Coal mining has always been boom-and-bust, but it is hard to shake the feeling that this might be the last bust. Some men picked up and left at word of mining jobs elsewhere, some went to work as linemen or truck drivers, and others, figuring they were too old or physically broken to start over, just dropped out of the labor force. It was as if the very identity of a Letcher County man had been declared insolvent.

“I could always tell the man who worked in the mines,” said Debbie Baker, a cleaner in Whitesburg, the Letcher County seat. For one thing, “they had money.”

She recalled a family who lived comfortably where she grew up; the father worked underground and his sons followed, one by one. “The next would get old enough and get a wife and go working in the coal mines,” she said. “I don’t think any of the men did anything else.”

“When the mines left, they all ended up on drugs,” Ms. Baker added. “And their women went to work.”

Women in coal country always found paying work in greater numbers during the lean times, cleaning houses or making burgers, earning enough to get the family by until the mines picked up again. When that happened — and it always did — wives often returned home or cut back on hours because they could and because someone had to, child care being an elusive commodity. But just tiding the family over is not enough anymore.

There is little hope of finding work that could replace a miner’s income; women in Letcher County still on average make substantially lower salaries than men. But in a place stricken by chronic disease and opioid overdoses there is one area where workers are in constant demand: health care. Signing bonuses for nurses can reach into the five digits.

It is impossible to miss driving into Whitesburg. Heading in from the east, there is an outpatient mental health clinic taking up a roadside mall and then, on a perch overlooking downtown, the county’s major hospital, founded by the miners’ union in the 1950s and recently expanded. Coming in from the west, there is a brand-new heart, vascular and neurology clinic that opened in the old Super 8 hotel building, and just beyond it, across from the grocery store, is the 75,000-square-foot Mountain Comprehensive Health Corporation clinic.

This is the region’s economy now, and its work force. At the regional network of M.C.H.C. clinics alone, there more than 110 nurses, according to Mike Caudill, the chief executive. Four of them are men.