during each of their meetings and tacked them up on the trailer walls. “You are what you eat, big boy,” one of them read.
Sam checked his blood pressure and bandaged a wound on his skin. The house smelled of unkempt cats, but she brushed a bug off the couch and sat down to visit for an hour before saying her goodbyes.
“Now hold on a minute,” Harry said. “You’re not leaving empty-handed.”
Sam tried to protest, but he disappeared into the kitchen and returned with a small bag.
“I wouldn’t be alive without you,” he said. “I’m sorry it’s not much, but it’s what we’ve got.”
Sam gave him a hug and went back to the car. She opened the bag and found a single can of Sprite, a pack of Fritos and eight pieces of hard candy. She closed her eyes for a moment and then drove in silence out of the mountains, until she made it back into cell range and her phone started to ring. One patient had a temperature of 101.6. Another couldn’t seem to pee. Cora called to say she was experiencing chest pain.
“Why does it feel like somebody keeps stabbing me?” she asked.
Sam listened to Cora describe her symptoms as she squeezed the wheel. “When was the last time you ate a real meal?” she asked.
Lunch had been a package of ramen noodle soup. So had dinner the previous night and lunch the day before. Cora hung up with Sam, checked her blood sugar and saw that it was 255, which was dangerously high. Sam had given her a pamphlet on heart-healthy foods, and Cora glanced at the list: avocados, pumpernickel bread, fish, blueberries, broccoli. She called out to her boyfriend, John Ratcliff, who was in the kitchen.
“Do we have any vegetables left?” she asked
“I doubt it,” he said, but he started to search the pantry and refrigerator. They had a bottle of mustard, a half-eaten microwave meal, a package of American cheese, a box of cornflakes and a bag of flour. This was what their kitchen often looked like at the end of each month, after they had used up their $380 in food stamps. The only accessible food within walking distance was at Pizza Hut, KFC, Taco Bell, Little Caesars, a dollar store and a tiny convenience mart where avocados sold for $2.99 each and a 12-pack of ramen noodles cost $2.50.
Cora turned on the television and saw an advertisement with close-up images of fried hash browns, steaming sausage patties and melting cheese, all on sale for a dollar. “Boy, doesn’t that look good?” she said. She muted the television and called into the kitchen. “Any luck?” she asked.
John came out holding a package of beef-flavored ramen. “Honestly, I’d rather starve,” Cora said.
He searched again and found a leftover bag of potatoes in the back of the pantry. He sliced them into cubes and doused them with salt. Sam had told him once that potatoes could cause a spike in blood pressure for diabetics, and that they were healthier when they were baked, but the oven was still broken. He filled a pan with oil and turned on a burner. “I found you some vegetables,” he called out to Cora.
They had been together for more than 20 years, and had taken turns as each other’s care givers. He suffered from seizures and had survived a quadruple bypass surgery. For the last decade, they had been measuring out their days to the relentless rhythm of her chronic disease: checking her blood sugar every few hours, decoding nutrition labels, taking six medications in the morning and five more with dinner.
He finished cooking the potatoes and stirred flour and milk together in a bowl. He dropped the mixture into the leftover oil to make what he called fry bread, Cora’s favorite. A few minutes later, he walked into the living room with two plates of fried carbs and a couple of Dr Peppers.
“This is so good,” Cora said. “Thank you. It’s exactly what I needed.”
They played a game of gin rummy and started to watch “Little House on the Prairie,” but Cora kept dozing off in her chair. She checked her blood sugar, and it was up to 270. Her mouth felt dry. She could feel the beginning of a headache. She tried to distract herself by playing a game on her phone, but her hands started tingling. “It never ends,” she said.
Her mother was diabetic. Her brother had died of complications from diabetes before he turned 60. Her daughter, 37, was already one of Sam’s patients. Her grandchildren were surviving mostly on processed school meals.
“I can’t remember the last time I felt decent,” Cora said.
“Maybe you should call Sam,” John said. Cora usually checked in with Sam at least once or twice a day, sometimes just to say good night, but now it was already close to 10 p.m.
“I don’t want to bother her,” she said.
The tingling persisted. Her headache got worse. A chill spread into her hands and then her arms. She slept for a few hours and then awoke to another day of Dr Pepper and ramen. By the next afternoon, her ankles were swollen, and her lips had gone numb. She called Sam, who was driving into the mountains to see another patient.
“I’ve got problems,” Cora said. “My lips keep going numb.”
“Your lips? Uh-oh. What’s your blood pressure?”
“I don’t know.”
“That isn’t good, Cora. I’ll be there in a few minutes.”
Sam drove out of the hills and back into Williamson, remembering the previous calamities that had brought her to Cora’s house and filled her patient file: “Pain in spine.” “Chronic pain.” “Neuropathy.” “Lower respiratory infection.” “Depressive disorder.” “Hypertension.” “Transportation insecurity.” “Obesity due to diet.” “Noncompliance with dietary regimen due to financial hardship.”
But lip numbness was something new, and Sam ran through the possibilities in her head. Cora’s lips could have gone numb from eating too much salt, since one package of ramen included almost a full daily serving of sodium. Or maybe she was freezing cold and losing feeling in her face — especially if the power company had made good on its threat to cut off the heat for nonpayment. Or the numbness could be a sign of anxiety, an allergic reaction or even an oncoming stroke. “I might have to transport her to the ER,” Sam said, as she parked out front and walked up to the house.
Inside, the dogs were barking and half a dozen relatives were gathered in the living room. It was the first day of the month, and Cora’s extended family had loaded up two cars to drive with her to the grocery store. Sam gently pushed away the dogs and made her way to Cora’s recliner. “I’m so sorry about all this, girl,” Sam said, as she took out a blood pressure cuff and reached for Cora’s hand.
Her blood pressure reading was 146 over 80 — high, but not an emergency. Her pulse was normal. Her blood sugar was in the typical range. Cora said she was feeling a little better, and she wanted to go shopping with her children and her grandchildren. None of them had groceries. She finally had a little money to spend. If she didn’t take the ride now, it could be days before she had transportation to the store again.
“Cora, listen to me,” Sam said. “You have to take care of yourself first.” She told Cora that she should consider going to an urgent care clinic or at least resting until she felt more stable.
“They could take me around the store in a motorized cart,” Cora said.
“It’s up to you,” Sam said. She packed her nursing bag as Cora weighed another impossible choice in a country where one urgent need was sometimes eclipsed by another.
“I have to get us some food,” she said.
Audio produced by Tally Abecassis.
