Long before the virus, many Americans were sinking under waves of despair. Without transformative policies, that despair, with the added fuel of the pandemic, may turn into a tsunami. The aftermath could leave communities under rubble for decades to come.
Just in the 21st century, Americans have been threatened by everything from foreign and domestic terrorism to an increasingly aggressive and militarized police. Unable to count on jobs, adequate safety nets, or health care, they have watched the affluent make a killing on Wall Street. They have been spoken down to by politicians and the media, sensing that unless they are rich, the political system will ignore their voices. As research has shown time and time again, they were right.
Accused of being bitterly divided, when Americans agreed on something, like a single national program to provide health care coverage run by the government, their preferences were dismissed by their representatives (including the new president) as radical or impossible. Things that make life worthwhile and bearable, like an affordable education or a dignified retirement, grew increasingly out of reach. The middle class was turning into a relic. The people watched America devolve into what looked like a third-world country, with two separate economies in which experiences, prospects and even life spans diverged.
Life expectancy in America dipped for the first time in decades in 2015. Experts hoped it was a fluke. It wasn't. It happened again in 2016. And again in 2017. Not since the Spanish flu had such a decline lasted so long. Many suspected economic inequality was a driving factor, noting that while poor and middle-class Americans were dying younger, the richest were not only living it up, but living longer. A recent Danish study shows that from 2001 to 2014, the life expectancies of wealthy Americans grew 140% faster than those in low-income groups – an outlier among nations.
Deaths of Despair
In a 2015 study, Princeton economists Anne Case and Angus Deaton sounded the alarm about midlife white men and women without college degrees dying by suicide, drug overdoses, and alcohol-related ailments at record rates. People in these groups reported feeling sicker, more stressed-out, more prone to chronic pain, and less able to work and cope with daily activities. While their incomes were higher than Hispanics and African-Americans without college degrees, these whites felt a sense of chronic loss.
Case and Deaton termed the trend "deaths of despair" – what happens when you can't get ahead no matter what you do. In a book released in March 2020, they named America's greed-driven opioid epidemic, job instability, a predatory health care system, shredded social safety nets, unbalanced labor markets, and globalization policies as factors contributing to the tragedy. The United States stood out among nations for its inequities.
Before the pandemic, sociologist Shannon Monnat of Syracuse University was tracking deaths of despair by drug overdose, especially those linked to the opioid scourge. She concluded that while Big Pharma behaved horribly in pushing drugs it knew to be highly addictive, opioids would not have seized communities in a death-grip without the growing gap between haves and have-nots. Policies had an impact on mortality, blocking access to medical care and failing to promote decent, secure employment. Inequality was killing people.
Her research, focused on whites (the group with the highest drug mortality rates over the last two decades, other than American Indians), showed a pattern of people dropping like flies in both cities and distressed rural communities that relied on disappearing manufacturing and mining jobs, as well as lower-paid, more insecure service industry employment. She found that misery in those places didn't just happen. It was stoked by politicians who refused to address jobs or health care or safety nets. When the pharma reps came to town, they found a worn-out population ripe for exploitation. Monnat saw that in communities with more economic stability, a strong social safety net, and better quality jobs, fewer people were dying from opioids.
Monnat is now working with a team conducting field research on how the coronavirus pandemic is impacting populations of drug users in New York state. What she is finding has her worried about the growing contagion of despair.
Overdose Deaths Surge
The Centers for Disease Control (CDC) has already reported a rise in overdose deaths in the U.S. during the COVID-19 crisis, with synthetic opioids fingered as the primary culprit. Monnat notes that the reason for the increase is not yet clear. While isolation and loneliness due to the shutdown may certainly play a role, she also considers the decreased ability of people with addiction to access in-person treatment and recovery programs, the challenges of telemedicine, and changes to treatment protocols.
Monnat also noted that, "the supply chain for drugs, just like the supply chain for toilet paper, has been significantly interrupted by COVID-19, causing further chaos." For example, the United Nations Office on Drug and Crime reports a decline in the international production of heroin and disruptions to its distribution due to factors like reduced air travel and border scrutiny. This has brought to the drug scene more fentanyl, a synthetic opioid pain reliever which is 50 to 100 times stronger than morphine. Drug smugglers like fentanyl because it's cheap to transport: a small amount packs a powerful punch.
Monnat observes that fentanyl was already a huge problem before the pandemic and responsible for most drug overdose increases over the past three years. Now, the deadly substance is even more prevalent, often mixed in with other drugs as a filler and showing up not just in heroin supplies, but also in cocaine and methamphetamines. Some overdoses may result from people not knowing what they're getting. "Fentanyl is increasingly showing up in pressed pill format," says Monnat," so people think they're buying an Oxy on the street but it's actually a fentanyl pill."
Monnat's research on drug use currently focuses on upstate, central and western New York. With her team at Syracuse's Lerner Center for Public Health Promotion, she is asking people about their patterns of use and treatment experiences both before and after the pandemic, along with things like job and family stress and mental and emotional health. One change that concerns her is the possibility of more people using drugs alone during the shutdown, without a friend who could revive them if they overdose.
COVID-19 is likely altering the geography and demographics of drug overdoses, a picture that has shifted over the course of the pandemic. Early on, infection rates had a high impact in cities, but over time, the case and death rates have become higher in non-metro areas. "These are the places that missed the first bout but may not have taken adequate precautions," says Monnat. "I'm looking at counties where there are high numbers of people who tended to support Trump, who believe that the virus is a hoax, refuse to wear masks, and ignore social distancing mandates." Monnat's own home county in New York, Lewis, recently saw the highest 7-day case increase rate of any county in the state, a grim title it has held for the last two weeks.
Beyond the health impact of the pandemic, Monnat worries about communities suffering economically, especially in places that rely on tourism and recreation.
"There's distress in some of what used to be economically better-off areas," says Monnat. "They've missed summer and fall seasons, and now winter, with the skiing and snowmobiling. We're now looking at Great Recession-type effects in those places, or even worse. Of course, some of these places never fully came back from the recession in the first place."
Drug fatalities before the pandemic tended to cluster more in areas linked to manufacturing or mining, but Monnat sees the recreation and tourism-dependent areas, along with service-dependent communities, as particularly vulnerable now. She points out that it's too early to know if deaths of despair are already occurring more in those areas because death data are not yet available at the regional or county level, but she expects to see geographic shifts, and demographic changes, too. "There will be a lot of factors to unravel," she explains. "People who would have moved to tourist areas for a season are not going to have moved there, so you might have a whole different demographic profile than you would have seen otherwise."
Monnat stresses that deaths of despair don't affect all groups equally, but notes that since 1990, drug overdose is the only cause of death that has risen across every age group, race, ethnicity, and both sexes. "The rates of overdose were already increasing among Blacks before the pandemic," says Monnat. "Mostly it was because of increased fentanyl exposure, especially among the older Black men who saw their once-reliable drug supply increasingly contaminated with fentanyl."
The despair of COVID-19 is not a new despair, necessarily, but something that has been brewing for decades. The once-emerging Black middle class has been decimated by the loss of unionized jobs, creating economic hardship and downward mobility. Monnat points out that inner city areas with large Black populations had been devastated long before now, and the pandemic has only made things worse. "What has changed is that fentanyl is more prevalent, and it's increasingly deadly" says Monnat. "With the pandemic disrupting the drug supply, the user community, treatment providers, and even harm reduction availability like syringe exchange, user populations are more vulnerable than ever."
Breakdowns on race and gender on drug overdose during the pandemic are not yet available, but Monnat is especially concerned about one group — mothers. The CDC has reported that drinking was already on the rise among women before the pandemic and that the uptick coincided with the Great Recession. A report by JAMA Network Open has revealed that the pandemic has accelerated that trend. Alcohol use is linked to both suicide and drug overdose and raises the possibility of fatality.
"There's so much added stress on mothers with school-age children, juggling work and caregiving," she warns. "You've got the drinking, but women also have high prescription rates for anti-anxiety medication, like benzodiazepines, and when you mix them with alcohol, that can increase risk of overdose. Besides the risk of overdosing on drugs, there's also the risk of creating chronic health conditions from heavy drinking over a long period of time that we wouldn't necessarily see manifest themselves in deaths now. But we might be seeing this group of mothers 20 years from now having higher rates of liver cancer or cirrhosis."
Monnat says that while the opioid crisis particularly impacted working class whites, at least in the earliest waves, the damage of COVID-19 will be spread among more groups. "And it's not just the pandemic," she explains. "There's what I call the '2020 effect.' The year was stressful because of race relations and a president who seemed to be creating chaos at every opportunity. Even 9/11 didn't impact the country like this. Every time you turn on the news it's something new to worry about, some new crisis or problem. The anxiety is constant, and everyone is exhausted."
What are the remedies?
Monnat emphasizes that above all, widespread and quick vaccination has to be at the top of the agenda for preventing more deaths of despair. "In order to restart everything and get people back to their somewhat normal lives, they have to feel safe going out into the workplace, or to recreation and other consumption-based and activity-based places."
She notes that reopening schools would help mothers, who bear the brunt of kids being at home. "That's really part of the vaccination piece," says Monnat. "With new variants and added risk, schools have to have proper equipment and protocols, like testing regimes similar to what is done on college campuses. Here at Syracuse University, we have a good model with regular testing, reporting of the results, and wastewater testing. You need procedures that not only protect people from contracting the virus but also immediately mitigate when you have cases on campus."
Monnat also sees an infrastructure bill as an obvious win for everyone. "For five years now I've been saying we need a new deal for the 21st century. The New Deal was put into place in western Europe after WWII to rebuild after a war. We haven't been through an official war, but in a lot of communities it sure feels like the economic and infrastructural and social fabric decay is a lot like the experience of war. Certainly, post-Covid, it will feel like we've been through what amounts to a short war. An infrastructure bill would create jobs, help our falling-down infrastructure, and it has bipartisan support. That should happen right away."
Monnat warns that COVID-19 will cast a long shadow, not just over human health but in communities that are breaking down. "Trust in government, trust in media, trust in science, even trust in your own family have been strained," she says. "Families have been torn apart because of different willingness to accept facts. There are good stories, like people caring for each other and bringing each other food, but on a macro-social level, the pandemic has accelerated a disruption in the social fabric of communities."
Tears in America's economic and social fabric are likely to have negative implications for decades to come. "The impact will affect the political candidates that people get behind and support, people's willingness to help out their neighbors," says Monnat. "We didn't come together in the same way that we did after 9/11. That tragedy created divisions, but it feels like between the pandemic and Trump and the murdering of unarmed Black men by police, we've had a year of the magnification of political and cultural and social divisions."
Is America's current capitalist system, with its large concentration of wealth and worsening disparities, equipped to handle the potential tsunami of despair? Like a growing number of experts, Monnat's answer to that question is "no." In her view, taking on economic inequality is crucial, and depends on the Biden administration's willingness to push through an agenda that creates a more equitable tax structure. "You see with the pandemic that the very rich have gotten richer, so they can afford to pay their share of taxes," says Monnat. "Where else are you going to get money to dig out of this hole? You can't get any more money from lower and middle-income taxpayers. Even more so than the Great Recession, we've continued to redistribute wealth toward the wealthiest and the only way to mitigate that is to change the tax structure."
The writing appears to be on the wall: Only a serious reform of American capitalism can address the kind of distress and insecurity so severe that it kills. Is the country ready for this critical shot in the arm?