A drug ravaged rural America: Bracing for the battle against Tranq

The opioid epidemic has, indiscriminately, ravaged both urban and rural communities in the United States. However, there is a new drug taking over the country, and concern over how this may impact rural America is at the forefront of many heath service providers. As they brace for the inevitable impact, the question remains how rural communities can combat pervasive drug use while battling the systemic issues that made them vulnerable to this drug crisis in the first place. Fortunately, there may be some legislative relief on the horizon.

Until a few months ago, fentanyl was thought to be the most lethal drug on the streets of America. According to the California Department of Public Health, “fentanyl is a synthetic opioid that is up to 50 times stronger than heroin and 100 times stronger than morphine.” The Center for Disease Control and Prevention (CDC) reported that in 2021,synthetic opioid-related drug use accounted for over 100,000 deaths. Of that number, fentanyl-related deaths account for over half of all opioid related deaths. This number is consistently rising every year.

The CDC also noted that in five states, "California, Connecticut, North Carolina, Vermont, and Virginia, the rate of drug-overdose deaths in rural counties were higher than those in urban counties." The entire country is marred by the effects of the drug epidemic, however, rural Americans face particular challenges for several reasons discussed in class. These include restricted access to health care, treatment facilities, and doctors. Other more structural issues include, special isolation, poverty, housing insecurity, transportation, and even lack of internet access which impacts rural American’s ability to see online health providers.

In fact, in 2021,"rural children and adults under 65 were more likely than their urban peers to be uninsured." This data is significant because it shows that rural America is already suffering from health care disparities that will limit their response to the latest drug emerging in already decimated communities: Tranq.

Tranq is a street name for the animal tranquilizer, Xylazine, and is typically an additive to already lethal opioid drugs like heroin, cocaine, and fentanyl. While, the origins of this concoction are thought to have emerged from Puerto Rico, the New York Times recently reported its rising prevalence in the United States. It is currently unregulated and not criminalized.

One of the most alarming symptoms of Tranq is that persistent use causes open, gapping wounds in or around the injection sites of people struggling with addiction. While this symptom is not seen when the drug is used as intended, namely for animals, it is leading to an alarming rise in infections. This sometimes necessitates amputations after tissue becomes necrotic and, in some case, completely dies off.

Other side effect of this deadly drug include amnesia, drowsiness, slow breathing, and dangerously low heart rate and blood pressure. It has been dubbed a “zombie” maker for the way in which it causes those consuming it to immediately enter a deep stupor.

Ironically, rural America needs Xylazine. The drug is commonly used to treat cattle and other commercial live stock. While the White House designated Xylazine as a national drug threat, there are other considerations for animal caregivers that need the drug to do their jobs. For example, veterinarians fear that if the drug were regulated, the medicine and their access would be heavily policed. Another consideration is that “[p]roduction of a classified drug would require additional quality control and security measures so costly that a manufacturer could raise the drug’s price or just stop making it altogether.”

However, if Xylazine were regulated by the FDA, police would be able to criminalize distribution for human use. Significantly, the police can’t arrest a person for sales or distribution of xylazine. Therefore, there is virtually no law enforcement ability to effectively curtail sales.

In an effort to appease both those who want to criminalize Xylazine and those who do not want to, Sen. Catherine Cortez Masto, a Nevada Democrat, Sen. Chuck Grassley, an Iowa Republican, and Sen. Maggie Hassan, a New Hampshire Democrat introduced a bipartisan bill that would make anybody purchasing the drug pay the same fines as if it were classified as a Schedule III drug. Their hope is to keep the drug accessible to those who would suffer from its regulation but punish those profiting from its illegal uses.

Unfortunately, paying fines does little to stop the harm already underway. In March, the DEA reported that it 2022, it had found Tranq in confiscated fentanyl mixtures in 48 out of 50 states. In a separate report, the DEA noted it had found Xylazine in all four regions of the United States: Northeast, South, Midwest, and West. The South experienced the worst increase over a two-year period with Xylazine-related drug incidents up by 193%.

All the data suggests Tranq is taking over and while the full scope of the problem is not yet known, it is clear that trouble is brewing.

Ironically, Republican legislators may offer some hope. In an uncharacteristically timely move, a bill led by Iowans Sen. Chuck Grassley and Rep. Randy Feenstra to prevent opioid addiction, overdoses and deaths in rural communities was signed into law in December of 2022. The Rural Opioid Abuse Prevention Act, allows grants to be used for pilot programs for rural areas to implement community response programs that focus on reducing opioid overdose deaths, which may include presenting alternatives to incarceration.

The Rural Opioid Abuse Prevention Act is a step in the right direction, and as rural America prepares for another battle, it is a measure of assistance in a dessert of need.

Democrats strategize how to reach "factory towns" in Midwest, Rust Belt

Blake Hounshell writes for the New York Times about a new report from the political nonprofit American Family Voices (AFV) titled "Winning Back The Factory Towns That Made Trumpism Possible."  Like an earlier report on this topic from AFV last fall, the report uses "factory town" as a term of art to refer to places reliant on manufacturing and union jobs.  These places have also become associated with widespread population health issues, including the illnesses associated with deaths of despair.  

Here's the lede from Hounshell's story: 

Should Democrats bother competing in the struggling factory towns of the Midwest?

A report released on Tuesday answers this question with an emphatic “yes.” But the fact that it is being asked at all speaks to the Democratic Party’s still-unresolved challenge of how to win back the more than 2.6 million voters it has lost in places like Ottumwa, Iowa, and Scranton, Pa., since 2012.

More than five years after Donald Trump galvanized the white working class in America’s fading industrial heartland, Democrats are still trying to understand what happened, and debating whether they should scrounge elsewhere for votes. Should they try to run up the electoral score in urban areas and inner-ring suburbs instead?

Basic electoral math suggests that they have little choice: It would be exceedingly difficult for Democrats to win a governing majority without holding onto their “blue wall” in the Midwest, and continued erosion in smaller communities might make that impossible in the near future.

Hounshell then goes on to discuss Democrats' efforts to take open U.S. Senate seats in two Rust Belt states, Ohio and Pennsylvania, and two in the Midwest, Iowa and Wisconsin, "all states that are dotted with places that have been hurt by the effects of global economic and technological change over the last few decades."  And these are not a paltry number of voters.  The prior AFV report noted, for example, that midsize and small manufacturing counties are 58% of the statewide vote in Wisconsin and half of the voting population in Michigan.    

The recommendations in this report are based on polling conducted by Lake Research Partners that "shows a population buffeted by the rising cost of living and suffering from health-related crises. A majority, for instance, said they or a family member had a chronic health condition. Majorities also said they had personally struggled with disabilities, job loss, mental health problems or addiction."

This is perhaps the most striking paragraph, quoting Mike Lux, a Democratic strategist whose roots are in the region and who is the primary author of the report, who spent much of the last year immersed in the study.  He commented that “probably the No. 1 surprise to me is how desperate people are for community.”

That quote reminds me of Robert Putnam's Bowling Alone, about the loss of community. 

Also regarding Iowa, where there were primary elections today, is this piece about the decline of Democrats in Dubuque, in the northeast quadrant of the state, which was historically the most Democratic part.  Elaine Godfrey asks, "Are Iowa's Democratic Days Gone for Good?"  Here are a couple of paragraphs of that story that link it to the American Family Voices report, featuring references to the Simpsons, a die-hard Democratic family with deep roots in Dubuque: 

After 60 years, voters in Dubuque County seem finished with Democrats. Nationwide, the trends are the same: Working-class voters without a college education are voting more in line with Republicans, while Democrats make inroads among more educated voters. The political winds that used to propel the Simpsons forward in each election are now blowing hard against them.

* * *

Last fall, 10,000 John Deere workers across the country, including many in Dubuque, went on strike for five weeks while they negotiated a new contract. One of Kelly’s cousins was on the picket line, and she told Kelly about men who went on strike wearing their bright-red trump 24 T-shirts. A decade ago, the thought of a UAW member in Dubuque openly supporting a Republican presidential candidate on the picket line was inconceivable. “Donald Trump wasn’t for you!” Kelly wanted to shout at them. “Not one of them should ever be wearing a Trump ’24 shirt. Because then we have failed them.”

Dubuque UAW members who swung to Trump didn’t do so because of his policy promises, though, Dan White, the former president of the union local, told me. Sure, they liked that he talked about keeping jobs in America, but mostly they really just appreciated the way he talked, and how he sounded like he was on their side. Fox News, talk radio, and social media helped reinforce that impression, Tom Townsend, the business manager of the local IBEW, told me. Many of his members have fully bought into the right’s portrayal of Democrats—that they’re all socialists who want to take their guns. They won’t listen when Townsend tries to tell them otherwise.

Changing the reputation that Democrats have in northeast Iowa right now will be a tough project.

Analysis of the "rural mortality penalty" (and related impacts on the electorate?)

This is from a brief by Shannon Monnat of Syracuse University's Lerner Center for Public Health Promotion, under the headline, "The U.S. Rural Mortality Penalty is Wide and Growing": :  

After decades of lower or similar mortality rates in rural areas than in urban areas of the U.S., a rural mortality penalty emerged in the 1990s and has grown since the mid-2000s. Although the rural–urban mortality gap has widened across all major racial/ ethnic groups over the past 30 years, it has widened the most among working-age non-Hispanic (NH) whites. 

This brief summarizes the results from a study published in Population Research and Policy Review that examined rural urban differences in mortality rates overall and from 15 specific causes among working-age (age 25-64) NH whites1 from 1990 to 2018and identified the causes of death that have contributed most to the widening of the rural mortality penalty. 

Results show that the rural mortality penalty is wide and growing and is pronounced across multiple causes of death. Growth in the rural disadvantage is due to smaller rural declines in deaths from cancers and cardiovascular diseases and larger rural increases in deaths from metabolic, respiratory, alcohol related, and mental and behavioral diseases and suicides compared to urban areas. Mortality rate trends are particularly concerning for the younger working-age group (25-44) and for females overall. Ultimately, high and rising mortality rates across a variety of causes and rural places, some of which have been occurring since the 1990s and others that emerged more recently, suggest that there is not one underlying explanation. Instead, failures across a variety of institutions and policies have contributed to rural America’s troubling mortality trends. 

This New York Times story about how Trump's base is shrinking seems tragically related, in the sense that working-class/poorly educated whites are often associated with rural America. The lede follows:  

But in 2020, Mr. Trump and Joseph R. Biden Jr. face a drastically changed electorate. The cohort of non-college-educated white voters — who gave Mr. Trump just enough of a margin to win the election in 2016 — has been in a long-term decline, while both minority voters and white college-educated voters have steadily increased.

The decline, a demographic glacier driven largely by aging, has continued since 2016. The number of voting-age white Americans without college degrees has dropped by more than five million in the past four years, while the number of minority voters and college-educated white voters has collectively increased by more than 13 million in the same period. In key swing states, the changes far outstrip Mr. Trump’s narrow 2016 margins.

His campaign leaders are betting that a two-year grass-roots mobilization that has yielded significant voter registration gains will overcome the demographic disadvantage and the polls, again.

“As a clear show of support for the president’s policies, Americans are registering as Republican with a Republican president in office,” said Samantha Zager, a spokeswoman for the Trump campaign. “And those significant voter registration gains prove President Trump is expanding his base and will win four more years in the White House as a result.”

Another farmer suicide feature, this one from the LA Times

Seema Mehta reports from Marcus, Iowa, on the suicide of farmer Troy Sand.  It's a shattering lede: 

On a mild spring day, Troy Sand took his middle son, Connor, out for lunch and to shop for a new laptop for college. Then he returned home, wrapped a single-shot shotgun in a rug, drove to his girlfriend’s house in nearby Cherokee, walked into the backyard and shot himself in the head. 

Sand was 51. His death devastated his large, close-knit family and shattered this tiny community of fewer than 1,200 people in northwestern Iowa. His death also represented a growing manifestation of despair in rural America — farmers taking their own lives. 

“When you have a suicide in your family, that person’s pain ends, but that pain gets put on everybody that’s left behind,” said Jill Vrieze, Sand’s younger sister.

Among the rural themes in this story is lack of anonymity, specifically as related to the stigma of mental health.  One data point included in the story regards the lack of mental health support in rural communities:  76 of Iowa's 99 counties have too few mental health professionals.   

Several presidential candidates passing through Iowa in recent months addressed the phenomenon of rising farmer suicides, which are sometimes framed as deaths of despair.  Here's what Bernie Sanders had to say:

For rural working-class people, life expectancy is going down. Doctors call it the diseases of despair. That means when people feel hopeless … they turn to alcohol, they turn to drugs, and increasingly in rural America, people turn to suicide.

Klobuchar and Booker also acknowledged the phenomenon; indeed, I note that Klobuchar is tweeting frequently about farm and ag issues, not surprising in light of her own midwestern roots.   

More coverage of farmer suicides on Legal Ruralism can be found here, including stories out of Australia and India. 

Cross-posted to Working Class Whites and the Law. 

Krugman conflates working-class whiteness and rurality (or, a return to The Geography of the Class Culture Wars)

Paul Krugman asserts in his New York Times column, "A Racist Stuck in the Past," that Trump is stuck not in the antebellum period, Reconstruction or even Jim Crow--but in 1989, a mere 30 years ago.  It's an interesting rhetorical strategy--to talk about the relatively recent past as "the past."  Krugman's point is that Trump conflates the urban with blackness and black dysfunction, and he dates this back at least to Trump's response to the brutal 1989 beating of the so-called Central Park Jogger:  Trump called for the death penalty for the so-called Central Park Five, the five men arrested for the crime.  The five were later exonerated, in 2002, but Trump has never admitted he was wrong about the men.

Krugman uses those events as a jumping off point to talk about how urban black dysfunction has evolved into rural white dysfunction in a short three decades, a trend he says Trump is in denial about:

[Trump's] vision of “American carnage” is one of a nation whose principal social problem is inner-city violence, perpetrated by nonwhites. That’s a comfortable vision if you’re a racist who considers nonwhites inferior. But it’s completely wrong as a picture of America today. 

For one thing, violent crime has fallen drastically since the early 1990s, especially in big cities. Our cities certainly aren’t perfectly safe, and some cities — like Baltimore — haven’t shared in the progress. But the social state of urban America is vastly better than it was. 

On the other hand, the social state of rural America — white rural America — is deteriorating. To the extent that there really is such a thing as American carnage — and we are in fact seeing rising age-adjusted mortality and declining life expectancy — it’s concentrated among less-educated whites, especially in rural areas, who are suffering from a surge in “deaths of despair” from opioids, suicide and alcohol that has pushed their mortality rates above those of African-Americans. 

And indicators of social collapse, like the percentage of prime-age men not working, have also surged in the small town and rural areas of the “eastern heartland,” with its mostly white population.

Note that Krugman's definition of rural is quite broad--seemingly any place not the inner city.  

Krugman goes on to explain how these events confirm what William Julius Wilson wrote decades ago: the problem of three or four decades ago was not "some peculiar problem with black culture."  Rather, the catalyst for the decline of African Americans was poor job opportunities and the attendant decline of the traditional family.  Krugman asks how one might test Wilson's hypothesis:   

Well, you could destroy job opportunities for a number of white people, and see if they experienced a decline in propensity to work, stopped forming stable families, and so on. And sure enough, that’s exactly what has happened to parts of nonmetropolitan America effectively stranded by a changing economy.

Krugman concludes:

What the changing face of American social problems shows is that people are pretty much the same, whatever the color of their skin. Give them reasonable opportunities for economic and personal advancement, and they will thrive; deprive them of those opportunities, and they won’t.

The colorblindness aspect of the first part of conclusion will annoy many, but I generally like Krugman's argument.  What I'm less comfortable with is his conflation of rurality with whiteness and white dysfunction.  Indeed, his column seems to me a terrific illustration of what I called, in my 2010 article, "The Geography of the Class Culture Wars," a progressive tendency to project what's wrong with America onto rural people and places, who are implicitly (and sometimes explicitly) raced white.

Cross-posted to Working Class Whites and the Law.

More on the demise of the small dairy farm

Jim Goodman, an organic dairy farmer in Wonewoc, Wisconsin (population 816) published this op-ed/guest piece in the Washington Post yesterday, "Dairy Farming is Dying.  After 40 years, I'm done."  The headline sums up well what he has to say, but here's one of the most compelling excerpts:

Unlike many dairy farmers, I didn’t retire bankrupt. But for my wife and me, having to sell our herd was a sign — of the economic death not just of rural America but also of a way of life. It is nothing short of heartbreaking to walk through our barn and know that those stalls will remain empty. Knowing that our losses reflect the greater damage inflicted on entire regions is worse.

Writing about the farm crisis of the 1980s, Goodman observed its knock-on effects:

Farmers felt the impact most directly, but there were few in rural communities who were untouched. All the businesses that depended on farm dollars watched as their incomes dried up and the tax base shrank. Farm foreclosures meant fewer families and fewer kids, so schools were forced to close . The Main Street cafes and coffee shops — where farmers talked prices, the weather and politics — shut down as well.

He also notes the link between the current farm crisis and the mental health crisis among farmers, writing:

This year, Wisconsin, where I live, had lost 382 dairy farms by August; last year, the number at the same point was 283. The despair is palpable; suicide is a fact of life, though many farm suicides are listed as accidents.

Earlier posts on this topic are here and here. 

As for the subsidies available to larger dairy farms in the just-signed Farm Bill, those he calls a "PR stunt."  What farmers want, he says, is a fair price for their product. 

Other topics addressed in this piece include going organic, agribusiness, and the collapse of the family farm. 

Farmer suicides in Australia, old news down under but now in the New York Times

The New York Times today includes a long-ish feature story on farmer suicides in Australia.  The headline is "A Booming Economy with a Tragic Price," which hints at the story's inequality and globalization angles, but not the mental health/rural services angle which is also a key component of this excellent reporting:

Family farms like Mr. Guy’s [who committed suicide in 2016] have been the producers of Australia’s agricultural bounty, and the bedrock of its self-image as a nation of proudly self-reliant types, carving a living from a vast continent. But as Australia’s rural economy has boomed on the back of growing exports, small farmers have not always shared in the bounty, with many forced into borrowing money or selling their farms.

This is old news "down under," according to my Aussie friends, and I've seen some coverage of similar trends in the United States, as here and here.  (This is also reminiscent of the deaths of despair associated with rural folks in the U.S., though in Australia it is men who are disproportionately dying). One reason, it seems, that this trend is now attracting so much attention in the NYT (this is part I of II in the NYT, on "Regional Australia," a term used to connote "rural" in that nation) is the family murder-suicide that occurred a few weeks ago in Western Australia.

Here's a further sobering, data-dense excerpt from Jacqueline Williams' feature story in the NYT:

Nationwide, people living in remote Australia now take their own lives at twice the rate of those in the city: Every year, there are about 20 suicide deaths per 100,000 people in isolated rural areas, compared with 10 in urban communities, according to independent studies of local health figures.

In very remote parts of the country, the figure is closer to 23, the studies say.

Data out of the state of Queensland are even worse, also indicating that the more remote the farmer, the higher the suicide risk.  

Williams then takes up that which differentiates what is happening in Australia from what is happening in other nations where farmers are experiencing higher rates of suicide:

[T]he crisis seems to be worsening at a time when, at least on paper, the [Australian] rural economy is quite robust.

* * * 

There is a painful irony here, they say, since Australia has embraced free trade in farm goods, and even pressed other nations to liberalize their markets, in the belief that agriculture is one of its most competitive industries. 

And Australian farm exports are growing: Last year, they totaled 44.8 billion Australian dollars, or $33.5 billion, up more than a fifth from just six years earlier, according to the National Farmers Federation. 

But many experts say the biggest beneficiaries are larger corporate farms. Family farms are less able to ride out fluctuations in far-flung global markets that can drive down prices of their crops while raising the cost of tractor fuel. 

 So, neoliberalism does a number down under, too.

As I hinted above, this story also includes important information on the dearth of services in rural Australia, and how mental health services are being delivered there--sometimes in innovative fashion.  The story is well worth a read in its entirety.                                                                         

More on deaths of despair, this time from Chillicothe, Ohio

Here is the Washington Post story by Joel Achenbach about addiction in Chillicothe, Ohio, population 21,727, where the poverty rate of 24.3%.  Achenbach further sets the stage:

Chillicothe is a historic town in a transitional landscape. To the north and west are fields of corn and soybeans, a classic, flat Midwestern terrain. To the south and east are the foothills of Appalachia, with winding country roads that, when crossing a stream, narrow to a single lane.

The story introduces a number of women living in a halfway house recovering from addiction, and then this summary of what is happening:

These women are trying to survive an epidemic of self-destruction in small-town and rural America. Death rates have risen sharply among whites, particularly women, particularly those with a high school education or less — the white working class that played a key role in the November election. Last year, overall life expectancy in the United States fell for the first time since 1993, when HIV was rampant. 

Today there is no emergent virus running amok. Instead, Americans are dying from a rash of pathologies, sicknesses and addictions that experts call “diseases of despair.”

This is the most recent of a Washington Post series of stories about these deaths of despair, most of them focusing on white women.  One of the prior stories, out of Las Animas County, Colorado, is here.