A DYING TOWN

Here in a corner of Missouri and across America, the lack of a college education has become a public-health crisis.

Drive 90 miles north on Interstate 55 from Memphis, then 20 miles west on Route 412, cutting through seemingly endless fields of cotton, rice, and soybeans. You’ll know you’ve arrived when you see the sign: Welcome to Kennett. Hometown of Sheryl Crow.

This small town in southeastern Missouri used to greet visitors with a different motto: "Service. Industry. Agriculture." But the machine-parts-maker closed and the trailer manufacturer left and the aluminum smelter went under. There’s not nearly as much industry around here as there used to be. Sheryl Crow’s Grammys aren’t going anywhere.

Route 412 becomes First Street, and downtown opens up with a McDonald’s to your left and a Burger King to your right. There are just two grocery stores in town, but fast-food restaurants are everywhere. It’s easier to find a pharmacy than a salad bar.

Outside the row of medical offices that border the hospital, people pause for one last smoke. Mr. Chan’s still sells doughnuts and kolaches, and Riggs Supply is, somehow, holding on, but there are many boarded-up storefronts along First Street these days. Down the road, a branch of the local college offers programs in education, criminal justice, and agribusiness. College-going isn’t so common, though. In this area, just one adult in 10 has a four-year degree.

Recently the town tried to revitalize the area around the old county courthouse. It added new streetlights and redid the sidewalks. But few people use them.

This is the Missouri Bootheel. The counties around here are called that because if you squint at a map, it kind of looks like the heel of a boot, jutting south from the rest of the state into Arkansas and Tennessee. The name comes from its shape, but it’s something of a metaphor, too. It can sometimes seem like life is trying to grind people down.

It’s a place, one of many in America, where disadvantages pile up. Researchers are uncovering links between education — or lack of it — and health, and they don’t like what they see. It’s not clear whether a college degree leads directly to better health, or, if so, how. But the findings are alarming: Educational disparities and economic malaise and lack of opportunity are making people like those in the Bootheel sick. And maybe even killing them.

Doctors’ visits and health checkups set the cadence of Annie Walters’s and Jim Anderson’s days.

If it’s Monday, it’s time for the visiting nurse, who checks Annie’s blood pressure and arranges a medicine tray with the many pills she’ll need for the week ahead. Twice a week they drive from Cooter, population 469, up the road to Kennett so she can have her legs unbandaged and bandaged again and medicated wraps applied to soothe the ulcers that blister her calves.

Routinely they see Dr. Abdullah Arshad, who treats Annie for chronic obstructive pulmonary disease, or COPD, the progressive lung ailment that robs her of breath and tethers her to an oxygen tank. They’re grateful that trips across state lines are less frequent these days, to see the specialists who monitor her kidneys and her lungs. Then there are sessions with physical therapists, who put Annie through exercises to build up leg muscles atrophied by periods when she’s been on bed rest or had to use a wheelchair to get around.

Their days have been like this going on eight years, ever since Annie developed a blood clot in her lungs and Jim quit his job to care for her full time. The pair aren’t married — Annie, who has been married six times, wouldn’t say yes — but Jim is devoted. He cooks all the meals, worrying that she could fall while balancing on her walker at the stove. He makes sure she gets exercise. In case the power goes out, he has stockpiled extra oxygen tanks, four large, six small.

Jim is Annie’s primary caregiver, but he’s had assistance since his own health scare. Bypass surgery five years ago — not long after his 58th birthday — has left him with five stents in his chest and a scar now just barely visible above his neckline.

With all of the appointments and checkups, some weeks the pair count themselves lucky to have one day free, when Jim can putter around the yard and Annie can catch up with her soaps.

But Jim and Annie aren’t unusual in having their days dominated by medical concerns. Here in the heart of the Bootheel, in Pemiscot County, where they live, and in neighboring Dunklin, where Kennett is the county seat, a quarter of all adults report being in poor or only fair health. Five days each month, per capita, are lost to poor physical health, and another five to poor mental health.

If that seems high, it’s because it is. Places like the Bootheel tend to be sicker than more-affluent and better-educated parts of the country. Even more troubling, recent research shows that the health gulf is widening. In the past two decades mortality rates for middle-aged white Americans without a college degree — a group that includes most residents of the Bootheel — have soared, reversing a century of improving longevity.

The authors of that research, a pair of Princeton University economists, call these "deaths of despair." People with a high-school education or less, they argue, have weaker job prospects, and, faced with declining economic and social well-being, turn to drugs and alcohol. Despair, in the guise of overdoses, cirrhosis, even suicide, claim the still-young.

It would be easy to say this is just about being poor, but people who study the phenomenon say it’s not that simple. Yes, having a job — and the paycheck and health insurance that come with it — matters. Those aren’t all that make a difference, however. Better-educated people live in less-polluted areas, trust more in science, and don’t as frequently engage in risky behaviors. Have a college degree and you’re more likely to wear a seat belt and change the batteries in your smoke alarm.

While "deaths of despair" grab the headlines, what often hurts people is more run-of-the-mill. Chronic illnesses like cancer and diabetes and heart disease cut short the lives of many and erode the quality of the days they do have. People with less education are twice as likely, for instance, to die of lung cancer or COPD, the disease with which Annie struggles. Heart attacks and strokes are far more common for those without much schooling — one study found that heart-attack rates for middle-aged adults who hadn’t finished high school were double those with a college degree.

College wasn’t in the cards for Annie. Now 66, she had a baby at 14 and dropped out of school. Jim did have a chance to go to college. Though his parents didn’t have the money, a farmer he worked for offered to pay for him to get a two-year degree. But Jim was sick of school, couldn’t imagine being in the classroom any longer. The offer, the farmer told him, was open-ended, but somehow, Jim says, he just never got around to it.

He doesn’t have regrets. He made enough to buy his own home, a truck, and a van. "If you make more money," he says, "you just end up spending more."

Instead he cycled through a series of jobs. He has been, in no particular order, an auto mechanic, a carpenter, an electrician, and a plumber. He has driven a truck and driven a tractor, been on the cleanup crew at a chicken-processing plant, and held down shifts in a grocery store and a service station.

Jim had his first cigarette at age 7 and smoked regularly for the next 50 years, until his heart attack. He had stopped drinking years earlier, but now he quit smoking cold turkey and cut out most caffeine. Tougher, though, has been changing how he eats, even though he knows both he and Annie need a better diet. He’s stopped with the fried foods and orders carefully at restaurants, but his kryptonite is ham, particularly around the holidays.

"It’s not a holiday without a little bit of ham," Jim says. "That’s what I live for anymore, the eating."

His doctor fusses at him if his weight creeps back up or his cholesterol rises, so he tries to stick to the straight and narrow. But he admits to some skepticism about always watching what he eats. His father, too, had a heart attack and was put on a restrictive "cardiac diet." It lasted just a few days before he woke up and fixed himself eggs, sausage, and biscuits. "It might kill me now, it might kill me in a year," he told Jim, "but I’m not about to starve to death." He lived another 22 years.

Jim once imagined buying a little camper in retirement and traveling around the country, but his and Annie’s health won’t allow it. So he finds himself just three miles from where he was born. A few months ago, he got the idea to clean out the closets, but he kept finding knickknacks and mementos from years past and people who are gone. Spring cleaning has turned to fall to winter, and he hasn’t thrown much away.

When the surgeon operated on Jim’s heart, he couldn’t repair all the damage that was done and warned Jim that one day he could have another heart attack. It doesn’t worry him much.

Jim and Annie’s primary physician, Dr. Arshad, came to the Bootheel 15 years ago. The region doesn’t produce many of its own doctors — few students aspire to medicine, and those who do must leave the area to earn a degree. Not many return.

So the Bootheel imports its physicians, Dr. Arshad included. A federal program offers medical-school graduates a deal: Work for two years in certain rural and underserved areas and get much of your debt forgiven.

For Dr. Arshad, two years became three, and then it was six, 10, 15. A few years back, Pemiscot Memorial Hospital, where he is medical director, nearly went under, burdened by bad debt. As the county hospital, Pemiscot Memorial must treat everyone who walks through its doors. Each year it provides at least $7 million in care to people who can’t pay the bill. With the hospital on the brink, many doctors closed their practices and left the area.

Dr. Arshad stayed.

Occasionally he thinks about leaving, but never for long. He’s part of the community here. People stop him in the grocery checkout line to tell him about their sore throats or the pain in their chest that’s been nagging them. They pull pill bottles out of their bags, medication that some specialist at one of the big hospitals in Cape Girardeau or Jonesboro has prescribed for them, and ask his advice: Is this really what I should be taking? What about the side effects listed here? They think of him as their physician.

When it comes down to it, he can’t leave. That’s his word, can’t. There is too much at stake here, the need too great. It’s tough and getting tougher to be poor and sick in the Bootheel.

With layoffs, many people have lost their health insurance. At Dr. Arshad’s clinic, if patients don’t have insurance, they are charged on a sliding scale based on income. But many can’t come up with even that much, so the clinic has them fill out a form saying they’ll pay later. Dr. Arshad holds his hands about 18 inches apart. That’s what his current stack of unpaid bills looks like.

"Of course," he says, "there never is a later."

Other patients no longer qualify for Medicaid because of state policy changes. In recent years, Missouri has tightened its eligibility requirements. It’s one of a handful of states not to participate in the Medicaid expansion under the Affordable Care Act.

The weakening of the social safety net has consequences. The gap in life expectancy between the state where people live longest and the one where they die earliest is more than seven years, and researchers attribute much of that to the difference in state policies for the poorest residents.

Change in mortality, 1998 to 2015

Among white non-Hispanics between the ages of 50 and 54

High school or less

+248

deaths per 100,000

Women

+133

Men

Bachelor’s degree or more

-57

Women

-105

Men

Source: “Mortality and Morbidity in the 21st century” by Anne Case and Angus Deaton, Brookings Papers on Economic Activity, 2017

Dr. Arshad knows that many of his patients face difficult choices when it comes to health care. They might get surgery but then skip crucial follow-up visits or miss appointments because they can’t get a ride. In the summer, office visits rise because in warmer weather people will walk, sometimes five miles or more, to see him.

For patients who pay out-of-pocket, he prescribes the cheapest medications. Still, he knows that for many, it is still too much, and that prescriptions will go unfilled. He’s had patients lose legs because they couldn’t find the money for needed drugs.

A lot of the health problems Dr. Arshad confronts are preventable. The map might say Missouri, but the Bootheel is more Mississippi Delta north, especially when it comes to food. He’ll give patients a sheet about eating healthier, for instance, and explain to them simple steps they can take to change their habits.

"But I have to be realistic," he says. "I can talk about healthy diets until I’m blue in the face, but it’s not going to happen."

Experts differ as to why, but people with more education are more likely to pay attention to scientific reports about health and wellness and to heed their advice. One home-health aide in Dunklin County says she repeatedly lectures those in her care about the importance of a healthy diet or the dangers of smoking only to find a McDonald’s bag in the trash or a patient on oxygen surreptitiously lighting up.

It’s also a numbers game: A McDonald’s double cheeseburger is half the price of a packaged salad at Walmart. Those habits are compounded by a highly sedentary culture. In Dunklin and Pemiscot counties, nearly one-third of people say they get no exercise in their free time.

Mortality for chronic diseases

Among white non-Hispanics between the ages of 50 and 54

Including cancer, heart disease, and diabetes among white non-Hispanics between the ages of 50 and 54

600
deaths per 100,000

Men, high school or less

400

Women, high school or less

200

Men, bachelor's degree or more

Women, bachelor's degree or more

0

2005

2015

Source: Chronicle analysis of National Vital Statistics System and U.S. Census Bureau data

But if unhealthy behaviors are far more common among less-educated Americans, it wasn’t always so. The wealthy and educated were once more likely than poor people to develop smoking-related illnesses or colon cancer from eating rich foods, for the simple reason that only they could afford what were considered luxuries.

The popularity of smoking waned among the better educated after the government started warning Americans about the dangers of tobacco. Between the mid-1960s and the 1990s, smoking rates for college-educated women tumbled 16 percentage points, while the rates for those without a degree fell by less than half that, 7.5 points. Around here, it can feel as if most everyone smokes.

Some of the Bootheel’s problems seem like a step back in time. Many mothers don’t get needed prenatal care. Premature-birth rates are high and birth weights low. In Pemiscot County, 11 of every 1,000 babies die before their first birthday, far above state or national averages. In Dunklin, the rate is only marginally better, 10 out of 1,000.

Not long ago a young boy came into the emergency room at Pemiscot Memorial with a severe asthma attack. His mother didn’t know how to use the inhaler properly. She hesitated before seeking help, and she drove him to the hospital herself rather than pay for an ambulance. The boy died.

"To have a kid die of asthma," Dr. Arshad says, "who’d have thought that could happen in 2017?"

Jake McKuin does his own stitches. He’s had a tooth pulled while lying in the bed of a pickup truck. A couple of years ago, he had heat stroke in the middle of a bean field. He went home, drank some Gatorade, called a nurse friend who set him up with an IV, and, after a couple of hours, went back to work.

His blood pressure is dangerously high at times — during a rare doctor’s visit a few years back, the top number was 180-something, he figures. But he shrugs it off. As a farmer, he has to make most of his annual income during a 70-day harvest, from September to November. Of course it’ll go up when life gets stressful. It’ll come back down; it’s no big deal.

Going without health insurance is a risky gamble for someone like Jake. Deep cuts and minor burns are commonplace in his line of work. He operates heavy equipment that can chop off a finger or a whole arm if he’s not careful.

But he’s a self-employed contractor who doesn’t receive benefits through his job. A plan under the Affordable Care Act would have cost him $806 a month, with a $15,000 deductible. The tax penalty for not having health insurance is far less. Many of the farmers and truckers he works with have also decided to go without. The Bootheel’s soil is as rich as ever, but crop prices are stagnant, and health-insurance premiums are increasing.

Lacking insurance can be devastating. Jake has learned that the hard way. A dozen years ago, he picked up a loaded gun by the barrel and it went off, putting a bullet through his right hand. He had to be flown by helicopter to a hospital in Memphis and treated there for a week. The bill, after a series of reconstructive surgeries: $287,000. (He says his family ended up paying about $35,000.) His hand doesn’t do much anymore.

Winding through the cotton and bean fields just outside of downtown Kennett, Jake drives back to his family’s welding shop one recent evening, to close up for the night. In late fall, the harvest done, cotton has been gathered into pillowy bales. A few errant wisps cling to the side of the road.

Near the shop, his pickup truck hits a large bump, jolting him. He grimaces, then laughs. "I’m getting too old for this." He’s 31.

It didn’t have to be this way. He got a bachelor’s degree from Crowley’s Ridge College, a Christian institution 40 miles away in Arkansas, becoming the first man in his family to get a higher education. He could have continued to law school, as he considered doing, and gone on to spend far fewer days worrying about stray sparks from power tools setting his jeans on fire.

For some of his high-school classmates, college was their one-way ticket out of the Bootheel. It was for his younger sister, who now lives in Arkansas. The kids who didn’t go to college, or who didn’t finish, are the ones who stuck around.

But his dad’s welding shop — a blue building just off a dirt road on the north side of town — is a successful business, and Jake is next in line to take over. Law school would have been expensive, anyway, and he didn’t really want to spend the next 30 years of his life indoors.

He’s been working on a farm since he was 8, when he was old enough to drive a tractor. In his teens, he started smoking. He’s smoked for the past 15 years, sometimes a pack a day, sometimes less. When he’s not on his combine in the field or working on a tractor-trailer in the shop, he’s often holding a cigarette and sipping a can of cold Pepsi. After 5 p.m., it’s a Michelob Ultra.

For this line of work, Jake didn’t need to go to college. Most of the guys he works with didn’t. Still, if things go bad, he’s got an education to fall back on. Farming is a tough industry, and he’s lost about $45,000 on his own crops over the past three years.

When people don’t have a plan B, it’s easy to lose hope.

One chilly evening in November, Jake is driving down First Street in Kennett. Most of the shops are dark. But in one, the lights are still on. It’s Bootheel Marine, the local boating shop. The owner must still be there, Jake says. His nephew committed suicide at 4:30 a.m. the day before.

Jake wonders aloud whether the suicide rate is high in the county. It is, especially among middle-aged white men.

Jake isn’t surprised to hear that. A year and a half ago, he got a call from one of his best friends, Tom Mastrianno, a construction contractor. When Tom called, it was usually about playing golf.

This time he just wanted to talk. Jake was busy. He said he’d call right back.

Twenty minutes later, the phone rang again. It was his friend’s fiancée. Tom had hung himself inside one of the houses he was building. He was 44.

Jake knew Tom’s construction company was going bankrupt. He knew Tom was worried about losing his house, his fiancée, and his two daughters. But he didn’t know how close his friend was to taking his own life. He can’t even remember exactly what he was doing when Tom called. Working on his combine? It had seemed so important at the time. Now all he remembers is that he shouldn’t have hung up the damn phone.

The whys and what-ifs after a suicide are hard questions to answer, but like any grieving friend, Jake has tried anyway. "Everything you could take from someone," he says, "he’d lost it."

If farming doesn’t pan out for Jake, there are plenty of other jobs he can do. Tom never got a college degree. He didn’t have a ton of options.

Sherry Thomas was poised to regain the thing that matters most to her, her four children. After more than a year in Dunklin County Family Treatment Court, known by most around here as "drug court," she was clean now.

At some graduations, people don caps and gowns. At her own, Sherry clutched a tiny screwdriver. She used it to affix a nameplate to a plaque hanging on the courtroom wall, adding her name to the roster of 95 others who have finished the program.

With the screws tightened, she threw her hands above her head in jubilation. "Yes!" she cried. "It’s a blessing, y’all!"

Sherry’s spot in the program won’t go unfilled for long. An intensive mixture of counseling, education, and treatment, it has room for only about two dozen participants at a time. But two-thirds of the cases of child abuse and neglect that come before the county’s juvenile court involve drugs.

Some people are referred to family-treatment court by friends or caseworkers. One woman says her sisters turned her in. Others lose their children while still in the maternity ward when their newborns test positive for drugs.

Until recently, the drug most likely to land a parent in treatment court was methamphetamine. Its ravages are plainly visible in Kennett, in the tight-lipped smiles and downcast stammers of those suffering from "meth mouth," the tooth decay, gaping gums, and cracked molars that are a side effect of the drug’s use.

Now the drugs of choice are opioids. Some, like heroin, are illegal, but others — fentanyl, hydrocodone, oxycodone — are available with a doctor’s note. Around town, people point out the pill mills, the physicians who will prescribe opioids for your "bad back," the pharmacies that can be paid in cash.

The Centers for Disease Control and Prevention reports that last year, 163 opioid prescriptions were written for every 100 Dunklin County residents.

Though drug use has been an issue in places like the Bootheel for some time, to many this is an epidemic, as people, the poorest and least educated especially, numb themselves to the disappointments of job loss or ill health. Missouri has done far less than other states to track the doctors who write prescriptions for powerful painkillers and the pharmacists who fill them. In the Bootheel, folks wonder why.

Not so long ago, men and women like those who end up in drug court could aspire to a decent life, with or without a college degree. People in the Bootheel have never been wealthy, but it used to be easier to get by, to earn a steady paycheck. The jobs that once went to folks around here, they say, are now being done by robots or Mexicans or some combination of the two.

If you haven’t got much education, you haven’t got much hope. That’s how Phillip M. Britt, the court commissioner, sees it. Drugs are people’s way of coping. "Life," he says. "Lots of the time that’s why they use in the first place. They can’t deal with life on life’s terms."

That’s the case for Sherry. The drug that cost her her children was meth, though she says she hadn’t been using for long. When social services took her kids away, her youngest child was just a month old. Her oldest was 10.

Sherry wasn’t much older than that when she first tried drugs, marijuana and alcohol mostly. In the seventh grade, she quit school and she started partying. It was her way of handling a chaotic home life and a mother who, she says, "talked crazy" and hit her.

"I’d lean on drugs to deal with my emotions," Sherry says. "I thought, ‘I’m not going to feel.’"

Drugs had helped inure her to a painful childhood, but the loss of her own children brought fresh anguish. When she was finally permitted a visit, her toddler daughter, her second-youngest, cried for her "other mother."

Mr. Britt has run treatment court since its inception, nearly 15 years ago. Some of the people in the program today he first met as children when their parents were in his courtroom.

Such a perspective could make a person gloomy, but the commissioner retains a glass-half-full outlook. "He has more compassion than anyone," says one staffer. "Still."

Each Wednesday, Mr. Britt and a dozen caseworkers and counselors crowd into a cramped conference room just off his courtroom and tick through a status report on all participants. Each one has a treatment plan, a personalized set of goals that will get him or her closer to regaining custody. Complete certain steps, and Mr. Britt might recommend supervised visits. Notch some more, and he might deem you ready to take your kids to a movie.

Some of the requirements are common. Everyone shows up for counseling, both individual sessions and group therapy. Everyone calls in daily to the "color line"; if your assigned color is randomly selected, you have to take a drug test.

And if they don’t have a high-school diploma already — many do not — Mr. Britt encourages participants to work toward earning one. The court will even help pay for the costs of taking the GED.

Partly that is a pragmatic choice by Mr. Britt, who is also a regent of Southeast Missouri State University. Jobs are hard to come by in the Bootheel, and without a diploma, you take yourself out of the running for all but the most menial. To win back your children, you have to show that you can support them.

But there’s another reason. "For so many of these folks," he says, "this is the first time they’ve ever completed anything."

Family-treatment court is about getting clean, to be sure, but it’s just as much about trying to give people the skills and education to get by, for themselves and for their children. No one’s ever encouraged them, Mr. Britt says. No one’s ever talked with them about what’s possible. As dramatic as this may sound, the court could be a bulwark, the buffer, between a life, even a death, of despair.

The staff meeting concluded, Mr. Britt calls court into session. The smell of cigarettes hangs in the air, and between cases, participants duck out for a quick smoke.

One by one, they stand before the bench to detail the past week’s successes and setbacks. While relapsing is a constant struggle, many of the hurdles reflect mundane challenges. One woman has had her car impounded and has no way to get to work or to see her children, who are staying with a relative an hour away.

"I know it can feel like one step ahead and two steps backward," Mr. Britt says.

She interrupts. "357 steps back, it feels like."

On this Wednesday, it is Sherry who steps forward. She’ll still have to submit to drug tests and resolve her custody case. But she’s come far from where she began. She has more confidence in herself, and more hope. She might try for the management track at Taco Bell, where she works.

"I’ve had a chance," she says, after the others toast her with cookies and sweets. She repeats, more quietly this time, "I count this as a huge blessing."

Freda Kershaw tries to make sure that people don’t turn to drugs, as Sherry did. But some of the problems that befell Sherry — dropping out of high school, raising children alone — could easily have been Freda’s own. She got pregnant at 14.

Her mother was shocked. She had always been a good kid, did her chores, kept her grades up. Mom worked nights and weekends, though, and often wasn’t around. Her father wasn’t in the picture. Freda had started hanging around with her older cousins and their friends. The wrong crowd, she says. It’s what she now calls an "unstructured environment."

Freda is from Caruthersville, the largest town in Pemiscot County, where the teen birth rate is more than double the state average. Many of those teen moms don’t finish their education, get too busy with child care to work, and are forced to go on public assistance. When Freda got pregnant, in 1979, she could have ended up just like one of them.

Erma Motton, her boyfriend’s mother, had other ideas. Finishing school is important. So is going to college. I’ll help take care of the baby.

Erma had always made ends meet, but she wanted more for her five children and for Freda: a steady paycheck, a house, a nice car. She wanted them to go to college. She says she even took some college courses when her kids were in their teens, so they could be close to someone who aspired to more than just working and coming home every day.

So Freda left behind her 3-year-old son, Sean, and went to Southeast Missouri State, 90 miles away, in Cape Girardeau. Four years later, after graduation, she came right back. She wasn’t sure what she was going to do, but her boyfriend and son were there, and her mother’s health was worsening. The Bootheel was where she needed to be. She got married and brought Sean home.

Freda worked at the county health department, then as a liaison for a team of health researchers at Saint Louis University. Later she got a master’s degree in public health and became a substance-abuse prevention specialist. She was living the life Erma had wanted for her.

As her career was coming together, her family was falling apart. Her husband was a great father, but he was struggling with drugs. Sean was starting to rebel. She wishes she’d taken him to college with her. Back in Pemiscot County, he had bounced around among several homes, raised by her mother, her brother and his wife, their older kids, Erma. It was stressful, and he soon got into trouble.

Sean, now 37, has been in and out of prison for the past 20 years. Recently he’s been abusing opioids. After his most recent arrest, Freda was actually grateful. "People would call me, concerned about the last state they’d seen him in," she says. "He could have lost his life if he’d stayed on the streets."

Her younger son, Abram, started college right after high school, but his girlfriend was pregnant. Freda told him what Erma had told her: Stay in college. I’ll help take care of the baby.

Abram wasn’t hearing it. He returned to Caruthersville and got a job at a steel mill 30 miles away. Now he’s a truck driver and able to provide for his family. But he’s on the road a lot of the time, away from his wife and kids. He would have been much better off, Freda says, with a college degree.

Once Sean leaves prison, Freda doesn’t know what she’s going to do. She wants him to get proper treatment for his drug problems and land on his feet. But she can’t invite him to live with her. We aren’t taking care of a grown man, her second husband told her. It was hard to hear, but she agreed.

She thinks drugs tighten their grip on the community as people lose the fight in them. It’s almost as if they’re medicating themselves to cope with the feeling that their life will never get better, she says. They feel that they’re born into it and they’re going to die in it. Many kids simply can’t picture a different future. "You see hopelessness in a whole new way," she says.

On top of her counseling job, Freda works part time for a nonprofit group within the University of Missouri at Columbia that helps at-risk youth. She wants to be sure someone is telling these kids that they can go places, that they can go to college, that their future is bright. Just like Erma told her.

The Mizzou nonprofit helps support a community center in Caruthersville, where kids can get a hot meal, play basketball, read books. It keeps them out of homes where family members are struggling with drug addiction and other domestic problems.

Freda sits back in a plastic chair, in a room off to the side of the center’s basketball court. She wears a jacket emblazoned with the logo of FCC Behavioral Health, the agency she works for, along with jeans and sneakers for running around with the kids.

A few young men are at the center this afternoon, playing basketball. Kevin Anderson graduated from high school a couple of years ago, the only one of five kids in his family to do so. He tried to sign up for classes at the local community college, but "everything didn’t go through," he says. Now he just wants to get a job, though he’s not sure where. He hasn’t tried college again.

"They got financial aid or whatever, but nobody gets that," he says. "It’s limited to certain people."

"They do have grants, you guys," Freda interjects. "Which is money you don’t have to pay back that will cover some of those costs."

"You have to qualify for it, though," Kevin says.

Yes, Freda says, but all you have to do is fill out a form. "It’s online," she says.

"I heard you gotta pay for that!" Kevin says, exasperated.

When young people from the Bootheel do go to college, they tend not to come back. They leave behind this community, its people, and its problems. Who can blame them? many locals will tell you. There are no jobs. There’s nothing to do around here.

We often talk about the economic payoff of a college education, about the job it will get you, the money you’ll make. Maybe, though, we need to think differently about the stakes, to view our educational divides in public-health terms.

Education matters, now more than ever. Get it, and chances are you will have a happier and longer, a wealthier and healthier life. Does going to college lead directly to better health? That’s a question for another day.

What is clear is that the college degree is a marker, a dividing line for health outcomes. As the benefits of having a degree accrue, so do the costs of not having one. You can see the toll here in the Bootheel, in all the Bootheels across America. In lives cut short by disadvantages that multiply.

Freda sees those disadvantages every day: in the people who pass through the counseling agency, in the kids she works with at the community center, in her own children. It will take a long time and painstaking effort to close those gaps.

Still, Freda says, so often all it takes is a gentle nudge to help people find a better path: Go this way, not that way. "That’s what I do for anybody, because of that seed that was sowed in me."

For some people, that path includes a college degree, she says, but there are other ways to continue an education. A community garden in Caruthersville used to give men who had recently gotten out of prison a chance to learn soft skills. They worked the land for $10 an hour.

Freda once could look outside her front door and see the tomatoes, spinach, and cabbage growing in the grassy lot across the street. Peppers, squash, okra, and collard greens, too. You could take what you wanted, at no cost.

The garden was a vibrant part of the community, Freda says. Many people who needed to change their diet because of heart trouble or diabetes suddenly had fresh produce at their fingertips. Some folks were inspired to start growing their own. It was in the middle of a residential neighborhood, easy to walk to.

"It just gave people hope," she says.

But in 2013, the funding ran out, and the garden shut down. Others have sprung up, but they, too, rely on grants. The money comes and goes.

Look outside Freda’s front door now, and you’d never know there used to be a garden there. The middle of the lot, where the vegetables grew, is a shade darker than the rest; that’s the only reminder. A few beer cans and fast-food wrappers are scattered across the grass. Every now and then, Freda’s husband crosses the street and picks up the trash.