COMMENTARY

A day of reckoning for Big Pharma: The elegy that Appalachia really needs

Sorry, J.D. Vance: The solution to my home region’s problems do not rest in any proverbial bootstraps

By Bobi Conn
Published December 27, 2020 2:30PM (EST)
Dr. Michael Ford's office sits closed after he was found guilty on 15 charges of prescription and Medicaid fraud in a remote area of southwestern Virginias coal country where prescription opioids flooded the area decimating communities like Appalachia, Virginia, on Monday July 22, 2019. (Melina Mara/The Washington Post via Getty Images)
Dr. Michael Ford's office sits closed after he was found guilty on 15 charges of prescription and Medicaid fraud in a remote area of southwestern Virginias coal country where prescription opioids flooded the area decimating communities like Appalachia, Virginia, on Monday July 22, 2019. (Melina Mara/The Washington Post via Getty Images)

The movie adaptation of "Hillbilly Elegy" recently debuted on Netflix, and in true 2020 fashion, the movie has inspired – or perhaps just revealed – disagreement and frustration over some of the same questions that arise from the book and its unexpected success in post-election 2016. 

The movie omits a lot of the book's commentary about the working class and "hillbillies," thankfully, and firmly places it in Vance's Ohio hometown, which keeps the movie firmly out of Appalachia (even the Kentucky scenes, ironically, were filmed in Georgia). But in the book, Vance makes it clear that his perception of Appalachia is based on childhood experiences there, and both his hero-worship and critiques of his uncles derives from time spent with them in early childhood at occasional events, like family reunions and funerals. Few of us would lay claim to a cultural identity by virtue of our grandparents having been born in the region. Even fewer of us would purport to write an elegy – a "lament for the dead" – for that culture, and paint its unflattering portrait in such broad strokes. 

Like many natives, I have a deep love for Appalachia even as I struggle to reckon with its complexities. I have some outlandish (and true) stories that may impress at a dinner of white-collar elites – particularly, my great-grandfather's moonshining exploits and friendship with Al Capone, and perhaps my father's gunfight outside my bedroom window.  

Other stories I know not to tell at fancy dinners, just as I've learned over the years how not to out myself as white trash. I wouldn't explain how my family didn't have clean drinking water and instead consumed a whole lot of pop (or soda, depending on where you're from) that rotted my baby teeth. I wouldn't tell them how I grew up learning the names of prescription pills. The most popular ones in my father's vocabulary were Percocet and Oxycontin. Lortabs were "the poor man's cocaine." I wouldn't tell them about the time my father spelled a word by saying, "V – V as in Valium." My adult son still laughs at that, and I savor the rare instances of humor that briefly lighten what has otherwise been a source of constant loss and heartache. 

There wasn't a lot to laugh about when I was a kid, though. In his younger years, my father terrorized our family. Sometimes he beat our dogs, and I ran to our back door often, hearing gunshots blast from our yard and bounce off the hills of our holler. I never knew who or what might get hurt next. In some ways, my life perfectly fit the stereotype of Appalachia that is so often depicted in popular culture, though never explored in depth. 

A lot of negative responses to both the film and book versions of "Hillbilly Elegy" claim that it misrepresents Appalachia and perpetuates stereotypes. Other Appalachians acknowledge that they relate to the story and are grateful to see it told. What we have in common is that all of us – even my gun-toting, pill-addicted father – are more complex than what "Hillbilly Elegy" would have you believe. 

This might be the kind of nuanced observation that results from immersion in culture, rather than something that can be discerned by looking in from the outside. There may be value in having outside perspectives contribute to the conversations about what a culture and region needs, but the people living within Appalachia are actually the experts on what it takes to survive here. We know a lot about what we need, though few politicians have shown any interest in hearing our input for decades. Academics, social critics, and consumers all have a duty to recognize the seduction of the outsider's gaze, and it is past time to accept the fact that the outsider's gaze is never fully informed, never in possession of the magic answer to someone else's problem.

* * *

When I wrote my memoir, I wrestled with one of the same questions Vance raises: At what point do we hold people responsible for their behavior, and how much of it can be attributed to their circumstances?

Like him, I grew up as the "forgiving child" – I always wanted to believe my father when he apologized to our mother, and at least once, we returned to him after escaping his control because he cried on the phone to me. As an adult, I've gone years without talking to my father because to talk to him almost always involves him asking me things like, "Why won't you come see me? You think you're too good?" 

My father's pill addiction was evident to me sometime around the late 1980s. Another relative from his generation had a taste for Valium. In the mid-2000s, multiple family members from my generation either overdosed or were incarcerated for narcotics, and mostly prescription opiates. When the formula for OxyContin was changed in 2010, making it impossible to crush and snort, I heard of more and more people starting to use heroin. Opiate addiction became a national problem at that point, as it began to affect the shrinking middle class, and I wondered at how it had ravaged my family and community for thirty years before it made the news.

I didn't really have to wonder, though. 

The history of Appalachia is largely untold – it is certainly not told on the national level, and I had to go to college before I learned much about it myself. I was a freshman when I learned about the Battle of Matewan and how coal companies hired private agents to terrorize, beat, and even murder the miners who tried to organize and strike for better wages. I already knew that coal mining had always been a dangerous job, but I learned that the coal companies owned every bit of the towns they built to support their mining operations – they owned the schools, the hospitals, and the stores. Miners were often paid in "scrip" (or "script") that held value at the company-owned facilities, and nowhere else. When the coal dwindled or became too costly to mine, the companies left, taking everything with them. Gone were the jobs, the stores, the hospitals, and the schools. There was no way to build generational wealth out of scrip, no way to save for the future.

These former coal towns are abundant throughout Appalachia – abandoned by the people who grew wealthy from their resources, leaving behind environmental disasters and, thanks to politicians who supported the wealthy owners, very little tax revenue to build anything new. There are other types of languishing towns in Appalachia, too – largely, those that sprung up around river ports and the railroad lines that bustled when our timber and coal were transported out of the region. When the natural resources were finally extracted to the point where profitability waned, and as the world's transportation network evolved, those who could leave, did. And those who stayed, struggled.

* * *

I was truly shocked by the Justice Department's recent $8.3 billion settlement with Purdue Pharma. As the makers of OxyContin, I have never blamed them for my father's personal decisions, but I have always known someone was getting rich off of his weakness, and the vulnerabilities that made it so easy for much of my community to turn to pills. 

Canadian psychologist Bruce K. Alexander introduced the concept of "Rat Park" in the early 1980s. Rat Park explored the popular theories about addiction that dominated the conversation in the 1970s, and which still persist. Previous studies placed rats in cages and gave them the option to drink plain water or water laced with morphine, heroin, or cocaine. The rats chose the drug-laced water and consumed it over and over, until they overdosed and died.

Alexander created Rat Park, which gave rats the same drinking options, but also provided them with options to play, socialize, and explore. The rats occasionally chose the drug-laced water, but they never overdosed, and they largely preferred the plain water. While the experiment can't be replicated in humans, as Alexander states, "there have been countless natural experiments in which people have been alienated from their societies in every possible way or had their cultures crushed. Addiction often follows these tragic events."

I think about Appalachia and our generations of economic hardship. Many white Appalachians trace their ancestry to Scots-Irish. Vance attributes his grandparents' clannish and protective behavior to those roots. I grew up being told that my paternal ancestors are Irish. With names like Conn and McKenzie, I'm sure they are from that same region. 

How can I distinguish, though, between the way those familial roots have passed through generations – even crossing an ocean – to turn my father into the kind of man who will have a gunfight with his own brother, and due to family loyalty, drop the legal charges soon after? 

What kind of responsibility does he bear for being a drug addict, when the place he was born into has seen economic strife since the beginning of its statehood? Before Kentucky was a state, it was a difficult place to physically survive. For many reasons, that truth has remained unchanged. The same mountains that rendered this region rich with coal have created a terrain that is difficult to travel. Barriers of all kinds – both seen and unseen – have made this land achingly beautiful and yet sorrowful. 

Violence is more prominent when a community or a family occupies a lower socioeconomic status, and the risk of domestic violence is higher when the family is in poverty. Children who grow up in poverty are more likely to suffer from health issues, developmental delays, behavioral problems, lower academic achievement, and unemployment in adulthood. In other words, being poor sets children up to fail as adults, and they often follow that trajectory, creating a new generation of poorly-equipped humans in the course of their struggle.

That's not to say we are all fated to generational cycles. Like Vance, I managed to create a much better life for myself – and my children – than I ever anticipated as a child. I was able to obtain a college degree due to the generosity of strangers who support the mission of Berea College and the institution itself, similar to how Vance credits Pell grants and Yale's financial aid for low-income students for his success. But rather than the Marines teaching me that my choices matter, I chose to have a child when I discovered I was pregnant at the age of 22, with one year of college left. I thought long and hard about what it might mean to have a baby, and I decided to commit myself to that baby. I decided to be a better parent, and a better person, than I actually knew how to be.

But, what about the members of my community who don't test high enough for scholarships or just don't want to go to college? What about the women and girls who find themselves pregnant but can't muster resolve and determination, and are only faced with the overwhelming anxiety I often battled as an unprepared and unsupported parent? I found a job in Lexington right out of college and over the course of the next twenty years, I clawed my way out of poverty. I was lucky. So was Vance. Most people aren't.

It was critical for me to take responsibility for my life, just as it was for Vance. Writing my memoir gave me the opportunity to fully explore my history, and figure out a way to still claim agency over my present and future. But I have plenty of loved ones who can't write a memoir, who haven't had one of those variables play out in their favor to fill them with determination and hope for the future. Many of my loved ones are still struggling against the burdens they have inherited.

This story is not ubiquitous across Appalachia, and that is part of why so many Appalachians have taken exception to "Hillbilly Elegy." Many of our grandparents – crucial to our well-being – conducted themselves with dignity and were neither abusive nor apparently mentally ill (evidenced in Vance's descriptions of his grandmother's hoarding, at the very least). There are plenty of stable families in Appalachia, with lifelong marriages, generational wealth, and emotional nurturing to boot. Our contributions to the arts and the enrichment of America are vast. But, I write about my family and my experience because ours is the scenario that has been presented to the rest of the world as some sad example for what the region has become. 

Personally and collectively, moving forward isn't about blame – it's about understanding, and taking appropriate action. Purdue Pharma has admitted culpability for exploitative marketing campaigns, for courting more than 100 healthcare providers whom they believed were diverting opioids into the black market and misleading the DEA. One of the most sickening statements from the U.S. Department of Justice reads: "Purdue learned that one doctor was known by patients as 'the Candyman' and was prescribing 'crazy dosing of OxyContin,' yet Purdue had sales representatives meet with the doctor more than 300 times." Purdue sales representatives specifically marketed to healthcare providers they knew were prescribing the opiate "for uses that were unsafe, ineffective, and medically unnecessary" – cruelly, under the direction of the marketing program called "Evolve to Excellence." The charges Purdue has admitted to range from May 2007 to "at least" March 2017. 

My generation of Appalachians can attest that their unscrupulous and insidious greed affected us long before that. 

It's one thing to put a rat in a cage with nothing but water and drug-laced water. It's another thing to reward doctors who put the drugs in the water. Appalachia has struggled culturally due to the many decades of economic pressure and outright theft that our people have endured. Our people grapple with the social and personal instability that have resulted from that economic reality, but that struggle takes place within a paradise on earth. Some of us have family bonds that transcend anything the outside world has to offer. 

J.D. Vance – who has never lived in Appalachia but had the pleasure of visiting for long weekends and "lazy summers" – admonishes Appalachians that "These problems were not created by governments or corporations or anyone else. We created them, and only we can fix them." He thinks the answer to this region's problems is that "hillbillies must wake the hell up." But history tells us something different, and Purdue Pharma's admission of guilt in fueling the opioid epidemic is just the latest in a series of thefts that have damaged this region's economic and social stability. 

Vance claims that public policy won't improve any of the problems in Appalachia, but in truth, public policies have allowed (and encouraged) companies to outsource U.S. jobs; public policies allow predatory companies like Purdue Pharma to exploit loopholes and manipulate data, at the expense of vulnerable populations; and public policies have long favored the robber barons who plundered this region, investing nothing in its future.  

Blame our Scots-Irish ancestors or the modern hillbilly – blame my own "white trash" family if you want. But the solution to this region's problems do not rest in any proverbial bootstraps. Most of us have learned how to survive against all odds, and our problems have not sprung forth from some vacuum, born only of our own moral failures. Those of us who have found our voice are trying to tell you. If you truly want to understand what's "wrong" with eastern Kentucky and Appalachia at large, listen to those of us who have lived it.


Bobi Conn

Bobi Conn is the author of "In the Shadow of the Valley: A Memoir" (Little A; 2020). She was born in Morehead, Kentucky, and raised in a nearby holler, where she developed a deep connection with the land and her Appalachian roots. She obtained her bachelor’s degree at Berea College, the first school in the American South to integrate racially and to teach men and women in the same classrooms. After struggling as a single mother, she worked multiple part-time jobs at once to support her son and to attend graduate school, where she earned a master’s degree in English with an emphasis in creative writing. 

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Commentary Hillbilly Elegy Opioid Crisis Pharmaceutical Industry