Genocide by Prescription The ‘Natural History’ of the Declining White Working Class in America
The ‘Natural History’ of the Declining White Working Class in America
James Petras and Robin Eastman-Abaya, MD
July 12, 2016
"Information Clearing House"
- 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, scores of 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 opioid, 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. This 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
suicide and overdose from 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
public image of the heroin-addicted returning Vietnam War soldier that shocked
the nation had 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 looked away. Suicides, overdoses and ‘sudden deaths’
killed many more soldiers than combat.
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.
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 they are scattered, incomplete
and generally lack any theoretical framework to understand, let alone confront,
conclude by discussing whether each ‘death by prescription’ is to be viewed as
an individual tragedy, mourned in private, or as a corporate crime fueled by
greed or even a pattern of ‘Social-Darwinism-writ-large’ by an elite-run
decision making apparatus.
advent of major political-economic changes induced by neoliberalism, America’s
oligarchic class confronts the problem of a large and potentially restive
population of millions 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’?
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.
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
overprescribing 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’ problem. 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.
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 is common to see healthy younger adults with
multiple prescriptions from multiple providers.
last few decades under neo-liberalism, rural county health department budgets
were stripped because of business-promoted austerity programs. Instead, the
federal government mandated that they implement expensive and absurd plans to
confront ‘bio-terrorism’. Often, health departments lacked the necessary budget
to pay for the costly forensic toxicology testing required for documenting drug
levels in suspect overdose cases among their own population.
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 overprescribing legal narcotics. The early crisis
received minimal attention from these bodies.
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.
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 the 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 of a young
adult while devoting paragraphs for a departed octogenarian.
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 life and employment has 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.
Dynamic Demography of Drug-Induced Death
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, but 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
woman on the extended family. They include grandmothers in their 50’s living
with three generations under one roof. In this demographic, women often provide
critical cohesion and stability for several generations at risk – even if they
had been taking ‘Oxy’ for their chronic pain.
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’.
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.
doctors had 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
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 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.
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.
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 decade-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
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.
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.
studies, at best, identify the victims of drug addiction. But their choice to
treat their despair as an ‘individual problem’ occurring in a ‘specific,
immediate context’ overlooks the greater political and economic structures,
which set the stage for premature death.
Political Economy of Overdose Deaths
remains of a young working class overdose victim is wheeled into a morgue, his
or her untimely demise is labelled a ‘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 medical community has merely functioned as the
transmission belt in this process, rather than as an agent for serving the
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.
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 pharmacologic
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.
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
accelerating 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.
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.
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 had 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
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 usual panacea: ‘education
and prevention’. This beehive of activity has come two decades too late into
the epidemic and reeks of cynicism.
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 with
epidemic from the beginning.
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.’
gain billions of dollars in profits from the ‘natural decline’ of redundant workers:
slashing social services and job benefits, such as health plans, pension,
vacation, job training programs, allowing employers to increase their 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’.
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.
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
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.
Petras is a Bartle Professor (Emeritus) of Sociology at Binghamton University,