The snow in Allegheny doesn't fall. It accumulates. It sits on the ground like a blanket that nobody asked for and nobody knows how to remove. I sat in my car in the clinic parking lot and watched it pile up on the windshield, layer by gray layer, and I thought about how my life was exactly like that windshield: covered in things I had not put there and did not know how to clean.

It was February 2008. The economy was collapsing. The steel mill had been closed for eleven years. The town had been dying for longer. I was thirty-four years old and I had the energy of a man of fifty and the prospects of a man of seventy.

My mother's room was at the back of the house. I could hear her breathing from the parking lot—a wet, rattling sound that had become the background music of my life. I got out of the car and went inside.

The kitchen smelled of boiled cabbage and the medical supplies that lined every counter. My mother sat at the table with a cup of tea she had not drunk. On the table, where it had been for as long as I could remember, was a bottle of bourbon. Unopened. The label said: "For when your father comes home."

My father left when I was ten. He drove a pickup truck to Pittsburgh and never drove back. My mother kept the bottle on the table as if his return depended on it. As if the bourbon was a timer counting down to a moment that had passed ten years ago.

"Good morning, Ray," my mother said. She was propped up on pillows. The cancer had taken most of the weight from her body. She looked like a bird now—small, fragile, all bones.

"Morning, Ma."

"Did you sleep?"

"No."

"Neither did I."

I made coffee. I drank it black. I did not drink anything else. Not beer, not whiskey, not soda. Water only. My mother had once asked me why and I had said, "Water doesn't make mistakes." She had not understood. I did not explain.

The clinic was cold. The heating system had been broken since December and the landlord said the repair would cost more than the building was worth. I wore my coat inside and kept my gloves on. The patients didn't complain. They were used to cold. Cold was the default state of Allegheny.

At ten o'clock, an old man came in with his hand. The steel mill had done that to a lot of hands—eaten them alive, finger by finger, until there was nothing left but stumps and scar tissue. This man's hand was different. The fingers were intact but the skin was black, the way it gets when the blood stops circulating. Gangrene. Slow, painless, inevitable.

"I can help," I said. It was the same thing I had said to Sarah Boudreaux in another life, in another town, with different words but the same hollow conviction.

I changed the dressing. I checked the pulses. I wrote a prescription for pain medication. The man paid me in cash—six dollars and forty cents—and said, "Thank you, Ray. You're a good man."

I was not a good man. I was a man who did things. That was all.

At noon, a young woman came in with a child. The child had a fever. The woman's eyes were red from crying. I checked the child's temperature—39.5 degrees. I prescribed acetaminophen and told her to come back if it didn't break by morning.

"I don't have a car," she said.

"I'll call a cab."

"I don't have money for a cab."

I wrote down the number for the community transport service. The woman took the paper and held it like it was something precious. "Thank you," she said.

I wrote in the chart: "Single mother, transportation barrier, follow up needed." Then I put the chart under the glass on my desk and forgot about it.

That was the pattern of my life: notice, document, forget.

Tommy came to the bar on Thursday. He always came on Thursday. He worked as a security guard at a strip mall and spent his evenings at a bar that had more ghosts than patrons. We had served together in the Navy—him in the logistics corps, me in medical. We were both from Allegheny. We were both nobody in particular. We were both friends in the way that men who have nothing in common except place of origin and failed futures sometimes are.

"Hey, Ray," he said.

"Hey, Tommy."

"Water again?"

"Water."

He nodded. He ordered a beer. We sat in silence for a while. The bartender was washing glasses. A television in the corner was showing a football game neither of us was watching.

"They're closing another plant," Tommy said. "In Indiana. Three thousand jobs."

"I heard."

"You hear a lot."

"I listen."

He was quiet for a moment. Then he said, "I heard something. About the prescription drugs. The OxyContin."

"What about it?"

"Somebody's paying doctors to write more prescriptions. More prescriptions, more pills, more people addicted. It's a pipeline, Ray. And our town is part of it."

I felt something move in my chest. Not emotion. Recognition. I had seen the pattern. I had written it in charts and notes and had filed it away under "things I cannot change."

"Who's paying?" I asked.

"I don't know. But I know your mother gets her pills from the pharmacy on Main Street. The same pharmacy that's seen a two hundred percent increase in OxyContin prescriptions in the last six months."

My mother's pills. I had never questioned them. Dr. Patel had prescribed them. Dr. Patel was a good man, a hardworking man, an immigrant who had come to this country to give his children a better life. I had never questioned him.

"Ray?" Tommy said. "You don't have to—"

"I know what I have to do."

I did not go to the pharmacy. I stood in the parking lot and looked at the building and I thought about going in and asking questions and demanding answers and fighting for my mother and for the old man with the black hand and for the young woman with the fever and for everyone in this town who was being slowly, quietly, systematically destroyed by people who would never know our names.

But I did not go in. I got back in my car and I drove home.

My mother was asleep. The bourbon bottle was still on the table. I sat in the kitchen and I drank a glass of water and I listened to her breathe.

In April, my mother died. She died in her sleep. I found her in the morning. She looked peaceful. I called Dr. Patel. He came over. He confirmed what I already knew. He put his hand on my shoulder and said, "You did enough, Ray."

I did not cry at the funeral. I did not cry at the burial. I went back to work the next day.

The snow had melted. The ground was brown and wet and covered in debris—branches, plastic bags, the detritus of a winter that had not been hard enough to be noble and not soft enough to be gentle. I sat in my car in the clinic parking lot and I watched a crow pick at something on the ground. I did not know what it was. I did not want to know.

My phone rang. It was Tommy.

"Thursday?" he said.

"Thursday."

"Water?"

"Water."

I hung up. I sat for a moment. Then I got out of the car and went into the clinic.

The door closed behind me.