Part Seven: Modern Appalachia

Drive through McDowell County, West Virginia, today and you will pass through towns that are not quite towns anymore. Welch, the county seat, once had department stores, movie theaters, a population of nearly a hundred thousand in the surrounding county. Now the population is under nineteen thousand and falling. Storefronts are boarded. The hospital closed. The high school graduated a class so small that everyone knew everyone. The coal that built this place is still in the ground, but the market that made it valuable has moved on, and the companies that extracted the wealth left nothing behind to replace it.

McDowell County is not all of modern Appalachia. That is the first and most important thing to understand about this part of the book. The same region that contains McDowell County also contains Asheville, North Carolina, where housing prices have been driven beyond the reach of longtime residents by an influx of remote workers and tourists. It contains Blacksburg, Virginia, where Virginia Tech anchors a growing technology corridor. It contains the Qualla Boundary, where the Eastern Band of Cherokee Indians operates a sovereign nation within the mountains. Modern Appalachia is not a single story of decline. It is a region of sharp contrasts, where collapse and reinvention are happening simultaneously, often within a few hours' drive of each other.

Part Seven covers the last four decades — from the 1980s to the present — and it is the part of the book where every thread from every previous chapter converges on the world you can see right now, outside your window, if you happen to be reading this in the mountains.

Coal's collapse comes first, because it is the defining economic event of modern Appalachia. The decline is not primarily the result of regulation, despite the "War on Coal" political framing. It is the result of market forces: natural gas made cheap by hydraulic fracturing, the falling cost of renewable energy, and the automation that eliminated jobs even when production held steady. The coalfields have lost hundreds of thousands of jobs over half a century. What replaces them is the question that hangs over every hollow and every county commission meeting in central Appalachia.

Then the opioid crisis — the catastrophe within the catastrophe. Appalachia was ground zero for the epidemic, and that was not an accident. A region with high rates of manual-labor injuries, collapsing economic opportunity, inadequate healthcare infrastructure, and a long history of pharmaceutical companies treating rural communities as markets to be exploited was precisely the kind of place where OxyContin would take root and metastasize. The crisis has killed tens of thousands, broken families, overwhelmed county budgets, and become yet another way the rest of the country looks at Appalachia and sees pathology instead of policy failure.

Politics. The region's shift from solidly Democratic to solidly Republican is one of the most dramatic political realignments in modern American history. Understanding it requires understanding everything that came before — the collapse of the union household, the culture wars, racial politics, economic abandonment by both parties, and the deep suspicion of distant authority that has been a feature of mountain life since the Whiskey Rebellion. It also requires reckoning with Hillbilly Elegy and its critics, because J.D. Vance's memoir became the lens through which much of America tried to understand Appalachian politics, and many Appalachians found that lens badly distorted.

Stereotypes and media. The new economy — tourism, immigration, remote work, and the gentrification that follows. The energy transition and whether the people whose land was sacrificed for a century of cheap energy will have any say in what comes next. And healthcare — from company doctors to rural hospital closures, from black lung to the deaths of despair, the long arc of a region where getting sick has always been more dangerous than it should be.

Seven chapters. None of them offers a simple story, because modern Appalachia is not simple. It is a place where people are fighting, creating, leaving, staying, returning, and reimagining what their communities can be — all at once, all under conditions they did not choose.

Chapters in Part Seven

  • Chapter 32: The Coal Economy's Collapse — Natural gas, renewables, automation, and the end of coal's dominance. Job losses, community devastation, the "War on Coal" framing, and the inadequacy of just transition proposals.

  • Chapter 33: The Opioid Crisis — From Purdue Pharma's marketing to the fentanyl wave. Why Appalachia was specifically vulnerable. Criminalization versus treatment. Harm reduction and the slow work of recovery.

  • Chapter 34: Appalachia and American Politics — From Yellow Dog Democrats to Trump country. Political realignment, cultural conservatism, economic populism, Hillbilly Elegy and its critics, and what Appalachian voting patterns reveal about America.

  • Chapter 35: Stereotypes, Media, and the Battle Over Appalachian Identity — Li'l Abner to Deliverance to Hillbilly Elegy. Poverty porn, ruin porn, the "pity industrial complex." How Appalachians are reclaiming their own narrative.

  • Chapter 36: The New Appalachia — Latino immigration, COVID-era remote work migration, tourism economies, gentrification, housing crises. Who benefits from reinvention and who gets left behind.

  • Chapter 37: Energy Transition — Coal-to-solar on reclaimed mine land. Wind energy. The Mountain Valley Pipeline. The justice question: the people whose land was sacrificed deserve a seat at the table.

  • Chapter 38: Health, Despair, and Resilience — Company doctors to rural hospital closures. Deaths of despair. The Frontier Nursing Service. Mental health, dental health, maternal mortality. Community-based care and the free clinic movement.

Chapters in This Part