Lee County, Virginia, is presented as both an early-warning site in the opioid crisis and a rural community where its consequences became difficult to separate from longer-standing poverty and poor health. Art Van Zee warned Purdue Pharma about the danger there in 2000; years later, the movement from prescription opioids to heroin, and the spread of infectious disease associated with injection, made the warning’s reach clearer.

Setting and early warning

During a visit to Lee County, Art Van Zee drove the author through coal camps west of Wise County, Virginia. The landscape included caved-in structures, cracked windows, Confederate flags, and burned-out houses left unrepaired. The author described the scale of the desolation as startling so close to home, while Van Zee cautioned that severe poverty and poor health were not confined to the small communities in view. In Appalachia, he observed, those conditions were increasingly hard to recover from.

The county had figured in Van Zee’s concerns long before that visit. In November 2000, he wrote to Purdue Pharma that he feared Lee County was a sentinel area, comparing its significance to San Francisco and New York City in the early years of the HIV epidemic. At the time, he could not know that the OxyContin epidemic would become a heroin epidemic, followed by further deaths from HIV and hepatitis C. The book uses the letter as an early warning whose implications emerged over time.

From prescription opioids to wider harm

Lee County’s crisis forms part of a broader transition described across the book: some people began with prescription pills and later turned to heroin, while the drive to avoid withdrawal helped sustain use and the circulation of drugs. The account does not reduce that change to individual decisions alone; it connects the spread of addiction with supply, social conditions, and gaps between health care and criminal justice.

The later consequences sharpen the meaning of Van Zee’s warning. The rise of heroin was accompanied by renewed HIV concerns linked to shared injection equipment, as well as hepatitis C. The sequence—from prescription-opioid exposure to heroin use and infectious-disease risk—makes the county’s sentinel status a description of interconnected harms, not merely of one drug or one period.

Rural conditions and unequal responses

The coal camps place the epidemic within the economic distress of rural Appalachia. The book contrasts these communities with the history of urban poverty shaped by deindustrialization, segregation, and urban renewal, while noting that rural areas had also come to face severe economic hardship and high drug, alcohol, and suicide mortality. Lee County’s setting therefore resists the idea that the crisis belonged only to cities or could be understood apart from the conditions in which people lived.

The book also examines unequal treatment within the national response. It reports that people of color were prescribed opioid painkillers at lower rates than white patients, while Black and Hispanic people were disproportionately represented among federal drug offenders. These national patterns complicate any account that treats opioid exposure, policing, and treatment as evenly distributed. They frame Lee County’s story within a wider argument about how medical decisions and criminal enforcement can produce different risks and consequences for different communities.

Treatment and significance

By 2017, Virginia health officials were working both to expand medication-assisted treatment and to curb its misuse. One model was Highpower, a Suboxone clinic in Lebanon, Virginia, established by Dr. Hughes Melton to serve people with limited access to care. The state’s efforts also included a push for syringe exchange and tighter controls on medication-assisted treatment prescribing. These measures reflect the difficult balance between making treatment available and addressing diversion, a problem the book places within a longer American history of changing drug treatments and drug control.

Lee County’s narrative significance lies in the distance between warning and recognition. Van Zee identified a possible sentinel area before the later sequence of heroin-related harm and infectious disease was visible in full. The landscape of the coal camps and the history of the epidemic together show why a crisis can be present long before institutions respond to it as connected, preventable, and public-health-related.