There is tremendous inequality in the United States today. Unemployment is much too high, wages and income are too low, millions of Americans are struggling to find affordable health care, and the gap between the very rich and everyone else is growing wider.

One of the most striking examples of this inequality is the large and widening gap in life expectancy that exists around this country. Within a state or even within a single city, life expectancy can vary widely depending on the neighborhood. Every American is affected by these disparities. The U.S. spends more on health care than any other country in the world; however, Americans in nearly all age groups and in all social classes have shorter life expectancies than their counterparts in 16 other high-income countries (Institute of Medicine, 2013).

At the county level, Fairfax County, Virginia, which sits just outside of Washington, D.C., has the highest average life expectancy in the nation with an average of 82 years. Just 350 miles away in McDowell County, West Virginia, the life expectancy for men is just 64 years – an 18 year difference. Men in McDowell County have the same life expectancy as men in Namibia. For women, the county in the U.S. with the highest life expectancy is sunny and wealthy Marin County, California, where the average is 85 years. The lowest in the nation is Perry County, Kentucky, with an average life expectancy of 73 years – a 12 year gap. The life expectancy for women in McDowell County, West Virginia, where life expectancy is second lowest in the country following closely behind Perry County, is equivalent to that of Mongolia (Wang et al., 2013; World Health Organization).

Sabrina Shrader, from Athens, West Virginia, testifies before the Senate Subcommittee on Primary Health and Aging on November 20, 2013.

Sen. Bernie Sanders, who chairs the Senate Subcommittee on Primary Health and Aging, held a congressional hearing in 2013 on “Dying Young: Why Your Social and Economic Status May Be a Death Sentence in America.” In addition to receiving testimony from physician and research experts on health, economic, and educational factors that contribute to disparities in life expectancy, Sanders also invited Sabrina Shrader, a 30-year-old social worker born and raised in McDowell County to participate in the hearing and share her personal story.

To follow up on the hearing, two members of Sanders’ subcommittee staff recently made the six-hour drive from Washington to meet with Sabrina and see McDowell County and her hometown of Twin Branch firsthand. Sabrina currently lives with her husband in Athens, West Virginia, which is located in Mercer County, about an hour-and-a-half drive from Twin Branch. She works full time for a nonprofit civic engagement organization and is pursuing a Master of Social Work degree.

When Sabrina finishes school and returns to McDowell, as is her hope, she will be among the 5 percent of McDowell County residents with a graduate degree. Only 64 percent of adults in McDowell County have a high school degree or higher, compared to more than 85 percent nationally. Fewer than 6 percent of McDowell County residents have a bachelor’s degree or higher, compared to the national average of nearly 29 percent (U.S. Census American Community Survey).

McDowell County is not home to any colleges or universities whereas nearby Mercer County has five. Therefore, people have to leave the county in order to get an education, and many people do not have that luxury nor sometimes the desire. Residents take pride in their county. The cultural differences between two adjacent counties, like McDowell and Mercer, with differing educational and work opportunities are significant.

Historically, education has been a reliable path to the middle class and Sabrina is committed to furthering her education. “For me, I never knew what the middle class was,” she said. “When I see middle class people I think they’re rich. Because they can buy food, they can buy gas, and they can get a car, and they can get a house. That’s what I always thought rich was. And, at the moment, I still can’t do all that. We are trying to get there, but it takes forever. And you have to do so much work, and it ain’t even about all the work you’re doing. You got to get to the right people. You got to find people that believe in you and will help you or you ain’t going to get nowhere.”

With the decrease in coal mining jobs over the past half century, work opportunities have become more limited in McDowell County and the population has declined dramatically. The unemployment rate is twice the national average (U.S. Census American Community Survey). There are nearly 80,000 fewer people living in McDowell County today than there were in the 1950s, and the population of McDowell has decreased by 38 percent in the past two decades alone (U.S. Census).

McDowell County is among the poorest counties among the poorest states in the nation. More than half of McDowell County households have incomes below $25,000 compared to one-quarter of households nationally. The median household income in McDowell County is under $22,500 – less than half the nearly $52,000 median household income at the national level. One in three families in McDowell are living in poverty, including more than 40 percent of those with children under 18 and more than 60 percent of those with children under five (U.S. Census American Community Survey).

Residents of McDowell County have limited Internet and phone access and face serious transportation challenges for meeting even the most basic needs. Those able to pay the high Internet service fees find themselves without working service for days at a time. Phone service is spotty at best and even landlines are unreliable during rainstorms. There are extremely limited options for public transportation and the winding two lane roads can be dangerous and sometimes impassable when weather is bad. There are very few grocery stores or gas stations and those goods services that are available are more expensive with fewer options than in other places. “There is a Walmart down here,” Sabrina said, adding “Walmart down here does not have the same food as the Walmart in Mercer County and it’s very expensive. The food down here [in McDowell] is basically all processed food. Even if people can get to Walmart, it’s a long drive to get there, and that’s it.”

Director Linda McKinney and her husband Bob McKinney stand outside of Five Loaves and Two Fishes Food Bank in Kimball, West Virginia.

At the Five Loaves and Two Fishes Food Bank in the McDowell County town of Kimball, Director Linda McKinney, her husband Bob, and their family know they must be resourceful to meet the needs of all in the community that rely on their services. There was a handmade sign in the window that said that they had distributed 32,000 pounds of food and produce in June 2014 to 1,235 individuals from 419 families, many of whom are, as Linda described, “the working poor.”

Fresh produce is a new addition to their offerings thanks to a partnership with West Virginia State University. The garden adjacent to the food bank produces plump fruits and vegetables and provides an opportunity to educate about gardening and healthy eating. There’s a large walk-in cooler where Linda could keep more fresh food, but the cost to keep it refrigerated would be prohibitive so for now it’s used for additional storage. Five Loaves and Two Fishes has a large supply of nonperishable food items and diapers, clothes, and other staples for young children. The food bank is clean, well-organized, and welcoming with a lobby designed so “you feel like you’re at home.”

Linda cooks on the dime for anyone who strolls through the door. When Senate staff arrived one day midweek in late July, just two weeks after Linda’s first grandchild was born, there was freshly prepared chicken salad. “We are certified with the state and then we cut out this wall so that in times of disaster we can cook and serve here.” Natural disasters are a way of life in McDowell County and the food bank serves as ground zero for disaster relief efforts, ensuring that residents get the goods and services they need. Five Loaves and Two Fishes also houses an exercise room where Linda and her daughter teach classes such as Zumba.

Clothing donations ready for distribution at Five Loaves and Two Fishes Food Bank.

While they are getting by through donations from local companies, significant challenges, similar to those experienced by people who rely on their generosity to meet basic needs, remain. For example, Linda described a proposed 17 percent increase in their electric bill that would threaten them to close their doors if enacted. This same rate increase would leave hundreds of food bank customers without power, including access to heat and safe drinking water, what amounts to a death sentence for many in the region.

A long cave tunnel which rests in the middle of a mountain, marks the entrance to Twin Branch Hollow, which was founded by Henry Ford as a mining community in the early 1920’s. While The New York Times reporter Trip Gabriel described much of McDowell County as “like a rural Detroit, with broken windows on shuttered businesses and homes crumbling from neglect,” Sanders’ staff found it green and beautiful. It is clear just by driving through that neighbors know and care about one another like family and take pride in their community.

Alma and Randy McNeely, who Sabrina calls Maw and Paw, reside at their home near Twin Branch in Hensley, WV along with their 11 dogs. Paw is 51 and Maw is 50. They are raising one of their grandchildren, Emalee Short, who is 16 and aspires to be a marine biologist or veterinarian. Maw and Paw have strongly encouraged Emalee to gain the highest education she can and always follow her dreams, even if that means she has to leave McDowell County and come back later. Emalee’s three younger siblings are raised by her other set of grandparents. The number of grandparents raising grandchildren in McDowell County is well above the national average. Sixty percent of grandparents are responsible for raising their grandchildren compared to fewer than 40 percent nationally. It is not uncommon for grandparents to be in their 30s or 40s. Teen pregnancy rates are among the highest in the country.

A cave tunnel marks the entrance to Twin Branch Hollow.

Nearly one in ten teenage girls in McDowell County will have a baby.

Sabrina’s best childhood friend Heather Wingate, age 29, shared vegetables from her garden. As she tended to her two small children, she described the substance abuse issues that plague McDowell County. McDowell has the highest rates of drug overdose deaths in West Virginia. She said it is difficult to maintain friendships because so many in the community are involved with drugs and the lack of available addiction treatment options poses serious challenges for those who are motivated to recover. Although, there are many challenges for people who live in McDowell County, the residents are passionate and talented. Heather’s craft is taking old and broken pieces of wood and turning them into masterpieces. She hopes to develop a successful business where she can create functional art pieces.

Sabrina Shrader (middle) wraps her arms around Randy (left) and Alma McNeely (right), in front of their home in Hensley, West Virginia.

Access to primary medical and dental care is also extremely limited. Nearly 40 percent of McDowell County residents report that they have fair or poor health making it the county in the state with the poorest self-reported health. Rates of smoking, obesity, and physical activity in McDowell are among the worst 10 percent of all counties nationally.

Fortunately, West Virginia is one of the 27 states that has currently expanded its Medicaid program. More than half of McDowell County residents have public health insurance coverage compared to three in ten people nationally (U.S. Census American Community Survey). While the expansion of health insurance in West Virginia will help to improve access to care for low income residents in the state, and may ultimately improve health and longevity, there remains a severe shortage of health professionals including nurses, doctors, and behavioral health providers in communities like McDowell County that may challenge efforts to improve the health of the population. Moreover, researchers recognize that other factors, such as education and income, which are often determined by where a person lives, also play a critical role in determining the quality of life and how long a person will live.

Until we recognize and address the social and health-related factors that contribute to life expectancy and strengthen the safety net, places like McDowell County will continue to fall behind. While it has long been assumed that life expectancy will increase and that future generations will live longer and healthier lives than their parents and grandparents, between 1985 and 2010, the life expectancy in McDowell County decreased by 1.7 years for women and 1.4 years for men. While no one gets to choose where they are born, and many Americans do not have the luxury of picking up and moving to a community with better schools or jobs, where you live matters for your health and life expectancy, perhaps more than anything else and more than ever before. At a time when the rich are doing phenomenally well and life expectancy overall appears to be on the rise, we must not forget places like McDowell County.