Troubling Numbers
Pillars of Salt, Post Eleven
Wytheville, Virginia lies in the foothills of the Blue Ridge Mountains, against the rising northwest rim of a wide valley through which Interstate 81 cuts toward Roanoke and the northeast. Wythe County, of which Wytheville is the county seat, sits near the epicenter of the opioid crises that has rocked central Appalachia in waves since at least 1999, but, I think, at early as 1996, the year after the slow-release pain killer OxyContin hit the market.
By 1999, regions of Virginia’s southwest panhandle were seeing a rise in overdose fatalities resulting from synthetic opioids, prescription drugs. Wythe County was among those on the southern most edge of the crisis’ epicenter. The flashpoint really occurred in McDowell and Wyoming counties, West Virginia, where greater than twenty people per 100,000 were already dying of opioid overdoses in 1999. The surrounding counties, and areas of eastern Kentucky, were beginning to see between eight and twenty people per 100,000 die of prescription drugs. In Wythe County, in 1999, between two and three people died of the county’s roughly 27,600 residents. By 2014, that rate had doubled to more than five people per year, and fifty or more people had died since 1999. During that period, the state of West Virginia experienced an increase in opioid-related deaths from four to thirty-five deaths per 100,000 — a 775% increase and twice the national average. In my home county in Maryland, between three and six people died of opioids in 1999. By 2014, more than fifteen people were dying every year.
Taken individually, county by county, it might seem like these are not huge numbers. But over time, spread across the region, multiplied by many counties, 500,000 people have died at a rate of 136 per day as of 2019. Assuming a steady rate, which is actually against the twenty-year trend of rising rates, an additional 28,000 may have died in the last two years from prescription opioids.
This statistical view, these rates and numbers, the view from overhead as I look at maps, cross-reference counties and changing death-rates over time, also overlooks the concrete effects of these lost lives on the communities where they occur. If one person dies every month in my home county, sometimes two a month, everyone knows. Many, many people know one or more of the names appearing with depressing regularity in the paper. Opioids have killed so many people that they are a major contributing factor to a historic downturn in life expectancy in the United States. Life expectancy in this country has decreased four years in a row, a phenomenon last observed in 1918-1919 after 117,000 people died in World War I and 675,000 had died in the Flu Pandemic.
But we are back to statistics again.
We might lament that I start here, in Appalachia, with the opioid crisis. That it might be reductive, or already done, another drop in the bucket. But there is something so paradigmatic about this crisis and its origins in the region. It would be hard to find another issue that encapsulates the travails of Appalachia so well.
When I first started thinking critically about the region, I was led to the conclusion that it existed as a sort of internal colony. The raw materials from the mountains were extracted and sent back east to the early industrial centers. Labor pools were created through the importation of immigrant work forces from Ireland, Northern Europe, Eastern Europe, and North Africa. Though the region remains predominantly white, with some counties as much as 95% white of some kind, that very American Way of categorizing demographics misses a lot of the region’s diversity.
Later, after I had been thinking about this colony theory for a little while, I discovered there were, unsurprisingly, some books with this angle already in print. In 1978, Helen Lewis, Linda Johnson, and Donald Askins published Colonialism in Modern America: The Appalachia Case. I echo what others have said about this model, that it gave me a sense of a regional collectivity that emerged as a result of historical exploitation. Parties external to the region own the vast majority of its mineral rights and nearly half of the surface land, desired for the purpose of material extraction. The local population serves as a labor and service class, largely excluded from the profits that come pouring out of the mountains. Well, not so much pouring out as dug, drilled, carried, and blown out of the mountains by the miners and forestry workers of the region who, when they are killed en masse by unsafe working conditions and indifferent if not outright hostile company owners, are held up as noble sacrifices to the Greater Good. But it is a Greater Good that does not encompass Appalachia. It is everyone else’s good, but not ours. The cow is slaughtered to feed the village, which we cannot say is done for the good of the cow.
It also helped me identify capitalist exploitation as the root of Appalachia’s problems. The fact that the region has problems, that “Appalachia” has almost become a natural pair with “problems.”
Seeing the region as a collective suffering under oppression also broke the spell of pathology that clouded my thinking on home. “What’s wrong with these people?” I would ask myself, as if I was not one of them. It had to be them. There was some hidden property that could explain the poverty, the drug abuse, the violence, that stereotypes the region. I had allowed myself to pathologize my entire community.
An anti-colonial framework gave me a way to systematically understand Appalachia without falling into the liberal trap of personal responsibility as if the region could boot strap itself out of the hole that had been dug for it. Or, rather, that it had been forced to dig for itself.
But there are problems with this framework, I soon discovered. It risked further marginalizing the Native American populations that had been the first victims of this colonialism by failing to recognize the original act of displacement that opened the region to white settlers, prospectors, and the eventual labor pools that flooded the region in successive waves of 19th and early-20th century immigration. I think Emily Satterwhite, in Dear Appalachia: Readers, Identity, and Popular Fiction, is correct about the dangers of imagining an indigenous white population in Appalachia — a sentiment with which I was all to familiar. I often proclaimed, in anger or frustration, that I am from here. This, I felt, gave me a special claim that arose, almost mystically, from autochthony.
Albert Camus served me here. I felt myself then a kind of pied noir among the green mountains. Where Camus had erred, I could still make corrections. Perhaps it would be easier for me, without a literal civil war and nationalist, anti-colonial struggle being waged around me. I didn’t know what that meant yet, and to be honest, I still don’t really know.
What I do know is that I want and wanted justice for the Omàmiwinini (Algonquin) and Haudenosaunee (Iroquois) tribes that once lived in the southern Appalachia plateau, among the Allegheny Mountains around my hometown. Were these compatible goals? Isn’t this just another historical contradiction to be overcome, the supposed antagonism between the working class descendants of colonial settlers and the descendants of displaced indigenous peoples? Some people would say solidarity is impossible. That the white working class, the white proletariat, is a myth. I don’t think I am that cynical. Or maybe I’m not a realist.
I am, however, amazed that, beginning in the 1990s, pharmaceutical companies found a way to capitalize on the pain of the working class, white, real, or imaginary.
The service jobs and hard labor that are most accessible in Appalachia produce a lot of chronic pain. Back and neck injuries, repetitive motion injuries, carpal tunnel, neuropathy, in addition to the well-known black lung and other industry-related illnesses originating in mills and factories around the region.
Originally, drugs like OxyContin were indicated for use as end of life treatments for cancer pain, especially what was called “breakthrough” cancer pain — a type of severe pain that “breaks through” normal pain being controlled or partly controlled by a regimen of opioids or other pain killers.
The problem for companies like Purdue Pharma was that there wasn’t enough people dying of cancer, experiencing breakthrough pain. So a massive advertising campaign was launched on the basis of statements made by FDA officials who had been bribed by the company to approve their drug under expanded indicators that would convince a generation of doctors that opioids were safe with low addiction risk in treating a host of chronic pain issues and short-term symptoms follow surgery or injury. Properly administered, the company assured, patients would not get addicted to the time-release pain medication. Except they definitely would get addicted.
To combat the tendency of long-term opioid users to become addicted, Purdue enlisted doctors to validate a theory of “pseudo-addiction.” Pseudo-addiction is the idea that pain patients will begin to show a higher tolerance for their medication, which required higher doses. What prescribers had to watch out for was that increased tolerance looked like addiction, and the need for higher doses looked like the drug seeking behaviors of an addict. Because they were the drug seeking behaviors of addicts. However, the theory of pseudo-addiction took hold and patients were being given higher and higher doses of drugs like OxyContin which soon became available in deadly 80 and 160 milligram pills.
This cycle, the exploitation of labor resulting in chronic pain conditions that were in turn exploited by unscrupulous drug companies and doctors who trapped patients in yet a further cycle of addiction, was a sad, near perfect illustration of the national attitude toward my region. Take whatever we can get, by any means necessary, and to hell with them. We are disposable — white trash — already disposed, pre-disposed, deserving of our poverty, irresponsible, our suffering a direct result of our own moral failings.
Perhaps our faith in medical professionals is a moral failing. Perhaps, if we have a moral failing, it is our naive belief that someone based in Stamford, Connecticut or Chandler, Arizona would have our best interest in mind.
How to untangle these knots? That was the question I began posing to myself as we entered fully into Appalachia along that Interstate 81 corridor. It was cool and a bit overcast. The wind was blowing back west. We slowed, exited the highway, and wound down the off-ramp into a holler.
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