Sam Runyon, a dedicated nurse, makes home visits to her patients in West Virginia, tackling chronic diseases like diabetes and obesity that prop up a national crisis. During a visit with Cora Perkins, a 64-year-old cancer survivor struggling with food insecurity, Sam witnesses the daily challenges stemming from poverty and inadequate nutrition. Cora’s health deteriorates due to poor eating habits and financial constraints, revealing systemic issues in healthcare access. Despite her efforts, including helping patients improve their conditions, Sam faces the harsh reality of chronic disease progression, illustrating the struggles of rural Americans battling health crises amidst socio-economic decay.
Sam Runyon made her way to the house, relying on memory while she perused her patient’s medical file, an extensive “problem list” detailing medications and chronic conditions that spanned several pages. A 45-year-old nurse, Sam had witnessed Cora Perkins triumph over two types of cancer. In past visits, she noted Cora’s arms turning blue due to diabetes, swollen ankles from congestive heart failure, and stomach cramps from lack of fresh food in the house. It had been a week since her last visit, and Sam pondered whether anyone had entered or exited through the front door in that time.
She knocked, but there was no response. Crossing the porch, she leaned into a hole in the window and called out, “Cora, honey? Are you alright?” A light flickered within, and a dog started barking. Sam pushed the door open and entered the living room, where she found Cora bundled up under a blanket.
“Sam. I’m so glad you’re here,” said Cora, 64, attempting to rise but losing her balance back into her recliner.
“You seem a bit shaky this morning,” Sam remarked. “Are you feeling really unwell or just the usual discomfort?”
It was a question she routinely asked patients throughout her week of home visits in West Virginia, moving from one looming crisis to the next in an area where chronic discomfort had become commonplace. All 31 patients on her roster at the Williamson Health and Wellness Center were under 65, yet each suffered from at least one chronic illness that had surged in prevalence across the United States in the last two decades: diabetes death rates up 25 percent, liver disease by 40 percent, kidney disease by 60 percent, hypertension by 80 percent, and obesity by over 95 percent, according to the Centers for Disease Control and Prevention.
Americans now endure more years living with chronic health conditions compared to individuals in 183 other countries monitored by the World Health Organization — a reality that Robert F. Kennedy Jr. described as a “national crisis” in his early days as health secretary. “We will reverse the chronic disease epidemic and restore health to America,” he assured Congress that morning, as Sam wrestled with the challenges of healthcare in Mingo County, where life expectancy had steadily declined to 67 years over the past decade.
“Are we calling that your breakfast?” Sam asked, gesturing at Cora’s side table where two bottles of sugar-free Dr Pepper sat beside a bag of pepperoni-flavored Combos.
“It’s the end of the month,” Cora replied. “It’s whatever’s left. I got the soda for cheap at Dollar Tree.”
“You know Dollar Tree isn’t a good place for real groceries,” Sam commented.
“How am I supposed to get to the grocery store without a car?” Cora challenged.
For nearly two years, Sam had visited Cora weekly, helping her shed 40 pounds, stabilize her blood sugar, and bring her cholesterol back to acceptable levels, but each solution uncovered another issue. Cora and her boyfriend often had less than $100 in their joint account, making assistance with government programs essential. Despite finally qualifying for food stamps, she couldn’t reach a store to shop. Occasionally, she would manage to purchase meat and vegetables, but with her oven usually out of order, she resorted to the cheap, ultraprocessed foods that made up 73 percent of America’s food supply. These unhealthy options worsened her health. Her ailments caused anxiety and depression, which in turn heightened her blood pressure and complicated her diabetes management.
“I’m not trying to nag you,” Sam said. “I get how overwhelming it seems. I see how hard you’re working.”
She pulled out her blood pressure cuff and commenced her examination while two dogs scampered across her lap, playfully nipping at her neck. Recently, she had been offered an additional $8 per hour to work as a nurse at a local hospital, with a clean office and supportive staff, but she preferred the chaotic intimacy of home visits, where she could spend an hour with her patients and witness the systemic breakdown behind their ailments. Having grown up nearby in a similarly dilapidated rental, she recognized the empty cooking oil jar in Cora’s kitchen, the notice for a $766 electric bill taped to the refrigerator, and the medicine cabinet filled with expired prescriptions.
Most of Sam’s patients saw improved health outcomes. They were more adherent to medication regimens and made fewer emergency room trips while under her care. More than half exhibited improved blood sugar levels or kidney function. Yet, in some cases, no intervention could halt the advance of chronic disease, leaving Sam named among the survivors in her patients’ obituaries.
“We still have work to do,” she told Cora. Her blood pressure was elevated, resting pulse at 93. Her legs were swollen, the result of a high-salt diet. Sam returned to her car, fetching a box from a nearby pantry that contained canned goods, noodles, and a bag of potatoes.
“I apologize for the lack of nutrition,” Sam said while organizing her nursing bag and embraced Cora.
“I’m pretty much accustomed to the junk,” Cora replied.
“You and everyone else,” Sam responded.
She had exhausted five cars on the winding backroads of Mingo County, gradually learning to navigate every pothole and measure every scar left on the hillsides from logging, coal mining, and mountaintop removal. This region had seen every resource, including its residents, exploited for profit. Driving into Williamson, population 3,042, she noted that over two local pharmacies had dispensed more than 20 million opioid painkillers in a decade, but rather than dulling people’s pain, the drugs intensified it. The downtown area was mostly empty, punctuated only by rehab facilities, budget law offices, and a methadone clinic. Passing a liquor store offering three-for-one vodka deals and a gas station advertising two-liter soda bottles for a dollar, she remarked, “Every business is either trying to kill you or selling a remedy.”
She arrived at a house on the outskirts of downtown to check on another diabetic patient, Joe Miller, 48, who was lying shirtless on his bed, incapacitated by hip pain while his pit bull chewed his socks. On his nightstand, a bowl of Kraft macaroni and cheese sat alongside a box of salt and a photograph of years past — a thin, smiling Joe in a button-down shirt, with his arm wrapped around his wife, now deceased from a heart attack in her 40s. Struggling with depression, Joe was nearing 300 pounds with dangerously high cholesterol. He shared with Sam that he’d been having a recurring nightmare where he discovered dynamite packed inside his chest.
She took his wrist to check his pulse, noting a heart rate of 130 beats per minute.
“Geez, Joe,” she joked. “Have you been sneaking out for roller coaster rides?”
He gestured towards a portable toilet in the corner. “That’s as far as I’ve managed to move from this bed in two weeks,” he replied. “It’s so tragic that I can’t help but laugh.”
“Well, let’s find ways to add some light to the situation,” Sam said. “But I can tell you’re in pain, and I dislike seeing that. We need to set up a talk with a counselor.”
Back in her car, she followed the Tug River into the mountains, cracking open her second energy drink of the day. “You have to deal with stress somehow,” she mused. “If there are any saints here, I haven’t met them.” Roughly half of the county’s 22,000 residents were obese, a quarter smoked cigarettes, and nearly 20 percent were diabetic — trends that had become increasingly common in rural America, where working-age adults faced mortality rates significantly higher than two decades prior, according to C.D.C. statistics. Individuals living in the country’s poorest regions were nearly twice as likely to suffer chronic diseases compared to those residing in affluent urban areas, giving rise to a politically charged atmosphere of resentment. Mingo County had historically been a solidly Democratic stronghold, but over 85 percent of voters supported Donald J. Trump in the 2024 presidential election.
Sam passed one of the sparse fresh grocery stores within a 30-mile radius, where inflation had inflated produce prices. Slowing next to a roadside stand, she observed a couple reselling off-brand soda, pricing 12-packs loaded with 500 grams of sugar for $3. “Fill up for cheap,” their sign advertised.
The road wound along a creek bed as Sam halted to check on a 43-year-old patient. Under her guidance, the woman had halved her average blood sugar, although diabetes was still causing her eyesight to deteriorate. “I brought you some exercise bands,” Sam said. “We’re going to get all Jane Fonda in here.”
Returning to her car, she grabbed another energy drink. “This job is like battling against gravity,” she commented, recalling the premature death of her younger brother in his early 40s from heart and liver failure. Her father battled diabetes while indulging in Wendy’s and multiple sodas daily. The father of Sam’s two children had been prescribed opioids following a workplace injury, falling into addiction thereafter. Sam had raised her children largely solo, juggling three jobs and attending nursing school at night, while often transporting family members to the methadone clinic. “I keep believing I can fix people,” she said.
She arrived at her final patient for the day, Harry Ray, who shared a single-wide trailer with his brother on a frozen hillside. Next to the house were two gravestones: one for their mother, who succumbed to kidney disease at 56; the other for their father, who died from diabetes at 61. Harry lost a leg to diabetes back in 2009, but with Sam’s support, he had shed nearly 75 pounds in two years. She had guided him in organizing his medications and managing his health conditions. Harry took notes during their meetings, pinning them up on trailer walls. “You are what you eat, big boy,” one motto read.
Sam checked his blood pressure and bandaged a wound on his skin. The house reeked of unkept cats, but she brushed a bug off the couch and settled in for an hour-long visit before bidding farewell.
“Now, just a second,” Harry said. “You’re not leaving here empty-handed.”
Sam attempted to decline, but he vanished into the kitchen and quickly returned with a small bag.
“I wouldn’t be alive without you,” he said earnestly. “I’m sorry it isn’t more, but it’s what we have.”
Sam enveloped him in a hug before making her way back to the car. She opened the bag, discovering a can of Sprite, a pack of Fritos, and eight pieces of hard candy. She shut her eyes briefly, then drove silently out of the mountains until she regained cell service and her phone began ringing. One patient had a temperature of 101.6, another couldn’t urinate. Cora called, experiencing chest pains.
“Why does it feel like someone is continuously stabbing me?” she asked.
As Sam listened to Cora detailing her symptoms, she gripped the steering wheel tightly. “When was the last time you ate a proper meal?” she inquired.
Lunch had been a packet of ramen noodle soup, just like dinner the night before and lunch two days prior. After hanging up with Sam, Cora checked her blood sugar, which was alarmingly high at 255. Sam had provided her with a pamphlet focused on heart-healthy foods, and Cora scanned the list: avocados, pumpernickel bread, fish, blueberries, broccoli. She called out for her boyfriend, John Ratcliff, who was in the kitchen.
“Do we have any vegetables left?” she asked.
“I doubt it,” he replied, but began searching the pantry and fridge. All they could find was mustard, a half-eaten microwave meal, American cheese, cornflakes, and a bag of flour. This was the state of their kitchen at month’s end, after exhausting their $380 in food stamps. The only accessible food within walking distance was from Pizza Hut, KFC, Taco Bell, Little Caesars, a dollar store, and a small convenience store where avocados were priced at $2.99 each and a 12-pack of ramen noodles cost $2.50.
Cora turned on the TV and saw an advertisement with close-ups of fried hash browns, sizzling sausage patties, and melting cheese, all marketed for a dollar. “Boy, doesn’t that look appealing?” she remarked. Muting the TV, she called out, “Any luck?”
John emerged holding a package of beef-flavored ramen. “Honestly, I’d rather starve,” Cora replied.
He searched some more, unearthing a leftover bag of potatoes from the back of the pantry. He chopped them into cubes and sprinkled them with salt. Sam had once warned him that potatoes could spike blood pressure for diabetics and that they were healthier baked, but their oven remained broken. So he filled a pan with oil and switched on the burner. “I found you some vegetables,” he called out to Cora.
Over their two-decade relationship, they alternated caregiver roles for one another. John endured seizures and had survived a quadruple bypass surgery. For the past ten years, their lives revolved around Cora’s chronic illness: checking her blood sugar every few hours, deciphering nutritional labels, and administering six medications in the morning and five more at dinner.
He finished cooking the potatoes and mixed flour and milk in a bowl. He dropped the mix into the remaining oil to create what he called fry bread — Cora’s favorite dish. Moments later, he walked into the living room carrying two plates of fried carbs and a couple of Dr Peppers.
“This is delightful,” Cora remarked. “Thank you. It’s just what I needed.”
They engaged in a game of gin rummy and began watching “Little House on the Prairie,” but Cora kept dozing off in her chair. She took her blood sugar and found it had risen to 270. Her mouth felt parched, and a headache was brewing. Trying to occupy herself, she played a game on her phone, but soon her hands began tingling. “It never ends,” she sighed.
Her mother was diabetic, and her brother had died from diabetes-related complications before turning 60. Her 37-year-old daughter was already among Sam’s patients. Her grandchildren largely subsisted on processed school meals.
“I can’t recall the last time I felt good,” Cora confessed.
“Maybe you ought to call Sam,” John suggested. Cora usually contacted Sam at least once or twice daily, if only to say goodnight, but now it was nearing 10 p.m.
“I don’t want to trouble her,” she muttered.
The tingling persisted, the headache worsened, and a chill crept into her hands, spreading to her arms. After a few hours of restless sleep, she woke to another day of Dr Pepper and ramen. By the next afternoon, her ankles were swollen, and her lips had gone numb. She dialed Sam, who was driving to see another patient.
“I have issues,” Cora said, “My lips keep going numb.”
“Your lips? Uh-oh. What’s your blood pressure?”
“I don’t know.”
“That’s troubling, Cora. I’ll be there shortly.”
Sam drove out of the hills and back into Williamson, recalling the previous challenges that had led her to Cora’s home and filled her patient file: “Pain in spine,” “Chronic pain,” “Neuropathy,” “Lower respiratory infection,” “Depressive disorder,” “Hypertension,” “Transportation insecurity,” “Obesity due to diet,” “Noncompliance with dietary regimen due to financial hardship.”
However, the lip numbness was a new concern, and Sam mentally sifted through the possible causes. Cora’s numbness could stem from excessive salt intake, as a packet of ramen contained nearly a full day’s sodium allowance. Alternatively, she might be freezing and losing sensation in her face — especially if the utility company had indeed cut her heat for nonpayment. The numbness could also indicate severe anxiety, an allergic reaction, or a potential stroke. “I might have to take her to the emergency room,” Sam thought as she parked in front of the house and approached.
Inside, the dogs barked furiously, and a half-dozen relatives gathered in the living room. As it was the first day of the month, Cora’s family had come to drive her to the grocery store. Sam navigated through the chaos, gently moving the dogs aside to reach Cora’s recliner. “I’m so sorry for all this, girl,” she said, preparing to check Cora’s vitals.
Her blood pressure measured at 146 over 80 — elevated, but not immediately alarming. Her pulse was steady, and her blood sugar appeared normal. Cora said she was feeling somewhat better and wished to join her family for shopping. They all needed food, and this was a rare opportunity; if she missed the ride now, it could be days before she found a way to the store again.
“Cora, please listen,” Sam urged. “You’ve got to prioritize your health.” She suggested Cora visit an urgent care clinic or at least take some time to rest until stability returned.
“They can take me around the store in a motorized cart,” Cora insisted.
“It’s your choice,” Sam replied, packing her nursing bag as Cora contemplated yet another impossible decision in a system where one urgent matter often overshadowed another.
“I need to get food for us,” she said.
Audio produced by Tally Abecassis.