ABINGDON, Va. – The hospital executives at the lectern called her a hero, and the struggle that had earned Emily Boucher that distinction showed on her face: in the pallor acquired over 12-hour shifts in the intensive care unit, the rings beneath eyes that watched almost every day as COVID-19 patients gasped for their final breaths.
The pandemic had hit late but hard in the Appalachian highlands — the mountainous region that includes Southwest Virginia and Northeast Tennessee — and over the winter many of its victims had ended up on ventilators tended by Boucher and her fellow nurses at Johnston Memorial Hospital.
They were enduring the traumas known to ICU workers across the world: days filled with death, nights ruined by dreams in which they found themselves at infected patients' bedsides without masks. But they were also enduring a trauma that many doctors and nurses elsewhere were not: the suspicion and derision of those they risked their lives to protect.
Conspiracy theories about the pandemic and lies recited on social media — or at White House news conferences — had penetrated deep into their community. When refrigerated trailers were brought in to relieve local hospitals' overflowing morgues, people said they were stage props. Agitated and unmasked relatives stood outside the ICU insisting that their intubated relatives only had the flu. Many believed the doctors and nurses hailed elsewhere for their sacrifices were conspiring to make money by falsifying COVID-19 diagnoses.
Boucher and her colleagues were pained by those attacks — and infuriated by them. Unlike their exhaustion, that anger rarely showed on their faces, but it was often there: as they scrolled Facebook to see local ministers saying God was greater than any virus, or stood in line with unmasked grocery shoppers who joked loudly about the covid hoax.
On that December morning when she became the first person to receive the coronavirus vaccine in the 21 counties served by her hospital's parent company, Ballad Health, Boucher breathed deeply as she described what she and her co-workers were up against. They were fighting not just for their patients' lives, she said, but "against misinformation and reckless practices that have led to this virus getting so out of control."
"I will never stop trying to convince everyone about the reality of COVID-19," she said.
As she rolled up her sleeve for her first injection of the newly approved Pfizer-BioNTech vaccine, Boucher didn't know if the rift in her community could be healed. But she hoped her example would at least inspire others to get inoculated.
Not everyone dismissed the suffering and death caused by the coronavirus. Churches and community groups had sent food and homemade masks to Johnston Memorial, and families had tearfully thanked Boucher and her co-workers for saving lives. Now medical science had delivered vaccines that could end the pandemic, and a new president who didn't undermine that science would soon take office.
"Today, for me, is a turning point," she said. "Today is an incredibly hopeful day."
As the needle slipped out of her arm, she raised and pumped her fist. A grin was visible at the edges of her Ballad Health face mask.
In the coming days, though, friends began texting her screenshots of comments on Facebook, where local TV news stations had posted photos and videos of her inoculation. Boucher had abandoned Facebook earlier in the pandemic. Looking at the messages, she remembered why.
Commenters speculated that the syringe might not have actually contained any vaccine. Others said she must be getting kickbacks from Pfizer. Boucher returned to her crowded ICU knowing that to some in her community, her vaccination was not a turning point and she was not a hero. She was just another part of the hoax.
"You're living this reality that people don't understand, and there's nothing you can say that will convince them," Boucher, 40, would later explain. "They just say you're lying."
The post-traumatic stress experienced by nurses and doctors during the pandemic has been compared to what soldiers suffer. But in places still rife with covid denial — often rural, conservative and devoted to former President Donald Trump — there is a difference: It is like having fought in a war that many believe never took place.
• — —
Boucher came to Johnston Memorial in 2017 when she and her husband, Shawn, moved from South Carolina to Virginia to start a farm. With a friend, they began raising chickens on a plot of land in Sugar Grove, a 40-minute drive northeast of the hospital.
Southwest Virginia calls itself the heart of Appalachia, and its idyllic valleys are home to both a proud history and a concentration of the ailments — obesity, heart disease, diabetes, drug addiction — that plague America's poor. Boucher was devoted to healing people with those chronic conditions, and at Johnston she joined an institution that seemed to have earned its patients' trust.
Founded in 1919, the 116-bed hospital was among Washington County's largest employers. More than a century of births, broken limbs, appendectomies, heart attacks and routine checkups had brought the families of the surrounding hills through its doors.
And so when the pandemic began, Boucher and other health care workers at Johnston believed their patients would rely on their guidance for staying safe. They were wrong.
Jamie Swift, a registered nurse who oversees infection prevention for Johnston and Ballad's other hospitals, recalled her realization that "people would trust Facebook more than they would trust us" — and her horror at the consequences as the winter surge began.
"You work all day, and you see people who are struggling to breathe, and you see the horrible side of what covid can do. And then you go home and you see restaurants that are packed and grocery stores where person after person is going in without a mask," said Swift, who in December was briefly hospitalized herself with the coronavirus. "There have been times when I broke down and cried. It was just devastating, because you leave the hospital and you come out into a community that doesn't believe that it's real and in what it can do."
For some, even a catastrophic bout of COVID-19 couldn't totally shake that skepticism.
"We never took it serious. We would joke about it, actually, and say that after the election it would all go away, that this was the Democrats' way to control us," said Jessica Goff, who lives in Chilhowie, Va.
When her mother, who is in her mid-50s, developed a sore throat after a family trip to D.C., they ribbed her, saying it must be the coronavirus.
It was. After Goff's mother developed a high fever, she was taken by ambulance to Johnston Memorial, and a week later she was intubated. Goff was furious, claiming that doctors had not adequately informed her family about the severity of her mother's condition. As a result, she said, she had advised her mother to refuse the proven COVID-19 treatment remdesivir.
She was comforted when she learned that one of her old high school friends was a nurse manager in the ICU, and thrilled when her mom recovered after several days on the ventilator. But she gives the credit to God, not to Johnston Memorial.
"It was definitely a miracle," she said. "I had rallied the prayer warriors." And while she no longer doubts the reality of COVID-19, she said she still believes it has been exaggerated and that hospitals are falsifying cases to make money.
"It's just like, what's real? What's not? Obviously the corona is real, but I don't think the numbers that they're reporting are actually accurate," said Goff, a 38-year-old information systems analyst.
She and her relatives are avoiding the vaccines out of concern about their safety. They have plenty of company.
Just over 38% of people in Ballad Health's 21-county service area have received at least one vaccine dose, according to data compiled by the company from the Virginia and Tennessee health departments. That is well below both the vaccination rate nationwide — 55% of the U.S. population has received at least one dose — and the statewide rates in Virginia (59%) and Maryland (61%).
The region's low vaccination level could make it vulnerable to further waves of infections as dangerous new strains of the virus, including the Delta variant, spread through the United States.
From top executives to front-line nurses, the employees of Ballad Health have redoubled their pleas for the unvaccinated people of the highlands to get the shot. Many aren't listening.
On a Friday night in May, Christy and Tony Statzer were shopping at a Kroger supermarket a short drive from Johnston Memorial. The couple had at times relied on local doctors and nurses: Christy went to Johnston's emergency room after a car accident last year, and their 6-year-old daughter had a corrective surgery on her legs at Ballad's hospital in nearby Johnson City, Tenn. But when it came to the coronavirus, they falsely accused the same hospitals of perpetrating a fraud.
"I just think there's a lot of people who had the flu, and they're saying it's covid to get money from it," said Christy, who is 47 and works as a janitor at a nearby college. "It's publicly known that if the hospital says it's covid they're getting kickbacks from the government."
What was in it for the government?
"One World Order. That's what they're after," Christy said. "The Democrats want it."
"They're pushing people to see how far they can get," said Tony, 48, a disabled former sawmill worker. "They used this as a test to see what they could get away with."
Virginia's mask mandate had just been lifted for the fully vaccinated. But the Statzers had never paid attention to that mandate, and they had not been inoculated — despite the repeated urging of Tony's doctor, who warned him that he was at high risk after having both a kidney and pancreas replaced because of diabetes.
Their opinions about the pandemic had been shaped by sources that include Facebook, YouTube, Fox News commentator Sean Hannity and conservative talk radio. They distrusted the evolving guidance from public health authorities.
Christy said, "Wasn't there one point where they were saying you could get it through your eyes?"
Tony shook his head.
"What's the point in wearing a mask if you can get it through your eyes?"
Anthany and Kayla Garcia were leaving the Swirled Frozen Treats next door to Kroger with cups of strawberry shortcake ice cream. The pair from Bristol, the nearby city straddling the Virginia-Tennessee border, said they had been inoculated, but not out of concern about the virus. They hoped to avoid masking up at work, as they avoided it elsewhere.
"I think covid is just a hoax," Anthany, 27, said.
"Even so, I don't think a mask would particularly keep you safe," added Kayla, 36. "If you can pass gas through the cloth of your pants and still smell it ..."
"There hasn't been any deaths," Anthany said, dipping a plastic spoon into his dessert.
The couple was still upset over having their work hours at a fast-food restaurant cut during lockdown, and didn't believe the figures published by Ballad Health, which showed more than 100,000 infections and 2,100 deaths in the region.
"I've never seen anybody who had it," Anthany said. "Like, how do they know it's covid that they're dying from?"
• — —
A few miles up Lee Highway, on the same Friday night in May, an 85-year-old woman lay with her eyes closed behind the glass door of Room 3314 in Johnston Memorial's ICU.
Her head was craned to receive the endotracheal tube snaking from her mouth, and her face was tilted toward the window, where the day's last light leaked in around a fan sucking out the contaminated air. The skin of her arms and legs was a hue between purple and charcoal, a side effect of vascular constriction caused by the ventilator. The blanket that covered her looked almost flat, as if her body had vanished.
It was a sight her 86-year-old husband and two sons, standing outside in the hallway, chose not to linger on. Instead, they watched Boucher as she knelt next to the chair in which the elderly man sat outside his wife's sealed room.
"I'll tell you, she's really sick," Boucher said.
She explained through her surgical mask that they were doing all they could. It was not yet time to explain what she suspected to be the truth: That the woman on the other side of the glass would never open her eyes again.
It was her second time on the ventilator. Earlier in the week they had tried to extubate her, and she began slowly to suffocate as her blood oxygen saturation dipped.
The doctors and nurses of the 14-bed ICU had learned to be wary of any covid prognosis. Some patients returned from the edge of death, and those almost in the clear could unexpectedly crash. But the message from the woman's body was clear: Her fight against COVID-19 was almost over, and the disease had won.
"It's good to meet y'all," Boucher said. "I wish it was under better circumstances."
"Well," the husband said.
One of his sons leaned forward.
"We should let her get back to work," he said.
"Oh, no, you're fine," said Boucher, whose shift had begun 11 hours earlier.
The husband looked at the floor, then looked at Boucher.
"Appreciate you and what you're doing," he said, then was quiet for a moment.
"Well. We been married 60 years. So."
These were the moments Boucher wished she could show to the maskless shoppers and covid deniers. But communicating the reality of the ICU wasn't easy.
In the spring, her newly vaccinated parents flew from Iowa to visit her and her husband for the first time since the pandemic began. They went out to a restaurant and found themselves waiting for a table next to a woman proclaiming that nobody could make her wear a mask.
Boucher imagined what she might say: I've just watched people die for week after week after week. But she stopped herself, as she had many other times.
"I was literally shaking," she recalled.
Yet for every bad interaction, there were others that reminded her of why she had become a nurse: conversations with the grateful families of her patients, chances to heal or at least bring comfort to people alone on the threshold of death.
On Saturday, the sons of the woman in Room 3314 returned to the ICU with a platter of cookies for Boucher and another nurse, Jeris Doane, who had cared for their mother. They'd left their father at home for the decision that must now be made.
Haytham Adada, the ICU's medical director, met them outside her room. This was a conversation Boucher had witnessed again and again between October and February, when one and sometimes two covid patients were dying every shift.
"In my medical opinion, if we keep her on the ventilator, we will be having this conversation again in a few days," Adada said.
One son shook his head. "She wouldn't want to be on this."
Adada left them to check on a newly arrived covid patient, a 69-year-old man whose chest now rose and fell in the mechanical rhythm of a ventilator, his bed draped in lines from the IV drips which Boucher had helped prepare for him that morning.
The sons of the woman in Room 3314 waited to sit with their mother through her final moments. This was a mercy of the late phase of the pandemic: Vaccinated relatives were permitted at a dying patient's bedside in full personal protective equipment. But first Boucher would have to extubate her patient for the last time.
It was the moment when she tried to bestow a measure of dignity on those in her care, cleaning them and doing what she could to make them comfortable. But there were things that could not be altered or concealed: The discolored arms and legs, the gaunt face, the rigidly gaping mouth. The short, quick breaths that revealed a weakened but desperate instinct to survive.
When she had finished, the sons entered.
Boucher yanked a curtain across the outside of the door.
Above the rim of her N95 mask she was blinking back tears.
"It just sucks," she said. "I'm tired of it."
• — —
The wind was blowing hard on the upper slopes of Whitetop Mountain, and Boucher's decision to explore the far edge of Buzzard Rock wasn't well-received among her fellow hikers.
"Please be careful!" Meagan Busby shouted.
"That's how people die in the Grand Canyon," Aliese Harrison observed. "The wind blows them off."
"She's freaking me out down there," said Emily's husband, Shawn Boucher.
It was Sunday afternoon, less than 24 hours after Boucher's patient had died. She and Shawn were on a hike, joined by Busby, Harrison and Chelsey Cardwell — all of them nurses who had worked with Boucher throughout the pandemic in Johnston Memorial's ICU.
They had climbed for two hours to reach this remote ridge traversed by the Appalachian Trail, but the effort was worth it. With its clean air and panoramic views of green mountains mottled with cloud shadows, this place seemed as far as you could get from the hospital in Abingdon — and from the lies about COVID-19 that circulated outside it.
Boucher scrambled back into view. She took in the vista with one arm around her husband. And then the group began its descent, talking and laughing as they marched down wooded slopes covered in wild geraniums.
People were still dying in their care, and new surges of infection might hit the unvaccinated in the summer or fall. But for the moment, the ICU nurses of Johnston Memorial could hope that the worst of the pandemic was behind them.
"Ohhhhh," Busby sighed. "Aren't you so glad it's over?"
"I was so scared," Boucher replied. "What if we had to take care of our own, or see one of my friends die?"
The fear was mostly gone now. The anger was not. Some of that anger they directed far beyond Abingdon, at a federal government that they believed had been derelict in its duties, leaving health care workers like themselves as the last line of defense.
But the betrayal by politicians in Washington was, in a sense, the easier one to accept, because they were not the people they'd seen maskless at the grocery store or struggling to breathe in the ICU.
"That's a part of what made it so hard, is that these people don't give a s — — about me and what I've done to keep them alive," Busby said.
She had thought about leaving nursing, as many others had, but had decided on another course. "Show up, do it anyways, because that's what I do. That's who I am," Busby said. "At the end of the day, I'm there to make somebody's life better."
Boucher had made the same choice. But her days in the ICU were numbered. During the pandemic she had completed a master's degree, and planned to become a family nurse practitioner specializing in endocrinology. Within a year, she hoped to move into primary care for the obesity, diabetes, heart disease and other sicknesses that had made so many of her patients vulnerable to COVID-19.
After the hike, the nurses sipped beers around a table at Sur 81, a Mexican restaurant in Marion. Boucher talked about the classes she still had to take. Her friends listened, knowing that the woman who had helped them through one of the worst times of their lives, just as they had helped her, would in the not-too-distant future be gone.
"I feel kind of awkward saying this, because I've never been in the military," Boucher said. "But I feel like the camaraderie was like we've been in the military."
Busby looked at her drink. "We've been at f — -ing war, man."
Americans like to think they revere those who fight their wars. The nurses who sat in the almost empty restaurant as the sun was going down that Sunday knew that this wasn't always the case.
But because of what they did, because of who they were, they kept showing up to work. Boucher returned to the ICU on Monday morning to find that the 69-year-old intubated during her last shift had taken a turn for the worse. His kidney had failed and he was now on a dialysis machine, as well as the ventilator.
But beneath the blankets she could see it: His chest was still rising and falling. He was fighting for his life.
And he would not be fighting alone.