Opioid epidemic health danger and medical crisis with a prescription painkiller addiction concept as a group of pills devastating a patient (Getty Images)

The opioid crisis — and now the pandemic — show how Americans don't believe in the social contract

Other nations stopped opioid overdoses while the US struggled. Something similar is happening with COVID-19



Jack Shuler
September 19, 2020 2:00PM (UTC)

In the Beforetimes, I travelled from where I live in Ohio to Vancouver, British Columbia, to report on how some Canadians were addressing the overdose crisis through effective community-centered harm reduction programs.

In the city's Downtown East Side neighborhood I visited peer-led overdose-prevention sites with ready-access to naloxone and oxygen and trained assistants on site. I spoke with workers at Insite, North America's first safe injection site, where people who use drugs can inject in a safe, secure environment without risk of overdose. And my community guide introduced me to his doctor at a clinic where he receives heroin-assisted treatment. Since he started the program his life has stabilized, he is no longer committing petty crimes to get his next fix, and he is gainfully employed. The experience was transformative for me. In that small community, one of the poorest in Canada, people were doing the things that researchers have said will actually slow the rate of overdoses.

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And it's mostly working: at Insite they've never had someone die of an overdose. But, as in the United States, an influx in the powerful drug fentanyl has led to a spike in overdoses and people who use drugs and their allies are calling for access to safer drugs. Indeed, research shows that the increase in overdose deaths is directly related to the war on drugs, to prohibition, to tired policies that have never worked. For someone who regularly reads comments from Ohioans lambasting health departments for simply distributing naloxone, the activism, the harm reduction efforts, fostered and supported by people who use drugs, well, it was eye-opening and refreshing to witness.

And yet, activists in Vancouver know it could be even better, that more lives could be saved. At a conference taking place while I was there, I saw this idealism, really this basic human decency, in action. Judy Darcy, a member of British Columbia's legislature and the province's first-ever minister for mental health and addiction was giving an opening address to over six hundred conference attendees. She was explaining the government's role in addressing the overdose crisis when a tall man with a shock of white hair stood up and shouted, "It's not good enough, Minister."

Darcy got quiet.

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The man continued, "This is an emergency health situation without an emergency health response. Please to the government—stop gaslighting us. Meet with drug users. Give us a proper seat at the table. This is not working. It's feeling so grim right now. We met with you last year, and one of the people in that meeting is now dead . . . We are not on an emergency response footing. We are on a status quo footing. And I beg you to please change that."

The room exploded with applause.

That man was Garth Mullins, a journalist and activist from Vancouver. "Crackdown", the groundbreaking podcast he hosts, centers the experiences of people who use drugs who also serve as correspondents on the front lines of a war. The podcast also centers on a healthy dose of righteous, justified anger. Anger may not always win you friends, and sometimes it will not help build alliances, but the reality is that sometimes anger comes from a place of truth.

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As I listened to Mullins, my mind turned to Ohio, where I live and where people were and are dying from unintentional drug overdoses, from languishing in prisons and jails, from the repercussions of being incarcerated, from living in a country that pays lip service to health care for all people.

These things can be fixed. Sometimes anger is justified. And in Canada, it seemed to me, some people were angry. Which is an appropriate response. But it's not a response I've seen often enough in the United States.

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After witnessing Garth Mullins speak out so eloquently and with such force, I texted my wife: "37 million people live in Canada. 4k overdose deaths in 2017. 12 million people in Ohio. 5,111 overdose deaths in 2017. Why are we not freaking out?"

She responded: "Because we don't believe in the social contract anymore." A few minutes pass and she texts again: "I'm not sure what that means, but it sounds smart."

* * *

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She was right, though. As European Enlightenment thinkers John Locke, Jean-Jacques Rousseau, and Hugo Grotius described it, the theory of the social contract says that we give up some of our individual freedoms in order to be protected by a government that is, essentially, us. Locke wrote in his Second Treatise on Civil Government that in order to live in a society we give up "natural liberty" for the "civil liberty" of the community and, in doing so, we should expect our government to always act with the "public" good in mind. It is a sacrifice, of course. And so in order to preserve ourselves, we must preserve everyone. It would follow then that we are obliged to promote greater social justice and protect the human dignity for all human beings.

But we're not protecting each other—if we ever have. Locke himself served as a secretary for the Lord's proprietors, the white men who invested in the colony of Carolina and seeded chattel slavery in the United States.

The problem is not the over 70,000 overdose deaths that happened in the United States in 2019. The problem is that there is a rupture in our social contract, a rupture made more obvious by the COVID-19 pandemic. Turns out her text message was prescient.

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A year later, and I'm again angry and disappointed by the collective American response to a health crisis, a response guided by a willfully ignorant president and bathed in selfishness, political divisiveness, and a blatant disregard for science and education. In the same way that people have for years believed nonsense and lies about drug use and overdose, this president believes nonsense and lies about COVID-19—and he shares them far and wide.

But it is more than a failure of his leadership, this rupture is not new.

In this precarious moment, our democracy hinges not on individual rights but on our commitment to each other—and that means reimagining the social contract. 

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For over 20 years now I have taught American literature at a small liberal arts college in Ohio. If anything, American literature is a testament to our troubled and hopeful history, written by women and men who have been suppressed and oppressed and despite it all still have some faith in the American project.

Always present is a tension between the needs and rights of the individual and the needs and rights of the community. On the deck of the ship the Arabella, John Winthrop gave voice to the myth American exceptionalism when he proclaimed his desire to create a beacon for the world, city on a hill. In that very sermon, though, Winthrop also talks about "charity," a concept straight out of Jesus Christ's Sermon on the Mount—the idea that we must love each other as we love ourselves. Winthrop claims that his new community must be a body that is connected by "love." He then offers a line that writer Sarah Vowell proclaims to be "one of the most beautiful sentences in the English language":

We must delight in each other, make other's conditions our own, rejoice together, mourn together, labor and suffer together, always having before our eyes our commission and community in the work, our community as members of the same body.

 Of course, we have never been this wonderful community. Indeed, the Puritans weren't even close to living up to his ideals in that moment as they were about to commence their project of murdering native people.

That tension between what we want to be and what we truly are, persists. I'm constantly disappointed in America, and yet, I love this place to an illogical degree. Claude McKay writes in "America," that "Although she feeds me bread of bitterness,/ And sinks into my throat her tiger's tooth,/ Stealing my breath of life, I will confess/ I love this cultured hell that tests my youth."

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Time and again, as a nation, we have failed, but time and again, people, usually the most marginalized, demonized, and criticized among us, have stood up and fought for the ideals penned by a slaver in the Declaration of Independence. Frederick Douglass wrote that the 4th of July was not for him and yet he insisted on the possibilities of the American project. He called the Declaration of Independence "the ring-bolt to the chain" of America's destiny. "The principles contained in that instrument are saving principles," he wrote. "Stand by those principles, be true to them on all occasions, in all places, against all foes, and at whatever cost." Activists like Douglass and Ida B. Wells, as well as the enslaved people who revolted from 1619 onward, were the true authors of our social contract. And yet, the paradoxes of the American experiment were present in his very existence. Despite it all Douglass still believed in the possibility of a nation we all were treated equal—a faith and idealism, as a white male, I can hardly fathom.

This past summer, we all were reminded of this faith when people, most of them much younger than me, went out into the streets to demand that police stop killing black people, just weeks after armed mostly white people bullied their way into the state house in Michigan to demand their "natural liberty" to do whatever the hell they want to do during a pandemic.

Community over self. Cooperation over individualism. Those young people in the streets get it.  

There are moments when this ethos emerges and we can all see the best of our country—an ability to demand justice, an ability to harness mutual aid and support. Nowhere is this more evident than in how we deal with our troubled healthcare system. Americans spend significantly more than other countries on healthcare—out of pocket and through private spending. Healthcare costs are high in the US, in part, because healthcare is big business. But centering the care of the human body in capitalism  has not worked out well for us. We have a low life expectancy including some of the highest rates of obesity, suicide, and unintentional drug overdose. Indeed, the very thing that helped spark America's recent infatuation with opioids was, in part, lack of access to adequate and preventive healthcare. If you injure your back, it's much easier to take a pill than to take time off time from work to visit a physical therapist (if one is available). It's much easier to search for a pill to stop addiction (an effort a recent Newsweek story lauded) than to address the social determinants of health, to figure out the underlying issues that are causing a health crisis—things like economic disparities or mental health.

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But how could we do that work? We don't fund public health adequately. Over the past decade, the CDC's budget fell by 10 percent.

So we have packed emergency rooms, shuttered rural hospitals, astronomical medical debt, and our over-reliance on police officers to respond to mental health crises or to reverse unintentional overdoses. What if we spent more on social services, addressing the social determinants of health rather than on police?

In Ohio, the advocacy organization Harm Reduction Ohio estimates, based on preliminary data, that unintentional overdose deaths increased about 23% in the first six months of 2020 versus the same period the year before. 1,964 lives lost. And last year, for the first time since the 1980s, black people in Ohio had a higher overdose death rate than white Ohioans. This preliminary data indicates that that trend continues. And we know, too, that Black people in America are twice as likely than white people do from COVID-19.

If we truly believed that all humans are equal, then we would not treat the very basic thing human beings must do, take care of their bodies, as a privilege or as another scheme for making money. We would respect scientific research. We would be horrified by GoFundMe appeals to pay down medical debt or pancake breakfasts to help pay for a neighbor's cancer treatment. (I shared that concept with a colleague in Denmark once and she was horrified. She was right to be.) These things have become a necessity in a country enamored with free market capitalism and where the invisible hand is more likely to punch you than to lift you up.

And yet, some Americans are inventive and scrappy, and they figure out how to support each other. In the midst of the HIV/AIDS epidemic, black and brown and queer people led the way in providing a public health approach to addressing the disease by offering clean needles to slow its spread—in many cases breaking the law to care for their communities. More recently in my own county, the mother of a young man who has struggled with substance use disorder for many years, began a similar underground program—at great risk to herself. Her rationale, she told me, was that she is going to help others because at some point she hopes that others will help her son.

Elsewhere in the United States people who use drugs and their allies have started underground safe injection sites and are distributing naloxone and drug testing strips, in places where they are not authorized to do so. And in Vancouver, all of the gains, all of the creative ways for addressing the overdose crisis have been led and developed by people who use drugs, many of them people of color. In other words, the most marginalized people—the very people who should be supported by our social contract and who are not—are the ones teaching this country what it means to live in community. They are leading by example. 

These activists are on the front lines of a new America, just like those people protesting the murders of George Floyd and Breonna Taylor in cities and small towns around the country. These are people who are pressing our public institutions to do better, to become more democratic. They are reminding all of us that we are not consumers but, in fact, are creators, that we are our government, that we are the ones who can sign the contract.

But our culture teaches that there are easy answers to our enormous problems. Once we have a vaccine for COVID-19, then what? Once we have redistributed the wealth of Big Pharma to the communities they plundered, then what?

Politicians and lawyers are committed to addressing Big Pharma's role in the opioid crisis—and they should be—but really, those companies were capitalizing on poverty, on a lack of legitimate public healthcare. They were doing what capitalists do—making lots of money.

No doubt the communities most affected could use the money that will come from the lawsuits, but it's a band aid. The solution is much bigger. We need to provide healthcare for all. We must treat substance use disorder as a health crisis. And we must listen to the experts.

Free market capitalism does not care about marginalized people. Elderly people are stuffed into often-abominable long-term care facilities. Delivery drivers become frontline workers and are thanked with bottles of water and granola bars left on doorsteps and must pay outrageous co-pays and figure out how to raise a family on the low wages that their non-unionized job provides.

Living in a country that actually appreciates and tries to re-establish a social contract will not always be pretty—people will get angry. But public decorum and a "be patient" attitude was exactly what Martin Luther King, Jr. decried in his "Letter from a Birmingham Jail" after some liberal white ministers questioned the timing of his protest in that city. King, Jr., wanted those in the "beloved community" to act immediately at the sight of injustice. Now. Right now. When people are dying, we're supposed to try to save them. Now. We are supposed to do the work of caring for our neighbors.

At the heart of this work must be a belief that all of the people in our communities matter and should be treated as humans—the unhoused, the people who use drugs, the people with mental health struggles, the elderly, all of them. And we can show that care by providing ample healthcare for everyone. No questions asked.

If the nation is to persist, then we have to resolve to give up a fraction of our own comfort for the good of others. We wear masks. If the nation is to persist, then we have to recognize that if we are doing something that bothers, that harms, others, then we have to stop doing it. We take down statues of slavers; we end the war on drugs; we commit to actually treating health issues for what they are.

There's another narrative for America, one that we've seen in fits and starts over the centuries. It's out there. I saw it on the streets of big cities and small towns of Ohio this past summer. And I've seen it in the county where I live over the past few years, as people struggle against the monster of overdose death.

On one of the first nights after George Floyd's murder, my wife broke out in a terrible rash and was having trouble breathing. After we called a friend to come sit in our home, the first non-family member to enter it since March, we raced to the hospital. Because of COVID-19, I wasn't allowed inside and so sat on a bench just outside the ER waiting room.

Minutes after I sat down, a woman raced up and stood outside the door near me. Then an older couple showed up. The first woman was crying and explaining what had happened. Her two neighbors overdosed—one the daughter of the couple. She called 911. And here they all were. Waiting. Hoping for the best.

I pulled out my phone and began watching livestreams from the protests in Columbus, in Brooklyn, in Chicago. I watched and waited, occasionally adjusting my face mask, moving from one city to another, watching the young people of this country rise up. They are not waiting. Neither should we.


Jack Shuler

Jack Shuler is the author of four books, most recently "This is Ohio: The Overdose Crisis and the Front Lines of a New America" (on sale now from Counterpoint Press). His writing has appeared in The New Republic, Pacific Standard, Christian Science Monitor, 100 Days in Appalachia, and Los Angeles Times, among other publications. He is chair of the narrative journalism program at Denison University. He lives in Ohio. Find out more at jackshulerauthor.com.

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Covid-19 Essay Opioid Crisis Public Health Social Contract

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