Karen Foli is a Nursology.net Advisory Team member

The miles of unbroken greenery, lush and velvety, can be deceiving. As I look out of the car window, gossamer mists float up high as mountains breathe in the morning air, stretching across miles. The natural beauty of the Appalachian Mountains in eastern Kentucky and Virginia seduces you with its beauty. Graveyards are overflowing with bouquets left by family and friends to honor their people. Surely a place with such quiet and color is a good place. Yet the purpose and uses of what was once considered widely popular, have now faced backlash. The kudzu, a Japanese vine imported into the South in 1876, once considered essential to mitigate erosion of the steep landscape, has now become a threat to the natural habitat. So too, coal that was once used freely as a source of energy in the United States, has now been usurped by cleaner energy sources. Despite these faltering presences, time tends to favor the old habits and old ways of living. This ancient place desperately needs to move forward but how to do this is far more complicated and pocked by loss.

We are going to visit family in a once booming coal mining town and have made this trip many times. A few decades ago, families thrived here and children received a good education and grew up to obtain good jobs. The mines provided salaries to purchase goods and services, fueling a livable economy. These salaries made way for small businesses to open and stay in operation. But everything has changed since the heyday when coal was an in-demand energy source.

Rural places have a heterogeneity to them that we often overlook. Some are agriculturally based; others are tourist areas. This is coal country. We pass coal cars, loaded and awaiting departure on the railroad tracks. So much coal in one place, pieces black and shiny like faceted gems. Closer to town, hollers stretch across prized level lands at the base of mountains with rows of houses side-by-side; cul-de-sacs and subdivisions have no meaning here. Directions are offered by buildings, often Baptist churches and bridges stand for places to turn, not GPS phones because internet signals are unreliable and often absent. The gas stations provide the closest thing to restaurant foods. Hot “miner sandwiches” made of generous sausage and egg on a biscuit, look enticing through the steamed glass at the checkout. The clerk smiles at you and recognizes the “northern” accent you cannot hide. But they are kind and welcoming despite knowing I am not a local.

And I am reminded of Winters and Lee’s Rural Nursing Theory (Winters, 2021) that explains so very much here. In this place, health means the ability to work, to be productive and to perform usual tasks (Long & Weinert, 2018). Silent conditions that endanger well-being are discounted as long as the person can get out of bed to clock into their jobs and ride the coal car below the earth. Social capitol means survival in a place that isn’t easy to live (Lee & McDonagh, 2018). Who you know and who they know can mean the difference between having transportation, housing, and food and not having basic resources. Those with connections become elevated in this society where wealth means more than money. It’s the ability to survive with the help of others.

The “backstage” (Goffman, 1959) of the town is present and becomes impossible to ignore. Dead animals’ carcasses, dog and deer, wait to feed eager and hungry wildlife. A distant gunshot echoes through the hills. Birds scatter as we drive past. Mobile homes and tin buildings that you are convinced could not be habitable have hands fluttering in the windows as thin curtains are pulled shut and lights turn on as evening approaches. I offer a silent good-bye to homes that have collapsed into their walls, folding upon their structures until grass and bushes obscure their humiliating demise. Thin, weary looking people give furtive glances as they shop for groceries. Their smiles and grimaces often reveal gums where teeth once were. Bears have become more aggressive and migrated down toward homes, hungry and preparing for hibernation. Trash is locked up and placed away from homes. Poisonous snakes pool in the rainwater puddles in driveways.

County warnings of metal contamination of water, arsenic and other metals, creates a demand for bottled water. Climate change has created flooding, once rare, now not uncommon. Winters are harsh with snowfalls and ice making the rounding and steep roads even more precarious. And you will drive here. Distance is part of rural living (Lee & Winters, 2018). Getting to town is at least 30 minutes and to a city means at least 90 minutes of hard driving. The local hospital, nestled into its own holler, is on life support itself, a critical place for residents to receive care without hours-long drive.

And yet, I sense a deep desire to survive in this place, to continue because, in addition to the mountains, there is beauty within the people who live here. So many of the young have left with older adults clinging onto what once was. Clans and what they represent pull those who leave back into the fold, even if only for a visit. Those who have passed are revered for what they sacrificed for their families, men who endangered their lives deep in the recesses of the coal mines. There is unconditional acceptance here. You are their people and no matter your disabilities or weaknesses, you are part of something that cannot be erased. You are home and accepted, and part of a culture to take pride in.
Despite being outsiders, we are invited to the weekly Sunday dinner because of who we’ve come to visit, an insider. We are advised to avoid speaking of specific ideological beliefs. And we respect our hostesses and that this is their home and we are guests. Some of the prepared dishes are from vegetable gardens whose bounty has been canned, and it is all delicious: corn casserole, fried chicken, greens, mashed potatoes, and barbeque ribs with apple or peach pie for dessert. Offers to “clean up,” are shooed away. We are guests. And I feel this presence of being valued and a community that is perhaps not as readily available in the north. Still an outsider looking in, I see its beauty. There is history and acceptance and affinity, a sense of belonging, to being an insider and an old timer (Lee & Winters, 2018).

Yet recognition of what was and what is now cannot be avoided. The work of Winters and Lee (2021), based on decades of empirical study, opened a new way of thinking about rural dwellers. How access, availability, and distance is framed makes sense within this theory. Old timers versus newcomers; outsiders versus insiders; social capital; and the meaning of health were made sense of through Winters’ and Lee’s work (Winters, 2021). Nursing theory allows me to understand this place, these individuals, and opens my humanity in ways that otherwise would not be possible.

As we leave and I once again stare out the window, I see the beauty of the mountains, trees tipped with the color changes of the fall season, the creek that runs at the bottom, and I see the beauty of the sweet people who reside in the hollers. I feel honored and humbled that I was able to sit at their kitchen table and share a meal as a novice insider, if only for a brief point in time. The one thing I cannot escape upon my departure is a feeling of sadness, loss, worry, and futility, about the inevitable abandonment to a way of life that is disappearing.

References

Goffman, E. (1959). The presentation of self in everyday life. Vintage.

Lee, H. J., & McDonagh, M. K. (2018). Updating the rural nursing theory base. In C. A. Winters & H. J. Lee (Eds.), Rural nursing: Concepts, theory, and practice (pp. 45-62). Springer.

Lee, H. J., & Winters, C. A. (2018). Rural nursing theory: Past, present, and future. In C. A. Winters & H. J. Lee (Eds.), Rural nursing: Concepts, theory, and practice (pp. 3-15). Springer.

Long, K. A., & Weinert, C. (2018). Rural nursing: Developing the theory base. In C. A. Winters & H. J. Lee (Eds.), Rural nursing: Concepts, theory, and practice (pp. 17-30). Springer.

Winters, C. A. (Ed.) (2021). Rural nursing: Concepts, theory, and practice (6th Ed.). Springer.