Driving through much of Appalachia you’ll still see tar paper shacks, people living in dilapidated homes with no electricity, and scant signs of economic opportunity. I grew up in the mountains of Western Maryland, across the Potomac from West Virginia, in the dying days of the coal and manufacturing industries there.

For the past two years I've lived in the foothills of Georgia’s Blue Ridge mountains. Not much is different. The economy in many towns is dependent on tourism. The best jobs—sometimes the only jobs—are at Wal-mart, state prisons, or the gas stations that dot the flawed Interstate Highway System, a project that the Appalachian Regional Commission pushed through the area to spur economic development.

This is a predominantly white area—almost entirely in some areas. It’s someplace we’d think should be prosperous. But it’s not. John Gaventa, who studied the exploitation of the region by coal companies in his book, likens the region to an “internal colony” of the United States.1 Billions of dollars have poured out of these mountains, but the people left behind are still suffering. And many of them have turned to drugs to dull the pain.

This region has been hit hardest by the recent heroin overdose crisis. Almost every county in Eastern Tennessee and Southern West Virginia had overdose death rates of >20 per 100,000 people in 2014. The rest of the region isn’t far behind.

The ‘White Working Class’ Problem

Last month New York Times columnist David Brooks wrote about the "white working class"—a demographic which has been hit hard by opioid misuse since at least the mid-1990s. Brooks lays the blame for this on the loss of an “honor code,” “a younger cohort that are more disordered, less industrious, more celebrity-obsessed,” and rampant consumerism. He neglects to mention the physical pain endured by blue collar workers in the region, or the mental and physical stress created by poverty, social isolation, and untreated mental illness.

In another recent article, J.D. Vance, a Yale Law School graduate and venture capitalist now living in San Francisco, blames the region’s social problems—including misuse of substances—on a lack of proper religion, saying:

In the white working class, there are far too many wolves: heroin, broken families, joblessness and, more often than we’d like to believe, abusive and neglectful parents. Confronted with those forces, we need, most of all, a faith that provides the things my faith gave to me: introspection, moral guidance and social support.

Brooks heaps praise on Vance's new book Hillbilly Elegy, which is described as “a passionate and personal analysis of a culture in crisis—that of white working-class Americans.” Vance, long gone from Appalachia, blames the people living “back home” for inviting heroin into the region. He likens Donald Trump’s appeal among the white working class to opioids, saying: “It enters minds, not through lungs or veins, but through eyes and ears, and its name is Donald Trump.”

Kevin Williamson of the National Review, an age-old conservative publication, tears into rural white America with a particularly bitter tone, saying: “The truth about these dysfunctional, downscale communities is that they deserve to die. Economically, they are negative assets. Morally, they are indefensible.” David French, of the same publication,blames rural America’s drug problems on government disability checks and a progressive “self-indulgent” culture.

In a post-Donald Trump world, even the most conservative writers and politicians find it fashionable to mock and ridicule these white working class Americans, who are traditionally among their most consistent supporters. These people latch onto Trump’s message because they feel abandoned. “White working class” now serves as a stand-in for poor, mostly rural Americans who now have more in common economically (and sometimes socially) with poor or struggling people of color than their white counterparts in Suburbia.

Misuse of substances and large-scale social problems are not new developments. Urban areas have struggled with substance misuse and violence spawned by the War on Drugs for decades. American Indians, who face similar poverty levels, police violence, and social isolation, have overdose rates at twice the national average—more than any demographic. These aren’t moral or spiritual problems, they’re structural. They’re ingrained in our culture.

Picking Up the Scraps

Recently, heroin overdoses have crept into affluent, white suburban communities. The people who live there are seeing their children die at higher and higher rates. Their voices carry substantial political clout and local news sources are eager to share their stories—a privilege often denied those without resources and influence. This phenomenon, not the struggles in Appalachia, on reservations, or in our cities, has spurred the creation of President Obama’s National Heroin Task Force. Obama proposed spending over $1 billion to combat the US opioid problem in 2015, but his plan has failed to produce meaningful results.

We have effective solutions to the opioid crisis in rural America and other parts of the country, but lack of access to treatment remains a problem. President Obama’s plan calls for increasing access to naloxone and evidence-based treatment; as I wrote several months ago, medication-assisted treatment with methadone and Suboxone have shown great success at treating opioid misuse. Unfortunately, these medications are inaccessible in many of the places they’re most needed.

Even if the U.S. were able to expand its treatment and prevention resources to effective levels, most of these efforts would only serve as Band-Aids. Poverty and social isolation are strongly linked to misuse of substances. And a 2014 SAMHSA report showed that 40% of people with substance use disorders also live with a diagnosed mental health condition.

Screenings and brief interventions have demonstrated some of the highest rates of success at treating early substance use and mental health disorders. These are all tools we need in our arsenal, but they’re not enough to slow the rate at which substance use problems are growing. Our current solutions are almost exclusively reactive responses to a problem which demands proactive solutions.

Looking for Answers

We can’t depend on politicians and government officials to solve these problems for us.

Donald Trump’s focus on the economic devastation created by neoliberal trade deals like NAFTA has struck a chord with the white working class. He raised the opioid overdose problem during the Republican primaries saying, “We are gonna try and help the young people and the old people and the middle-aged people and everybody that got addicted,” Trump provides few specifics, though, as to how he plans to help, aside frombuilding a wall to keep drugs from crossing the border (presumably from Mexico).

Hillary Clinton has held a position similar to President Obama’s for most of her presidential campaign, but other than a grant for naloxone from the Clinton Foundation, she’s rarely spoken about addiction or mental health. Her economic policies, which have included support for free-trade deals like NAFTA and the Trans-Pacific Partnership, would do little to improve conditions for those on the expanding margins of the U.S. economy.

Congress recently passed a bare bones Comprehensive Addiction and Recovery Act (CARA), which calls for expanded naloxone access, Law Enforcement Assisted Diversion(LEAD), and greater access to evidence-based treatment. But the legislation fails to provide new funding for these services. President Obama signed it into law, but the White House acknowledges CARA falls short saying, “some action is better than none.”

Some states continue to cut funding for detox facilities, state-funded rehabs, and MAT. This leaves rehab for poor Americans either out of reach or placed in the hands of faith-based organizations, which often place strict requirements on clients’ behavior and turn away people who refuse to conform to certain religious beliefs.

Many politicians have placed blame for social problems in communities of color on spiritual or moral failings. Now they’ve taken the “welfare queen” trope and alleged exploitations of the (extremely strict) Social Security Disability system to the white working class. These problems are actually caused by a system which reproduces poverty, suffering, and isolation across generations and exacerbated by a War on Drugs which has yielded mass incarceration, uprooted and displaced entire communities, and led to the school-to-prison pipeline.

Models for Developing Successful, Community-Driven Solutions

In the 1980s, when the State failed to take action, HIV and AIDS rights activists developed grassroots organizations to solve problems in their communities. More recently, grassroots harm reduction organizations have developed naloxone distribution networks, syringe exchange programs, and testing for hepatitis C and HIV. These programs have found great success where they’re available, even with limited (or no) funding.

The devastation left in the wake of the War on Drugs—lack of access to substance use or mental health treatment, social isolation, and structural poverty—are connected. We can’t approach the problem from just one angle. Solutions will have to come from people in the communities most impacted by these problems. And they are—slowly.

We see flickers of hope in the mountains of Appalachia, on the reservations, across the South, and in urban areas. Social movements and resistance to the status quo are sweeping across the U.S. in recent years, and they intersect with each other in ways we haven’t seen in decades, if ever. Change is coming, but let’s hope it’s not too late for those we leave hanging on the margins and those who continue dying from opioid overdoses at record levels.

References:

1. Gaventa, John, On Power and Powerlessness, 1980