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I left my home state of West Virginia 30 years ago to embark on a career in internal medicine. What drew me back in 2015 was the opioid crisis — and the even bigger health crisis it is part of.

Opioid addiction takes a greater toll in West Virginia than in any other state. In 2016, the last year with complete statistics, a West Virginian was dying of a drug overdose every 10 hours. As a physician who helps manage the largest medical system in West Virginia, I’ve learned that as big as the opioid addiction crisis is in our state, it is not the root problem. Instead, it is a symptom of a much larger problem, one of hopelessness, isolation, and despair.

It’s this problem that must be addressed if we’re going to create a sustainable solution to the opioid epidemic and the state’s heavy burden of chronic disease. The good news is that in doing so, we can begin to transform the health of West Virginians for the better.


When West Virginia teachers go on strike demanding fair wages, coal miners are laid off, when kids see violence and abuse erupt around them, people begin to live in fear. That often pushes aside the basic building blocks of a healthy life, such as proper sleep, exercise, and nutrition. Taking their places are chronic stress and a mindset of scarcity.

To address the root causes of this epidemic, we need to look deeper, tap social and behavioral sciences, and transform the backward way we think about health care in the United States.


I have spent a good part of my medical career investigating the root causes of disease. That work has taught me that they go deeper than our health care system often acknowledges.

Right now a good chunk of the U.S. population— 45-to-55-year-old non-Hispanic white men and women — are dying at a rate not seen since the height of the AIDS epidemic. They are increasingly dying of alcoholism, overdose, and suicide.

Economists Anne Case and Angus Deaton of Princeton University analyzed U.S. mortality data from 1989 to 2013 to uncover those grim statistics, and collectively dubbed them “deaths of despair.” You can easily see them in West Virginia. Some of my own family members and friends in the state have been hit by this epidemic.

These deaths aren’t pinned simply to falling income. Case and Deaton found that they are linked to frayed social and emotional support, which can cause serious and, in some cases irreversible, harm to people’s health.

Chronic social stress can also shift the body’s physiology, predisposing people to disease. Behavioral psychologist Elissa Epel, Nobel laureate Elizabeth Blackburn, both of the University of California, San Francisco, and several colleagues evaluated two groups of well-matched mothers — one with chronically ill children and one with children in normal health. They speculated that the moms with ill children would be more stressed and would age faster biologically than moms with normal children. As predicted, they found that mothers who felt chronically stressed aged biologically up to 17 years faster than mothers who didn’t, as measured by the length of their telomeres — structures on the tips of chromosomes that resemble caps on the tips of shoelaces and that grow shorter as cells age.

The twist to this study is that the moms who aged faster biologically did so whether or not their children were sick. This means that what’s critical is not the stress we’re under, but how we perceive it.

Other studies support this, including the landmark Adverse Childhood Experience Study, in which researchers gave a 10-question test to adults asking about different types of trauma, neglect, family dysfunction, and other adverse experiences they had experienced as children aged 18 years and younger, then measured their incidence of chronic disease, addiction, overdose, and suicide.

Those with at least four such adverse experiences had attempted suicide 12 times more often than those who had no adverse experiences. Those with at least three adverse experiences had a life expectancy five years shorter than those who had none, and those with at least six had a life expectancy 20 years shorter than those who had none.

In West Virginia, life expectancy in the state’s southwestern counties is 20 years shorter than in the longest-lived counties in the nation. This suggests that our perceptions of our lives determine not only our risk of addiction, overdose, and chronic disease, but also our biological age. In other words, looking at life fearfully with a mindset of scarcity physically ages people, diminishes their health, and makes them prone to drug addiction and other ills.

Alternatively, if we look at our lives as full, abundant, and safe, we can reduce stress, improve our health, and maintain our vitality.

If we can address the epidemic of hopelessness and isolation in West Virginia and across the United States, we will also address our health crises.

At West Virginia University, we’ve begun trying to doing just that, using our state as a laboratory to test new solutions. For example, we’ve partnered with civic leaders in Harrison County to create a community-wide initiative called Healthy Harrison to rebuild the community and improve the health of the local population.

Healthy Harrison includes a workplace wellness program, an in-school walking program for both children and staff, and an opioid addiction program developed in partnership with local health care providers. Through the addiction program, we developed the first comprehensive guide to help individuals struggling with opioid addiction and public service ads for local television that tell the stories of people recovering from addiction. West Virginians are proud and stoic and self-reliant by nature and culture. But sharing our struggles helps remove the stigma, reframe our stories, and instill hope.

To be sure, reducing the supply of prescription drugs like Percocet and OxyContin, as well as illicit drugs like heroin and fentanyl, would slow the epidemic, as an in-depth analysis from the National Bureau of Economic Research suggested earlier this year. We also need to take the advice of President Trump’s commission on the opioid crisis, which advised him to rapidly expand treatment capacity.

The goal of these efforts is not to spend tons of money, but to do something different. We need to invest in health, understand what health really is, and determine how we can realize it.

More than 70 years ago, psychologist Abraham Maslow theorized that humans have a hierarchy of psychological needs that must be met to help us fulfill our potential. We need food, water, warmth and rest; we need to feel safe and secure, both physically and psychologically; and we need to feel like we belong and are loved.

Only then can we thrive.

When Anthony Bourdain, the late itinerant chef and storyteller, visited West Virginia not long ago for one of his final episodes of “Parts Unknown,” he described how “every meal might have begun with saying grace, but there was nothing hypocritical about it. People do care about each other. Friends, family, and the community are held close.”

When it comes to the opioid epidemic, and a host of other health problems, that could just be our state’s — and our nation’s — saving grace.

Clay Marsh, M.D., is vice president and executive dean for health sciences at West Virginia University.

Correction: An earlier version of this story misspelled the name of Anne Case.

  • Very important information, and precisely described — ” looking at life fearfully with a mindset of scarcity physically ages people, diminishes their health, and makes them prone to drug addiction and other ills.” It’s not all genes, nor public health like sewage and vaccines. I taught in poor inner-city public schools and much of the same despair is present that children bring from home into the classroom. The psychological ambience is evident in the aggressiveness and interpersonal denigration children are exposed to. Learning that a bullet came through a home window of one of my students, or of the incarceration of a father, or single parenthood, or drugs, or dropping off the child at six in the morning at childcare, or maybe a child who had to transfer because her mother could not afford a 35 cents per day bus fare. Incorporating all factors is important in determining quality of life and means to improve it. Low wages, sub-minimum living wages, lack of jobs equals a “mindset of scarcity”.

  • 30 years ago I was a different person hanging with the wrong people and had friends In WV conditions are deplorable in some areas. These folks still lived at the end of a holler with outhouses real ones in rickety homes that could hardly be called homes growing Pot on the top of the mountain. Some areas of WV should just be declared uninhabitable and the residents evacuated there are never going to be factories moving into these areas and the people are stuck in perpetual poverty.

  • This country is still in denial about the “Epidemic of Despair.” Physicians refused to acknowledge the damage done by years of economic deprivation. In many cases they used the economic status to deny necessary healthcare. They chose to blame the victims of the economic disparities rather than look at them. Reducing the supply of the prescription drugs in an ill advised manner led to thousands of deaths, including the suicides of people with chronic pain. The mass media portrayal of injured blue collar workers as “Losers” and the refusal to treat or count the number of people whose lives were ruined with an injury or surgery, helped to accelerate the genocidal “Epidemic of Despair.”

    This nauseating miscegenation of fact and fiction based on alternate facts, and Positive Psychology is exactly how we got here.

    • You have clearly established the framework and underlying justification for providers to address/include details on the psychosocial determinants of health or socio-economic determinants of health (SDOH) or socio-economic health disparities in each patient’s health record. These are the evidence-based and contextual elements that are essential to good patient care.

  • Until we cure the root causes leading people to use opioids, we are fighting a loosing battle. (Excluding those who are in chronic pain and need the relief to even live some semblance of a “normal” life.) Addiction to opioids and other drugs are the first attempt to solve the deeper problems facing these individuals. Once the effects of the addiction become “normal” and no other hope is available, then suicide or other life-destructive activities come into play. Jobs and the restoration of the family structure are needed.

    • Thank you for clearly articulating the crux of the issue, particularly as it relates to jobs and the restoration of the family structure. That said, the words of President Theodore Roosevelt resonate even more so today, “We stand for a living wage. Wages are subnormal if they fail to provide a living for those who devote their time and energy to industrial occupations. The monetary equivalent of a living wage varies according to local conditions, but must include enough to secure the elements of a normal standard of living-a standard high enough to make morality possible, to provide for education and recreation, to care for immature members of the family, to maintain the family during periods of sickness and to permit of reasonable saving for old age.”

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