by Beth Macy
It was a fitting state of affairs for what happens after the out-of-state RAM do-gooders depart and Tyson’s grant-funded Health Wagon staff of twenty is left to tend to the health needs of the region’s uninsured. The program is called the Health Wagon because it was founded in 1980 by a Catholic nun and medical missionary named Sister Bernie Kenny, now retired, who first provided care out of the back of her red Volkswagen Beetle.
At our first stop, Tyson treated the swollen wrist of a substitute teacher whose pay had just been reduced from $70 to $56 a day. She was a casualty of school district depopulation and austerity, measures that included closing two schools in the town of Appalachia, one of which was now a food bank. In St. Paul, where our RV was presently stalled, the middle-school roof had become so tattered that buzzards had descended on it a few months earlier to eat the rotting tiles. With no money for repairs, school administrators resorted to temporary measures to divert the vultures, erecting giant inflatable tube men, the silly beacons you see waving from car dealerships.
The fifty-four-year-old teacher hadn’t had insurance in decades, not since she was pregnant and qualified for Medicaid; her husband, a former Walmart worker disabled by a series of strokes, was on Medicare. Because Virginia hadn’t approved the Affordable Care Act Medicaid expansion, she patched together free coverage at RAM events and occasional visits to Tyson’s mobile unit when it came to town. She had to be practically dying before she went to see her family doctor, who accepted cash at a discount rate of $63 per visit.
In a state with an increasingly flimsy safety net, people like Tyson had been left to clean up the politicians’ mess. As the health care debate over repeated attempts to repeal the ACA raged in Washington and opioid activists waited for President Trump to declare the epidemic an official national emergency—to free up immediate federal disaster relief funds for cities and states—between patients Tyson followed the machinations on her phone, fuming as she scrolled.
A devoutly religious wife and mother from nearby Coeburn, she was finding it hard to remain optimistic. In our first interview, she’d been distraught over the recent death of a forty-two-year-old patient caused by untreated hepatitis C. Though he hadn’t used or injected drugs for eight years, he could not afford to see a specialist. And by the time treatment could be arranged, “the damage was already done, and he couldn’t overcome it,” said his father, who owns a twenty-seven-acre cemetery.
The man buried his son near his office so he could visit him daily, he said. He invited me to tour the Wise County graveyard, where he offered to point out the scores of people he’d personally buried thanks to “OxyCoffin,” as the pills are now known here.
Months later, Tyson found herself crushed by a repeat in the continuing tragedy: In spite of 24/7 news cycles and a dense web of interconnectedness, here was one more death that gained no media traction and inspired zero public action. She could give all the interviews she wanted during the month of RAM, but the truth was that the extent of the suffering here garnered very little attention outside the spectacle of the annual health care event.
Unremarked on were the slow-simmering and increasingly common stories of people for whom no treatment could be secured. This time Tyson was crying about Reggie Stanley, forty-five, who died in a Charlottesville hospital while awaiting a liver transplant, after twelve years of untreated hepatitis C. “This patient was such a good person. He did make the wrong decisions initially,” Tyson said of Stanley’s IV drug use, but he’d been sober for several years. She’d tried desperately to get him into treatment, but like 90 percent of her patients, he was uninsured, and Tyson could not persuade a gastroenterologist to take him on as charity care. (She has since had success dispensing free medication provided by the company that makes Harvoni, the expensive hepatitis-curing drug.) By the time Stanley made it to a liver-transplant list, his disease was too advanced.
“You can fix it upstream, when it’s affordable, or you can wait till they present back in the ER with stage-four cancer or cirrhosis, and they still need extended hospital stays,” Tyson said. “It’s a drain on the system no matter what, so why can’t we fix it upstream?”
Tyson kept looking at Stanley’s obituary on her phone, which included a photo of him beaming in his Clintwood High graduation gown. “He was a great guitar player, great singer, and a good soul who was loved by many,” one of the guest-book mourners wrote.
The region’s health-department director, Dr. Sue Cantrell—the same one who’d warned state supervisors about the epidemic two decades before, only to have her pleas dismissed as “a regional problem”—was slowly making inroads. With the Scott County, Indiana, HIV epidemic still in mind, Cantrell had been holding town-hall meetings in the coalfield counties throughout the summer of 2017 to sound the alarm. Though Virginia had recently passed legislation paving the way for syringe exchange programs, every legislator in the coalfields had voted against the bill, citing widespread local law enforcement concerns, even though crime historically has not risen in communities with access to clean needles. Across the border in West Virginia, a 2015 syringe exchange had resulted in lowered overdose deaths and five-times-greater access to treatment and disease prevention services. Cantrell was hoping to arrange a visit from a West Virginia police chief to talk to local authorities, and her staff was already teaching users to clean their syringes between injections, giving out Clorox packets and plastic cups. She sometimes offered free food to entice patients both to be tested and to return for their results.
The RAM clinic offered free hepatitis C testing for the first time—a pharmacy professor estimated that 75 percent of IV drug users in the region have contracted it “and have no idea”—and handed out take-home naloxone kits with training to almost four hundred people. “In a rural area like this, just trying to get people to their appointments is huge,” Cantrell told me. Two patients in the MAT clinic she runs in nearby Lee County, Virginia, either hitchhike or walk to their appointments, some from a distance of more than five miles.
She’d floated the idea of turning some of the area’s subsidized housing units into “clean living facilities,” with wraparound services and support group offerings, not unlike substance-free college dorms. “We need to support this as a chronic disease the same as we support cancer and other diseases,” Cantrell said. “Not just evidence-based treatment and drug prevention programs but broadening it to meaningful education that leads to jobs with a living wage so there are options to stay in the area—or to leave.”
At the Narcotics Farm in Lexington, Kentucky, researchers had once referred to the latter as “the geographic cure.”
The idea of moving away from the site of addiction’s onset appealed to younger people who grew up among addicted family members as well as to the recovering addicts themselves, and it had worked for some, like many of the returning Vietnam soldiers. But opioids are much more available today than they were then—summonable by text or via online cryptomarkets, aka the dark web—and vastly more potent.
“The biggest lesson of the science behind drug addiction is that alternate reinforcers are essential,” Nancy D. Campbell, the Narcotics Farm historian, told me. “If you want to keep people away from drugs and drug-related crime, you have to have rewarding activities. It’s work. It’s play. It’s an emphasis on the kinds of activities and relationships that people build their lives around. If we don’t do something to rebuild these communities, I don’t see this current drug configuration ebbing in the way that drug waves of the past historically have.”
The question echoed louder by the day in rural America: How do you inspire hope in a middle-school boy whose goal in life is to become a “draw-er,” like his parents before him and their parents before them? Did a president who bragged about winning a swing state—telling the president of Mexico, “I won New Hampshire because New Hampshire is a drug-infested den”—win because voters genuinely thought he could fix it, or because too many people were too numbed out to vote?
Voters
should judge politicians at all levels on the literal health of their communities, lawyer Bryan Stevenson explained. And while most Americans support federal financing of health care and even a slim majority approves of single-payer, those reforms will likely remain political nonstarters until more voters begin defining themselves in contrast to the billionaire class holding sway in Washington. Also needed are more efforts to court nonwhite voters, including Hispanics (of whom 74 percent are currently registered to vote), African Americans (69 percent), and Asian Americans (57 percent).
“You’ve got too many leaders just not responding to problems,” Stevenson said. “Think about with HIV, with smoking, with Zika, you had this energetic leadership from people who were saying, ‘We’re going to win this.’ The mind-set of ‘This is unacceptable’ has to be brought into the way we think about addiction and the opioid epidemic. But part of the problem now is, we’re so hopeless…that we don’t try very hard.”
America’s approach to its opioid problem is to rely on Battle of Dunkirk strategies—leaving the fight to well-meaning citizens, in their fishing vessels and private boats—when what’s really needed to win the war is a full-on Normandy Invasion.
Rather than puritanical platitudes, we need a new New Deal for the Drug Addicted. But the recent response has been led not by visionaries but by campaigners spewing rally-style bunk about border walls and “Just Say No,” and the appointment of an attorney general who believes the failed War on Drugs should be amped up, not scaled back. Asked in August 2017 why he hadn’t taken his own commission’s recommendation to label the epidemic a national emergency, President Trump dodged the question. He said he believed the best way to keep people from getting addicted or overdosing was by “talking to youth and telling them: No good, really bad for you in every way.” A few days later, he seemed to change his mind, saying he would make the emergency official, even as he remained tethered to a law-and-order approach.
But months later, he still had not followed through. When the so-called emergency was retrumpeted in an October 2017 press conference, Trump sounded bold and even hopeful, but his ballyhoo fell short of an official declaration, and included no additional treatment funding. At the time, seven Americans were dying of overdose every hour.
To be fair, the crisis had been cruelly ignored by both sides of the political aisle. The Obama administration had also been slow to address the crisis and tepid when it did. Caroline Jean Acker, the historian who is also a harm-reduction activist, told me she was scolded during a 2014 NIDA meeting for championing needle exchange and naloxone distribution after a speaker attempted to separate “good” addicts, or people who became medically addicted, from the illicit, or “bad,” users—as if there were no fluidity between the two. “The worst thing for politicians, I was told, was for them to appear they were being soft on drugs. Even under Obama, federal [Substance Abuse and Mental Health Services Administration] employees were told not to use the term ‘harm reduction,’” she said, sighing.
No matter where I turned in central Appalachia, the biggest barriers to treatment remained cultural. Stigma pervaded the hills and hollows, repeating itself like an old-time ballad, each chorus featuring a slightly different riff.
At the RAM event in Wise, a kerfuffle erupted when a local judge volunteering at the event accused a pharmacist of giving Narcan training to a local Boy Scout troop without their parents’ permission; she claimed the kids would party harder knowing they had Narcan to revive them. “Just ridiculous,” one trainer told me.
But across the region, where it seemed every family had at least one soul crusher of a story, it would take more than one fairground debate to convince people that harm reduction was necessary to save lives, even as the region had the worst hepatitis C rate in the state. One-third of children in central Appalachia now lived with a nonparent adult, and 96 percent of the adopted kids weren’t orphaned—they’d been removed from their drug-addicted parents by social service workers.
At another Health Wagon event, a man overdosed on meth in the parking lot while his friends took off, running up the mountain, according to the responding EMT, who recognized a familiar unconscious face. “Repeats,” as Giles Sartin refers to many of his overdose calls, saying: “It’s rare you’ll get somebody who’s just now getting hold of it.” Sartin, twenty-one, has been an EMT since the tenth grade. He made the decision to train the day he was sitting in a freshman English class and heard the double thump of two classmates seated behind him hitting the floor.
They’d overdosed on OxyContin during a lesson on grammar and punctuation.
“Last week I Narcanned the same person for the fourth time,” Sartin said. When the man woke up, he punched Sartin’s EMT partner and broke his nose. He’d been speedballing painkillers with meth, which makes users paranoid and gives them “ridiculous strength.” It was such a problem that Sartin’s rescue squad had to adopt a new protocol: Even though people could die, they waited now for police to arrive before they went inside the patients’ homes.
“There’s communities where we’re like an ice cream truck,” Sartin said of the ambulance. “They’ll try to steal our needles, our gloves, everything,” especially in the Lee County hamlets of Keokee and St. Charles.
When I explained that my book began with OxyContin abuse in Lee County in the late nineties, Sartin cut me off with a warning: “Ma’am, there are spots in St. Charles where I would advise you not to be there at night. If they catch ya and don’t know ya, well…I don’t know.”
Tyson had revised the Health Wagon’s safety procedures, too. Whereas in Lebanon she tends to set her RV up outside a Food City grocery, or near the town square in St. Paul, she has learned to avoid residential neighborhoods in smaller communities. In the former coal camp of Clinchco, a close call had persuaded her to switch locales from a neighborhood to the police station parking lot.
Some neighbors had rushed to her RV, screaming and banging on the door for help. “We get to their trailer, and in the living room we get ready to work on the first person we see on the floor, but that wasn’t even who they were talking about,” Tyson recalled. The real patient was in the rear room, they were told, but her body was already growing cold. Meanwhile, others in the trailer were screaming at Health Wagon staffers “to get the f—outta here!”
“I still stand by what we did, trying to revive her, but the dynamics here are changing, and you can no longer just go blindly in,” said Tyson, who was genuinely afraid during the exchange.
Even law enforcement tightened up procedures. In June 2017, the DEA recommended that first responders wear safety goggles, masks, and even hazmat suits to avoid skin contact with fentanyl and other powerful synthetics after reports of officers having to be Narcanned when they inadvertently brushed up against them on calls.
But these guidelines came way too late for caregivers in the coalfields: Tyson’s life-and-death scare in Clincho took place more than a decade earlier—in 2006.
As a Lebanon prevention leader put it in a recent town-hall meeting called Taking Our Communities Back: “We are pioneers when it comes to this drug epidemic. We can tell people what will happen in their other communities in twenty years because it’s already happened here to us. We are the canaries in the coalfields.”
If it sounds like alarmist antidrug hyperbole—a version of Nixon’s speech identifying drug abuse as “public enemy number one”—it’s not. University of Pittsburgh public health dean Don Burke recently published a study forecasting the epidemic’s spread. Charting drug-overdose deaths going back to 1979, he added a new wrinkle to the work of Anne Case and Angus Deaton, the economists who pointed out the soaring “deaths of despair” among midlife white Americans.
Drug-overdose deaths had doubled every eight years over that time: Three hundred thousand Americans had died of overdose in the past fifteen years, and lacking dramatic interventions, the same number would die in just the next five.
“The numbers by themselves are disturbing, but more dis
turbing is the pattern—a continuous, exponential, upward-sloping graph,” Burke told me in 2017. A year before, more than a hundred Americans a day were dying from opioid overdose. Some epidemiologists were predicting the toll would spike to 250 a day as synthetic opioids became more pervasive.
Opioids are now on pace to kill as many Americans in a decade as HIV/AIDS has since it began, with leveling-off projections tenuously predicted in a nebulous, far-off future: sometime after 2020. In past epidemics, as the public perception of risk increased, experimentation declined, and awareness worked its way into the psyche of young people, who came to understand: “Don’t mess with this shit, not even a little bit,” as another public health professor put it. But that message has not yet infiltrated the public conscience.
What about the more than 2.6 million Americans who are already addicted? Will the nation simply write them off as expendable “lowlifes,” as Van Zee’s patient still believed?
“My hope is that there is an end in sight,” Burke told me. “Some natural limit, or some policy where we deflect the curve downward.” But even in states where downturns have intermittently appeared—such as in Florida, following the crackdown on pill mills—“eventually those places snapped back to that curve, and we don’t know why,” he said.
In the carefully couched words of an academic, Burke suggested that the War on Drugs should be overhauled, with input gathered from other countries, including Portugal, that have decriminalized drugs and diverted public monies from incarceration to treatment and job creation.
He wondered whether drug cartels were the economy’s new invisible hand—a modern-day Adam Smith creeping around America’s suburbs, cities, and small towns, proffering stamped bags of dope. The economist had assumed the free-market economy would operate efficiently as long as everyone was able to work for his or her own self-interest, but he had not foreseen the elevation of rent-seeking behavior: the outsized greed of pharmaceutical companies and factory-closing CEOs, and the creation of a class of people who were unable to work.
