Total Depravity: The Origins of the Drug Epidemic in Appalachia Laid Bare

In an excerpt from his essay collection, Australian journalist Richard Cooke reports on the American opioid crisis through the astonished eyes of a foreigner visiting steel and coal country.

Richard Cooke | Excerpt from Tired of Winning: A Chronicle of American Decline | Black Inc. Books | May 2019 | 21 minutes (5,527 words)

They shall take up serpents; and if they drink any deadly thing it shall not hurt them; they shall lay hands on the sick, and they shall recover.

Mark 16:18

One night John Stephen Toler dreamed that the Lord had placed him high on a cliff, overlooking a forest-filled valley. He had this vision while living in Man, West Virginia, where some of the townsfolk thought he was a hell-bound abomination; he countered that God works in different ways. The mountains were where he sought sanctuary, so he felt no fear; but as he watched, all the trees he could see were consumed by wildfire. It was incredible, he said, to see ‘how quick it was devoured’, and the meaning of the parable was clear. The forest was Man and the fire was drugs, and when the drugs came to Man, that was exactly how it happened – it was devoured ‘so fast, that you didn’t even see it coming’, he said. We were in Huntington, West Virginia, and by now John Stephen Toler was in recovery.

Huntington, the second largest city in West Virginia, once had a population of more than 100,000 people, but that number has reduced to some 48,000, and almost one-quarter of these, some 12,000 citizens, have either latent or active substance-use disorders. In a local coffee shop (the owners, incongruously, Australians), the woman behind the counter mentioned this affliction, and said, ‘But everywhere has problems, doesn’t it?’ Not so oblivious as it sounds. An incurious visitor could notice nothing amiss in the city, except its absences. Half-empty streets seem rangy and architecturally relaxed. There are plainclothed sex workers, who sit on the steps of churches, and homeless men pushing trolleys, but for the most part the epidemic is so unnoticeable it is almost subterranean.

Huntington, the second largest city in West Virginia, once had a population of more than 100,000 people, but that number has reduced to some 48,000, and almost one-quarter of these, some 12,000 citizens, have either latent or active substance-use disorders.

The back room of an outreach program called First Steps had become a makeshift confessional, and John Stephen Toler and I were making use of it. First Steps was decorated with the distinctive paraphernalia of recovery: flyers with hopeful clip art, polystyrene cups, wristbands marking time and achievements – but in West Virginia treatment was too common to trouble with euphemisms. The centers were in indiscreet locations. They had open-fronted windows, roadside signs with changeable letters (the same kind churches use), unambiguous names. It was the drugs – they were mainly opioids – that were hidden. There was a whole interstitial city in Huntington, in semi-abandoned buildings, on gas station patios, under bridges or behind dumpsters.

Huntington’s nadir (so far) came on 15 August 2016, when there were twenty-eight overdoses in four hours, two of them fatal. Most were in the surrounds of the Marcum Terrace public housing estate, a cluster of low-rise apartments that distills social problems. A friend, a journalist, was in town not long after this date. She was kept briefly housebound by bad weather, and when the spell of filthy rain broke into a clear, warm day, she went for a walk. She said the streets were nearly empty; Huntington’s sylvan parkland, some of it stretching to the banks of the Ohio River, was left to the white-tailed deer. In the houses and apartments, a force held sway that was stronger than the elemental drive towards the sun.

John Stephen had overdosed years ago, on some other hot day, not in August. His mother found him in a car with closed windows, not breathing – an event commemorated in a tattoo, ‘Life Goes On’, shaped like the graph of a pulse sensor. He was twenty-four when we met, but apologized for looking older ‘because of the drugs’, enough years of use to place a permanent furrow on his brow. His own addiction seemed indistinguishable from the regional misfortune, as though they had gone through parallel entropies – before he became a liar and thief, before he caught his felonies in Atlanta, Georgia, he was known for being so helpful. ‘Everyone knew John Stephen Toler,’ he said (adding, ‘Not because I’m a whore’). He was bisexual and did not hide it. Not uncontroversial in Man, but for some reason, the homophobes made exceptions. ‘There’s no fear in this queer,’ he said. ‘No shame in my game. You don’t have to like me, but you do have to respect me.’

He had since been to ‘hell’s basement’. ‘We’re the fuck-up of fuck-ups,’ he said. Addiction was a ‘disease of more’. In one 24-hour period, he lost his car, house, job, husband, and dog, and then went to jail. Both his parents had substance-use disorders, on and off, his father more on than off. Unless you were a coal miner or in the medical field, it was hard to make it in life, and the coal jobs were not what they were. Man had succumbed so quickly because it was a ‘shithole’, he said, small enough to miss if you blinked while driving down the four-lane. The money had gone with the coal, and people began selling dope to get money, and then selling dope to get dope, and then selling dope to do dope. Dealing meth became a quick way to make a living, and dealers would use it and get addicted. ‘But what about all the initial customers?’ I asked. What created the demand in the first place? Why were opioids a bigger problem than meth almost everywhere, and especially here? Why had this happened all over Appalachia?

Beyond hazarded guesses, John Stephen Toler did not know.

***

Drugs are as societally influential as any other widespread technology. Pharmacology leaves its mark on historical periods as surely as politics does, and the effects and side effects of millions of doses imprint beyond individuals and into the consciousness of entire eras. Modernity portions into these dynasties: the turn of the twentieth century ruled by morphine, then the amphetamine ascendancy of World War II; a tussle between cannabis and LSD following, the 1980s buoyed by cocaine’s confidence . . . Prozac and MDMA, Valium and Quaaludes – all have a cultural impact far beyond those consuming them.

The influence of opioids on rural United States today eclipses these precedents. Perhaps only London in the throes of the Gin Craze, or Imperial China after the Opium Wars, could compare. This new phase, described as ‘the opioid epidemic’ (seldom capitalized), has different characteristics. It has been so frequently outlined by statistics that there is an accompanying complaint: that, like the old irony about deaths and statistics, these factoids muffle rather than amplify the tragedy. But the calamity is on a scale that cannot be quantified by other means.

Graphed by year, overdose deaths form a precipitous climb, and at its peak (2017) are 70,237 dead Americans. Publications present this funerary Everest as part of a mountain range of comparable mortalities. The overdose death apex is taller and steeper than that of guns, dwarfs car accidents and breast cancer, is a head or more over the total US battle casualties of the Vietnam War and shades the AIDS epidemic at its most severe. Opioids by themselves have reduced the average American life expectancy for the first time outside a war.

Beyond the numbing accountancy, though, the epidemic has done little to impress itself onto the wider American culture. So far, OxyContin has produced no Hogarth, no Coleridge, no De Quincey, no Easy Rider or Drugstore Cowboy, no Junkie or The Long Weekend. There is no country music equivalent of Bowie’s Berlin period, or not one with any wattage. There is some book-length journalism, a sliver of fiction, some recovery-themed Christian hip-hop and, perhaps by analogy, the zombie-themed television series The Walking Dead. Then a blank. The destruction of much of working-class America by opiates and opioids has happened silently. There seems almost nothing creative to say about it, or no way to say it.

Geography contributes. Heroin has made a modest come-back in New York City, where, along with pain pills, it fills a bit part in polypharmic alt-literature. But opioids have hit hardest in the parts of the United States that are spare and wooded, and the country does not speak to itself in the voice of these places. Visiting the heartland, you catch a drawl in hospitality workers straight away – wait staff and laconic barkeeps with a narcotic film over their eyes, repping a parodic version of laid-back regional charm. One restaurateur couple in Lexington, Kentucky, opened a diner called DV8, focused on addiction recovery. Before that, thirteen of their employees died from addiction in ten years. Drugs were so unavoidable that recovery had to be integrated into the branding to contain the problem.

In Ohio, I met a lawyer, fresh from her garden, whose practice had become largely drug-adjacent. ‘This fentanyl and carfentanyl is a national security issue,’ she said, wiping her soily hands on her jeans. She was talking about the ultra-powered synthetic opioids, first manufactured for end-of-life care and veterinary anesthesia, that killed most efficiently. ‘It’s coming from China, and someone should look at that, because they are killing us.’ At first this seemed flatly racist, but the idea of a reverse, twenty-first-century Opium War, the colonized’s revenge, was too interesting to stop thinking about.

In chemical terms, carfentanyl is as mortal a threat as nerve gas – more poisonous by median lethal dose (one nanogram) than the venom of the Mojave rattlesnake. It was once unregulated, but after containing its production, the Chinese government made a pointed statement:

  1. America consumes 80 per cent of the world’s opioids. 2. China, a country in which these substances could be purchased online at wholesale prices, does not have an opioid problem. 3. If America has an opioid problem, it is not because of pharmaceutical imports but American-manufactured prescription drugs.

All true. At the heart of this domestic consumption is the region of Appalachia, set in mountainous seclusion between Kentucky, Virginia, Pennsylvania and West Virginia. Appalachia, when it is thought of at all, occupies a kind of ‘herrre be dragyns’ place on the American mind map of most Americans, occupied by doodled stereotypes: coal, hillbillies, Deliverance playing on repeat. Opioid addicts were just added to the stereotypes, a single letter changed to neologize them as ‘pillbillies’.

West Virginia is especially overlooked, as though it is the Appalachia of Appalachia. Since the late 2000s, it has used this cover to make something like a statewide suicide attempt. It was not just that West Virginians overdosed; West Virginia itself overdosed. In the six years between 2007 and 2012, drug wholesalers shipped 780 million hydrocodone and oxycodone pills into its borders. The town of Williamson, Mingo County (population 2900), stocked 10.2 million hydrocodone pills and 10.6 million oxycodone pills in its two small pharmacies. In 2008, in the nearby hamlet of Kermit, the same wholesaler supplied 5624 prescription pain pills for every one of the town’s 400 residents. Some of this pill pyramid was taken away (the editor of the Williamson local newspaper tried to persuade me that Kentucky ‘out-of-towners’ were to blame), but most doses were consumed locally, and added to. West Virginia was a net importer, and into the pile came the product of Florida pain clinics, spirited via the highways (the Greyhound buses taking this route are nicknamed ‘The OxyContin Express’). The merchandise of heroin dealers in Cleveland and Detroit and Indianapolis came over the hills, until the valleys and hollers of Appalachia seemed to fill like bowls.


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When problems are as regionally pervasive as this, people start to impugn the landscape. Here that means the mountains surrounding, which incubate clannishness and remove. The ranges did not look sinister to me – they lifted foliage to a height and angle where the leaves pixellated the sunlight – but you could trick yourself into believing that their topography created something cursed in the benighted planes of their steppes. People, even Appalachians themselves, sometimes spoke about locals as though they were hill tribes, encamped at a distance from the modern world.

There was a streak of residual Celtic fatalism that was not just mythic. The Democratic West Virginia Senator Joe Manchin was fond of saying that West Virginia had ‘more veterans per capita, fought in more wars, shed more blood, lost more lives’ than any other state. It was no longer true, but widely believed – he was not the only person I heard say it – and Manchin also claimed that West Virginia had ‘done all the heavy lifting. We mined the coal that made the steel that built the guns and ships, built the factories, built the middle class that gave you the quality of life you have today.’ Even in this telling, it was a scorned effort nationally. If there was something corrupting in the mountains, it was the coal. Coal was at the heart of the opioid epidemic. It was extracted from the land, but also made extractions from those laboring for it. Coal has killed West Virginians in subtle and various ways for well over a century. It bowed them, it crushed them; it took their sinews and their lungs. As late as the 1920s, Appalachian coal miners were still boys, as young as eight, preferred because their hands were small enough to work the seams. If these boys were severely injured or killed, the conveyor belts did not stop. After the whistle blew at the end of the shift, the gore and body parts (traumatic amputations were frequent) would then be collected.

Around the same time organized-labor laws were weakened, a company called Purdue Pharma ‘invented’ OxyContin, which meant taking a powerful opioid analgesic, giving it a slow-release coating that could be circumvented easily, concealing its potential for abuse, and marketing it aggressively to working-class communities increasingly unable to afford preventative medical treatment for chronic pain.

In 1921, a series of armed labor disputes known as the West Virginia coal wars culminated in the Battle of Blair Mountain, where miners with rifles fought pitched battles with Pinkerton agents, the army and the police. Together these combatants fired more than one million rounds at one another. The colored neckerchiefs of the resisting miners originated the term ‘redneck’, and the confrontation means the Second Amendment of the Constitution is locally sacrosanct. In most places, armed defense against government tyranny is a hypothetical. In West Virginia, it is a memory.

Still, the twentieth-century union bosses were accomplices to coal’s murders. Black lung was understood early, and too well, and when mechanized drills were introduced, the coal dust they produced was finer, so inhaled more deeply, and killed men with the same efficiency that made the mines more productive. Appalachian Magazine records that the legendary United Mine Workers of America leader John L. Lewis ‘decided not to raise the black lung issue because it might impede the mechanization that was producing higher productivity and higher wages’. Variations of this inhumane calculation persist.

I had not, before coming to Huntington, ever heard of a ‘coal doctor’ before, but this profession has a long history, rarely an honorable one. Often coal camps were lonely, rough places with few services, and coal doctors were rugged men who travelled long distances to provide medical aid to the workers. They were often chancers, and have retained some of this quality to this day. Not long ago, miners would finish their work and rise to the top of the pit to find a physician, ready to hand pills to any man with pains. As the unions faltered and their protections were stripped away, time spent sick became time unpaid, or an invitation to be laid off. Pain management was no longer just optimum, it was indispensable, and then, naturally, addictive.

Around the same time organized-labor laws were weakened, a company called Purdue Pharma ‘invented’ OxyContin, which meant taking a powerful opioid analgesic, giving it a slow-release coating that could be circumvented easily, concealing its potential for abuse, and marketing it aggressively to working-class communities increasingly unable to afford preventative medical treatment for chronic pain. Its supposed regulators at the Federal Drug Administration were bribed or lied to, and it was disseminated through profiteering doctors. The City of Huntington has sued Purdue Pharma and other companies involved in these practices, trying to compel them to responsibility, so far without success.

In the First Steps back room, a man called Steven Little told me a version of all of this, but before he even spoke, his eyes hinted at his private history: he was a pastor; he was a former addict. A quintessentially Appalachian combination, and one that let him speak with a profound spiritual gravity. He was from Kentucky but had come to Huntington on a calling.

‘Appalachia has always been a familiocentric region,’ he said. ‘And when you have families dependent on steel and coal, and those resources and jobs are taken away, you’re still left with the families. And families still have to provide for each other, and you get the release of a multi-million dollar product – OxyContins – whereby you can make a quick sale, and make a big buck, and you can still provide for your family. It was the perfect storm of events. The coal and the steel was taken away, and to some extent, the ease to sell dope was introduced around the same time.

‘This multi-million dollar, hundred-million dollar advertisement campaign – based upon false research: that Oxycontin was the miracle drug, that it’s not addictive. And so you get this mass push, and this influx of this highly addictive substance into this community. Where there’s already this hole that has to be filled – nature abhors a vacuum – so it will fill itself with whatever it can.’

That hole was present in his own experience: teenaged flashbacks to childhood molestation, hanging with the bad crowd in high school, years of snorting Oxy (though diabetic, he hated needles), recovery, then a slip from complacency. He decided to let loose for a night and within a few hours had a mistress/ drug dealer (his ‘adulteress,’ he called her in recollection, though without judgement), and within a week a $1000 habit. All this while his wife was pregnant with their first child. They separated; he moved the other woman into his former marital home. One morning he came back and the house was stripped; everything was gone, stolen. He fell down on his knees in the garage and asked for higher help.

Pastor Little told me how once he had been waiting at his dentist’s office, early for an appointment, and the technician had offered him magazines. He told her he was good for now, but she said that if he wanted some entertainment, he could look out that window there, and probably see some of them nasty old druggies, shooting up behind the dumpster. Here was an opportunity, and seeing as he had some time to kill . . . She was in tears by the time he had finished his story – he had once been one of those nasty old druggies behind the dumpster. Next visit she buttonholed him. She was volunteering with addicts. Something called Project HOPE.

Superficially heartwarming – but why did a worker in the medical field need a conversion experience to understand basic care? She should have known better; Huntington was full of doctors and nurses who should have known better. They treated substance use disorders grudgingly – First Steps clients sometimes copped undisguised disdain – and there was a resilient community belief that overdose victims should only be revived a certain number of times (a three strikes system was mooted), or not at all. Facebook comments on overdose stories were best avoided.

Pastor Little had been doing a survey on first responders and compassion fatigue. ‘I think those not in the recovery community assume – wherever that assumption comes from, assume it is a moral sickness – it is a moral impairment. Even the technician lady. She said, “If they really wanted to quit, they would quit.”’

He was clinical, unemotional, but not cold. ‘I think studies now suggest it’s not so much a moral deficiency as it is a combination of biological and cultural deficiencies. Like I told you before, not everybody who comes out of a broken home has addiction, but 80 to 90 per cent, according to Adverse Childhood Experiences scores, come out of broken homes.’

Take the psychological test called the Adverse Childhood Experiences Study (‘Did you often or very often feel that . . . you didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you?’) and it delivers something called an ACE score, which sounds crude, but predicts addiction and chronic disease with a subtlety and precision that seems almost cruel.

‘They’re broken down into different categories. I have five,’ said Pastor Little. ‘Terry may have seven or eight.’ Five was very bad.

Eight – that was almost off the charts. It was a multi-cause mortality risk. Not many eights were alive past sixty.

Terry ran First Steps.

***

I liked Terry Collison a lot. One of her friends had cajoled her into this line of work, but she was a natural, and everyone could tell. Every morning she opened a special website that posted mugshots of recent arrests, to see if any of her charges were in the jail. It was getting overcrowded, but most of the criminals weren’t too dangerous. People stole strange things here, she said, like patio plants and garden furniture, failures of risk–reward ratio, when Huntington homes were so often protected by cameras and firearms. Only the substance affected would chance a bullet for a concrete gnome.

The police had not been called to First Steps in many years, and when we talked, Terry would keep one ear open to the other room, where the clients were. If she caught the keening note that comes before an argument, she would keep our conversation going as she got up, and then from beyond the door . . . ‘I’ve asked you to stop cussin’, and you know what happens if you don’t – you leave.’ Response unintelligible, tone sheepish. She told me that on one occasion a client had threatened her, and she had only smiled – her smile still has trace quantities of the hippie she used to be – and said, ‘Try me, punk.’ The real danger, she said, came not from the person threatening her, but from all those men leaping to her defense, escalating something that didn’t merit escalation. They loved her, and she loved them. She called them her babies.

In our meeting, the raised voice came not from someone with a substance use disorder, but a young, floridly psychotic woman, who had been sieved out of the health service and ended up here, where she was not supposed to be. Someone had stolen her cherry red BMW, she kept saying. There was no cherry red BMW.

Not everyone was a candidate for recovery, and sometimes these individuals (who were most commonly men) felt distanced from society, like divers on the end of a line. There were a few rough sleepers out in tents by the Ohio River, and one man, when he had his history tabulated, was found to have been sheltered for only three of the last fifty years. He kept all of his possessions in a cart. The homeless still had phones, and Terry would return from a short trip to find individuals sitting against the outside wall, tethered to the power outlet.

Terry’s office window looked out onto 7th Street, and she would commentate the passing parade, telling the stories of the men and women she knew. ‘There is a pimp who rides on a motorized cart,’ she said, but we did not see him. ‘That’s one of our little prostitutes’ – a woman with a too-tight ponytail, a former student at Marshall, Huntington’s university. Good grades, very intelligent, from a good family. Kept a needle in her bra and used it until the point broke off.

One tentative suggestion, frequently made in Huntington, is that the crisis has had a silver lining for Appalachia. It has led to the thawing of some signature emotional frigidity. It was impossible to maintain stigma on such a scale.

Sex workers did not dress the part in Huntington – they were identified by their location, especially those church steps, where they were not shooed away. A local television news service, which Terry maligned for its sensationalism, illustrated its reporting on sex workers with a red stiletto, and she scoffed at the thought. ‘I mean, can you imagine,’ she said. ‘No one in Huntington is wearing red stilettos.’ It was as fictive as the BMW.

We went for a drive around Huntington. We saw the women who glanced up at the sound of a car. We saw Marcum Terrace: looking insoluble, overhung by some skeletal trees. A gas station where someone had been shot. The Springhill cemetery, hilly and full of running animals in the late afternoon. We did not gawk at the headstones seeking overdoses. Instead we went to see the memorial for the Marshall crash. An austere monolith with tributary offerings: fan paraphernalia, Mardi Gras beads, a football so old and dusty it looked made from stone as well.

The Marshall crash was perhaps the most poetic cause I heard proffered as the root of Huntington’s opioid crisis. In 1970 the local college suffered what Wikipedia calls ‘the worst sports-related air tragedy in U.S. history’. The football team’s plane clipped a mountain forest on a hazy November day, and all the players were lost. Coaching staff and a team doctor, too. Houses dyed their sheets black and hung them out the windows. The first choice Marshall team, the Herd, had to be reconstituted from shocked freshmen. Some had never played before. They lost.

The people who told me this origin theory, predicated on ‘heartbreak’, seemed to half believe it, as though they realized at some point during the telling that they were really discovering the limits of their own memories. The Marshall crash had not created Appalachian melancholia; it was just the first true piece of it that they could recall. Before then, the penury and isolation were entrenched enough for America to mistake them for something pure.

Travel writers visited like it was a foreign land, and in the nineteenth century, expeditions from missionaries and musicologists tried to divine the traces of a some white Shangri-La.

I was told of petroglyphs at a place called Indian Caves, written in some ancient relative of Gaelic, left by ‘Irish missionaries who arrived centuries before Leif Erikson’. It was a fake, a telling one: the hoaxer imagined the earliest kernels of colonization among West Virginia’s Caucasian ‘primitives’.

Not all the atavism was fabricated. There was still a primeval sense of suspicion in Huntington, and there were local behaviors and customs that Terry would recount, smiling and rolling her eyes. She detested Trump, and she thought the prospect of the coal mining industry returning to Huntington was farcical. There was a kind of magical thinking to this notion. A cohort really believed it, so much so that coal miners often refused to retrain for other occupations. If things were done the old way, then the old ways would return. It was a strain of Luddism that was exasperating until you realized it was correct. The ‘new’ jobs would not be the same calibre of the old, unionized mine jobs. Pretending they would be – that was the real pretending. The whole culture of West Virginia is set up to valorize this labor. The service industries were there to serve the mines. Mining was not just prized – it was prized by demeaning other jobs, jobs done by workers with soft hands. There are many families with three generations of coal miners; few will have a fourth. West Virginians have loved the things that kill them for a long time, and it is a love that can be respected as a form of resistance and commitment. Coding cannot provide this fatal romance.

One tentative suggestion, frequently made in Huntington, is that the crisis has had a silver lining for Appalachia. It has led to the thawing of some signature emotional frigidity. It was impossible to maintain stigma on such a scale. Eventually there were too many social lepers to shun (though there were hold-outs who tried). Addiction has finally created a real sense of community, and the beginnings of a proper public health response. And then following the silver lining was another cloud: the drug war is becoming more therapeutic and less punitive as the victims change from urban blacks to rural whites.

***

I went to church before leaving. Each week, Pastor Little went to an interdenominational prayer meeting, partly addressed to the opioid crisis, and he invited me along. But he had morning car trouble, and a few other pastors cancelled, and by the time I reached the brick veneer temple (everything in Huntington seemed to be brick veneer, even the strip clubs) and descended to the crypt – past a stack of evangelical magazines, their covers complaining about ‘progressive perniciousness’ in the classroom – there was just me and two pastors, Pastor M. and Pastor B., and the meeting was cancelled.

We stayed to talk anyway, sitting at folding tables eating muesli bars and drinking coffee with French vanilla creamer. Pastor M. was a Nazarene, and a former wrestler who let you know this with his handshake. He had grown up in Kentucky, and when he went to school in California, the other pupils asked if he was used to wearing shoes. Pastor B. was from the Church of God. There are about eighty different organizations called the Church of God around the world, and once, he had been invited overseas by a different Church of God, and after arriving realized it was a cult, and they realized they couldn’t have him preach, and everyone was stuck trying to be polite.

There was usually a ‘no theology’ rule at the interdenominational meeting, to prevent arguments, so I joked that we could talk theology if they wanted, seeing as the meeting was cancelled. We spoke about the concept of total depravity. This is the idea, central to the harder forms of Calvinism, that since the Fall humanity’s sin is absolute, and no individual can be redeemed by their actions. Humanity is so iniquitous it is pointless for us even to attempt to avoid sin, and the most extreme forms of this idea suggest we are unable even to accept God’s grace. Worship is cowering; God’s will and fate are indivisible. Individual will is near-meaningless, and the world can only stew in corruption until its apocalypse.

Set against this are the Wesleyan ideas that underpin Methodism. Heaven is distant (it seems almost an afterthought sometimes to this school), and man’s duty is to make the earth as Godly as it can be. This is achieved through a series of steps, and I realized, rather sluggishly, that the step-based treatment programs I had encountered shared a common source in these ideas, much like Alcoholics Anonymous.

There are denominations within recovery that mimick these theologies as well. Pastor Little told me that some of the pastors (I was not sure if Pastors M. and B. were among them) believed that God could cure addiction by prayer alone, and there were jonesing supplicants at the altar every week. Medically assisted recovery was frowned upon by some who insisted on staying ‘clean’, and even among the medicated there were differences: some medically assisted recovery groups rejected methadone, while others endorsed its use. Recovery, addiction and religion seemed to swirl together. It was a pious place, where the treatment centers are often run out of churches.

Appalachian Christianity was splintered and strange. It had once been considered almost heretical, and Pastor B., who was not from here, had taken some time to understand it. Parishioners were very particular – they complained when he wore jeans – and changes to the service or the sanctuary were almost seen as blasphemous. ‘Someone might have put money in to help build that sanctuary fifty years ago,’ he said, ‘and they feel like they own it.’ There were still small churches in the hollers where the congregation would handle venomous snakes or drink poisoned Kool-Aid. There were feuding churches, sometimes even of the same denomination. He had heard a story, years ago, of a visitor to a small town who had sought out a Baptist church on a Sunday, and found two, almost identical, on either side of a road. The alderman greeted him: ‘Are you a Democrat or a Republican?’ When the man replied that he was a Republican, the alderman pointed across the street and said ‘over there’.

‘There is a saying that in West Virginia, everything is political but the politics,’ Pastor B. concluded.

Pastor M. told me about an early Pentecostal missionary, a barely tolerated presence in some mining camp full of hard men. They ignored him, and let him know he was ignored, until one day the whole camp arrived en masse to his tent, bending the brims of their hats in their hands, asking to join his ‘congregation’.

‘May I ask,’ said the missionary, ‘what made you change your minds?’

‘Well,’ said their leader, ‘we have been poisoning the water in your well, and as you are unaffected, we figure you must have something to teach us.’

* * *

Richard Cooke is The Monthly’s US correspondent and contributing editor. His work appears in The New York Times, The Best of Longform, Best Australian Essays, The Saturday Paper, The Guardian and Australian Foreign Affairs. He is the current Mumbrella Publish Columnist of the Year, and was a finalist in the 2018 Walkley–Pascall Prize for Arts Criticism.

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