30 The New York Review
were either unemployed or living on
disability payments.^5
This pain seems to be real. At no
time do Silva or Macy suggest that any-
one is faking it in order to live large
on food stamps. But a combination of
prescription and recreational drug use,
sky-high smoking rates, depression,
anxiety, and other emotional prob-
lems—which may worsen the actual
feeling of pain, according to neuro-
scientists^6 —along with poor access to
good health care, seems to have ampli-
fied the effects of work injuries, acci-
dents, and the physical and emotional
scars of domestic violence and trauma
resulting from military service.
Pain, observes Silva, has become a
powerful organizing factor in the lives
of just about all of Coal Brook’s adults.
But ethnic differences in the way peo-
ple respond to their afflictions could
help explain white hypervulnerability
to deaths of despair. The lives of Silva’s
black and Hispanic informants, like
those of the whites, were full of school
failure, incarceration, addiction, and
health problems. On top of that, they
faced raised middle fingers and mut-
tered N-words in the streets. They felt
unwelcome at churches and sporting
events, their kids were bullied by white
classmates, and they were keenly aware
of racism in the criminal justice system
and in their workplaces. But their vision
of the future tended to be less hope-
less and bleak than that of the whites.
One, for example, obsessively read
self-help books, and another proudly
showed Silva his prison diplomas from
parenting and accounting classes. Per-
haps because most of them grew up in
urban ghettos, Silva’s poor blacks and
Hispanics expected things to turn out
even worse, and for them, Coal Brook
was almost a land of opportunity, if a
shabby and disappointing one.
Silva’s white informants, by contrast,
tended to see themselves as lonely war-
riors facing strange, undefined threats
to their community. Weird conspiracy
theories were common. Graham Hen-
dry, a white nursing-home aide who’d
been chain-smoking since age nine
and had recently lost three friends to
heroin, believed that September 11
and the Sandy Hook school massacre
were hoaxes, that FEMA was building
a network of concentration camps for
minorities, and that the government
put fluoride in toothpaste and alumi-
num chloride in deodorant in order to
calcify people’s pineal glands, allowing
the authorities to control their minds.
“Everybody is getting cancer,” Mary
Ann Wilson, a fifty-one-year-old white
smoker, told Silva. “There’s something
in the air,” said her adult daughter
Vivian, also a smoker. Could it be land-
fill from those trucks from New York,
they wondered? Or the dust kicked up
by the mines?
Many of the white men carried guns
everywhere—to high school football
games, the supermarket, the sub shop.
Their anger focused on a faceless gov-
ernment that neglected people like
them and on supposedly shiftless im-
migrants and minorities who feasted
at the public trough. Some embraced
white nationalist ideas, which uncon-
vincingly concealed deep feelings of
loneliness, shame, worry about the fu-
ture, and a yearning for solidarity.
Other white men adhered to a stoic
and lonely individualism. Jacob, di-
vorced from his unfaithful wife,
discharged from the navy for health rea-
sons, and having failed a test to become
a construction foreman, still believed in
self-reliance and self-sacrifice and had
the word “courage” tattooed all over
his body. Joshua, the non voting twenty-
eight-year-old, sought a Zen-like sus-
pension from the world: “I think if we
live with a fearless approach to life with
unconditional love, then we can be the
stillness in the chaos, we can endure.”Whereas most whites aspired to a
lonely-hero ideal, many of Silva’s non-whites upheld an image of what the so-
ciologist Michèle Lamont has called the
“caring self”—altruistic, part of a mu-
tually supportive kin network, cogni-
zant of how their own suffering linked
them to that of past generations. And
they found real hope in their children,
whom they attempted to shield from
racism. The whites were also devoted
to their children but were often so pre-
occupied with their own problems that
they struggled to be good parents.
Addiction, violence, and despair are
common to all human societies that have
seen their cultures destroyed, whether
South Africans uprooted by apartheid,
Native Americans herded onto reserva-
tions, or African- Americans stranded
in urban ghettos. The psychiatrist
Mindy Fullilove calls it “root shock,”
the loss of one’s emotional ecosystem
following the destruction of cultural,
social, and political capital resulting
from mass displacement, natural di-
saster, or economic upheaval. The an-
thropologist Oscar Lewis observed it in
rural migrants trying to eke out a liv-
ing in the slums of Mexico City; Ralph
Ellison witnessed it during the Great
Migration among black migrants who
discovered that mid-twentieth-century
Harlem wasn’t necessarily the prom-
ised land after all. In his 1964 essay
“Harlem Is Nowhere,” Ellison wrote
that in the South, a stable family struc-
ture, authoritative religion, and “tech-
niques of survival which...[made]
Hemingway’s definition of courage,
‘grace under pressure,’ appear mere
swagger,” enabled them to endure Jim
Crow racism. But in the North, without
those supports, they lackedone of the bulwarks which men
place between themselves and the
constant threat of chaos. For what-
ever the assigned function of social
institutions, their psychological
function is to protect the citizen
against the irrational, incalculable
forces that hover about the edges ofhuman life like cosmic destruction
lurking within an atomic stockpile.Out of the ashes of the current
catastrophe, America’s white working
class seems to have fashioned a new
culture of pain and trauma, rooted in
white America’s peculiar imperative to
seem happy all the time (unless you’re
sick) and to personalize and depoliticize
financial hardship. This self- defeating
belief system is reinforced by neoliberal
“government is the problem” slogans and
self-help gurus such as Melody Beattie,
author of Codependent No More, who
warn against getting wrapped up in
other people’s problems. “If Tori dies,
that’s on her,” one of Silva’s informants
said of her drug-addicted sister.
This new culture flourishes amid
rampant pharmaceutical marketing that
shunts vulnerable depressed people
onto a path, via side effects and addic-tion, to further health problems. Entry
i nto th is cu lt u re st a r t s ea rly. I n Vi rg i n ia
coal country, Beth Macy was told that
some parents, worried about their chil-
dren’s financial prospects, urged their
pediatricians to diagnose them with at-
tention deficit hyperactivity disorder,
so that they might eventually qualify
for disability. Ritalin, most often pre-
scribed for ADHD, is a “pipeline” drug
to the disability rolls, a local health
official told her. A doctor who worked
at a summer camp said that in the
1970s, very few kids were on prescrip-
tion medications, but now one third
are, mostly for ADHD and depression,
but sometimes even for psychosis.The victims of America’s pain epidemic
might be experiencing something simi-
lar to what Frantz Fanon called North
African Syndrome—a mixture of stom-
ach ailments, vague aches and pains,
heart palpitations, and headaches that
afflicted Algerian migrants in France
during the 1940s. Baffled French doc-
tors could find no physical cause, and
treatment offered no relief, so they dis-
missed their patients as malingerers.
But Fanon, channeling Jean-Paul Sar-
tre’s equation of existential despair with
physical nausea, understood that these
migrants, raised to believe that they
were part of a great French empire, were
responding to the mental agony of lone-
liness. Poor and adrift on the outskirts
of French cities, rejected and conde-
scended to by French people, they were
liminal and lost, even to themselves.
Opioids, my drug-using friends say,
don’t just ease pain. They liken the
effect to the warmth of bonding with
a newborn or being praised for a great
piece of work. These drugs stimulate
the dopamine system in the brain,
which, among other things, helps make
the world appear more meaningful.
No wonder they seem to be the perfect
medicine for the anomie that is blight-
ing so many American lives.There are solutions to this disaster.
Case and Deaton would like to see
tougher rules for prescribing opioids,
the regulation of outsourcing firms
so they don’t exploit workers, a stron-
ger safety net for the unemployed, in-
creased access to higher education, and
more and better retraining programs
for people in depressed areas. Corpo-
rate mergers should be better scruti-
nized to ensure they aren’t devouring
competition, and wages and tax credits
for the poor should be increased.
But most of Case and Deaton’s ire fo-
cuses on the health care industry, which
not only underperforms but is also
wrecking the US economy. We spend
twice per capita what France spends on
health care, but our life expectancy is
four years shorter, our rates of mater-
nal and infant death are almost twice
as high, and, unlike the French, we
leave 30 million people uninsured. The
amount Americans spend unnecessar-
ily on health care weighs more heav-
ily on our economy, Case and Deaton
write, than the Versailles Treaty repa-
rations did on Germany’s in the 1920s.
If, decades ago, we’d built a health
system like Switzerland’s, which costs
3 0 p erc ent le s s p er c apit a t ha n ou r s do e s ,
we’d now have an extra trillion dollars a
year to spend, for example, on replacing
the pipes in the nearly four thousand US
counties where lead levels in drinking
water exceed those of Flint, Michigan,
and on rebuilding America’s bridges,
railroads, and highways—now so run-
down that FedEx replaces delivery van
tires twice as often as it did twenty
years ago. Median income growth over
the past thirty years would have been
twice what it actually was, and many of
the 45,000 uninsured Americans who
die annually because they can’t afford
care might be alive. More and better
jobs might also be available to people
without BAs. In the US, health insur-
ance accounts for 60 percent of the
cost of hiring a low-wage worker. Many
employers opt instead to hire contract
workers with no benefits, or illegal im-
migrants with no rights at all.
Silva’s Pennsylvania informants, in-
cluding those most critical of minorities
on welfare, do support the expansion
of access to education, health care,
fair pay, and good jobs. “A political
candidate who puts economic justice
for working-class families at the cen-
ter of their platform,” she notes, “and
who does not shy away from criticizing
the collusion of financial and politi-
cal elites, could have a shot at gaining
their support.” Interestingly, many
informants, including Trump support-
ers like Steven, the sixty-two-year-old
janitor, indicated that they would have
voted for Bernie Sanders had he been
on the ballot in 2016. It’s worth noting
that 117,000 Pennsylvanians who voted
for Sanders in the primary cast their
general election ballots for Trump, who
won the state by only 44,292 votes.
If you include those who have left
the workforce altogether, the US un-
employment rate is almost as high as
it was in 1931. Back then, the grand-
fathers of today’s non-BA whites were
drawn to Franklin Roosevelt, who sup-
ported generously funded public works
programs and expressed open con-
tempt for greedy corporate tycoons.
Perhaps a Democratic candidate with
similar policy positions will offer
America’s struggling workers a rea-
son to go to the polls in 2020 without
feeling like fools. Q(^5) Beth Macy, Dopesick: Dealers, Doctors,
and the Drug Company That Addicted
America (Little, Brown, 2018), p. 125.
(^6) “Induction of Depressed Mood
Dis rupts Emotion Regulation Neuro-
circuitry and Enhances Pain Unpleas-
antness,” by C. Berna et al., Biological
Psychiatry, Vol. 67, No. 11 (June 1, 2010).