And McDowell County has the highest death rate for prescription drug overdoses in the country. Twelve people die each month from abusing prescription pills.
Those are the extremes. On a more basic level, there are daily challenges.
Many of the students here have never sat in a dentist's chair to have their teeth cleaned. There is no central water system here so fluoride is not readily available. And it's a long drive through treacherous terrain for anything beyond an emergency.
That will change next year if leaders can pull off their plan. The Reconnecting McDowell leaders are trying to recruit dentists to work with the schools to set up medical clinics, not just for students but also their parents.
They're also looking to expand the existing efforts to help parents' reading skills.
The U.S. Department of Education estimates 22 percent of the adult population in the county lacks basic literacy skills. So project managers decided to introduce literacy centers not just for children, but also their parents and grandparents. At seven locations adults sit with educators and learn basic skills.
For others, there are home visits to help them learn reading skills.
"Parents want what's best for their children," said Jacki Wimmer, an early reading teacher who makes regular visits to seven families. "Some children come to school and they've never held a book."
And for the traditional functions of a school? Those, too, need work.
Of the 350 teaching positions in McDowell County, 51 were not filled at the start of the school year. Those who considered moving here couldn't find housing. In the mountainous region, there's no flat land to build new houses. Rental property is hard to come by. The Reconnecting McDowell project has talked about building an apartment building of its own to house 20 or 25 teachers. Plans are in the works.