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Slavalachia: The New Music Tradition Uniting Across An Ocean, A Pandemic And A Revolution

This article was originally published by 100 Days in Appalachia, an independent, non-profit digital news publication incubated at the Media Innovation Center at the West Virginia University Reed College of Media. Sign up for their weekly newsletter here.

Belarusian musician and activist Siarhei Douhushau was in Chicago in March of 2019 on a U.S. tour presenting folk art and music from his eastern European home. Nadzeya Ilkevich, then a second-year graduate student at Ohio University, caught wind and lured her friend and fellow countryman to Athens, Ohio – an Appalachian foothill college town of about 40,000 – to perform traditional Belarusian songs using flutes and a hurdy gurdy, which is a hand-cranked hybrid of a violin and small piano.

Brett Hill was at Jackie O’s – a popular “uptown” brewpub – that night. Hill is the frontman for Hill Spirits, a modern Appalachian folk quartet based in southern Ohio.

“We asked Siarhei if he wanted to jam the next night,” Hill said. “Fortunately enough, he did want to…The evening was spent feasting, drinking, singing, shouting and growing to learn of each other’s traditions for the first time.”

Among the Madness, Someone Yelled, “Slavalachia!”

That evening, the namesake was born as both an Appalachian-Slavic folk ensemble and a cross-cultural folk alliance.

“As a cultural manager, this is the kind of collaboration I would like to see continue,” Ilkevich says.

She immediately grew the project, adding Maria Chichkova, of Torban Folk Band, from Lviv, Ukraine, to the Slavalachia lineup. Torban is a traditional ensemble that creates new arrangements around traditional Ukrainian acapella songs. “This is our traditional song transformed for a modern listener.”

Ben Stewart is a member of Brett Hill’s band Hill Spirits and traveled to eastern Europe in early 2020 for the Slavalachian music exchange.

According to Chichkova, traditional music in Ukraine is alive and well. But in Belarus, the health of traditional music, along with Belarusian culture, has long been tyrannized by centuries of Russian encroachment. Ilkevich says most families speak Russian as the primary language. The 2009 Census says about 70 percent of the population speak Russian at home.

“During Soviet times, and before Soviet times, the Russian government – and I’m not accusing the people – [was] trying to absorb…the Belarusian language and culture, and replace it with theirs,” Ilkevich says.

People grew disconnected from their traditional and folk music as these customs were increasingly portrayed through a Soviet lens, Ilkevich says.

Ilkevich says the situation in Belarus has only deteriorated during dictator Alexander Lukashenko’s 26-year reign. He is partial to the Soviet influence, she explains. “He changed the flag and symbol of the country. He tried to remove [the] Belarusian language from [schools].”

But in 2020, the political tension hit a climax when Lukashenko proclaimed himself the winner of what opposition leaders called a fraudulent election. Citizens poured into the streets in August last year for weeks of demonstrations, and neither the United States nor the European Union recognizes Lukashenko as the legitimate leader.

But Ilkevich says the uprising amidst a pandemic has stoked a fire of curiosity about Belarusian folk traditions among the people.

“Thanks to the revolution, we have a [real] boom of traditional culture,” she explains. “People started speaking [our] traditional language. They started being interested in their roots, to value the land they are from. Not just the culture, but even the land is endangered.”

In this file photo taken on Sunday, Aug. 23, 2020, a woman waves an old Belarusian national flag standing on the roof as Belarusian opposition supporters march to Independence Square in Minsk, Belarus. Protests broke out Aug. 9 after an election that official results said gave Lukashenko a sixth term in office, but that opposition figures and some poll workers said were manipulated. The nationwide demonstrations, some of which attracted up to 200,000 people, were the largest and most sustained challenge to Lukashenko in his 26 years of repressive rule.

Douhushau has been at the cultural front lines of the revolution. He says the COVID-19 pandemic is back-seat fodder compared to the revolution in his home country. “The pandemic became a good excuse for the current government to manipulate.”

Douhushau sarcastically says the borders are closed in Belarus because of COVID, but the government is allowing concerts to continue.

Douhushau explains the uprising in Belarus initially started with people rallying around a foreign song and a generic flag of white stripes, but has shifted toward the traditional songs and the historic flag of the country – symbols and songs of a country before Russian influence.

“We find our identity in a traditional culture. Everything is in there: our songs, our language, our genetic code,” Douhushau says. “Traditional song accompanies all the people’s protests and uprisings – the most powerful, the most emotional and the most influential.”

From Slavic Traditions to Appalachia – A World Away

Two months before the world locked down and seven months before the Belarusian revolution began, Appalachian musician Brett Hill and his Hill Spirits bandmate Benjamin Stewart flew to eastern Europe. The January 2020 trip was the first full meeting of Ilkevich’s Slavalachia brainchild.

Ilkevich, Chichkova, Douhushau, Hill and Stewart met in the airport in Lviv, Ukraine, where Chichkova held a white markerboard with Slavalachia inscribed on it.

“We were trying to film, but the guards wouldn’t let us,” Ilkevich remembers. “Siarhei started playing flutes, and the guards kicked us out.”

Left to right, Marichka Chichkova, Brett Hill, Siarhei Douhushau and Benjamin Stewart – the full Slavalachia lineup – first met in the Lviv, Ukraine, airport January 16, 2020.

It was during this trip, Hill says, he started to understand how both Slavic traditional music and Appalachian traditional music were so closely tied to one another. They are less about sonics and more about connections to their respective cultures-at-large.

Over the following weeks, members of Slavalachia deepened their connections with one another and each other’s respective folk traditions. They traveled around eastern Europe, practiced in small villages near the Białowieża Forest of Belarus, deep in the Carpathian Mountains of Ukraine, and ultimately played their first live concert (remember those?) at Lviv’s Dzyga, a major cultural center.

Douhushau opened. Hill and Stewart played next and even taught a Georgian men’s vocal choir a moonshiner song.

“They just loved that stuff….It just lit the room on fire. Absolutely lit it on fire,” Hill says.

The Ukrainians went third, and the full supergroup – all three acts – played out their inaugural set as the closer to the first official Slavalachia showcase.

Ilkevich, the manager and producer of the project, was thrilled.

“They were jamming. Some other musicians came to the stage. The concert was one hour longer than we were supposed to have. It was big!”

Hill witnessed the health of Ukrainian traditional music as a major component of Ukrainian culture, but in Belarus, he saw the polar opposite. Instead of being celebrated, in early 2020, traditional Belarusian music wasn’t really known by its people.

Brett Hills is the frontman of Hill Spirits, an Appalachian folk band based in southwestern Ohio.

“Appalachian traditional music finds itself between these two in terms of their stages of cultural health,” he said. “Appalachian folk music is not going anywhere, but it has not earned respect that it might have even 100 years ago, when Bascom Lamar Lunsford was performing for the Queen of England.”

In other words, Appalachians aren’t exactly sitting around the dinner table singing traditional songs like Ukrainians might, but no dictator is trying to sweep their heritage under the rug like in Belarus either.

“I still get messages from Ukrainians…asking when we’re going to come back and perform more of that music,” Hill says. “[The result has been] my musical project, Brother Hill, being about three times as listened to in Russia, Ukraine, Belarus and eastern Europe than in the U.S.”

“That solidifies it, too. The foreigners dig this Appalachian music a little more than the Americans do!”

Before Slavalachia, Douhushau says he knew nothing of Appalachian music.

“If I was searching this on the internet, I would never be interested in it. When I met [Appalachian musicians] personally, it opened this music for myself. I started to understand it and feel it. We started to improvise with that music and that opened my soul towards it. “

Chichkova echoes that she had zero previous knowledge of Appalachian music, but she says there is familiarity with her Ukrainian traditions. She hears it as music of the mountains, of nature, and “…about people and relationships. We are very connected to each other. And now our music is connected…The spirit is the same…All traditional music speaks one language.”

Before the Americans Returned to Ohio, Slavalachia Began Carving its Next Cross-cultural Exchange

But then Ilkevich says, “COVID f*@!ed everything up – beautifully!”

Plans were in the works for the next collaboration in the U.S. when the virus essentially shut the world down. Athens, Ohio, Mayor Steve Patterson invited Torban to showcase Ukrainian music in venues throughout the college town where Douhushau had played the year prior. She says the City of Lviv was ready to sponsor the trip to promote Ukrainian culture abroad. The Americans started scheming their return to Ukraine to record an album with Douhushau as the full Slavalachia outfit.

Brett Hill says his work on the Slavalachia collaboration has taught him about the similarities of Slavic and Appalachian music traditions.

Even with COVID, the project has not been fully put on hold.

During 2020, the musicians had what Hill calls a light-medium success recording remotely in response to Lukashenko’s controversial re-election in Belarus. Musicians half a world away used digital platforms to continue communicating and practicing, even recording tracks that were sent back-and-forth – tracks that were a direct response to the political uprising in eastern Europe, a resistance piece.

“We utilized a song that I have been singing since I was a little boy, called ‘Which Side Are You On?’” Hill says, a song widely known for its use during various protest movements throughout history, especially in Appalachia. “My father was a union man, his father before him was a union man, workers carpenters, elevator operators…This song is a song that reins true in hills of Appalachia or streets of Belarus.”

Filmmakers in Ohio, Belarus and Ukraine gathered footage, and a music video for the song was cut and released in support of the uprising. The video, like the song, was cut and assembled from three remote locations. It’s been viewed nearly 9,000 times.

Despite kicking out one track, the musicians are much more eager to play together in person rather than in a virtual space. They have recently put the videoconference practice on hold.

“Unfortunately, a monitor does not give energy,” Chichkova says. “I like to feel live bodies…I think it’s normal because it’s an energy.”

Ultimately, the hybrid of styles among these differing folk traditions presents an opportunity for tangible collaboration and ongoing camaraderie, Hill says of Slavalachia.

Ben Stewart. along with bandmate Brett Hill, played traditional Appalachian folk music in early 2020 for audiences in Ukraine and Belarus, before the COVID-19 pandemic essentially closed down in-person cultural exchanges around the world.

“The point of Slavalachia is to band together, make super dope music that has never been – as far as we can tell – made before by the fusion of these three traditions, and also help support each other’s not only musical projects…but support each other’s folk traditions.”

Hill says he hopes to travel to Ukraine to perform once coronavirus restrictions begin to loosen up – and when Douhushau can find time to travel during the Belarusian revolution.

For now, Ilkevich is awaiting a transfer from Lviv to Prague, where she will continue to work in cultural promotion in the Czech Republic. One of the many productions on her post-COVID to-do list is Slavalachia. She wants to keep filming and compile the footage into a documentary – her husband is a documentary filmmaker.

“I’m keeping everybody together and watering Slavalachia-land for them to grow.”

Chad J. Reich is a freelance journalist, multimedia producer and MFA candidate at the Scripps College of Communication at Ohio University. His MFA documentary “A Monolithic Folly: Fracking Colorado’s North Fork Valley,” was named a Finalist in the Student World Awards. In June 2021, Chad will join Western Colorado University as the official photographer and videographer.

Editor’s Note: Two characters in this story speak English as a secondary language, and one speaks only Belarusian. Quotes have been edited for clarity but retain accuracy and authenticity.

Your Pandemic-Era Sourdough Starters And Victory Gardens Never Went Away In Appalachia

The title of the article was “The Quarantine Garden Has Taken Off: Seeds are the New Sourdough.” I stumbled on to it two days after my stepdad went to Home Depot and found out that they were out of pitchforks, and a week after the owner of the permaculture company we’d used for our yard lamented having trouble finding the lumber and soil she needed to install raised gardening beds. The local garden shop, too, I discovered, was under threat of running out of seed packets.

In the Quarantine Garden piece for New York, journalist Chris Crowley noted that people making a run on seeds and soil during the COVID-19 pandemic were doing so for a number of reasons, including “wanting to nurture something during a time of isolation, or to simply fill the void presented by a sudden surplus of time.” Others, he said, were doing a kind of panic gardening, concerned about their ability to access food at a time when grocery store shelves were eerily bare.

Folks that aren’t trying to grow tomatoes and peppers for the first time are learning to make sourdough bread, as the article’s title referenced. They’re making “garbage stock” out of leftover produce scraps. They’re trying their hand at canning vegetables. They’re learning about wild foods growing around their own yards, growing culinary and medicinal herbs on their window sills, making, out of necessity, nearly all meals from what’s already at home. These are practices that our parents and grandparents were intimately familiar with, but that technology and the unrelenting pace of modernity have rendered nearly obsolete.

What is it then about a global-scale pandemic that’s waking up in people that kind of nostalgia for more simple living? That’s stirring a latent, but deep, desire to return to the old ways, especially in terms of food?

TJ Smith, director of the Foxfire Museum in Mountain City, Georgia, and editor of the latest edition of the Foxfire Book of Appalachian Cookery, thinks a lot of it boils down to comfort.

“I think anytime, in any crisis, there is a very human desire to comfort oneself,” he says. “We talk about comfort food and what that means — there is a comfort in going back to those old cookbooks, cooking meals at home, making meals more of a family gathering than an afterthought.”

Indeed, as orders to shelter in place began spreading across the country, so too did a deeper sense of slowing down and turning inward. As businesses, workplaces and restaurants all began to close, inside our homes, it seemed like space was opening up. Time spread out, and we began filling it with things like planting seeds and baking bread, making home cooked meals from comforting old recipe books eaten as a family around the kitchen table.

For Smith and his family, that meal has been soup beans.

TJ Smith cooks Thanksgiving dinner in this photo taken by his wife Elaina.

“It’s something that both my wife, Elaina, and I grew up with in our homes,” he says. “When the store shelves started being cleared by worried folks, Elaina and I managed to find a large bag of dried beans in our search for shelf-safe foods. We had some leftover Christmas ham in the freezer, and we cooked up a great big cast-iron pot of soup beans. Elaina made cornbread and we ate on that for a few days. It was delicious and comforting. We both remarked how much we wished we could take some over to our folks, that they would really appreciate it.”

While many people in the U.S. were experiencing a kind of quarantine-induced nostalgia for these old traditions, some across the Appalachian region were simply shrugging their shoulders, looking out and seeing their fellow Americans perhaps discovering for the first time practices and folkways that they’d never abandoned.

“When we talk about people going back to traditions, that’s because as we’ve become more modernized, we’ve moved away,” says Ronni Lundy, a Corbin, Kentucky-native and Appalachian food writer. “But we’ve never really given this stuff up in Appalachia.”

Lundy’s comfort food of choice during this time has been speckled butter beans.

“The way my mom made them,” she says. “They cook up to a beautiful, soothing creaminess…my mother cooked them to that state in just enough water to keep them from going dry. Then she added a chunk of butter and a splash of half and half to make a sauce, and salt to taste, just heating that gently until it was ready to serve. She served them with cornbread, of course.”

“I find them fresh in the summer, but in certain parts of the mountains and the South, they are available frozen, and I usually have two packages in the freezer. When I’m feeling blue or run down, I make them and they seem to both comfort and strengthen me. It was one of the first dishes I made in the early stage of quarantine.”

When Lundy was a girl, she’d sit on her aunt’s front porch and shuck the beans they grew.

“They taught me how to break the end and pull the string down and break the other end and pull the string back on the bean,” Lundy says. “I would watch them thread it up on a needle and thread, and they would hang that in a dry place in the house…We developed these things, like drying beans for shuck beans, or drying our apples so that we could through the winter make apple stack cakes and fried apple pies. We’d have dried beans on hand, cure every part of the hog.”

Ronni Lundi with her mother and father taken outside of her Great Aunt Bert’s store in Corbin, Kentucky.

Growing your own food and making it last through the seasons, wasting nothing, using what you have on hand to feed your family — this is a kind of generational knowledge instilled in families all across Appalachia. It’s a way of living — one based on resilience and resourcefulness — that hasn’t been lost, and that’s also been a deep source of consolation and security during this global health crisis.

“When we’re talking about comfort food — when you eat it, it makes you feel kind of petted,” says Lundy. “But there’s also another kind of comfort that we’re seeking right now, which is the comfort of being reassured that we know how to survive. And how to survive well.”

Smith agrees. The Foxfire Book of Appalachian Cookery is full of passed-down information about how to do the utmost with what you’ve already got in your pantry or garden — a more newly-adopted tenet for some in our current pandemic times.

“The recipes that come out of the cookbook are very much rooted in creating meals out of what’s at hand,” he says. “Like, open your cupboard, see what ya got, let’s figure out something to do with it.

It’s a ‘make do and mend’ mentality that so many people are rediscovering right now, at a time when scarcity anxiety is high, that Appalachians and many other marginalized cultures have been doing for centuries. No-waste eating, preserving food, for example — these weren’t just the chic culinary trends that we’re seeing in mainstream media and on Instagram today.

“You had all of these wonderful vegetables and fruits that are associated with the South, but you were not going to make it through an Appalachian winter unless you figured out how to dry and preserve them,” says Lundy. “Well before the invention of Ball jars and modern canning methods, we dried and we pickled and we built cellars to store potatoes. We were doing all of these things as a matter of survival.”

“I lived in Southwest Louisiana for a number of years,” Smith recalls. “Those cultures that are like Appalachia, the Cajun culture, Creole culture, we see that these people and their foodways are really based in stretching a dollar in the most real way possible. And zero-waste eating — we talk about slow food and zero-waste eating? They were OG.”

That’s worth noting, too, that many of the traditions we’re being called back to, when so many are losing their jobs, when some kids don’t know where their next meal is coming from — the practices that are being romanticized right now — are actually based in an all-too-familiar reality that people that come from lower economic backgrounds have been living in since long before the arrival of COVID-19.

“You have groups of people who this is their reality all the time or this was their childhood because their parents were lower on the socioeconomic scale or were poor and did struggle and did have to be creative with things,” Smith says.

“In my mind, that class really becomes our teachers in how to get by through this period when you don’t have everything you need, or when there’s a possibility of scarcity. There’s a whole socioeconomic group in the country that’s often been ignored but who does have knowledge about how to survive. And I’m hoping that those people’s voices are elevated and raised and that we get to hear more from that population, because they’re the ones that know.”

Samantha Foxx, a North Carolina beekeeper and owner of Mother’s Finest Urban Farm in Winston-Salem, came from a family where nothing was wasted when it came to making meals. It’s a lesson she’s been deeply grateful for in these uncertain times.

“It’s a big part of our culture, making something out of nothing,” Foxx says. “The majority of the time when I was young, my grandmother raised me and that’s how she operated. If she was cooking turkey, she would take the necks and make the gravy. Everything was transformed into something. And I’m really grateful I had those types of experiences growing up because it’s molded me into being such a [resilient] adult — having a sense of working for myself and producing something out of nothing to survive.”

Samatha Foxx uses beekeeping not just to provide, but to also connect with her family, pictured here with her son.

Foxx moved from Chicago back to her home state with plans to become a cosmetologist. She fell in love with farming and beekeeping instead and with the slower pace and more simple living farming can provide. She started Mother’s Finest Urban Farm with that commitment to simple living in mind.

“You kind of just get away from things that are already inside you,” she says, crediting the farm with bringing her back.

Foxx grows elderberries, Jamaican Scotch Bonnet peppers, Trinidad Scorpion peppers and other produce. She sells eggs from the chickens she raises, sells honey from her own hives. She makes elderberry syrup, and Fire Tonic from her peppers, and sells all her goods at farmer’s markets in her community.

She’s noticed a huge uptick in demand for her products as a result of the pandemic. She’s also noticed many folks around her embracing slow living and the old ways to combat the anxiety that this situation has brought. Neighbors and community members are coming to her asking how to start their own gardens, grow their own food, use what’s growing around them to make meals.

“Now, I think people are more aware of what’s going on around them as a whole. They’re like, ‘Wow, I had no idea all of these things in nature were around me.’ We were so hurried, rushed and busy that [we] didn’t even really pay attention to it.”

Maybe that’s the deeper lesson then that this pandemic can illuminate for us as lockdowns lifts and life slowly begins to open again. Maybe it’s called us back to something deeper within ourselves and our communities, shifting our priorities for good.

“I think that’s where everything is going to lead back to,” says Foxx. “Going back to those things that we initially started at, to a more simple type of life for some people. I think some of that simplicity will come back.”

Lundy sees this pandemic as an opportunity to remind us how strong we are, how strong those old traditions — the meals and methods of our grandmothers — have made us, and how damaging it’s been that modernity has taken us so far away from them.

“I think for many of us, [this situation] is giving back, or deepening, our sense of self-worth and ability to survive,” she says. “The language of our culture at large is a language that gives value to power and it gives value to the money that you have or the amount of things that you can purchase. It gives value to violence. It does not give value to care, and caretaking, and nurturing and compassion.”

The pandemic, she believes, is providing an opportunity to shift that paradigm.

“I use the phrase ‘small graces and tender mercies’ a lot lately. And a lot of the things that make our life rich right now are those kind of things. They’re cooking with your kids at your house. Or having your neighbor call you on your cell phone and say, ‘I have more greens than I can deal with,’ or ‘I just picked some ramps and left them on your porch.’ I think there’s a real possibility that we will come through with a stronger sense of self, and a better sense of how to survive and thrive in a modern world without having to get back in the same cycle of trying to earn money that doesn’t buy us what we give up for it.”

That’s the hope anyway, she says.

Beth Ward is a Georgia-based writer and editor whose work has been published in/on NPR, West Virginia Public Radio, The Rumpus, The Bitter Southerner, Atlas Obscura, BUST, and elsewhere. She currently serves as the managing editor of the Dream Warriors Foundation, an organization that supports Atlanta’s womxn community through grants and community outreach, and as a volunteer nonfiction editor for the VIDA Review, the literary magazine of VIDA: Women in Literary Arts.

When ‘Crazy Pills’ And Jesus Weren’t Enough To End The Stigma, These Women Took Action

In her 1988 research paper “The Social Context of ‘Nerves’ in Eastern Kentucky,” medical anthropologist Eileen VanSchaik wrote that in the late 19th and early 20th centuries, women reporting “nerves” or “sick headaches” would turn to “doctor books” for advice on their “feminine nervous systems.” There they were cautioned, for example, of the danger of “nervous prostration, excitability, fainting spells, most likely organic diseases of the uterus or womb, and many other distressing female troubles.”

Traditionally, in Appalachia, a diagnosis of nerves can mean a number of things: anxiety, disorientation, loss of energy, chronic discouragement. In her research in Appalachian North Carolina, Lisa Curtin, director of the clinical psychologist program in Appalachian State University’s department of psychology, still occasionally hears the term “nerves” used in the region to describe an affliction that’s often treated with “nerve pills,” commonly Valium or Xanax.

Nomenclature has evolved over time, but dismissiveness of depression lingers. As a teenager in the early 2000s, Carol Lemon was told to take her “crazy pills.”

Lemon, 34, has lived in Parkersburg, West Virginia, for most of her life. The oldest of three girls, she was pressed early into the role of mother figure. “My parents always worked,” she says. “My mom had two jobs; my dad had two jobs. So I was always looking after my little sisters.”

Everything that went wrong in the family, she says, was thrust upon her – somehow, ultimately, her fault.

It was too much. She was depressed; she recognized that. But no support was forthcoming.

“A lot of times,” Lemon says, “it was, ‘Oh, you just need Jesus. You need to get back into church.’ I’d get scriptures thrown at me.” Or: “‘You know better; your grandpa’s a pastor. You just need God.’”

The first time Lemon attempted suicide was at 18, after being sexually assaulted. “Nobody believed me. The cop said, ‘Well, you’re 18. He said it was consensual. Goodbye.’”

She was withdrawn; she was cutting herself. Her family would admonish her to “Get over it; stop acting like this. Take your crazy pills.”

She acknowledged, at last, that she needed someone to talk with. She sought help. “I wanted to live. Something in me wanted to.” Lemon was fortunate that behavioral-health services were available in her community; she found help at Westbrook Health Services in Parkersburg.

Barriers to seeking behavioral-health care in largely rural regions can be formidable. Foremost is the availability and accessibility of services. More limited access to campaigns that educate people about mental illness is a factor. The “tough-it-out” mentality endemic to rural communities is another barrier.

Scrutiny also plays a role. The close watch of neighbors, Curtin suggests, can lead to “at least a perceived stigma.”

“There’s an adage in rural communities,” she says, “that if you don’t remember what you had for breakfast, ask somebody else – somebody knows what you’re doing.” Many decline to seek care out of fear of judgment.

The onset of COVID-19 presents its own set of challenges: anxieties around health, finances, sheltering and uncertainty – anxieties that, Curtin says, manifest much like depression.

But recent research has led her and her colleagues to believe that women living in rural areas are probably more open to treatment than previously believed. She stresses, though, that providers must acknowledge the barriers women have faced to seeking and benefitting from care.

‘I’m Not Allowed to Be Depressed’

The reactions Carol Lemon encountered, according to research from Cutin and medical anthropologist Susan Keefe, are rooted in how depression has been historically perceived in central Appalachian communities. Not uncommonly, women experiencing depression believed, or had someone in their life who believed, “that somehow they weren’t right with God, or that this was a sign that they needed to work through something; that prayer would ease their soul,” Curtin says.

Then there’s the stigma. The fear, for example, of your car being spotted outside a mental-health facility and henceforth being perceived as a damaged person, a burden on your family. Or the fear of being judged fundamentally inadequate, a complainer unwilling to acknowledge that “life’s hard; get over it.”

Curtin says that self-stigma, the instinct to blame oneself when in distress, tends to be more difficult to overcome than external stigma. A woman might ask herself, Curtin says, “Why am I not strong enough to get past this?”

Michaela Johnson carried such a burden.

Johnson, 30, of Parkersburg, began experiencing depression after the birth of her third child, Jameson. It was a difficult pregnancy and a particularly hard delivery. Just before Jameson was born, she experienced her first panic attack.

“I kept thinking,” Johnson says, “‘If you can’t stop yourself, they’re gonna put you to sleep. They’re not gonna let you be on this table acting crazy.… They’re not gonna let you be a nut job. You need to calm yourself down.’”

She couldn’t catch her breath; she was certain she was going to die. “That went through my head: ‘I’m gonna die and my husband’s gonna be a single dad and my kids aren’t going to have a mom.’”

Jameson spent a month in neonatal ICU, two hours away in Morgantown, West Virginia. Johnson felt guilty about being away from her other kids and that her husband had to shoulder all responsibilities back home.

“My husband has depression and anxiety,” Johnson says, “so I worried about him.” She would tell her mom, “‘He won’t be able to do this; someone needs to keep him calm.’ I had to worry about him because he doesn’t worry about himself.”

And she was overwhelmed with the sense that “my body didn’t do what it was supposed to do.”

“I cried every day,” she says. “Every day.”

Claire Snell-Rood, a medical anthropologist now on faculty at the University of California, Berkeley, began studying the context of Appalachian women experiencing depression in 2013 as a postdoctoral fellow in the University of Kentucky College of Medicine’s Department of Behavioral Science. She says that many Appalachian women she’s interviewed have told her, “I’m not allowed to be depressed. No one wants to hear about it.” Her goal was to change that.

Research shows that residents of largely rural central Appalachia are 25 percent more likely to experience mentally unhealthy days than the average American. Snell-Rood was interested in what that meant in everyday life in Appalachia and how it was addressed in a region with relatively few health-care resources.

With her colleagues, she conducted research on the prevalence of depression specifically among Appalachian women.

Women are almost twice as likely as men to be diagnosed with depression. Studies have associated the higher risk with biological differences and, Snell-Rood says, with “gender divisions of labor and the fact that women bear a lot of social burdens that are very stressful, especially in terms of caregiving.”

Some researchers, she notes, suggest that the rates are not so different between genders, that men just tend to present depression differently, through aggressive behavior, for example, with women being more likely to internalize and ruminate on their feelings, exhibiting symptoms more commonly associated with depression.

There are effective treatments for women in rural communities who struggle with depression. Johnson grew weary of berating herself; she realized she needed to talk with someone. She was diagnosed with depression and PTSD, and now sees a therapist weekly.

“At first, it was dealing with everything,” she says, “and now it’s more just like friendly banter.”

Meeting Women Where They Are

Properly treating depression in a rural community, Lisa Curtin says, requires not only services that are accessible but that are culturally acceptable, which often involves incorporating someone’s religious beliefs.

Curtin has had clients who’ve told her upfront: “I don’t care what religion you are; I just need to know that you’re accepting of me being Christian, and that it’s not going to be an issue for you.”

Some of the larger churches in her western North Carolina community offer therapy sessions with counselors who are professionally trained and identify as Christian. In interviews with them, Curtin learned that “they weren’t necessarily counseling people on their faith, but they could use tools that the client was already using, such as prayer.” Or the counselor might cite a verse from the Bible to reinforce that what they’re experiencing isn’t a failing and that they’re not spiritually remiss.

This is a cognitive intervention, Curtin says, “but you’re using the client’s language and what they’re familiar with, what’s meaningful to them.”

Another treatment option that can be particularly effective in rural communities is an integrated approach to care: offering behavioral-health services within primary-care or other medical practices. Curtin used to have a private practice in an OB-GYN office.

She says this integrated approach is becoming more prevalent, particularly in federally qualified health centers.

Much like the practitioners of treatment that builds from religious beliefs, Claire Snell-Rood set out to identify culturally appropriate avenues of expression and recovery in the region.

She chose to study a program called Wellness Recovery Action Planning, or WRAP. Women from eastern Kentucky communities met in group sessions overseen by community health workers from the University of Kentucky’s Center of Excellence in Rural Health in Hazard. The stipulation was that participants were already engaged in some manner of treatment, whether medication, counseling, or both.

The evidence-based WRAP model is designed to encourage overall wellness and self-management – to help participants develop simple, everyday coping strategies; identify early-warning signs of a mood change; and create crisis and post-crisis plans.

The overall-wellness focus was well received. The women individualized their care plans, defining which resources worked best for them.

Snell-Rood says that comfort with the word “depression” varied among participants, as did skepticism with “what it meant to accept a mental-health diagnosis or label.”

A WRAP precept is to minimize clinical terminology. The women embraced the fact that they could admit that they experience distress without “hooking themselves on to this wagon of clinical baggage, which in some ways can be really helpful,” Snell-Rood says, but can also generate un-welcomed perceptions.

“I think it’s a pride thing,” says Keisha Hudson, a community health worker and one of the facilitators of the WRAP sessions, of the reluctance of women in her community to accede to a diagnosis of depression. “You’re supposed to be a pillar, the glue that holds the family together. You’re not supposed to be weak.”

“We women take it all on – the children, the home,” says Carole Frazier, also a community health worker and session facilitator.

A core message of the WRAP program, Frazier stresses, is “that you shouldn’t be ashamed.”

‘Greater Clarity’

Snell-Rood says that in the initial days of her study, it was difficult to get women to show up for interviews. “But once people sat down, I was amazed at how much they shared, and how many people were glad to have a space to talk about depression.”

When Carol Lemon first began seeing a therapist, she had some trepidation about being seen entering a behavioral-health facility. Now she shares her experiences on social media. “I wouldn’t be alive without this place,” she says of Westbrook Health Services. “I know I wouldn’t.”

“I’m a hairdresser,” Michaela Johnson says. “So I talk. I talk openly with people about it. I’m definitely not ashamed.”

Carol Lemon, 35, of Parkersburg, is photographed at Westbrook Health Services in Parkersburg, West Virginia, on Dec. 4, 2019. Lemon, who struggles with Major Depressive Disorder and social anxiety, has been coming to Westbrook for mental health services for the last decade. For Lemon, finding therapist Kelli Nay has been a game-changer.

Lemon says she has good days and bad – but more good than bad. “I’ve had to cut a few people out of my life for my mental health. That would be family. It’s still a work in progress.”

Each day, she reminds herself that she doesn’t want to go back to being made to feel that everything is her responsibility, her fault. “I do not want to live my life like that. I have to remind myself of that every day.”

The pressures and isolation of the coronavirus pandemic present new challenges for anyone confronting behavioral-health issues.

“The uncertainty and lack of control associated with COVID predictably relates to depressive and anxiety-related symptoms,” Curtin says. “Isolation, loneliness and limited access to social support” can also heighten the risk of depression.

Curtin says that since the outbreak, former clients are reaching out to therapists they haven’t seen for a while, “which is good, but certainly suggests people are struggling.”

“On the positive side,” she says, “some people report greater clarity of their values.” Rural communities generally offer easier access to uncrowded outdoor spaces, and Curtin is seeing people taking advantage, getting more exercise than before.

She also notes the critical role that telehealth has played in filling the face-to-face void. Therapists and clients have had to quickly adapt to services being provided via a computer or smartphone, and, Curtin says, have done so successfully.

Many throughout Appalachia have no access to the internet and no phone, a reality the pandemic underscores. Health-care professionals are advocating for a commitment to the expansion of broadband to the remotest regions as another integral tool in resolving the persistent disparities in physical and behavioral health.

As Economies Reopen, Former CDC Director Says Rural Americans At Higher Risk

As businesses in communities across Appalachia – and across the country – begin to reopen, Richard Besser has been vocal about the measures he feels should be met to counter the spread of COVID-19, most particularly, the disproportionate effect reopening too soon will have on underserved and marginalized communities.

Besser served as acting director of the Centers for Disease Control and Prevention under Pres. Barack Obama and is now president and CEO of the Robert Wood Johnson Foundation. RWJF is the largest private institution in the country devoted solely to improving the nation’s health.

Besser is concerned about the challenges rural communities faced before and that are now more critical in the midst of the pandemic. He also worries that the pandemic is being “hyper-politicized.”

“We can’t see science, and public-health science, as the enemy of economic recovery,” Besser said. “We can’t see the interests of rural states and the interests of more urban states as being in opposition. We need to see the solutions to this as fundamental societal issues that we all have to tackle and find a way to come together around these issues.”

What’s given him cause for hope, Besser said, is that “there’s been a lot of legislation that’s been passed in Washington with near unanimous support. And that’s a good thing. I hope we can get back towards that.”

He spoke with 100 Days in Appalachia’s Taylor Sisk about his concerns for rural communities.

***Editor’s Note: The following has been edited for clarity and length.

Taylor Sisk: We’ve been reading for a while about the potential risk of COVID-19 to rural communities. I’d like to talk about how that’s now manifesting. Do you anticipate the rural infection rate rising to the level of urban areas? And what are you now seeing that alarms you or that maybe gives you reason for hope?

Dr. Richard Besser: What we’re seeing now across the nation, as there’s more and more data available and as the virus spreads, is that rural communities are seeing some of the biggest growth in cases. There’s data showing that in rural middle-American states, the rate of increase is about twice that of the national average. That is concerning. It’s concerning because I worry that the call to reopen the economy, people’s fatigue with staying home and people’s need to earn an income is potentially out of sync with the risk that is still there in so many places.

Sisk: Statistically speaking, rural communities are older. They have lower incomes. They have poor access to health care. In the context of COVID-19, demographically, what concerns you the most about the health of rural communities?

Besser: All of those factors put people in Appalachia at an increased risk. The good news about COVID is that the vast majority of people who get this infection will do well. But older people or people with underlying medical conditions are at increased risk of dying from this. In communities where the population is older, that’s a problem. In communities that, economically, are on the edge, It’s a problem.

People are being forced to make really hard decisions about going to work and having money to put food on the table and pay rent, or staying home and away from others so they can help protect themselves and their families and communities. And if it’s a community where incomes are lower, and there’s less savings, there’s not much of a choice there. People are going to be out and about more, and that increases their risk.

In so many parts of rural America, we’re seeing hospitals and other health-care facilities close. And that’s a challenge, because what you want is that if someone is developing symptoms they have the opportunity to be tested, to know if they have COVID, that they’re provided with support so that they can isolate away from family members and others. And we know that in rural America very many people live in households with multi-generations. So while someone who is sick may not be in a high-risk group, there could be several people at home who are and there may not be the space to be able to isolate away from other people.

These things all put people at increased risk of not just having COVID infection but of having more severe infection and spreading it to others.

Sisk: Even in communities with low infection, there’s a lot of stress over the threat of catching a virus, over finances, over the unknown. Can you talk about the repercussions of that stress on both behavioral and physical health?

Besser: We know that in the short term we deal with stress well, physically. The feeling of stress gets us to change our behavior; that fight-or-flight feeling of stress helps you run from danger.

But when that stress occurs over time, day in, day out, over extended periods, it’s not good for our bodies; those stress hormones become very dangerous. And for people who are exposed to chronic stress, it sets them up for other health issues, inflammatory issues, whether it’s heart disease or lung disease or increases in the risk of infectious diseases.

So chronic stress is not a good thing – the stress of worrying about where finances are coming from, from losing jobs, of all of a sudden having your kids at home and not only having to be a mom and a breadwinner but also a teacher and a principal. There’s a lot of stress on everybody. Thinking about how to use public-health science to get people back to work in as safe a way as possible is critically important.

Sisk: In an op-ed piece for USA Today, you wrote, “Those who have been historically marginalized in our country must not be marginalized again in a rush to reopen.”

A large percentage of rural residents are blue collar workers. A large percentage work in the service industry. As we reopen our communities, these people are being told to go back to work, and I’ve heard some among those workers say that while they’re being referred to as essential, they feel that they’re being considered expendable. What are your thoughts on how much risk is acceptable as we reopen?

Besser: The second part of that is: Who has to accept that risk? That idea of who’s essential and who’s expendable is so important to talk about. We know that people of color and lower-income people have been more likely to be in the category of essential worker, have been more likely to get COVID, have been more likely to be hospitalized and more likely to die.

As the economy opens up and people are being told to go back to work, we can’t continue down this path of saying that lower-income workers, essential workers, are also expendable workers. We need to make sure that everyone who’s going back to work is doing so based on the best principles: So, cases have to be going down. There has to be room in hospitals and health-care facilities not just for people with COVID but for people to be seen for all of their medical issues. We need to make sure that for every industry that’s coming back online, there are agreed-upon standards for how to protect workers and that they’re enforceable.

There’s such a power differential when someone in the service economy is told to come back to work. They get there and they’re told, “Well, it doesn’t look good for you to wear a mask.” What can they do? The option is not go to work and not get paid or not wear a mask and increase your risk. So we want to make sure that workers are protected as they’re coming back online, and that they’re not coming back to jobs until the conditions in their particular communities are such that it’s safe to do so.

Sisk: I know you said that as we reopen, we must “embrace the fight.” And I think that’s what you’re describing there. What all does embracing that fight entail?

Besser: Well, from a public-health standpoint, it means demanding that there’s data so that you can see problems as they arise, making sure that you’re able to see who’s getting infected and who’s getting hospitalized, who’s dying based on race and ethnicity, geography and income level, so you can see if particular communities are getting hit hard and look to address that.

You want to make sure that testing is available widely, and that you’re looking at the testing rates broken down in the same way so that you can identify particular areas where there isn’t enough testing or where the testing is showing that there’s ongoing transmission.

And I think one of the hardest things, and most important things, is that when someone is infected, or they’ve been exposed, you need to work with people in communities to identify safe places for them to spend that 14-day period when they could be spreading this to somebody else or they could be brewing infection. If you’re not doing that – if you’re just telling someone you’re infected and go home and isolate – you’re not recognizing that for so many people across this country that’s not possible to do without exposing other people. You’re just identifying where those little clusters and outbreaks are going to be happening; you’re not really preventing them. These are some of the short-term things.

Long term, there’s a lot we have to do to change the safety net in America. We’re the wealthiest nation in the world and we don’t guarantee paid sick leave and family leave for everybody. Less than half of the lowest-wage earners have sick leave or family leave. We don’t ensure that everyone has unemployment insurance. We have more than 28 million people who don’t have health insurance – and now so many people are losing their jobs, that number is gonna be skyrocketing. There’s so much that we need to do as a nation to show that we value each and every person and that we truly believe that, in America, everyone should have a fair and just opportunity for health.

Sisk: Should there be one standardized set of metrics that every community adheres to as it reopens? Or should those metrics be flexible based on demographic factors?

Besser: I think that there should be a core set that everyone is using, and then areas can do more. What are the metrics that should be collected? Clearly breaking down data by location – not just state and county, but down to the zip code. Breaking down data by income, by race, by gender. If you’re doing that, you’re going to be able to see things that you otherwise wouldn’t. And right now those data aren’t available to even be able to say specifically how different communities are doing.

Sisk: You appeared last week on CNN COVID-19 Townhall and the hosts played a clip of President Trump in which he said of health-care workers: “They’re running into death, just like soldiers run into bullets. I see that with the doctors and the nurses and so many of the people that go into these hospitals. It’s incredible to see. It’s a beautiful thing to see.” What’s your reaction to that analogy?

Besser: When I heard that, it didn’t strike me as a beautiful thing. What would be a beautiful thing would be to ensure that every worker in America has what they need to be protected – whether you’re a health-care worker or someone providing the care that’s so needed in health-care facilities, or you’re a poultry worker or meat processor or someone putting food on shelves so that people can go to the store, or you’re driving a bus – whatever it is you’re doing. It would be a beautiful thing if every single person had the protective gear that they needed so that their risk wasn’t any higher than it had to be. And what I said was, what those workers are doing is heroic. They are heroes, just as all the other essential workers are heroes. But it’s not beautiful that in America we’re letting people put themselves in a risky situation where they shouldn’t have to have the level of risk that they currently do.

Sisk: I’d like to pull another quote from your op-ed. This is something that really stuck with me:

“Whether because of lack of access to health care, low household income, immigration status, racial discrimination, disability, lack of safe or affordable housing or myriad other factors, millions of people are going to pay for our nation’s interest in equities that have existed for generations. They’ve become even more apparent and appalling, during this pandemic.”

What do we need to do as a nation to bridge these disparities in vulnerability that are based on where you live, how much money you make, the color of your skin?

Besser: These are profound societal questions. As we look across rural America, and we look at areas where there’s been major disinvestment, what can we do to spur investment in communities so that we’re supporting people in rural America, hard-working people, people who want a good-paying job that will allow them to take care of their family and save some money for the future? How do we spur that investment? There’s a lot of money that’s going to be coming forward to try and spur our economy during recovery. We need to apply that kind of equity lens and ensure that those dollars are going to some of the hardest-hit communities, communities that were in danger before this pandemic. You have communities that are truly at risk of going away because of this pandemic.

Sisk: Is it a different set of issues if we’re talking about bridging disparities in health care between rural and urban communities, as opposed to bridging those disparities among races and ethnicities? Or are these fundamentally the same issues?

Besser: There are different drivers for different issues. Rural America is extremely diverse. There’s a ton of data that shows that when you add issues of racial disparity, income disparity, geographic disparities together, it’s more than additive. So, if you’re looking at the prospects for Black Americans, Latino Americans, indigenous people, they’re worse at every income level. There are, fundamentally, things that have to be addressed from the perspective of structural racism that’s entrenched in our society, in our history. Beyond that, though, there are issues that are affecting people of every race in every community in rural America and the needs of rural America are critically important, regardless of race.

Need A Laugh In Your New Quarantine Life? Check Out This Series From Appalachian Filmmakers

We’re all making tiny time capsules. You may not recognize it, but we’re all doing it, saving up the memories and experiences of our COVID-19 journey in some way.

Perhaps your Instagram has become a collection of your isolation crafts, or the evolution of your sourdough, the devolution of your hairstyles. Maybe you’re journaling fastidiously or saving all of your wine corks from virtual happy hours in a special jar labeled vin du corona.

Even if you’re not actively preserving the moment, when this is all over, the exponential increase in email communication will sit there in your inbox. There will be an enduring electronic legacy of Amazon and Doordash and Instacart receipts, all to remind you, should you ever care to look, of the months we all stayed home.

Tijah Bumgarner and Curren Sheldon have hit on an especially refreshing — and entertaining — way of encapsulating the new American reality. Both run in the same film industry circles in West Virginia — Bumgarner teaches film production at Marshall University and has done extensive narrative and documentary work; Sheldon is an Academy Award- and Emmy-nominated documentary filmmaker. Pre-COVID (that’s how we’re all marking time now, right?), the two were neighbors, friends and occasional script-workshopping buddies. When the pandemic forced on-site filmmaking to an immediate halt and college campuses adjourned to dystopian Zoom-classrooms, the two had to get creative about how to be creative.

Filmmaker Curren Sheldon in an episode of the series “Quarantine Life,” which he co-created.

Sheldon said that after the mind-numbing boredom of the first three weeks of quarantine – ”the longest weeks of my life” – he and Bumgarner decided to work on something light to distract them from the monotony. The idea for a short, scripted series “just sort of sprung up,” he says. “We just started doing it for something to do.”

For most of us, just needing “something to do” has probably produced little more than a windowsill full of scallion and romaine butts floating in murky water — maybe a freshly organized pantry or wardrobe for the overachievers. Not so for Bumgarner and Sheldon.

Their “Quarantine Life” series, available on their YouTube channel Hot Contents, is a collection of comedic shorts the co-creators say are based on true stories — a claim which might be dubious to someone time-traveling a few months ahead from January, but is fully acceptable to any week-eight isolation warrior. Who among us, after all, hasn’t gone to absurd lengths for a safe glimpse of a friendly face, or had a minor meltdown when faced with the most basic of errands?

The shorts are wonderfully concise, like little snacks — but less like a whole bag of Cool Ranch Doritos and more like those Alison Roman hors d’oeuvres you’ve been practicing while dreaming of future dinner parties and forcing on your kids in the meantime. “Quarantine Life” offers a chance to revel in the bewildering mundanity that so many of us stare down daily, now that our lives have moved fully into our houses.

“Times are weird, and tough, but there’s still some sort of collective absurdity that we can all smile at,” Sheldon says.

Although both creators have a history of working on Appalachia-focused documentary projects, you won’t find any overt references to mountain life. “It’s more about the American-universal reach — the shared experience,” Bumgarner says. “We hope those waves go even further than just the region.”

Both collaborators say the project is a healthy outlet, both for the new small anxieties of everyday life and for pent-up creative energy. Bumgarner says that, although there’s not much else going on in isolation, the invented timeline they work on — sharing two finished shorts a week to their YouTube channel — has injected an energy and a welcome urgency into her work week.

“When we’re normally writing scripts,” she says, “you never really know when you’re going to be able to shoot them, or if you’ll even be able to raise the money to be able to work on the next feature.” The shorts, on the other hand, offer near-instant creative gratification and provide immediate engagement with an online audience hungry for relatable content, and eager to share their feedback.

Their condensed production schedule, however, in no way equates to a reduction in quality; the series is beautifully shot. After adjusting to seeing celebrities, news anchors, coworkers and grandmas alike rendered only in tiny, grainy Brady-Bunch-boxes on our computer screens, it is startlingly intoxicating to see new faces doing every-day things in high definition. It’s as if the axes of perception have flipped: Since we now live in the uncanny valley, realistic representations of humans doing now-normal things feel a bit eerie.

While there are certainly challenges to socially-distanced filmmaking, Bumgarner and Sheldon have relied on the participation of co-quarantined partners and friends — and a little sneaky editing to splice together scenes from their separate homes — to bring the series together with relative ease. Sheldon says they’ve done their best to use what’s already at their disposal, “in order to show what this current moment is like for a lot of people,” with the hope that we can all eventually look back and say, “I can’t believe that was our reality.”

But for now? The two already have plenty of ideas for upcoming videos and are sure the partial reopening efforts we all look forward to will be rife with new micro-anxieties they can spin into observational comedy.

“It’s cathartic to replay your own life out on the screen,” Bumgarner says.

They plan to keep producing “Quarantine Life” shorts for as long some sort of isolation measures are in effect. After all, Sheldon says, “You have to keep living your life — as safely as possible — but you have to keep doing stuff that is creative and makes you happy, or you’ll drive yourself mad.”

In ‘Rx Appalachia’ Lesly-Marie Buer Explores Gender Inequities In Recovery In Appalachia

Lesly-Marie Buer was living and working Colorado when she became interested in substance abuse treatment and harm reduction programs. Buer grew up in East Tennessee, in the Knoxville area, but moved west and attended the University of Colorado where she got a master’s in public health.

“But then I was talking to friends who were going through treatment programs in East Tennessee, and they were telling me about them. Most of these were guys and most of the research I had seen [on recovery] was on guys,” Buer recalled. “I was looking for what was going on with women trying to make it through treatment programs in Appalachia and I just couldn’t find anything. So I decided that’s what I really wanted to look at for my dissertation.”

Buer moved back east to attend the University of Kentucky and soon began living alongside women in recovery in rural Kentucky communities, interviewing them in detail and trying to understand their struggles. Those interviews and her research resulted in “Rx Appalachia: Stories of Treatment and Survival in Rural Kentucky,” being released Tuesday, May 12. Buer spoke about the book and her research with 100 Days in Appalachia’s Taylor Sisk before its release.

***Editor’s Note: The following has been edited for clarity and length.

Taylor Sisk: You open your book with a quote from a book by Anne Pancake called Strange as this Weather Has Been. Could you read that quote for us and then tell us why you chose to open your book with it.

Lesly-Marie Buer: “I’ve learned something about times like these. And times like these you have to grow big enough inside to hold both the loss and the hope.”

I think that I’ve seen this with my generation growing up in Appalachia, but also in my research as well. Most friend groups have lost some friends to overdose death or to suicide, sometimes it’s hard to tell the difference which, and that takes a toll. You know, you start getting scared when you get phone calls from friends late at night thinking that it’s another death.

But at the same time, there’s so much beauty and activism here. And you see that with the youth and all the youth groups that are happening in Appalachia. They have these beautiful radical ways of conceptualizing what Appalachia is going to look like, and I saw a lot of that with the women I spoke to who are going through substance use treatment. They had all these imaginings of what life could be like and there was so much hope in those imaginings, yet there was so much hurt as well.

Sisk: The subtitle of your book is stories of treatment and survival and rural Kentucky. Why did you choose that title?

Buer: So, most the people I worked with and spoke with, they had really been placed in situations that were very risky. And so, so much of their life was focused on surviving, not really necessarily on thriving or moving past that, but just getting through the everyday and I was just catching them at a certain point with one of a big thing in their life was trying to survive treatment. And that was the one of the biggest hurdles.

So as they were trying to work through treatment, they were also trying to survive in their family and in their communities, which was no small feat for a lot of them as they were trying to deal with issues of child custody, not having jobs, you know, maybe not getting the child support they rode and just placed in these situations where it just seemed like not much was going right.

Sisk: You spent a lot of time in these rural Kentucky communities. Tell us about the course of your research.

Buer: One of my biggest focuses was just trying to be there. I have family in rural East Tennessee, I’m from East Tennessee, but that doesn’t mean I know what it means to be in rural Kentucky.

And so, I got a studio apartment there. I lived there, tried to go to community events. I went through a round of festivals for every vegetable and fruit you can think of. But when you start talking to people and saying what you’re doing, then you get all sorts of stories.

I would talk to treatment providers and walk through what treatment looked like for them, and if I was allowed in, go to some group sessions for treatment. I went to a lot of court sessions, just anything I could get my hands on that I thought would relate to this, church services, city council meetings, anything I could go to, to just try to feel what it was to be in that place.

And then I talked to a lot of women. I talked to 40 women at least once, most of those conversations were about an hour, hour and a half. Some went to three or four hours and those are the most the women I ended up going back to talk to a few times to try to really get their story, see where they were at in treatment and sort of followed them through.

Sisk: You chose not to use the real names of these women or the agencies they were seeking help from in the book so, in general terms, tell us who these women are.

Buer: Almost everyone I talked to were mothers. And there was a lot of hurt in people’s lives. So, about half the women had been sexually assaulted at some point, about half the women had experienced domestic violence. So just being placed in very at-risk situations, where oftentimes the options were either a bad option or a terrible option. And sometimes you just got to go with bad over terrible.

Most had a hard time providing economically for themselves and their families, and that’s not because of some lack of will or anything like that, but because there was just a lack of access to jobs, especially if they had gotten any sort of record either a criminal felony record or a record through Child Protective Services, it was really impossible for them to enter the workforce in those counties where the biggest sources of employment are oftentimes through some sort of health care or through the school system. And then they were regulated, they could not participate in that economy.

Sisk: You close the book with some recommendations on how to change the health care system. What are those?

Buer: Medicaid expansion has been very successful in addressing some issues in Kentucky and so I would love to see more support for Medicaid expansion in other Appalachian states. I’ve also seen a lot of success around harm reduction programs and I would like to see broader community support for those. When I talk about harm reduction, I’m thinking about programs that really meet people where they’re at and try to provide services that people who use drugs say they want, not just services that other folks think they need.

And then the last one is really stigma reduction. I would love to see less judgment on people just because of one behavior that’s in their lives, because people are a lot more things than just one behavior.

Sisk: So many of the women in your book are were facing drug offenses and you use the term a just alternative to incarceration. What would that look like?

Buer: I think in critiques of how the response to opioid use versus crack use and heroin use in the past there’s been this idea that some people– especially in rural areas– are seeing a just alternative to incarceration, but what I saw in eastern Kentucky was in no way just.

A lot of the women there were not being incarcerated, or at least being incarcerated for long periods of time, but they were being processed through state systems that were very punitive, whether that was punitive social services or punitive Child Protective Services, and so while we’re looking at trying to decriminalize drug use or at least not incarcerate as many people [for it], I hope we don’t fall into the pit of just sending people through underfunded state programs that still marginalize people even though it may not be incarceration.

I think a just alternative is really meeting people where they’re at, seeing what they need, what they say they need and trying to supplement people’s resources, especially when they don’t have access to an economy or a social situation where they can provide for themselves and their family. The last thing we want to do is forcing people through programs that just further hurt them. So we really need to be about reducing harms and not increasing harms.

Lesly-Marie Buer is a harm reductionist and medical anthropologist living in East Tennessee. She has a PhD in anthropology and a graduate certificate in gender and women’s studies from the University of Kentucky and a master’s in anthropology and master’s in public health from the University of Colorado.