Rural America is already dealing with many other infectious diseases: hepatitis B and C, HIV due to needle sharing from injection drug use, and chronic diseases like obesity, cancer, and diabetes. A 2014 study demonstrated the widening health disparity between rural and urban areas, showing a life expectancy of 79.1 years in large metropolitan areas, 76.9 in small urban towns, and 76.7 in rural areas. The opioid crisis has disproportionately driven down life expectancy in the rural U.S. because of drug-overdose deaths. Other “diseases of despair,” as described by the Princeton professors Anne Case and Angus Deaton in 2015, including heart and lung disease, stroke, Alzheimer’s, diabetes, and suicides, have been on the rise in the rural heartland as well.

In our clinics in Kanawha County, we see people from every walk of life. We have many elderly patients with chronic illnesses and conditions such as obesity and heart, lung, and kidney disease. We also have a large and growing medication-assisted treatment program for people in recovery from opioid use. We see the homeless and the working poor. We provide a pulmonary rehabilitation center for coal miners who have black lung and other occupational lung diseases. Our school-based health staff help children afflicted by the opioid crisis. All of our providers also advocate for those without adequate transportation and for children who rely on schools to keep them fed. We provide this care even as the system as a whole faces cuts.

While West Virginia ranks among the highest in the number of hospital beds per 1,000 people in the nation, several rural hospitals in the state have closed. In late February 2020, Fairmont Regional Medical Center, an acute-care facility of 207 beds in my hometown, announced its closure. Across the country, a record 18 hospitals in rural areas shut down in 2019, and 161 rural hospitals have closed since 2005.

Read: America’s rural hospitals are dangerously fragile

Public-health systems in rural states like West Virginia also rely on financial backing from the federal government that is not always forthcoming. Through the Prevention and Public Health Fund, the Centers for Disease Control and Prevention funneled roughly $625 million a year to state and local initiatives, such as immunizations for children, grants for local needs, and programs to respond to infectious diseases. However, according to a Trust for America’s Health report, from 2013 to 2027 the fund will receive nearly $12 billion less than the law had promised. Also within the CDC, a program that helps state and local health departments prepare for and respond to emergencies has lost nearly 30 percent of its funding since 2002, except for a short-term increase in funds to address the Ebola and Zika outbreaks.

Sixteen states have decreased their public-health budgets over the years. According to a 2016 analysis by Trust for America’s Health, the median state funding for public health was $33.50 a person in the 2015 fiscal year. Nevada was the lowest, at $4.10 a person, while West Virginia spent the most, at $220.80. But the report notes, “Only 7.1 percent of adults have diabetes in Utah compared to 14.1 percent in West Virginia, and only 10.3 percent of adults in Utah are current smokers compared with 27.3 percent in West Virginia.” Shrinking local health-department budgets compound the problem. In 2016, the state government proposed cutting aid for local health departments by 25 percent.