The Opioid Epidemic Is This Generation’s AIDS Crisis

Snow covers a cemetery in Gloucester, Massachusetts. Photo: John Moore/Getty Images

Those of us who lived through the AIDS epidemic retain one singular memory: The plague that ravaged our lives was largely invisible to others. The epidemic was so concentrated for a while in a gay male subculture often itself veiled by various closet doors that straight people without gay family members or friends couldn’t see it. There was blanket media coverage, of course. But in your everyday life, if you were straight, you could live quite easily in the 1990s without coming across someone with AIDS. While gay men were living in a medieval landscape of constant disease and death, many others carried on in safe, medical modernity, that elysian period in human history when most diseases can at least be treated, if not cured.

It occurred to me reading this reported essay by Christopher Caldwell that the opioid epidemic is the new AIDS in this respect. Its toll in one demographic mostly white, working-class, and rural vastly outweighs its impact among urbanites. For many of us in the elite, it’s quite possible to live our daily lives and have no connection to this devastation. And yet its ever-increasing scope, as you travel a few hours into rural America, is jaw-dropping: 52,000 people died of drug overdoses in 2015. That’s more deaths than the peak year for AIDS, which was 51,000 in 1995, before it fell in the next two years. The bulk of today’s human toll is related to opioid, heroin, and fentanyl abuse. And unlike AIDS in 1995, there’s no reason to think the worst is now over. Caldwell notes that:

[I]n Maryland, the first six months of 2015 saw 121 fentanyl deaths. In the first six months of 2016, the figure rose to 446 … The population of addicts is like the population of deer. It is highest in rustic places with access to urban supplies. Missouri’s heroin problem is worst in the rural counties near St. Louis. New Hampshire’s is worst in the small cities and towns an hour or so away from the drug markets of Massachusetts: Lawrence, Lowell, and Boston.

These are the contemporary equivalents of the urban gay ghettos of the 1980s and 1990s. Within them, “carnage” is not an exaggeration:

Salisbury, Massachusetts (pop. 8,000), was founded in 1638, and the opium crisis is the worst thing that has ever happened to it. The town lost one young person in the decade-long Vietnam War. It has lost fifteen to heroin in the last two years. Last summer, Huntington, West Virginia (pop. 49,000), saw twenty-eight overdoses in four hours. Episodes like these played a role in the decline in U.S. life expectancy in 2015.

Sure enough, the last time U.S. life expectancy dropped was in 1993, because of AIDS. And this epidemic is dramatically escalating. Among men aged 25–44, deaths from synthetic opioids like fentanyl more than doubled between 2014 and 2015. No year in the AIDS epidemic showed such a swift increase in mortality.

There are major differences between the two health crises, of course, but none of them are very encouraging. AIDS was eventually overcome by innovation by pharmaceutical companies. The heroin epidemic is, in many ways, the creation of those very same companies, thanks to their cynical marketing of opioid products in the 1990s. Treatment for opioid abuse, much more complex than prescribing anti-HIV meds, can also be as deadly as the addiction itself. Many fatal overdoses occur among people who managed to get sober for a while, because their resistance had gone down the Philip Seymour Hoffman scenario.

But for me, the real parallel is the cultural isolation. This is a plague many of us who are cocooned in urban, prosperous bubbles can ignore if we want to. But, if we do, we’d be mimicking the same indifference much of straight America exhibited toward gay men in the 1980s and early 1990s. A tiny minority of heroes like J.D. Vance, author of Hillbilly Elegy are moving back to the heartland to tackle the health emergency. But for most of us, the scale of this compounding tragedy is all too easy to ignore.

Worse: Funds for AIDS research kept rising and rising through the 1990s. Today, the Trump administration’s proposed cuts to Medicaid could drastically reduce treatment options in a spiraling crisis. Silence = Death, once again. But where, one wonders, is the ACT UP of the red states?

How much can politics achieve? Your answer to that question, it seems to me, is a pretty good indicator of where you are on the right-left spectrum. One reason I still call myself a conservative (despite much probably deserved mockery) is that I’m pretty skeptical of government as a solution to the core problems of being human. This doesn’t make politics unnecessary: Au contraire. You have to do what you can say, in protecting civil rights, or guaranteeing universal health care. But if politics is your path to happiness, it has its limits.

In my own adult lifetime, to take an obvious example, politics has helped transform the environment for gay people. One reason I long believed in marriage equality was because I felt that the denial of marital rights both directly hurt gays, by denying them benefits and the like, and also did so indirectly by culturally signaling that they were somehow less as human beings than straight people. Take those barriers away, and you could mitigate the pain of many, make the lives of gay kids and teens more bearable, help others handle stigma, even enlarge the scope of human happiness. And so I’ve watched myself and others in the gay world shift and change as the atmosphere has been revolutionized.

And yet: Gay people are still, depending on the study, between two and ten times more likely than straight people to take their own lives. We’re twice as likely to have a major depressive episode. And just like the last epidemic we lived through, the trauma appears to be concentrated among men. In a survey of gay men who recently arrived in New York City, three-quarters suffered from anxiety or depression, abused drugs or alcohol or were having risky sex — or some combination of the three.

This essay by Michael Hobbes is the best account I’ve read that helps explain why this is still so: how the pressures of being out of the closet can be as intense as those being in it; how badly many gay men treat one another; how the disappearance of gay spaces and the proliferation of apps has intensified mutual objectification and a deeper sense of loneliness. The extraordinary suffering gay men once lived with and still do in the vast majority of the world is no longer. We can thank politics and culture for that. But the struggle of being a small minority, of being male, and of being human endures. Growing up gay and different, especially in our teens, will always be traumatic to a greater or lesser degree. Homophobia, especially in this demographic, will never disappear, as our sexualities blossom at the same time our need to belong and to conform intensifies. And so our psychological baggage, lightened perhaps, stays with us. Politics, we discover, cannot do the work of life. Only life can do the work of life.

Some more thoughts about intersectionality as a religion. The first is that I’m not the only person noticing the evolution of elite private colleges into de facto religious institutions. Jonathan Haidt decries a modern auto-da-fe here. Michael Rectenwald argues for re-secularizing the university here. William Deresiewicz in the American Scholar homes in on one key thinker in the entire matrix of “social constructionism”:

The presiding presence is Michel Foucault, with his theories of power, discourse, and the social construction of the self, who plays the same role on the left as Marx once did. The fundamental questions that a college education ought to raise — questions of individual and collective virtue, of what it means to be a good person and a good community — are understood to have been settled. The assumption, on elite college campuses, is that we are already in full possession of the moral truth. This is a religious attitude. It is certainly not a scholarly or intellectual attitude.

I’ve always found Foucault a really interesting (if unpersuasive) thinker — as long as he is considered alongside countless other ways of understanding the world we live in. But if he is the default foundation of all thinking in a university, the university itself has been deconstructed. Stephen Carter fingers Herbert Marcuse’s theory of “repressive tolerance” as well. (How about we substitute the now tired term political correctness with the less euphemistic repressive tolerance?)

Analytically, it makes sense to see how various inequalities are related — such as race and wealth. But an individual is so much more than a compounding sum of group identities. We don’t just vary in racial or gender demographics. We have different individual genetics, upbringings, religions, levels of attractiveness, interests, ambitions, dumb luck, and on and on. Aspects of our personal identities that liberate us can be just as potent and revealing as those that oppress us.

It’s also a useful insight, it seems to me, to see “intersectionality” as responding to a practical problem on the “social justice” left: how to prevent each oppressed group fighting the others. If everything is connected, and if you can’t separate out one oppressed identity from all the rest, then we have a chance for a truce: Everyone against white straight men! There’s something perfectly perverse about an anti-sexist and anti-racist movement agreeing on an “enemy” that is defined by sex and race. What’s also revealing is where the intolerance is strongest. Brookings’s Richard Reeves and Dimitrios Halikias have crunched the numbers. The answer is: the most expensive colleges. Specifically:

The average enrollee at a college where students have attempted to restrict free speech comes from a family with an annual income $32,000 higher than that of the average student in America.

What you have here is an elite class paying for their kids to avoid ideas that might make them uncomfortable. Worse, as Deresiewicz explains:

[L]ower-income whites belong disproportionately to precisely those groups whom it is acceptable and even desirable, in the religion of the colleges, to demonize: conservatives, Christians, people from red states. Selective private colleges are produced by the liberal elite and reproduce it in turn. If it took an electoral catastrophe to remind this elite of the existence (and ultimately, one hopes, the humanity) of the white working class, the fact should come as no surprise. They’ve never met them, so they neither know nor care about them. In the psychic economy of the liberal elite, the white working class plays the role of the repressed. The recent presidential campaign may be understood as the return of that repressed—and the repressed, when it returns, is always monstrous.

All of which is presciently foretold in Coming Apart, a book about soaring inequality and elite isolation … by the man, Charles Murray, the students refused to hear. And the beat goes on.

The Opioid Epidemic Is This Generation’s AIDS Crisis