This was found on a podcast available under Ezra Klein's label--It is an interesting interview with one of my favorite modern authors.
The featured topic is Kingsolver’s latest novel, Demon Copperhead and her perception that Urban America holds many prejudices against rural America (and more specifically, her home, Appalachia). This is not a benign prejudice, has caused a lot of harm, and is in part, an example of how the polarization we are witnessing in the US comes about. Some points:
She makes the case that Big Pharma singled out Appalachia as a place to, with focus, sell huge quantities of highly addictive narcotics (Oxycontin for example) under the guise of legitimate medical need. This history and the social organization of Appalachia made them an inviting target: it is poor. Its economy has long been one of serial extractions (timber and coal). With this claim, she paints a picture of Appalachia as a sort of banana republic ie the social and governmental structures have been subservient to those of whichever big business is involved. I would argue that Louisiana and Alaska are similarly afflicted by such an imbalance of power. Once more, the local societal /regional norms have no (to date) effective defenses; the mountains lend themselves to isolation and self sufficiency but not a uniform or organized system—so they have been victimized. The poverty that follows has made access to medical care poor (as it is in all of rural America) and lends itself to a reliance on medications as a focus of care given how few doctors there are, how much it costs to see
them, and the ability to get to them reliably.
Regarding the opioid epidemic: it sounds like a conspiracy—and one that might be true; that case was made in court. Of interest, with many other doctors, there were medical educational programs in the 1980’s suggesting that traditionally, “we” in the US underrated pain, the “sixth vital sign” and should in fact more aggressively try to treat it with opioid medications. In my case, working in an integrated health care system, all of us learned and were influenced by our prescribing habits which were reviewed by peers—and the burden of medical problems flowing from those prescribing patterns was also reviewed—something that did not happen in the decentralized medical world of rural America. I for one, believe Big Pharma is illegitimate: too much power and influence is the reason the government has not negotiated for prices that are the norm in other parts of the world much less taken practical looks at the products being advertised. We are one of the few countries in the world that allow direct to consumer advertising of brand new and expensive drug treatments. Producing miracle drugs is not a free license to lobby and gouge when there are tools —well demonstrated and usable tools—elsewhere in the world to reign these.
She relates her own experience going to college and having people come up to her and ask her to say specific words as though her pronunciation was quaint or funny. This was not welcome attention and feeds a prejudice most of us have. Perhaps you have a similar experience to mine: Did you ever notice that in movies about ancient Rome (The Robe, Ben Hur, or Spartacus) that the Roman leaders speak with a British Accent? Spartacus and Ben Hur spoke American—-but not rural American— English. In my day to day, unconsciously, a speaker of proper English from England gets awarded 10 extra IQ or validation points whereas, someone speaking with a Southern or Midwestern accent gets 10 demerits. THAT’s what Kingsolver is talking about.
I found myself running out of material in my first-year college creative writing class. When out of ideas, Mark Twain advises going to the Bible for inspiration (the settings are irresistible). I was taking philosophy 101 which included Socratic philosophy so I wrote a story about going to heaven and seeking out Socrates but finding that he had been taught English by a farmer from Missouri before the Civil War. The incongruity of his intellect and his English was something that became the focus of the story. My inspiration given my limited life experience at eighteen years was growing up in a Navy town where one met people from rural America (it was amazing how many people from Kansas joined the Navy) and seeing first-hand, that an accent can be disarming when evaluating the competence of a competitor or simply a stranger for the first time. Maybe to Kingsolver’s point—this is not new. Accents led to stereotypes from day one in this and other countries. Linguistically an interesting side-bar: Merry Melodies with Bugs Bunny in the 1930’s commonly found the voices of geriatric characters speaking with a “hillbilly” accent. I read an analysis once that explained this: in the 1930’s we (USA) reached a tipping point where over 50% of the population lived in cities. Increasingly in those years, people began to move away to the city and acquire new accents—which did not exist in rural America or Appalachia for that matter—but mom and dad who likely stayed in the country, maintained that pattern of speech.
Kingsolver is passionate about defining drug addiction as a medical problem and not a moral problem. Sending drug addicted people to Penitentiaries will not find them penitent ie reflecting on their sins — nor will it help them beat their addictions. She notes, that your child with cancer is not disciplined, controlled, and then thrown out of the home for a period of time before offering up chemotherapy. She speaks to reform of the legal system to accommodate this reality. I like this premise but as Copperhead Demon illustrates, drugs affect behavior which in turn, does lead to criminality. We need to rethink a nuanced justice system for managing the behaviors that flow from drug addiction. I don’t have a clue of “nuanced” as a concept compatible with modern policing which is obviously a very diverse product.
The cities of Portland and San Francisco have experimented with the de-criminalization of personal drug use. I suspect rehab services are liberally offered and not accepted; that is part of the disease. The optics that follow this in these downtowns are depressing and affecting the behavior of many non-addicted people. Substance Abuse not uncommonly leads to psychological aberrancy and criminal behavior. The root cause needs to be addressed—no argument—but the crime remains very real affecting strangers, people we know, the costs and access to products, the costs of insurance, not to mention violent crimes within and outside that community. Short of incarceration for what you can catch them at, if the user has little to lose, what tangible thing is to be done to shift that behavior? Forcing people to change is not something for which we can proudly demonstrate our succeses.
Many of the points made about Appalachia are those consistent with poverty in general which is not a regional problem. There is poverty everywhere. Each state gets allocations from the Feds to support Medicaid with an intended goal of supporting the poor. Depending on the year and state, 30-50% of pediatric care in the United States is delivered to Medicaid eligible patients. Think about that. Medicare* is the last rung of medical insurance before you fall into the pit of “let the buyer beware” and cobbled together charity care —-or no care at all except for the Emergency Room. Kingsolver discusses the loss of a generation who are orphaned, with not enough food, no counseling or only that available in schools that are in turn, underfunded. This is not just Appalachia, it is a third to a half the youth in the USA. That speaks poorly for our current priorities not to mention for our future.
* In Washington state, a family of four qualifies for Medicaid if its annual income is less than $40,000.
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