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Diving Deep into Harm Reduction

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Medicine worker disposing medical waste into plastic containers with protective glove. Photo: Adobe stock.

Part 1: Why W.Va.’s Largest Needle Exchange Closed

In December  2015, with support from the city of Charleston, the Kanawha-Charleston Health Department launched a harm-reduction program that included a needle exchange. The primary goal was to reduce the risk of diseases commonly spread by sharing needles.

Now, only thing that remains of the harm reduction program is a syringe kiosk where people can deposit used hypodermic needles.

At its peak  the program served more than 400 people a week,mostly from Kanawha County. But some came from surrounding counties as well,a factor that became a point of contention for many in the city.

“It became basically, a line of people just to line up to get needles between 10 and 4 on any given Wednesday,” said outgoing Charleston mayor, Danny Jones who been an outspoken critic of the program.

In the months before it closed, Jones publicly called the program a “needle mill” and “mini-mall for junkies.”

“On any given Wednesday, they might have given out 12,000 needles,” he said during a recent interview.

In reality, the average number of needles given out during the weekly Wednesday exchange was about 5,000 serving about 190 visitors, according to data obtained from the health department. That’s about 26 needles per person, per week. The highest number of  needles the program ever gave out in a single week was just over 11,000 to 417 people.

While 5,000 seem like a lot, the average heroin user injects several times a day. So 26 needles a week gets a person about three injections a day with a clean needle.

“A syringe exchange program should really be called a harm reduction program,” said Dr. Artis Hoven, an infectious disease specialist with the Kentucky Department of Health.

She said harm reduction is an all-encompassing idea to reduce the risk of many things associated with addiction such as “provide naloxone, provide referral to care for people with substance use disorder, they do HIV and Hepatitis C testing.”

And in Charleston, it seemed to work.

While the Charleston program was open, the city did not see an HIV outbreak, according to interviews conducted by Charleston-Gazette Mail. During that same time period, 15 counties in southern West Virginia did have a small HIV outbreak — none of the three counties where the outbreak started had a harm reduction program, according to a Centers for Disease Control and Prevention Report.

Recorded incidents of Hepatitis C rates in West Virginia did increase — by a lot — during the course of the program, but so did efforts to test more people.

But in Charleston, reports of discarded needles in the community began to skyrocket and people were alarmed.

Firefighters reported having to crawl over them while putting out fires in abandoned structures; a local elementary school requested a biohazard container from the city so they could clean up an alley before school; and police officers reported finding huge numbers of syringes on people who were arrested.

Both the Fraternal Order of Police and the Charleston Professional Firefighters Association wrote letters to City Council expressing major safety concerns for first responders.

Concerns might have been exacerbated because the program grew really fast. In the two years the program was open, more than 651,000 needles were distributed. Only about 66 percent of those needles were returned.

According to the Centers for Disease Control and Prevention, the risk of contracting HIV is nominal for for healthcare professionals stuck by needles on the job — around .3 percent — with some studies suggesting even less. Outside experts like Peter Davidson from the University of California San Diego say needle litter is an annoyance but not the major public health concern an HIV or Hepatitis C outbreak would be.

“No one in the world has ever obtained HIV from stepping on a needle in the street,” said Davidson. “Needles in the street are a piece of trash. It’s not something you want seeing laying in the gutter, but they’re not actually a very hazardous object.”

In some ways, it doesn’t matter what the risk is. If someone finds a dirty needle on a playground or in a shopping mall bathroom, public reaction is strong. And for non-users, any risk of contracting HIV or hepatitis from a dirty needle is too much.

But closing a harm reduction  program in the biggest city in the state could have huge public health implications for the region, according to former state Commissioner for Public Health Rahul Gupta. Gupta said it’s “not in the best interest of the community” when needle exchange programs like this one are shut down “reactively.”

“It plays into that stigma and is more harmful long-term than it is beneficial,” he said in an interview shortly before he left his job.

Gupta said it’s more harmful because not only are you removing your best tool for preventing needle-born illnesses, but, as we’ll hear later in this series, the closure may impact public perception and support for other harm reduction programs across the state that are trying to open or stay open.

Part 2: Public Safety and Public Health

Best practices for harm reduction programs call for flooding a community with clean hypodermic syringes. Research shows that in addition to reducing the prevalence of blood-borne pathogens in the community, well-run programs help remove potentially infectious syringes from the community. But some people say that wasn’t happening in Charleston.

Photo: Todd Huffman via Flickr [CC BY 2.0]

Reports of needles found in public places in Charleston began to escalate in early October 2017.

Mayor Danny Jones said the city tried numerous times to complain and the Kanawha-Charleston Health Department didn’t do anything to address their concerns.

Then city health officer Michael Brumage took issue with that accusation,pointing to efforts, such as the founding of the statewide harm reduction coalition. He said one of the objectives of the coalition was to bring needles into other communities so there wouldn’t be such a burden on the city.

But in October 2017, the city public safety office established a code for needle pickup calls to help the city accurately collect data on locations, numbers and types of needles to be picked up.

About a week later, the city proposed running a pilot program with retractable needles. The idea was that if the needles could only be used once and then retract into a plastic chamber, it would reduce the risk of needlestick injuries to the community and first responders.

At the time, Brumage was all for the idea. He wrote an an email, which was part of documents released to West Virginia Public Broadcasting through a Freedom of Information Act request, to city attorney Paul Ellis.

“[T]he limitations … are acceptability and cost. Should we get support or donated supplies, I am all in for a pilot with evaluation. This could be a very interesting trial. We would like to bring in some researchers for this as well. Let’s do it! It’s worth a shot.”

Over the next few weeks, the Charleston Fire Department found a manufacturer willing to donate the needles in exchange for tracking how well they worked. After consulting with Brumage and his staff, the city requested 250,000 needles from the manufacturer for a six-month trial.

Everything seemed to be on track to start a pilot project using retractable needles in early spring 2018.

At least that’s what the city thought. Meanwhile, Brumage was in communication with a researcher at Johns Hopkins University in Baltimore, Maryland. The researcher reinforced something with him that  he said he already knew — that “retractables were unpopular among people who used IV drugs.”

In 2010, the national Harm Reduction Coalition issued a statement against auto disable syringes. They said the syringes do little to help control epidemics of HIV, hepatitis C, and other blood-borne viruses among people who inject drugs because many people inject drugs a half dozen times a day. Without needles you can use more than once, users revert back to sharing equipment.

“So, at that point I was kind of in a bind since I told the city we would implement the retractable syringe program. But now knew if I did, we’d actually be putting the public at risk,” said Brumage.

So given the current recommended practices, Brumage and the Johns Hopkins researcher decided to reduce the pilot instead to about 10 to 12 people. In meeting minutes from a call, also released in the FOIA,, Brumage’s staff appeared to confirm the new plan with the company that had agreed to donate the syringes.

Brumage said he thought the needle manufacturer then told the city about the change. But no one did. So city officials said they felt blindsided several weeks later when they learned the pilot program no longer included the entire patient population.

“They refused retractable needles,” Jones said in an interview.

It was more complicated than that, but it probably felt like a refusal to the city because of the  change in plan wasn’t communicated. And I mean, remember, law enforcement, emergency responders and some members of the community were now expressing a lot of concern about needle litter and felt like they had to do something.

“I want to protect the public. I want to protect the law abiding public,” said Jones.

In late March of this year, Charleston Police Chief Steve Cooper decided — as he was legally empowered to do — that the health department may only give out retractable needles.

Essentially, Brumage said, the police were “ directing the health department to adopt — what appeared to be from the medical literature to be dangerous and unethical practices.”

But other public health experts said making a harm reduction program fit the needs of the community takes a lot of compromise.

“Public health has never been and will never be about my way or your way. It will always be what’s the best way to input science and marry it with art and put it into practice,” said former public health commissioner Rahul Gupta.

From a public health perspective, harm reduction programs are still the best tool the city a city? has to prevent the spread of needle born illnesses. But politically — at least in the state’s largest city — it’s closed indefinitely.

Part 3: Community Acceptance, Perception and Stigma

A girl is telling her friend a secret. Photo: Adobe Stock.

Less than two years after it began, the Kanawha-Charleston Health Department shut down it’s harm reduction program. Among other things, the program provided thousands of clean needles to drug users with the goal of reducing needle borne diseases, but faced significant pushback from some in the community.

As the state continues to grapple with the drug epidemic and its impact to public health, those running harm reduction programs in other West Virginia communities say the closure of the Charleston program, and the narrative that the needle exchange program was destroying the city, is having a negative impact on public perception of harm reduction efforts.

“Everyone understands that this drug epidemic is the biggest public health issue that we have dealt with,” said Terry Harlin, administrator of the Fayetteville harm reduction program. “I feel like what happened in Charleston hurt us a little bit.”

Harlin said when the Charleston program closed in [insert when here], members of the community began questioning the necessity of the Fayette County program.

“We definitely started hearing people locally, ‘well it didn’t work in Charleston so why would you continue doing that here?’” she said. “Even though there’s lots of evidence and research out there that show that harm reduction does help to prevent the spread of disease and does help to get people the help that they need.”

A Shifting Narrative

The trickle effect to other programs like Fayetteville’s likely happened in the last six months the Kanwaha-Charleston program was open, when the narrative around the program shifted. Outgoing Charleston Mayor Danny Jones was especially outspoken critic of the program.

“Needles were everywhere and our property crimes went through the roof,” he said.

No study has been done quantifying whether the harm reduction program caused an increase in needle litter, making it hard to confirm the veracity of the claim. But we do know, according to data from the health department, that during the two years the program was open, more than 650,000 needles were distributed and only about 66 percent of them were returned.

West Virginia University public health researcher Robin Pollini said that doesn’t mean the unreturned needles ended up on the street. In West Virginia it is legal to dispose of sharps in the trash if you package them and label them in a certain way, she said.

“And so the Charleston program, just like many programs across the state, gives out puncture proof containers and information on how to dispose of those safely,” said Pollini. “And so we don’t have any idea how many of those ended up properly disposed of in household trash and how many didn’t.”

Dr. Susan Gardner, assistant dean of the University of Charleston School of Pharmacy, said she has seen little evidence of widespread needle litter.  The school of pharmacy was one of the volunteer groups very involved in the Kanawha-Charleston Harm Reduction Program.

“There are times where I just took a walk on the East End looking — looking!,” she said. “[I say to myself] ‘ok, if it’s this bad surely I’ll see it.’ And the only time I’ve ever come across a needle in Charleston is doing a syringe cleanup.”

Us Versus Them

But without a study of Charleston’s needle litter, there’s also no way to prove that the 200,000 unreturned needles didn’t end up on the streets.

Members of the Charleston police department said they’ve observed much less needle litter since the program closed, but the department also has reams of photographs from first responders and community members of needles found in public spaces.

Comments on news articles and Facebook posts seem to paint a community drowning in needles.

On some level, needle litter itself, isn’t the issue.

“So part of the narrative that was built around the Kanawha program was this us and them of like ‘we’re the community and those people are drug users,’” said Pollini, from WVU. “Those people are part of our community they’re West Virginians right?”

In Wyoming County a Different Narrative

Wyoming County launched its needle exchange program in May. Executive Director Fred Cox said their program has been relatively well-received — he guesses because they had a small HIV outbreak prior to the program opening.

“A picture’s worth a thousand words I’d guess you’d say,” Cox said. “So, that picture was really clear to us here and I really do think that help changed some minds.”

He said if they hadn’t had the outbreak he doesn’t think they would have had to support to open the program as a prevention measure.

Some speculate that may be another reason Charleston’s program struggled in the end.

Outgoing Charleston mayor Jones said there were no reports of outbreaks of hepatitis C or the AIDS virus prior to the launch of the city’s harm reduction program.

“It’s not up to us to ruin a town over the fact that people have communicable diseases,” he said.

Rahul Gupta, formerly the head of the state’s public health department, said harm reduction is a multifaceted idea that encompasses not just needle exchange, but testing and family planning and treatment of diseases.

“And other issues that come across that are consequential in some ways like needle litter and other things there have to be plans in place to address those — what we can’t afford to do is ignore them,” he said.

There often are demands, Gupta said, to do things differently. But he believes there’s always a middle ground you can get to with negotiation. And you do that, he said, because “people’s lives are at stake.”

Part 4: Best Practices vs. Community Acceptance

Current best practices for harm reduction programs include a couple provisions: No retractable needles should be distributed, patients should get as many needles as possible regardless of how many they bring back, and barriers to accessing needles should be as low as possible. But sometimes those recommendations are at odds with community acceptance for the practices.

Photo: Ashton Marra, 100 Days in Appalachia

In late March, shortly after the Kanawha-Charleston Health Department closed its harm reduction program, Mayor Danny Jones wrote a letter to Rahul Gupta, then state commissioner for public health, asking that the West Virginia Bureau for Public Health audit the program.

“The review provided very specific recommendations that needed to be met in order to restart the program,” Gupta said.

These included improving data collection and analysis about exactly how many people were using the program and what services they were using; putting in place a plan to deal with needle litter; improving communication with community stakeholders and requiring that people pick up needles they need in person.

After the audit came out, the Kanawha-Charleston Health Department requested a review of the audit from seven harm reduction experts around the country, including Dr. Peter Davidson from the University of California San Diego. All seven letters were critical of the audit.  

“I think the best way to describe it was that the people who wrote the audit had a very particular idea in mind about what a syringe distribution program should look like,” said Davidson.

In his letter Davidson wrote that “almost all of the recommendations in the audit represent severe, and in some cases unconscionable, barriers to effective, evidence-based, primary prevention of blood borne virus transmission.”

“You know one of the reasons syringe distribution programs exist in the way they exist at all is because is because the sort of traditional public health clinic model hasn’t served people who use drugs very well at all,” Davidson said. “And it hasn’t been very good at providing them with the basic tools they need in order to prevent the transmission of infectious disease and prevent overdose.”

Davidson said ideally, harm reduction programs have as low a barrier of entry as possible so the maximum amount of people will participate. And the recommendations made in the audit would raise the threshold of how easy it was to access resources, but he also says there’s room to adjust programs to fit the communities they serve.

“I wouldn’t expect a needle exchange in rural Appalachia to look the same as a needle exchange in San Francisco for example,” he said. “That would likely lead to a program that didn’t serve the population very well at all.”

And in Charleston, there were actually two harm reduction programs being held simultaneously: the one at the health department and a much smaller, clinic-based program operated by Health Right, the biggest free clinic in the state.

“Back in 2011 we noticed an increase in patients that were coming in with various stories, histories of being diabetic, they would pick up the needles for the program but not the insulin,” said executive director Angie Settle.

She said they began to suspect an increase in IV drug use among their patient population.

“So we kind of quietly started the program with the needle exchange it was mainly internal not something we broadcasted, but those patients that needed it knew of the service and as they came in we were screening every patient for IV drug use,” Settle said.

Because Health Right is a clinic working with a limited number of patients with whom they already have close relationships, they could run their program differently than the health department, which was trying to do a mass public health push, serving the whole city.

Health Right is also a one for one exchange — you bring a needle back, you get a fresh one — which for most harm reduction experts is not considered best practice. But since patients can come as many times a week as they want, Settle said it seemed to be the best choice for her program.

They also require every patient to meet with a counselor when they come in for needles. Basically, participation in Health Right’s program requires a lot more effort from patients, which means not everyone will use it, but Settle said that running a conservative program is preferable to not having a program available at all.  

“You know the reality here is you’ve got a drug-using population that, in fact, is going to keep using drugs whether or not you have a syringe exchange program or not,” said Dr. Artis Hoven, an infectious disease specialist with the Kentucky Department of Health.

But without a program, she said, the community is just opening itself up to the easier spread of communicable diseases.

“There is something called the art and science, if you will, of risk or harm reduction,” said Hoven. “And for many of us we are still learning what that art is and what that science is. We’re trying to make it better and to make it something that is effective.”

But if Charleston were to consider harm reduction again, a lot of community healing, conversations, and compromise would likely have to occur. And the biggest barrier may be one of the most intangible ones — addressing stigma.

Part 5: A Community Divided

When the Kanawha-Charleston Health Department closed its harm reduction programs, one of the biggest criticisms of the program was that it led to an increase in crime, vagrancy and homelessness. Those claims are not without merit.

Photo: Adobe stock

“I mean, that’s some of the stuff that people don’t really think about,” said Sgt. Matt Webb, who has been on the Charleston Police force for 20 years. During a ride-along, Webb was tracking a case of a man who was stealing vehicles and using them in other crimes. He pulled into an office parking lot where about eight cars were parked around a side-by-side ATV – effectively making it impossible to access the off-road utility vehicle.

“It’s the bigger picture of the drug issues. Guys out stealing somebody’s side-by-side … those people probably work hard every day to try to take care of their families and have things like that, and here he’s trying to support his drug habit and he goes and steals a side-by-side.”

During the 2018 mayoral election, crime and safety related to the drug epidemic became a political theme.

“One of the issues we have in our downtown area and is not just perception — it’s become reality unfortunately — is there is a belief that there is a public safety issue in downtown Charleston,” said mayoral candidate J.B. Akers during a fall debate between him and then-candidate Amy Goodwin televised by WCHS.

Akers was publicly critical of the syringe exchange component of the Charleston harm reduction program during his campaign. In the months leading up to the election, the program increasingly became a politically charged, divisive issue.

This fall, the City of Charleston completed a $100 million renovation on the Charleston Civic Center. The Civic Center overlooks the Elk River and abuts the Charleston mall. On other side? The Kanawha-Charleston Health Department.

“That health department shouldn’t be there,” said outgoing mayor Danny Jones.

The Charleston harm reduction program happened once a week. And as the program grew, that meant up to 400-some patients were coming through in a six-hour period for needle exchange as well as getting vaccinations, testing for diseases and accessing family planning services, among other services. This volume was a big deal for the downtown community.

“Having a program that was outside the city limits or at least within the city limits but in a less trafficked place by regular business people and people doing shopping in the city of Charleston would be an important thing to do as well,” said former city health officer Michael Brumage. Brumage said one of the lessons learned from the program was that they’d likely rethink the location.

Over the last couple of years, complaints of vagrancy and a rise in a criminal transient population have increased — a change Jones attributes to the harm reduction program and the geography of the state.

“It’s the confluence of the interstates,” he said.

Charleston is at the intersection of two major interstates — 64 running east to west and 77 running north to south, which Jones said made it easy for people outside of the city to come in and utilize resources meant for residents.

“I know it’s been a long time since I’ve started this profession, but when I first began this profession, I knew of two homeless people in town,” said Sgt. Webb. “And now, I mean, they’re all over the place.”

Sgt. Webb said that addiction and a bad economy go hand-in-hand.

“I’m pretty certain that the addiction aspect of what we’re dealing with has a lot to do with the economy,” he said. “You know, when you’re down on yourself you look for ways to make yourself feel better. I’m far from a doctor, but I’m sure a lot of people who are out here addicted to drugs had some kind of traumatic experience or they’re trying to fix something.”

A few months after the program closed, a Facebook group started, called “Charleston Has Had Enough!”, where members post photos of other people using drugs, stealing packages, panhandling, etc. Now, almost one of every 10 Charleston residents is a member.

None of the ten administrators or moderators returned requests for an interview, but in a Sept. 16 post, one of the founders wrote: “Word is going around that this group is all about shaming junkies. Anyone who believes that is an idiot. No. This is a group about shaming the so-called leadership that got us in the mess, namely the Kanawha County Health Dept. who convinced the city that free needles were a great idea.”

Danny Jones is a member.

“It was a really bad situation for our city. Needles were everywhere. Property crimes went through the roof. And now that it’s over, our property crimes have gone way down,” Jones said.

That’s a slightly misleading assertion. Larceny — meaning theft of personal property — has actually fallen considerably from 2014-2017, according to data obtained by West Virginia Public Broadcasting from the Charleston Police Department.

Burglary/breaking and entering spiked in 2016 (the first full year the program was in operation) but then fell to pre-program levels the second full year the program was in operation.

Breaking and entering into a car has risen continuously since 2014. And there was a massive spike in auto crimes in 2016 and no decline during the program’s second year of operation. But data like this does not prove why some crime went up after the harm reduction program opened and some went down. And speculations only seem to divide community.

In an off-the-record conversation, a member of the Charleston Fire Department said the closure of the Charleston program had set the city back 10 years in terms of acceptance of harm reduction. How to move forward is a subject incoming mayor Amy Goodwin addressed in the October debate televised by WCHS.

“Leaders lead,” she said. “Leaders don’t take the blame or cast the blame on someone else. They look at what they’ve done wrong and they say, ‘let’s improve it.’ They look at something that may be a problem in the city and they work with everyone; they bring everyone to the table. They don’t villainize; they don’t marginalize folks.”

At this point, bringing everyone to the table is going to take a lot of work, but it’s not impossible.

“I would be interested in being on some kind of board where they hold discussions about trying to find answers to these questions,” Sgt. Matt Webb said. He said it’s really challenging working with a population struggling with addiction.

“It’s frustrating,” he said. “If we go to somebody’s house and they’re having a heart attack, we send them to a doctor and the doctor can hopefully fix their heart. They give them a heart cath, they give them open heart surgery, they’ll do bypass – whatever. When it comes to somebody who is addicted to opioids – a lot of times, I know it’s not true, but they give off the impression that they don’t want help but it’s because the addiction is so great they feel like they don’t want help.”

And if someone does want help, he said, it doesn’t get much easier.

“Are there beds available in rehab places? How are they going to pay for it? Those are sometimes hard answers to get.”

But whether a board is created to discuss these issues like Webb mentioned — or even if enough people are willing to sit down and really listen to one another to address the still present public health risk of needle borne diseases — remains to be seen.

This series was originally published by West Virginia Public Broadcasting. Read them individually: Part 1, Part 2, Part 3, Part 4 and Part 5

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Appalachia

A Regional Focus on Health Care, Community by Community

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Understanding Appalachia requires coming to grips with the complexities and challenges of rural healthcare.

It means understanding that addiction isn’t just an opioid issue, as methamphetamines make a comeback in our communities. It means understanding that health goals reflect a Maslow’s Hierarchy of Needs chart from one community to the next, and that how we define wellness is as diverse and place-based as other forms of Appalachian culture. It means understanding that there are no one-size-fits-all solutions in the creative ways that our communities tackle addiction, vaccines, mental health, access and affordability.

With support from Jim and Alexis Pugh, we hired a part-time editor/reporter for developing this beat. We’d like to introduce him to our readers and invite story pitches for tackling this topic together.

— 100 Days in Appalachia

Introduce yourself to the 100 Days audience. How does your background inform your perspective on health and health care issues in Appalachia?

I’ve been covering rural health throughout the Southeast for some years now. Appalachian born, in the mountains of Western North Carolina. I began writing about health care on a regular basis in 2008 with a series of articles on the breakdown of the mental health care system in North Carolina. I then began to more fully appreciate the complexity of health care issues and the range of repercussions of the decisions we make societally about health care.

I worked for a couple of years under a grant to cover rural health issues in North Carolina, and that job allowed me to spend a lot of time on two-lane roads – those roads William Least Heat-Moon coined the “blue highways” for the color in which they appeared on old Rand McNally maps. I’ve since been doing the same work as a freelancer, from the Finger Lakes region of New York to the Mexico border. I love driving those roads, realizing that I’m now somewhere I’ve never been before, then arriving at my destination and exploring how the issues this particular community is grappling with are the same and different as others elsewhere.

I’m looking forward to now returning my focus to Appalachia. I divide my time between Nashville, Tennessee, and Carrboro, North Carolina. I make the trek between those two cities every couple of weeks, and whenever I’m headed west and begin the climb up Old Fort Mountain or headed east and hit Pigeon River Gorge, I feel the tug. It’s less than a hundred-mile stretch, but it’s so distinctly Appalachia.

With 100 Days, I’m psyched to reorient along a roughly north-south axis, unfolding this region that ambles from Schoharie County, New York, to Kemper County Mississippi. Granted, much of this work will be done from my desk in Nashville or Carrboro. But I’ll always be looking forward to that next excursion.

Of course, not all of Appalachia is rural. I do enjoy Appalachia’s metropolitan areas, love discovering them anew, and look forward to further delving into their particular health care issues and successes.

Urban or rural, I’m intrigued by the role that place plays in the health care issues communities face and in their outcomes. I’m so looking forward to witnessing Appalachia.

When people see that we’re launching a health vertical, it might seem like we’re late to the game, that any number of outlets already have a strongly established focus on issues in this area. In what ways do you hope to lead the conversation about health in Appalachia?

Appalachia is facing some considerable health care challenges. In addition to the rising costs of care, rural communities are experiencing diminishing access to services, including hospital closures, and difficulties in recruiting health care professionals. Rural and urban communities alike have been particularly hard hit by opioids.

But Appalachia isn’t a monolithic region, and there are nuances to these issues from one sub-region to the next, from community to community. While underscoring shared concerns, I intend to draw out those distinctions. I most especially want to bring attention to the particular ways in which communities are finding solutions

When I write that I’m from Western North Carolina, I capitalize the “W,” as those in the region commonly do – because beyond identifying the region geographically, “Western” is an integral part of a proper noun, denoting cultural distinctions. I could ramble on about what those distinctions are – the libertarian instinct, etc. My point is that place matters. Murphy, North Carolina, in the far southwestern corner of WNC, is 355 miles from Raleigh, the state capital.

There are four other state capitals closer to Murphy. To assume that all North Carolinians share a sense of place, an identity, would be a mistake. I want to explore the contours of geography and culture, and how they shape health, health care, attitudes, practice and policies.  

I intend to report on the challenges individual communities are facing and their responses to those challenges, and on decisions that the federal and state governments make and the outcomes of those decisions – whether to expand Medicaid coverage, for example, and the implications of that decision.  

Are there any specific topics you think media outlets outside of the region do a bad job of covering here or that have perpetuated stereotypes of the people in Appalachia? In what ways do you hope to challenge those views?

I think there’s a perception that Appalachia is waiting for a handout, that people in the region are expecting the federal government to solve all their problems. I hope to help counter that narrative.

The first piece I wrote for 100 Days was titled “New Report Cites Economic Woes, Addiction and Optimism in Appalachia.” It was about the results of a survey conducted by the Robert Wood Johnson Foundation, National Public Radio and the Harvard T.H. Chan School of Public Health titled “Life in Rural America.” Those results underscored the loss of jobs and the scourge of addiction. But the researchers also found that rural Americans are largely optimistic about their future, placing their faith in a shared sense of community. I described how that sense of community is expressed in Moorefield, West Virginia.

I strive to take a solutions-oriented approach to my work. I’ve written about the closures, mergers and acquisitions of hospitals and the ripple effects they have on communities. That’s certainly an issue today in Appalachia. In reporting on these transactions, I’ve described how communities have responded – at times, rebelled.

I intend to tell the stories of ground-level, multi-fronted responses to the health care challenges Appalachian communities are experiencing.

The focus outside, and inside, the region, in terms of covering health in Appalachia, is largely focused on the opioid epidemic. In what ways do you hope to shine a new light or further the conversation around this topic?

I refer to my answer to the previous question: solutions. Whenever possible, I intend to report on solutions.

Recently, I attended a listening session hosted by the Appalachian Regional Commission in the small town of Wilkesboro, North Carolina. The objective was to discuss workforce issues related to the opioid epidemic. Participants brainstormed job-placement strategies and how communities can engage substance-abuse treatment programs, recovery initiatives and other services. They shared information on available resources in the community. People had driven up to three hours to attend – health care professionals, business owners, social workers, elected officials, academics, law-enforcement officers and plain-old concerned citizens. It was an impressive display of solution-oriented community resolve.

I’ve reported on naloxone initiatives, needle-exchange programs, law-enforcement assisted diversion programs and health care professionals assisting mother and child in alleviating the effects of neonatal abstinence syndrome, addressing the stigma attached to medical-assisted treatment. I’ve ridden along with a peer support specialist who helps former inmates in recovery and others who assist those exiting the criminal justice system.

I intend to remain attentive to programs focused on the treatment, care and recovery of those with substance-use disorders and on the prevention of addiction, but with an eye toward how we are solving these problems in our communities.

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Appalachia

Distress Grows For Ohio Valley Farmers As Trade Deals Stall

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Barry Alexander with a handful of yellow soybeans. Photo: Liam Niemeyer/Ohio Valley ReSource

This story was originally published by the Ohio Valley ReSource.

West Kentucky Farmer Barry Alexander doesn’t have an answer on when the Trump administration will reach a trade deal with China, now a year into tariffs that have hamstrung some Ohio Valley industries.

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Alexander is optimistic these continued negotiations will be worth it, but his plan in the meantime lies in massive, silver storage bins on Cundiff Farms, the 13,000-acre operation he manages.

He pulls a lever, and out tumbles a downpour of pale yellow soybeans.

Video: Liam Niemeyer/Ohio Valley ReSource

“These beans have been in here since Halloween day,” Alexander said. “The large bin on the right, that’s 350,000 bushels. The next-size bins down, that’s 180,000 bushels. To give reference, a thousand bushels is one semi-truck load.”

He’s been trying to hold onto about half of his soybean and corn bushels, waiting to see if he can sell for a better price before he’s forced to start planting again in early April.

Crop prices have crashed partly because of Chinese tariffs, and the losses have put a strain on some farmers he knows.

Barry Alexander, a lifelong west Kentucky farmer, in his small office. Photo: Liam Niemeyer/Ohio Valley ReSource

“There are farmers that have decided to retire because they didn’t want to work through these things now. We’re to that point,” Alexander said.

Alexander said he’s survived in part because his sprawling farm has resources to work with: eight full-time employees, two new $550,000 combines he traded up for, and the storage bins to help ride out bad crop prices.

“Our large structures are not cheap, but financially for our farming operation, they’re a necessity for us to do what we do,” Alexander said.

Farmers like Alexander are coping with losses from tariffs and a continuing trade war, and it’s not clear when it will end. A March 1 deadline for negotiations with China was delayed indefinitely by President Trump, and an agreement with Mexico and Canada that Trump signed in November has yet to be ratified by Congress. The retaliatory tariffs on U.S. crops and dairy remain, compounding problems caused by overproduction and low crop prices, and small farmers are suffering the most.

Massive, steel storage bins, half-full with grain, on Cundiff Farms in west Kentucky. Photo: Liam Niemeyer/Ohio Valley ReSource

Size Matters

“If you look at all the large farmers, these guys have the storage facilities to wait out bad prices,” Kent State University-Tuscarawas Agribusiness Professor Sankalp Sharma said. “For a lot of these small guys…they couldn’t actually store their commodity, they still had to deal with those lower prices.”

Sharma and others argue grain prices have been low for five years because farmers are overproducing, and tariffs are only making the situation worse.

“The United States soybean harvest this year in general was just crazy. There was a bumper crop, and prices were down because of that,” Sharma said. “This was just your classic demand and supply situation.”

Both Ohio and Kentucky set records for soybean harvests in 2018: 289 million bushels and 103 million bushels, respectively. This is up significantly compared to two decades ago, when Ohio harvested 162 million bushels and Kentucky harvested a little over 24 million bushels in 1999.

Farmers are also becoming more efficient than ever before — Ohio set records in 2018 for most corn and soybean bushels produced per acre.

Oversupply problems haven’t been limited to grains, though. Small dairy farmers are also dealing with excess supply and tariffs, with hundreds of cases of extra milk being dumped at Ohio Valley food banks.

Farms At Risk

Greg Gibson’s operation is small, but his family has made it work for decades. He milks 80 cows at his dairy farm in Bruceton Mills, West Virginia, and he took over the operation in 2002. The past year of tariffs hasn’t been easy.

“Everything’s down. Historically, if milk price is down you can sell some corn or you could sell some replacement animals are something,” Gibson said. “But nothing has a lot of value to sell right now, so it’s really hard to generate any additional revenue. And a lot of that is because of the trade problems we’re having.”

Like many Ohio Valley farmers, Gibson is receiving payments from the $12 billion in federal relief from the Market Facilitation Program intended to to help those who suffer losses from tariffs.

Small farms are squeezed by the dairy crisis. Photo: Nicole Erwin/Ohio Valley ReSource

Gibson appreciates Trump’s efforts to renegotiate trade deals, and like Alexander, is cautiously hopeful about the prospects of new trade deals.

But he said he’s also disappointed in Trump because the payments are not nearly enough to recoup his losses. He says milk’s price has plummeted nearly a dollar per hundred pounds of milk sold and the payments only reimburse 12 cents of that.

“I would have rather him said ‘I got to do this. You’re going to take the hit. Sorry.’ Don’t promise me you’re going to take care of me and then don’t,” Gibson said.

Some commodity associations including the National Corn Growers Association and the National Milk Producers Federation have called on the Trump administration in past months to bolster what they call lackluster relief payments.

Gibson’s squeezed budget has had him extend paying off his farm loans and put off paying several repair bills. He’s also had to put up his 150-year-old family farm as collateral for his loans.

Farm lenders say Gibson’s situation isn’t unique right now. Senior Vice President of Agricultural Lending Mark Barker helps oversee lending for Farm Credit Mid-America, which serves most of Ohio and Kentucky.

“Are we doing things differently? Well, sure,” Barker said. “Because we have customers coming in now and telling us ‘I’m struggling at this point. I’m challenged.’”

Barker said while most people are making their loan payments right now, the rapidly increasing amount of debt farmers are taking on to deal with depressed prices is concerning, especially for smaller operations.

“It seems like the larger producers, you think about their equipment and everything else, they’ve got some added advantages,” Barker said. “It doesn’t mean the smaller producer is necessarily ‘out,’ but I do think they got more challenges in this current environment.”

U.S. Department of Agriculture economists predict nationwide farm debt will reach $263.7 billion in 2019, levels of debt not seen since the 1980s farm crisis, when thousands of farm families defaulted on their loans amidst a trade embargo with the Soviet Union and high loan interest rates.

New Farmers

Tom McConnell leads the Small Farm Center at West Virginia University’s Extension Service and tries to help small farms succeed, in a state that has the highest proportion of small farms in the nation. He’s lived through the 1980s farm crisis and saw many dairy and beef farmers lose their farms.

He said one solution for small farmers to withstand these depressed prices is to switch to crops that bring a higher value, like vegetables. But those can be more labor-intensive, and the transition can be difficult.

“If you’ve been in a family that has milked cows or grown row crops for three generations, and I suggest you grow three acres of sweet corn and five acres of snap beans, there will be some resistance to that,” McConnell said.

McConnell said it might take a new generation to redefine what a successful small farmer business model can look like.

One of those younger small farmers is Joseph Monroe, who moved from Indiana to central Kentucky to raise beef cattle and grow tomatoes and greens. Monroe believes a way forward for smaller farms is to find ways to work together to sell products and have a greater market impact.

“I think there needs to be some pioneers and some examples out there of how to draw up a contract to work together,” Monroe said. “I think we need to throw all the darts and see what hits.”Share on Twitter

This story was originally published by the Ohio Valley ReSource.

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Appalachia

Plastics: The New Coal in Appalachia?

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Gas processing plants like this MarkWest plant in Butler County, Pennsylvania, separate natural gas liquids from natural gas. Photo: James Bruggers

With the natural gas fracking boom, plastics production is spreading in the Ohio River Valley. But at what cost to health and climate?

MONACA, Pennsylvania — Along the banks of the Ohio River here, thousands of workers are assembling the region’s first ethane cracker plant. It’s a conspicuous symbol of a petrochemical and plastics future looming across the Appalachian region.

More than 70 construction cranes tower over hundreds of acres where zinc was smelted for nearly a century. In a year or two, Shell Polymers, part of the global energy company Royal Dutch Shell, plans to turn what’s called “wet gas” into plastic pellets that can be used to make a myriad of products, from bottles to car parts.

Two Asian companies could also announce any day that they plan to invest as much as $6 billion in a similar plant in Ohio. There’s a third plastics plant proposed for West Virginia.

With little notice nationally, a new petrochemical and plastics manufacturing hub may be taking shape along 300 miles of the upper reaches of the Ohio River, from outside Pittsburgh southwest to Ohio, West Virginia and Kentucky. It would be fueled by a natural gas boom brought on by more than a decade of hydraulic fracturing, or fracking, a drilling process that has already dramatically altered the nation’s energy landscape—and helped cripple coal.

But there’s a climate price to be paid. Planet-warming greenhouse gas emissions from the Shell plant alone would more or less wipe out all the reductions in carbon dioxide that Pittsburgh, just 25 miles away, is planning to achieve by 2030. Drilling for natural gas leaks methane, a potent climate pollutant; and oil consumption for petrochemicals and plastics may account for half the global growth in petroleum demand between now and 2050.

Map: Ethane Cracker Plants on the Ohio River

Despite the climate and environmental risks, state and business leaders and the Trump administration are promoting plastics and petrochemical development as the next big thing, more than three decades after the region’s steel industry collapsed and as Appalachian coal mining slumps.

“We have been digging our way out of a very deep hole for decades,” said Jack Manning, president and executive director of the Beaver County Chamber of Commerce.

“When Shell came along with a $6-to-$7 billion investment … we were in the right spot at the right time,” he said.

Everyone wants jobs and economic growth, said Cat Lodge, who works with communities in the Ohio River Valley affected by the shale gas industry for the Environmental Integrity Project, a national environmental group. But not everyone wants them to be based on another form of polluting, fossil fuels, she said.

“While the rest of the world is dealing with global warming, Pennsylvania and Ohio and West Virginia are embracing developing plastics, and that just appalls me,” Lodge says. “It’s just not something I see as the future and unfortunately that seems to be the push to make that the future. And that’s upsetting.”

Lodge and her husband moved from Pittsburgh to the countryside 18 years ago in search of fresh air and open land. They have a small farm in a corner of rural western Pennsylvania, where winding roads trace the contours of Appalachian hills and a stark transition fueled by a shale gas boom is underway.

“We still love it, but little by little, and quickly over the last several years, we have become totally surrounded by the oil and gas industry,” she said.

Rising Demand, but Also Pushback on Plastics

The natural gas that’s pulled from deep underground in the Utica and Marcellus shale formations has done more than outcompete coal for electricity generation.

Drilling companies have also extracted a lot of natural gas liquids, particularly ethane, also called wet gas. It’s used to produce ethylene, which then gets turned into plastics, providing an additional revenue stream for the oil and gas industry. It’s the industry’s latest play, and it comes at a time when industry analysts and the federal government say the demand for plastics is skyrocketing.

Illustration: Plastics: From the Gas Plant to Your Home

“These materials are hooked into just about every part of the economy, from housing to electronics to packaging,” said Dave Witte, a senior vice president at IHS Markit, a global data and information service. “Today, the world needs six of these plants to be built every year to keep up with demand growth.”

IHS Markit calls the Appalachian or upper Ohio River region “the Shale Crescent.” Last year, it reported that the region’s gas supplies could support as many as five large cracker plants, like the one Shell is building. The plants “crack” ethane molecules to make ethylene and polyethylene resin pellets and would be in close proximity to a number of manufacturers that use those products to make everything from paints to plastic bags.

Chart: 3 States' Natural Gas Boom

IHS does see some headwinds, including an international backlash against plastics. It published a report last summer that found that worldwide pressure to reduce plastic use and increase recycling was one of the biggest potential disruptors for the plastics industry and was “putting future plastics resin demand and billions of dollars of industry investments at risk.”

The oil and gas industry might find themselves with stranded assets, needing to abandon Ohio River valley communities, said Lisa Graves-Marcucci, a Pennsylvania-based organizer for the Environmental Integrity Project.

“Do they really care,” she asked, “if they can make money for the first 10 years or 20 years of their operation, but then plastic goes away in the world? What happens to the communities that are left behind?”

She said she is also worried about such a major investment in oil and gas as the world grapples with the effects of climate change.

Visions of an Appalachian Plastics Hub

The idea for a plastics hub in Appalachia got a lift in December with a reportto Congress from the U.S. Department of Energy. It described a proposal for the development of regional underground storage of ethane along or underneath the upper Ohio River.

Storage is needed to help provide a steady and reliable stream of ethane to ethane cracking plants, and it would be important for the development of a regional petrochemical complex in the upper Ohio River valley, the report concluded.

Storage is another growing part of the plastics pipeline as natural gas is turned into natural gas liquids and eventually into plastics. Credit: James Bruggers
Storage is another growing part of the plastics pipeline as natural gas is turned into natural gas liquids and eventually into plastics. Credit: James Bruggers

A West Virginia business, Appalachia Development Group LLC, has proposed developing storage for ethane, possibly in mined salt or limestone cavernsdeep underground. It’s in the second phase of an application process for $1.9 billion in loan guarantees from the Department of Energy for the project, according to the department.

“We have sites of interest in Pennsylvania, Ohio and West Virginia,” said Jamie Altman, a representative of Appalachia Development Group. “We are aggressively pursuing private capital.”

The Energy Department is thinking big, too.

Its report projects ethane production in the Appalachian basin would continue rapid growth through 2025 to a total of 640,000 barrels per day, more than 20 times greater than five years ago. By 2050, the agency said ethane production in the region is projected to reach 950,000 barrels per day.

China Energy signed an agreement with West Virginia in 2017 to potentially invest $84 billion in shale gas development and chemical manufacturing projects in the state. Late in January, West Virginia’s development director, Mike Graney, told state senators that China Energy was looking at three undisclosed “energy and petrochemical” projects. An announcement could be made later this year, he said, though President Donald Trump‘s trade war with China was causing delays.

Other experts see a natural gas industry that’s subject to booms and busts and question whether the region is headed down another unsustainable path, like coal.

“We are less optimistic than the industry that this will really boom out,” said Cathy Kunkel, an energy analyst with Institute for Energy Economics and Financial Analysis, an environmental think tank that just published a reportdetailing how the natural gas industry in West Virginia hasn’t lived up to earlier expectations for jobs and tax revenue.

There is a huge amount of international competition for plastic production, she said. “All of the major oil exporting countries in the Middle East are talking about making massive investments in petrochemicals over the next five years or so,” she said. “That contains the risk that you will be exporting into a market that would be oversaturated with products.”

Increasing amounts of plastic waste are ending up in streams and oceans. Credit: Rosemary Calvert via Getty Images
IHS Markit, a global data and information service, published a report last summer that said worldwide pressure to reduce plastic use and increase recycling was one of the biggest potential disruptors for the plastics industry and was “putting future plastics resin demand and billions of dollars of industry investments at risk.” Credit: Rosemary Calvert via Getty Images

The Energy Department report also cited “security and supply diversity” as a benefit of developing a new plastics and petrochemicals hub in Appalachia. The bulk of U.S. plastics and petrochemical plants are currently along the Gulf Coast, where they face supply disruptions caused by hurricanes, it said.

Vivian Stockman, the interim director of the Ohio Valley Environmental Coalition based in West Virginia, called that a “hugely ironic” justification for an Appalachian plastics hub, since science is showing that global warming can intensify hurricanes.

Economic Benefits, with Health Concerns

The Shell plant was lured to Beaver County by Pennsylvania officials with some $1.65 billion in tax incentives. It’s scheduled to open “early next decade,” company spokesman Ray Fisher said. This year, as many as 6,000 construction workers will be working on it, and Shell says it plans 600 permanent jobs to run the plant.

It’s in Potter Township, a community with fewer than 700 residents. Rebecca Matsco, who chairs the township commission that gave Shell the local zoning permits, said she sees the plastics plant as an industrial upgrade from a dirty zinc smelter that had stood on the property for about a century, and that Shell cleaned up.

“It had become a real environmental burden, and we do feel like Shell has been a real partner in lifting that burden,” Matsco said.

Others, however, see the cracker plant as its own environmental burden—a new source of emissions that cause lung-damaging smog and heat the planet.

People in Pittsburgh were sad to see so much of the steel industry go, but they don’t miss the dirty skies, said Graves-Marcucci, an Allegheny County resident. The economic resurgence that followed was centered around health care, academic institutions and cleaner industries, she said.

Pittsburgh has been brushing off its sooty steel city past and is now pledging to slash its carbon emissions. But the Shell cracker plant alone, just 25 miles away, would emit 2.25 million tons of carbon dioxide a year, effectively wiping out nearly all the gains in carbon reduction that Pittsburgh plans to achieve by 2030, said Grant Ervin, Pittsburgh’s chief resilience officer.

The Shell plant will also emit as much smog-forming pollution as 36,000 cars driving 12,000 miles year; that would equate to about a 25 percent increase in the number of cars in Beaver County, said James Fabisiak, an associate professor and director of the Center for Healthy Environments and Communities at the University of Pittsburgh.

The environmental and health threats will only increase with a plastics hub buildout, and no regulators are looking at those potential cumulative impacts, Graves-Marcucci said.

Two More Communities Could Get Cracker Plants

About 70 miles southeast of the Shell plant, another community waits for news about what could be the region’s second major ethane cracker plant, in Belmont County, Ohio.

PTT Global Chemical, based in Thailand, and its Korean partner, Daelim Industrial Co., Ltd., could announce any day whether they intend to proceed with an ethane cracker plant after getting state permits in late December. That plant would be along a section of the Ohio River in Belmont County where hulking old manufacturing plants and shuttered businesses paint the very picture of the nation’s Rust Belt.

Bellaire, Ohio, is a few miles from another proposed cracker plant. Belmont County officials are waiting to hear whether PTT Global Chemical and its partner are going to invest $6 billion to build the facility. Credit: James Bruggers
Bellaire, Ohio, is a few miles from another proposed cracker plant. Belmont County officials are waiting to hear whether PTT Global Chemical, based in Thailand, and its Korean partner are going to invest $6 billion to build the facility. Credit: James Bruggers

“Do you know what the biggest export is from Belmont County? Our youth,” said Larry Merry, an economic development officer with the Belmont County Port Authority, overlooking the Ohio River bottomlands where the cracker plant would be constructed on the cleared-away site of a former coal-fired power plant.

Merry, who has been working to secure the plastics plant, called the oil and gas industry “a great employer for us that’s provided a lot of investment that’s helped.”

But it’s not fully made up for losses in steel and coal, and this cracker plant “is about jobs and opportunities so people can make the most of their lives,” he said.

He brushed aside any concerns about climate change or too much plastics. “How are we going to live and have products? Until you come up with a solution, don’t expect the world to shut down,” he said.

A spokesman for PTT American said he could not say when an investment decision will be made.

A third potential cracker plant is planned for Wood County, West Virginia, but it has been delayed because of unspecified “challenges” with its parent company, the Department of Energy report said.

“It just blows my mind that there could be three or four cracker plants, or even one,” said Steve White, a western Pennsylvania builder. “That’s some serious investment. It just shows you where everything is headed and how much development is coming.”

White is also a pilot, and he said he has observed from the cabin of a Cessna 3,000 feet aloft the spread of oil wells, pipelines and processing plants across shale drilling zones in Pennsylvania, Ohio and West Virginia, slicing up farms and encroaching on homes, schools and businesses.

“We are just in the way,” he said.

This article was originally published by Inside Climate News.

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