Leaded gas and an aging population.

Edit: That's a pretty flippant response to a complicated answer.

You could write a book about how West Virginia got into this mess. We're a third world country right here in the United States. Most of our industry is owned by foreign (out of state) interests. We generate wealth and it gets shipped out with no benefit to the people who live here. Our natural resources alone should make us wealthy, but they are stolen from us and we are left sick and impoverished.

Then come the Republicans, with their rhetoric of "gubbmint interference" and these brain-damaged idiots lap it up. We elect a Democrat governor who then switches parties to support Trump. How do we react? We fucking reelect him.

If signs could vote Trump would have won last time. Biden isn't my entire identity. He's just a competent person that I voted for.