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Genocide by Prescription: The ‘Natural History’ of the Declining White Working Class in America
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By James Petras and Robin Eastman-Abaya, MD
Axis of Logic
Tuesday, Jul 12, 2016
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James Petras and Robin Eastman-Abaya |
Introduction
The white working class in the US has been decimated through an
epidemic of ‘premature deaths’ – a bland term to cover-up the drop in
life expectancy in this historically important demographic. There have
been quiet studies and reports peripherally describing this trend – but
their conclusions have not yet entered the national consciousness for
reasons we will try to explore in this essay. Indeed this is the first
time in the country’s ‘peacetime’ history that its traditional core
productive sector has experienced such a dramatic demographic decline –
and the epicenter is in the small towns and rural communities of the
United States.
The causes for ‘premature death’ (dying before normal
life expectancy – usually of preventable conditions) include the
sharply increasing incidence of suicide, untreated complications of
diabetes and obesity and, above all, ’accidental poisoning’ – a euphemism
used to describe what are mostly prescription and illegal drug overdoses
and toxic drug interactions. No one knows the total number of
deaths of American citizens due to drug overdose and fatal drug
interactions over the past 20 years, just as no central body has kept
track of the numbers of poor people killed by police nationwide. But
let’s start with a conservative round number - 500,000 mostly white
working class victims, and challenge the authorities to come up with
some real statistics with real definitions. Indeed such a number could
be much higher – if they included fatal poly-pharmacy deaths and
‘medication errors’ occurring in the hospital and nursing home setting.
In
the last few years, thousands of Americas have died
prematurely because of drug overdoses or toxic drug interactions, mostly
related to narcotic pain medications prescribed by doctors and other
providers. Among those who have increasingly died of illegal opioids -
mostly heroin, fentanyl and methadone overdose, the vast majority first
became addicted to the powerful synthetic opioids prescribed by the
medical community, supplied by big chain pharmacies and manufactured at
incredible profit margins by the leading pharmaceutical companies. In
essence, this epidemic has been promoted, subsidized and protected by
the government at all levels and reflects the protection of a
profit-maximizing private medical-pharmaceutical market gone wild.
This
is not seen elsewhere in the world at such a level. For example,
despite their proclivity for alcohol, obesity and tobacco – the British
patient population has been essentially spared this epidemic because
their National Health System is regulated and functions with a different
ethic: patient well being is valued over naked profit. Our situation arguably
would not have developed in the US if a single-payer national health
system had been implemented.
Faced with the increasing incidence of
returning Iraq and Afghanistan veterans dying from overdose and suicide or prescription opioids and mixed drug reactions, the Armed Forces
Surgeon General and medical corps convened ‘emergency’ US Senate
Hearings in March 2010 where testimony showed military doctors had
written 4 million prescriptions of powerful narcotics in 2009, a 4 fold
increase from 2001. Senate members of the hearings, led by Virginia’s
Jim Webb, cautioned not casting a negative light on ‘Big Pharma’ - among
the largest donors to political campaigns.
The 1960s' public image
of the heroin-addicted returning Vietnam War soldier that shocked the
nation has morphed into the Oxycontin/Xanax dependent veteran of the new
millennium, thanks to ‘Big Pharma’s’ enormous contracts with the US
Armed Forces and the mass media looking away. Suicides, overdoses and
‘sudden deaths’ killed many more soldiers than combat.
No other
peaceful population, probably since the 1839 Opium Wars, has been so
devastated by a drug epidemic encouraged by a government. In the case
of the Opium Wars, the British Empire and its commercial arm, The East
India Company, sought a market for their huge South Asian opium crops
and used its military and allied Chinese warlord mercenaries to force a
massive opium distribution on the Chinese people, seizing Hong Kong in
the process as a hub for its imperial opium trade. Alarmed at the
destructive effects of addiction on its productive population, the
Chinese government tried to ban or regulate narcotic use. Its defeat at
British hands marked China’s decline into semi-colonial status for the
next century – such are the wider consequences of having an addicted
population.
This paper will identify the (1) the nature
of the long-term, large-scale drug induced deaths, (2) the dynamics of
‘demographic transition by overdose’, and (3) the political economy of
opioid addiction. This paper will not cite numbers or reports – these
are widely available. However those are scattered, incomplete and
generally lack any theoretical framework to understand, let alone
confront, the phenomenon.
We will conclude by discussing
whether each ‘death by prescription’ is to be viewed as an individual
tragedy, mourned in private, or a corporate crime fueled by greed or
even a pattern of ‘Social-Darwinism-writ-large’ by an elite-run decision
making apparatus.
Since the advent of major political-economic
changes induced by neoliberalism, America’s oligarchic class confronts
the problem of a large and potentially restive population of
marginalized workers and downwardly mobile members of the middle class
made redundant by ‘globalization’, and an armed rural poor sinking ever
deeper into squalor. In other words, when finance capital and elite
ruling bodies view an increasing ‘useless’ population of white workers,
employees and the poor in this geographic context, what ‘peaceful’
measures can be taken to ease and encourage their ‘natural decline’?
A
similar pattern emerged in the early ‘AIDS’ crisis where the Reagan
Administration deliberately ignored the soaring deaths among young
Americans, especially minorities, adopting a moralistic ‘blame the
victim’ approach until the influential gay community organized and
demanded government action.
The Scale and Scope of Drug Deaths
In the past two decades, hundreds of thousands of working age Americans
have died from drugs. The lack of hard data is a scandal. The
scarcity is due to a fragmented, incompetent and deliberately incomplete
system of medical records and death certificates – especially from the
poorer rural areas and small towns where there is virtually no support
for producing and maintaining quality records. This great data void is
multi-faceted and hampered by the problems of regionalism and a lack of
clear governmental public health direction.
Early in the crisis,
medical professionals and coroners were largely in ‘denial’ and under
pressure to certify ‘unexpected’ deaths as ‘natural due to pre-existing
conditions’ – despite overwhelming evidence that there had been reckless
over-prescribing by the local medical community. Fifteen to twenty
years ago, the victims’ families, isolated in their little towns, may
have derived some short-term comfort from seeing the term ‘natural’
attached to their loved-one’s untimely death. Understandably, a
diagnosis of ‘death by drug overdose’ would evoke tremendous social and
personal shame among the rural and small-town white working class
families who had traditionally associated narcotics with the urban
minority and criminal populations. They thought themselves immune to
such ‘big city’ problems. They trusted ‘their’ doctors who, in turn,
trusted ‘Big Pharma's assurances that the new synthetic opioids were
not addicting and could be prescribed in large quantities.
Despite the local medical community’s slowly growing awareness of this
problem, there was little public attempt to educate the at-risk
population and still fewer attempts to rein in the over-prescribing
brethren physicians and private ‘pain-clinics’. They, or their nurse
practitioners and PA’s, did not counsel patients on the immense dangers
of combining opioids and alcohol or tranquilizers. Many, in fact, were
not even aware of what their patients were prescribed by other
providers. It would not been not unusual to see healthy younger adults
with multiple prescriptions from multiple providers.
Through the
last few decades under neo-liberalism, rural county heath department
budgets were stripped through business-promoted austerity programs.
Instead, the federal government has mandated that they implement
expensive and absurd plans to confront ‘bio-terrorism’. Often, health
departments lacked the necessary budgets to pay for the costly forensic
toxicology testing required for documenting drug levels in suspected
overdose cases among their own population.
Further
compounding this lack of quality data, there was no guidance or
coordination from the federal and state government or regional DEA
regarding systematic documentation and the development of a usable
database for analyzing the widespread consequences of over-prescribing
legal narcotics. The early crisis received minimal attention from these
bodies.
All official eyes were focused on the ‘war on drugs’ as it
was being waged against the poor, urban minority population. The small
towns, where over-prescribing doctors formed the pillars of the local
churches or country clubs, suffered in silence. The greater public was
lulled by media mis-education into thinking that addiction and related
deaths were an ‘inner city’ problem, one that required the usual racist
response of filling up the prisons with young blacks and Hispanics for
petty crimes or drug possession. But within this vacuum, white
working class children were starting to dial ‘911’…because, ‘Mommy won’t
wake up…’. Mommy with her ‘prescribed Fentanyl patches’ took just one
Xanax too many and devastated an entire family unit. This was a
prototype of a raging epidemic. All throughout the country these
alarming cases were growing. Some rural counties saw the proportion of
addicted infants born to addicted mothers overwhelm their unprepared
hospital systems. And the local obituary pages published increasing
numbers of young names and faces besides the very elderly – never
printing any ‘cause’ for the untimely demise while devoting paragraphs to a
departed octogenarian.
Recent trends demonstrate that
drug deaths (both opiate overdose and fatal mixed interactions with
other drugs and alcohol) have had a major impact on the composition of
the local labor force, families, communities and neighborhoods. This is
reflected in the lives of workers, whose personal lives and employmenthave been severely impaired by corporate plant relocations, downsizing,
cuts in wages and health benefits. The traditional support systems,
which provided aid to workers damaged by these trends, such as trade
unions, public social workers and mental health professionals, were
either unable or unwilling to intervene before or after the scourge of
drug addiction had come into play.
The Dynamic Demography of Drug-Induced Death
Almost all publicized reports ignore the demography and differential
class impacts of prescription-related drug deaths. The majority of
those killed by illegal drugs were first addicted to legal narcotics
prescribed by their providers. Only the overdose deaths of celebrities
manage to hit the headlines.
Most of the victims have
been low wage, unemployed or under-employed members of the white working
class. Their prospects for the future are dismal. Any dream of
establishing a healthy family life on one salary in ‘Heartland America’
would be met with laughter. This is a huge national population, which
has experienced a steep decline in its living standards because of
deindustrialization. The majority of fatal overdose victims are white
working age males, with a large proportion of working class women,
often mothers with children. There has been little discussion about the
impact of an overdose death of a working age parent on the extended family.
This includes grandmothers in their 50’s. In this demographic, women
often provide critical cohesion and stability for several generations at
risk.
Apparently the US minority population has so far escaped this
epidemic. Black and Hispanic Americans had already been depressed and
economically marginalized for a much longer period – and the lower rate
of prescription drug deaths among their populations may reflect greater
resilience. It certainly reflects their reduced access to the
over-prescribing private-sector medical community – a grim paradox where
medical ‘neglect’ might indeed have been ‘benign’.
While
there may be few class-based studies looking at comparative trends in
‘overdose deaths’ among urban minorities and rural/small town whites
from sociology, public health or minority-studies university
departments, anecdotal evidence and personal observation suggest that
minority urban populations are more likely to provide assistance to an
overdosing neighbor or friend than in the white community where addicts
are more likely to be isolated and abandoned by family members ashamed
of their ‘weakness’. Even the practice of ‘dumping’ an overdosed friend
at the entrance of an emergency department and walking away has saved
many lives. Urban minorities have greater access and familiarity with
the chaotic big-city emergency rooms where medical personnel are skilled
at recognizing and treating overdose. After decades of civil rights
struggles, minorities are possibly more sophisticated in asserting their
rights regarding use of such public resources. There may even be a
relatively stronger culture of solidarity among the marginalized
minorities in rendering assistance or an awareness of the consequences
of not taking someone’s neighbor to the ER. These urban survival
mechanisms have been largely absent in the white rural areas.
Nationwide,
US doctors have long been dissuaded from prescribing powerful synthetic
opioids to minority patients, even those in significant pain. There are
various factors here, but the medical community has not been immune to
the stereotype of the Hispanic or black urban addict or dealer.
Perhaps, this widespread medical ‘racism’ in the context of the
prescription opioid epidemic has had some paradoxical benefit.
Whatever
the reason, urban minority addicts, while experiencing overdose in
large numbers, are more likely to survive an opiate overdose than small
town or rural whites, unfamiliar with narcotics and their effects.
In
the rural and small-town (deindustrialized) US heartland there has been
an enormous breakdown in community and family solidarity. This has
followed the destruction of a century-old stable employment base,
especially in the manufacturing, mining and productive agricultural
sectors. Only post-Soviet Russia experienced a similar pattern of
declining life expectancy from ‘poisoning’ (alcohol and drugs) following
the nationwide destruction of its socialized full employment system and
the breakdown of all social services. Furthermore the loss of the
tough Soviet police apparatus and the growth of an oligarch-mafia class
saw the tremendous in-flooding of heroin from Afghanistan.
The growth of opioid addiction is not based on ‘personal choice’, nor
is it the result of shifts in cultural life styles. While all class and
educational levels are included among the victims, the overwhelming
majority are the younger white working class and the poor. They cover all
age groups, including adolescents recovering from sports injuries, as
well as the elderly with joint and back pain. The surge of addiction is
a result of major shifts in the economy and the social structure. The
regions most affected by overdose deaths are those in deep, prolonged
and permanent decline, including the former ‘rust belt’ regions, small
manufacturing towns of New England, upstate New York, Pennsylvania and
the rural South and agricultural, mining and forestry regions of the
west.
This is the product of private executive decisions to (1)
relocate productive US companies overseas or to distant, non-union
regions of the country, (2) force once well-paid employees into lower
paid jobs, (3) replace American workers with skilled and unskilled
foreign immigrants or poorly paid ‘temps’, (4) eliminate pension and
health benefits and (5) introduce new technology – including robots-
which cuts the labor force by rendering human workers redundant. These
changes in the relationship of capital to labor have created enormous
profits for senior executives and investors, while producing a surplus
labor force, which puts even greater pressure on young first-time
workers and workers with seniority. There have been no effective job
protection/sustainable job creation programs to address the decades of
declining well-paid employment. Good jobs have been replaced by minimum
wage, service sector ‘MacJobs’ or temporary poorly paid manufacturing
jobs with no benefits or protections. All across this devastated
heartland, expensively touted programs, such as ‘Start-Up New York’,
have failed to bring decent jobs while spending hundreds of millions of
public money in free PR for state politicians.
The drug
addiction epidemic has been most deadly precisely in those regions of
industrial job loss and working wage decline, as well as in the
depressed, once protected, agricultural and food processing sectors
where union jobs have been replaced by minimum wage immigrants. The
loss of stable employment has been accompanied by a slashing of social
services and tremendous cuts in benefits – just when such services
should have been bolstered.
Precisely because the
so-called ‘drug problem’ is linked to major demographic changes
resulting from dynamic capitalist shifts, it has never been the focus of
elite-run government and corporate foundation grant research – unlike
their fixation on the ‘radicalization of Muslims’ or ‘trends in urban
crime’. Research tended to focus on ‘minorities’ or merely nibbled at
the periphery of the current phenomenon. Good studies and data would
have provided the rationale and basis for major public programs aimed at
protecting the lives of marginalized white workers and reversing the
deadly trends. The decades-long, nation-wide absence of research and
data into this phenomenon has justified the glaring absence of an
effective governmental response. Here the ‘neglect’ has not been
‘benign’.
In parallel with the increase in opioid
addiction, there has been an astronomical increase in the prescription
of psychotropic drugs and anti-depressants to the same population – also
highly profitable to ‘Big Pharma’. The pattern of prescribing such
powerful, and potentially dangerous, mood altering medications to
downwardly mobile Americans to ‘treat’ or numb normal anxieties and
reactions to the deterioration in their material condition has had
profound consequences. Such individuals, often on unemployment
assistance or MEDICAID, may be expected to follow a complex daily
regimen of up to nine medications – besides their narcotic pain
medications, while trying to cope with their crumbling world.
Where a
dignified job with a decent wage would effectively treat a marginalized
worker’s despair without unpleasant or dangerous ‘side effects’, the
medical and mental health community has consistently sent their patients
to ‘Big Pharma’. As a result, post-mortem toxicological analyses often
show multiple prescribed psychotropic medications and anti-depressants
in addition to narcotics in cases of opioid overdose deaths. While this
may constitute an abdication of the medical provider’s responsibility to
patients, it is also a reflection of the medical community’s utter
helplessness in the face of systemic social breakdown – as has occurred
in the marginalized communities where drug overdose deaths concentrate.
Demographic studies, at best, identify the victims of drug addiction.
But their choice to treat their despair as the ‘individual problem’
occurring in a ‘specific, immediate context’ overlooks the greater
political and economic structures, which set the stage for premature
death.
The Political Economy of Overdose Deaths
When
the remains of a young working class overdose victim is wheeled into a
morgue, his or her untimely demise is labelled ‘self-inflicted’ or
‘accidental’ opioid overdose and a great cover-up machine is turned on:
The sequence leading up to the death is shrouded in mystery, no deeper
understanding of the socio-cultural and economic factors are sought.
Instead, the victim or his/her culture is blamed for the end-result of a
complex chain of elite capitalist economic decisions and political
maneuverings in which a worker’s premature death is a mere collateral
event. The media community has merely functioned as the transmission
belt in this process, rather than an agent for serving the public.
The vast majority of overdose fatalities are, in reality, victims of
decisions and losses far beyond their control. Their addictions have
shortened their lives as well as clouded their understanding of events
and undermined their capacity to engage in class struggle to reverse
this trend. It has been a perfect solution to the predictable
demographic problems of brutal neoliberalism in America.
Wall Street and Washington designed the macro-economy that has
eliminated decent jobs, cut wages and slashed benefits. As a result
millions of marginalized workers and the unemployed are under tremendous
tension and resort to pharmacological solutions to endure their pain
because they are not organized. The historical leading role of trade
union and community organizations has been eliminated. Instead,
redundant workers are ‘charged by Big Pharma’ to dig their own graves
and class leaders are nowhere to be found.
Secondly, the
workplace has become much more dangerous under the ‘new economic
order’. Bosses no longer fear unions and safety regulations: many
workers are injured by the acceleration of the pace of work, longer
hours, faulty job training and lack of federal supervision of working
conditions. Injured workers lacking any judicial, trade union, or
public agency protection rightly fear retaliation for reporting their
work injury and increasingly resort to prescription narcotics to cope
with acute and chronic pain while continuing to work.
When employers allow workers to report their injuries, the low coverage
and limited treatments available encourage providers to over-prescribe
narcotics on top of other medications with potentially dangerous
interactions. Many pain clinics, contracted by employers, are eager to
profit from injured clients while pharmaceutical companies actively
promote powerful synthetic narcotics.
A vicious chain is
formed: The pharmaceutical industry’s mass production of narcotics has
been among its most profitable products. Corporate pharmacy chains fill
the prescriptions written by tens of thousands of ‘providers’ (doctors,
dentists, nurses and physician assistants) who have only a limited
amount of time to actually examine an injured worker. The deteriorating
work conditions create the injury and the workers become consumers of
Big Pharma’s miracle relief – Oxycontin or its cousins – which a decade
of drug salesmen has touted as ‘non-addicting’. A long line of highly
educated professionals, including doctors and other providers,
pathologists, medical examiners and coroners carefully paper over the
real cause, the corporate decision makers, in order to protect
themselves from corporate reprisals should they ‘blow the whistle’. Behind the scientific façade there is a Social Darwinism that few are
willing to confront.
Only recently, in the face of incredible
numbers of hospitalizations and deaths from narcotic overdose, the
federal government has started to release funds for research. Academic-medical researchers have started to collect and publicize data
on the growing epidemic of opiate deaths; they provide shocking maps of
the most affected counties and regions. They join the chorus in urging
the federal and state agencies to become more actively involved in the usual
panacea: ‘education and prevention’. This beehive of activity has come
two decades too late into the epidemic and reeks of cynicism.
Funding for research into this phenomenon will not result in any
effective long-term programs for confronting these small community-based
‘crises of capitalism’. There is no institution willing to confront
the basic cause: the devastation of capitalist labor relations in
post-millennial America, the corrupt nature of
state-corporate-pharmaceutical linkages and the chaotic, profit-driven
character of our private medical system. Very few writers ever explore
how a national, public, single-payer, health system would have clearly
prevented the epidemic from the beginning.
Conclusion
Why does the capitalist-state and pharmaceutical elite sustain a
socio-economic process, which has led to the large-scale, long-term
death of workers and their family members in rural and small town
America?
One ready and convincing hypothesis is that the
modern dynamic corporate elite profits from the results of ‘demographic
change by overdose.’
Corporations gain billions of
dollars in profits from the ‘natural decline’ of redundant workers:
slashing social and job benefits, such as health plans, pension,
vacation, job training programs, allowing employers to increase rates of
profits, capital gains, executive bonuses and raises. Public services
are eliminated, taxes are reduced and workers, when needed, can be
imported – fully formed – from abroad for temporary employment in a
‘free labor market’.
Capitalists profit even more from
the technology gains – robots, computerization, etc. – by ensuring that
workers do not enjoy reduced hours or increased vacations resulting from
their increased productivity. Why share the results of productivity
gains with the workers, when the workers can just be eliminated? Dissatisfied workers can turn inward or ‘pop a pill’, but never organize
to retake control of their lives and future.
Election
experts and political pundits can claim that white American workers
reject the major establishment parties because they are ‘angry’ and
‘racist’. These are the workers who now turn to a ‘Donald Trump’. But a
deeper analysis would reveal their rational rejection of political
leaders who have refused to condemn capitalist exploitation and confront
the epidemic of death by overdose.
There is a class
basis for this veritable genocide by narcotics raging among white
workers and the unemployed in the small towns and rural areas of
American: it is the ‘perfect’ corporate solution to a surplus labor
force. It is time for American workers and their leaders to wake up to
this cruel fact and resist this one-sided class war or continue to mourn
more untimely deaths in their own drug-numbed silence.
And it is
time for the medical community to demand a ‘patient-first’ publicly
accountable national health system that rewards service over profit, and
responsibility over silent complicity.
Please note James Petras's new collection of essays with Clarity Press:
THE END OF THE REPUBLIC AND THE DELUSION OF EMPIRE
ISBN: 978-0-9972870-5-9
$24.95 / 252 pp. / 2016
© Copyright 2016 by AxisofLogic.com
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