The young woman sat on a city bench in Athens, Ohio, smoking a Marlboro. She told me her name is Keri, she's 29, and she has a 10-year-old daughter and a history of drug addiction and mood disorders. She'd just been to a court hearing to get custody of her child. Bad as things are for her, they used to be worse, she said.
"I'd want 10 Percocets to get through the day," she said. At first she could buy a 5-milligram pill for just US$5 on the street, but the price rose to US$7 and she soon switched to heroin, which cost only about a third as much.
But she managed to overcome the addiction and now wanted to put her life back together and be with her child again.
"I feel optimistic," she said. "And that's a feeling I'm not really familiar with."
This brief interview came during a road trip in June that ultimately led to a story published online Thursday by The Post about another community: Chillicothe, Ohio, about an hour's drive west of Athens, via U.S. Route 50.
The Post this year published a series of stories in a project called Unnatural Causes: Sick and Dying in Small-Town America. It focused largely on the opioid epidemic and the rise in the death rate among midlife white Americans. I worked on a broad overview of the trend for a story that ran in April. After sorting through lots of data, I wanted to hit the road and talk to people trying to survive this epidemic of self-destruction.
This was a challenging story to report and write, because it's a national phenomenon without a single, simple explanation. A study by Princeton economists Anne Case and Angus Deaton published in late 2015 brought national attention to the spike in the white death rate. Our data analysis showed that this was driven largely by increased mortality in white women, and we also found a geographical gradient: The death rates had jumped most significantly outside big cities.
I decided to drive west from Washington on Route 50, a historic road once labelled "the Backbone of America" by Time magazine. It goes more or less straight across the country's mid-section from Ocean City, Md., to Sacramento.
In D.C. it's known as New York Avenue in one stretch. West of the Washington suburbs, beyond Winchester, Va., it finds its true self as an antiquated cross-country road that links towns so small they never quite rated a stoplight. The drive across the Alleghenies is particularly serpentine; this is hardly an interstate highway.
The lack of demographic diversity along Route 50 is striking. Many counties are more than 95 percent white - and experiencing rising death rates. For example, in Athens County, home to Ohio University, the death rate for white women ages 35 to 54 rose 24 percent in the first decade and a half of this century, according to The Post's analysis of CDC records. To the southeast, about an hour away on Route 50, Parkersburg, W.Va., sits on the bank of the Ohio River in Wood County, where the death rate for that same group of white women has spiked 51 per cent.
The citizens of these communities are often falling victim to drugs, drink and suicide - the so-called diseases of despair. These diseases do not adhere to any obvious boundaries - they're not limited by race, gender, geography, income or education. But they've found a great deal of traction in places facing economic decline and social stagnation. That describes much of rural and small-town America and certainly the industrial areas of the so-called Rust Belt.
A century ago most Americans worked on farms. Those jobs largely vanished because of mechanisation and corporate agriculture. Then, as globalisation took hold, factory jobs grew scarcer in small cities as well. The U.S. economy began to concentrate wealth in big cities and along the coasts. Unions lost power and unskilled labour jobs saw little or no wage growth.
Now add to this the prescription painkillers heavily marketed since the 1990s. There arose a pill economy, with pills as good as cash. The opioid epidemic exploded in places that are far away, physically and culturally, from the neighbourhoods where lawmakers and media figures typically live. Tom Vilsack, the secretary of the Department of Agriculture, toldThe Post that he considered quitting his job because he felt Washington had forgotten about rural America.
Along the road, I talked to judges, police officers, truant officers, addiction recovery counsellors, addicts, and ordinary people coming and going. There was a common theme: This isn't the place it used to be.
When passing through Parkersburg, I interviewed Judge Darren Tallman, who runs a juvenile "drug court." He told me he sees a culture in decay, with long-established values under assault. He described a typical encounter with a teenager:
"What's your life plan?" Tallman will ask.
"I'm going to go for disability," the kid will say.
"What's your disability?"
"I get nervous. I have a drug problem."
Tallman said he has a lot of "empty chair cases," where there's a child, the child's grandparents and an empty chair where an actual parent ought to be. Typically the father is long gone and the mother is a drug addict.
"What I see is the breakdown of the family," Tallman said. "The family structure is not as strong as it used to be."
Eventually I reached Chillicothe, where, at a yard sale on Main Street, a resident told me that a serial killer was on the loose and that young women were disappearing. She had a teenager daughter and was concerned about her safety. But the police and other civic leaders told me otherwise: The only serial killer was heroin, they believe. I made three more trips to Chillicothe in the coming months.
Addicts told me how demented they get when they're using - how they'll steal from their grandparents or rifle through the pants of a friend who has just overdosed. When they hear that people are overdosing they think: that must be good stuff. That's what we want.
Brandy Morris, 38, is a former heroin addict now working as a counsellor. She started dealing marijuana when still a teenager, long before heroin was common, she told me. She's been sober for eight years, and the secret, she says, is being honest about the drug and its seductive powers.
"I love heroin," she said in Schlegel's coffee shop in downtown Chillicothe. "Sitting here today, I can admit - I love heroin."
Teri Minney, head of the Ross County heroin partnership project, said something similar: "That euphoric feeling - it's the best they've ever felt in their life. It's the best they've ever felt about themselves. They're invincible all of a sudden. Their problems are gone. The problem with heroin is that it owns you in such a short time. It's a drug that takes over your mind."
No wonder the county coroner talks about the Zombie Apocalypse.
The stories this year focused on issues of public health and cultural decline. But there was a political story happening simultaneously. In early March we reported a correlation between support for Donald Trump and rising death rates.
Then, after the election, an analysis by the Economist magazine found that the most compelling predictor of any U.S. county's partisan shift between 2012 and 2016 was not race, income or education levels but health. The most dramatic changes in voting patterns happened in counties with low life expectancy and high rates of diabetes, obesity and heavy drinking.
Correlation isn't causation. That's a basic rule when writing about health and science. What's clear is that places like southern Ohio were fertile ground for an inflammatory candidate vowing, however vaguely or implausibly, to turn back the clock and restore life to the way it used to be. And as noted in this space last week, these citizens now face a future that includes the elimination of health care reforms that gave many of them health insurance for the first time.
This national health crisis didn't emerge simply by chance, accident, or bad luck. This is the society we have made. And there is no magic cure. The best way to stop addiction is to keep people from getting on that train to begin with. The battle to save lives will have to be waged one person at a time and one day at a time.
One thing that always struck me: Chillicothe is a pretty place. From Grandview Cemetery, west of town, you can the city, the steeples and towers, the smokestack of the paper mill and the forested hills that frame the Scioto River Valley. The mayor, Luke Feeney, told me that someday this could be a destination for mountain bikers. Certainly from the cemetery, in the right light, it looks like a pleasant place to live.