At the end of a long day on the inpatient service during my pediatric training in Cleveland, Ohio, I met with the medical team. As the senior resident in charge of three interns and a medical student, I reviewed the day’s events and made a to-do list for the intern on call that night. As we ran through the list of children on the unit, an attending physician, whom I will call Dr. A, appeared at the open door of the conference room, inquiring about a new patient admitted to our team under the neurology service.
Dr. A was a skilled neurologist and a kind man whom I considered a model of compassionate medical care. Whenever I called him at night with an urgent clinical question, he would dismiss my apologies for disturbing his sleep with a polite, “Not at all. How can I help you?” Having just been awakened well after midnight, he would then answer my question in a thoughtful and precise manner, making certain I understood his plan and rationale and encouraging me to call back if I needed further advice. That was the kind of doctor I hoped to become. I was further intrigued by his personal history. He emigrated from South Africa to the United States to escape the madness of apartheid. Though he arrived as a fully trained pediatric neurologist, the American medical system required him to start over from the beginning, a training regimen that I was told had been abbreviated when his brilliance as a physician grew clearer. By the time I arrived for my residency training, he was already a distinguished member of the pediatric neurology faculty.
The intern who had admitted Dr. A’s patient offered a brief description of what had brought the family to the hospital, what been done so far, and what test results we awaited. Up to that point, the intern’s presentation was spot-on. He then added, as if apologizing for not having more to share, “We are having some trouble communicating with the family. They have a severe case of WVE.” At this, I grimaced and turned to assess Dr. A’s reaction to what I knew was an egregious lapse in professionalism. His face impassive, Dr. A asked, “And what is WVE?” The intern, suddenly unsure of his standing, stammered in reply, “W-West Virginia Encephalopathy. It’s a term we use for the uneducated Appalachian families we get here.” I wanted to say in protest, “Well, it’s not a term I use,” but I held my tongue, waiting to hear how the neurologist would deal with the slur that people migrating from rural West Virginia to Cleveland’s west side suffered from a brain disease (“encephalopathy”), rendering them dull-witted and slow to learn. There came a long uncomfortable pause before Dr. A, speaking slowly and emphasizing his South African accent, said, “I’m from West Virginia.”
Other than the intern’s mortified facial expression I do not recall what followed, though I hold that exchange as a key teaching moment in my medical education. Residency—the long, arduous apprenticeship following medical school—can beat empathy out of the most compassionate person. Physicians who say they never met a patient who left them feeling angry or resentful are either selectively forgetful or campaigning for sainthood. Most of us, however, in remembering why we entered the profession, find a way to shake off bad experiences and recover a sense of mission, perhaps even joy. Why a doctor would choose to insult patients, making them into the irritant other, mystified me. I knew it was not enough to say the physician and patient are fellow, flawed human beings deserving of respect and courtesy.
Dr. A taught by example that a physician must identify with the patient and family, taking their part not only against disease and suffering, but against discrimination and disparagement. Many of the Appalachian families I cared for then and later in my career lacked my social and educational advantages—more likely a consequence of economic and historical factors than any individual failing—and these disadvantages rendered them prone to fall ill and die early. The same was true of the African American, Native American, and rural Honduran families I had the privilege to accompany. Those experiences prompted me to ask why these disparities existed and how I might participate in their redress. As Rudolf Virchow, the nineteenth-century physician, pathologist, and founder of social medicine, wrote:
Medicine . . . as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution: the politician, the practical anthropologist, must find the means for their actual solution. The physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction.
Dr. A and the lessons I learned from him have been on my mind since JD Vance’s selection as the 2024 Republican Vice-Presidential nominee reignited controversy over his memoir, Hillbilly Elegy: A Memoir of a Family and Culture in Crisis (2016). Though I am not of Appalachian descent, I was born and grew up in Cincinnati, forty minutes south of Vance’s boyhood home of Middletown. I returned to southwestern Ohio as a pediatrician, providing direct care for diverse, largely underserved populations for twenty years. I have lived and worked in Appalachian’s urban diaspora without being of it, and I have heard my fill from privileged professionals anxious to declare their intellectual superiority. Such people often speak as much from their ignorance as from lack of fellow feeling. Although face-to-face human encounters are the likeliest cure for a hard heart, willingness to learn can hasten a recovery already in progress. Books by themselves cannot change the unprepared heart, but a well-chosen book often sharpens and magnifies life’s lessons.
I had not read Hillbilly Elegy before Vance—Ohio’s junior senator with not quite two years’ experience in elective office—was picked as Trump’s running mate. Reading the book this summer, however, I recalled the buzz surrounding its publication, with strong opinions for and against. It was no surprise that Vance and I approach the issue of generational Appalachian poverty from different directions. I was educated early on by Jesuits, however, and I read Hillbilly Elegy with the “Ignatian presupposition” in mind, namely, “to be more eager to put a good interpretation on a neighbor’s statement than to condemn it.” Focusing on JD Vance the author while bracketing off Vance’s career as wealthy venture capitalist, ambitious politician, and belated acolyte of Donald Trump (a man he once called “cultural heroin”), I identified moments of goodness. Vance’s narrative—which topped the New York Times best seller list and was later made into a critically panned Netflix movie directed by Ron Howard—is often entertaining, sometimes deeply insightful and, on occasion, genuinely kind. Unlike the stories Vance-the-candidate now tells about immigrants—lurid tales of ignorance and depravity rather like those that I heard about Appalachian migrants while I was growing up in Cincinnati—his book often extends understanding and compassion toward people in difficult circumstances.
That Hillbilly Elegy criticizes federal welfare programs, which even at their best are blunt instruments of social change, neither surprises nor alarms me. I do not share Vance’s neoliberal convictions. Even by the principle of subsidiarity, there are times and circumstances where government assistance to those in poverty proves an efficient remedy. I agree, however, with Alasdair MacIntyre that the nation-state does not and cannot serve as ultimate guarantor of the common good. Yet I and many readers even slightly to the left of Vance-the-author part company with him over his uncritical use of the “culture of poverty” narrative that Daniel Patrick Moynihan and others wielded against African American families in the 1960s. The belief that nothing but the isolated individual’s grit and gumption ever lifted anyone out of poverty helped justify federal policy changes under the Reagan, George HW Bush, and Clinton administrations that—depending on one’s political views—either encouraged the poor to take “personal responsibility” for their social conditions or punished and shamed them for their plight.
What Vance largely ignores about Appalachia are large-scale structural problems: corporate greed (e.g. Purdue Pharmaceutical’s campaign to flood the region with addictive opioids), ecological devastation (e.g. mountain-top removal and unsustainable farming practices), grossly inadequate funding for rural health care and education, and the constant drain of regional talent to urban jobs, opportunities, and power centers. I do not fault Vance for embodying the assumption that anyone with real talent and ability will leave Appalachia for the big city. Countless others have done so. I do quarrel with his readiness to blame those who never got farther than Middletown or who stayed in dying remnants of a once-thriving rural economy. I have met too many hardworking people still mired in poverty to believe individual effort always triumphs over longstanding adversity. I am also disappointed—but not surprised—by Vance’s disregard for the many workers and labor organizers who stayed to do good and difficult work. Over the course of generations, these men and women struggled to better themselves and their neighbors, often only to see those efforts forcibly crushed by corporate-government alliances. It is not quite fair, however, to complain that the book at hand is not the one I would have written. Based solely on what Vance-the-author writes in his memoir, I find myself questioning his judgments, not doubting his character.
Yet Vance’s authorial voice and sympathetic tone won praise from conservative and liberal reviewers when the book first appeared. The Wall Street Journal approved of Vance’s emphasis on “religion, discipline, and family,” and his insistence that others “hold themselves responsible for their own conduct and choices.” Rod Dreher, a conservative writer and celebrity convert to Catholicism before moving on to Orthodoxy, wrote, “for Americans who care about politics and the future of our country, Hillbilly Elegy is the most important book of 2016.” A New York Times review claimed Vance offered “a compassionate, discerning sociological analysis of the white underclass that has helped drive the politics of rebellion, particularly the ascent of Donald J. Trump.” Lawrence Summers, who served as Secretary of the Treasury under Bill Clinton before becoming president of Harvard University, said of Hillbilly Elegy, “Anyone wanting to understand Trump’s rise or American inequality should read it.”
Such praise, I fear, reveals less about Vance’s book than it exposes the literary and political world’s ignorance of rural communities that dig the coal and raise the food urban Americans insatiably consume but choose not to think about. Like Harry Caudill’s Night Comes to the Cumberlands (1963) and Jack Weller’s Yesterday’s People (1965), Vance’s book explained—or explained away—a region that simultaneously repelled and fascinated observers across the political spectrum. Those more curious about Appalachian cultural otherness than their own harmful patterns of consumption and exploitation initially found Vance a genial guide to a region they otherwise happily ignored. Conservatives welcomed Vance’s “tough love” approach, content with his reassurances that “hillbillies” could become successful entrepreneurs if they only tried. When Vance’s politics proved more neoliberal than liberals liked—and it is crucial to recognize that what passes for liberalism in the United States is more neoliberal than it cares to admit—they turned against him, condemning Vance for blaming the poor while they then blamed those same poor for supporting Trump.
In a 2017 Salon article, Elizabeth Catte, a Tennessee-born historian now living in Virginia, named this the “liberal shaming of Appalachia,” citing commentators who decried America’s “hillbilly problem” after Trump’s election. Catte found in such commentary “reminders to those of us who live in these regions that we are equally loathed by both the right and the left.” In an NPR interview the following year, Catte faulted Vance for projecting “his realities onto the lives of everybody in the region,” while also calling out “strangers with cameras, people who come to the region maybe not just to see poverty but a particular kind of poverty that they need and want to find.”
Not everyone accepted Vance as a timely interpreter of Appalachian reality. Writers well-acquainted with the region in all its complexity responded in diverse ways. Some found merit in Vance’s book, seeing it as an opportunity for greater understanding. Kelli Hansel Haywood, whose website identifies her as Kentucky-based freelance writer, yoga instructor, and “spiritual/yoga/self-transformation guide,” claims Vance “dares to mention that, despite a myriad of grants, policy reform, and welfare relief thrown at these problems, we are experiencing the same issues we tried to address in the 1960s.” She concludes, “it’s time to stop debating whether Vance is right or wrong . . . we should be getting into the parts of the community that national reporters seem to find with exploitative ease and get the real story, claim it, and understand it.”
Others rejected Vance’s as a trustworthy interpreter of Appalachian reality. Some were particularly blunt. Ivy Breshear, a writer and community developer whose family has called Perry County, Kentucky home since before the Civil War, wrote, “Elegy has no class, no heart, no warmth. It’s a poorly written appropriation of Appalachian stereotypes about violent, ignorant, and slovenly hillbillies who refuse to help themselves despite having every opportunity to do so.” Others raised more targeted critiques. In 2017, Jared Yates Sexton, now a professor at Georgia Southern University, “The thesis at the heart of Hillbilly Elegy is that anybody who isn’t able to escape the working-class in essentially at fault. Sure, there’s a culture of fatalism and ‘learned helplessness,’ but the onus falls on the individual.” Elizabeth Catte expressed concern that several universities used Hillbilly Elegy as an instructional text, noting that most colleges in Appalachia had not followed suit, unwilling to give Vance “the final word on Appalachia.”
With all these reactions, one might wonder if Vance’s book resembles the parable of the blind men and the elephant, each critic extrapolating from a part in order to define the whole. Vance himself wondered as much in a new afterword added to the book in 2018, writing:
I’ve heard, for instance, from someone on the Left that my book is a victim-blaming piece of anti-government libertarianism, and then, in the very same week, from someone on the Right that my book’s premises, if accepted, would justify a massive expansion of government welfare programs. Both of these things can’t possibly be true.
Yet, in an election year when the Democratic presidential nominee embraces fracking and careens to the center in her economic policies while the Republican makes across the board tariffs a platform centerpiece and trims his rhetoric on abortion to the moment’s prevailing wind, perhaps both can be true.
Admittedly, Hillbilly Elegy’s subtitle, A Memoir of a Family and a Culture in Crisis, suggests Vance intended his book as a personal take rather than a comprehensive account. As I read Hillbilly Elegy, I began thinking about similarly accessible books that responded to, complemented, or counterbalanced Vance’s social analysis and judgements. A friend with Appalachian roots suggested the most obvious—and in many ways the best—choice, Appalachian Reckoning: A Region Responds to Hillbilly Elegy (2019). Featuring essays, poetry, and photographs from more than two dozen contributors, Appalachian Reckoning permits many voices—not all of them critical of Vance—to question, rebut, or move past simplistic accounts of the region’s presumed otherness. Indeed, several of the Appalachia-based authors I cited above are included in this remarkable volume.
Elizabeth Catte’s What You Are Getting Wrong About Appalachia (2018) uses data and illustrative examples to explore how outsiders disparage, disdain, and ultimately dismiss her region through stereotypes, cultural distortions, and “othering.” She complicates the standard “poor white trash” narrative with nuanced, realistic accounts of race, class, and gender. That said, her defense of Appalachia is clearly a personal matter, written in an urgent, angry voice that may strike some readers as ranting. There is much to be learned in these pages, but those searching for a dispassionate, scholarly analysis should proceed with caution.
To understand how the pillage of lightly populated but resource-rich areas corrupts character and community, I recommend Wendell Berry’s The Unsettling of America: Culture and Agriculture (1977). Berry hails from western Kentucky—outside Appalachia proper as defined by the Appalachian Regional Commission—and this book, a classic text, has little to say about coal mining, opioids, or presidential politics, but it remains the clearest account of the spiritual, social, and ecological costs of power divorced from place. Berry argues that American habit of fragmenting and exploiting the land
Has been accompanied by the growth of the idea that work is beneath human dignity, particularly any form of hand work. We have made it our over-riding ambition to escape work, and as a consequence have debased work until it is only fit to escape from. We have debased the products of work and have been, in turn, debased by them.
The consequences of this debasement extend throughout a culture like tendrils of fungus through a rotten stump, corrupting our understanding of community, bodily integrity and health, technology, social cohesion, and class. From its colonial foundation to this day, Berry claims, the United States has relegated land-based manual labor to those it scorns: the poor, the slave or indentured servant, the sharecropper, the “hillbilly,” the “rube,” and the migrant. Seen through Berry’s interpretive lens, the impulse to disparage the rural other as a problem to be solved or an obstacle to overcome becomes almost understandable, if no less dehumanizing.
Readers looking for layered fictional renderings of contemporary Appalachia can look to Demon Copperhead (2022), the latest book by the Kentucky-raised novelist Barbara Kingsolver. In this modern retelling of Charles Dickens’ David Copperfield, a young man in the mountains of Virginia endures family chaos, substandard schooling, an injury-shortened high school football career, opioid addiction, and more than his share of loss. Co-recipient of the 2023 Pulitzer Prize for fiction, the novel was generally well-received, though Lorraine Berry (no relation to Wendell Berry) of the Boston Globe called it “poverty porn,” making “the people of Appalachia into objects of pity, but in doing so, also intimates that falling into drug abuse, rejecting education, and ‘clinging’ to their ways are moral choices.” I do not share that assessment, but it suggests the challenges inherent in getting Appalachia right. I invite others to make their own judgments. Beautifully written in a convincing first-person male voice, Kingsolver’s five-hundred-page Bildungsroman is well worth reading.
Denise Giardina’s West Virginia-based novels, Storming Heaven (1987) and The Unquiet Earth (1992), span nearly a century of her state’s troubled history of coal mining as told through the eyes of multiple narrators. The daughter of a mine company bookkeeper and a nurse, Giardina drew on her childhood experiences in the coalfields to guide significant life choices, including labor activism, opposition to mountaintop removal mining, a campaign for the governor’s office as the official candidate of the Mountain Party, and ordination as a deacon in the Episcopal Church. In Storming Heaven, she braids the lives of her fictional characters with historical events such as the 1921 Battle of Blair Mountain, during which union organizers were ultimately defeated by US Army and company agents using planes, bombs, and poison gas. The Unquiet Earth takes a similar approach, incorporating the 1972 Buffalo Creek Flood, when a series of poorly constructed and woefully maintained company dams collapsed in heavy rains, killing 125 people and rendering homeless more than four thousand others. Through her novels, Giardina introduces readers to a history Vance barely mentions.
Another frequent lacuna in accounts of Appalachia—Vance’s included—is the fraught category of race. In 1991, after reading a dictionary definition of “Appalachian” as “a white native or resident of the Appalachian mountain area,” Frank X. Walker, an author, educator, and lifelong Kentuckian, coined the term, “Affrilachian” to push against the assumption that his region and its literature were uniformly white. More than thirty writers, visual artists, and musicians native to or residing in Appalachia have since identified with the term. Walker’s poetry collections, which include Affrilachia (2000), Black Box (2005), and Last Will, Last Testament (2019), render deeply personal experiences in clear, precise language. He also has a remarkable skill for the persona poem, with collections that bring to life the Civil Rights activist, Medgar Evers; a celebrated nineteenth century horseracing jockey named Isaac Murphy; and most vividly of all, York, who accompanied his enslaver, William Clark, as the only African American member of the Lewis and Clark expedition.
For other poetic voices, see Black Bone: 25 Years of the Affrilachian Poets (2018), edited by Bianca Lynn Spriggs and Jeremy Paden. As for Affrilachian fiction, I highly recommend Crystal Wilkinson, whose 2016 novel, The Birds of Opulence, chronicles successive generations of women in a Glack Appalachian township who contend with family secrets, judgmental neighbors, and the challenges of living off the land. Wilkinson’s prose borders on the poetic, rich with sensory image and telling detail.
I could go on, but that is a start. Any real solution to the othering of Appalachia will demand open hearts and minds, embodied encounters, and enduring relationships. In the meantime—and whatever the outcome of this year’s election—JD Vance will remain only one voice among many opening a doorway to this misunderstood region. It is not my place to tell someone not to read a book. For those ready to learn, however, particularly those wanting to transcend stereotypes, simplistic explanations, and a long tradition of romanticized squalor, a library of lively and readily accessible literature awaits.
