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In the nineteenth century it was common for Westerners to blame China’s civilizational crisis on the country’s inward-looking culture, particularly the inflated sense of self that was implied in the idea of the ‘Middle Kingdom’, and the pretensions to cultural (and even racial) superiority that led many Chinese to refer to foreigners by terms that Europeans generally chose to translate as ‘barbarians’ or ‘devils’.
This being a time when elite Westerners were beginning sbscribe, with increasing enthusiasm, to various cults of individualism, many also came to regard the collectivism of the Confucian order as one of the greatest of China’s weaknesses, the root cause of its self-absorption and arrogance. Implicis in this was the belief that in individualistic, Western societies, where institutions were established through participatory processes, there could never be a similarly widespread breakdown of trust in institutions; not, in such societies, would people ever be so deluded as to imagine that they were the centre of the world and paramount among nations. China’s crisis was, therefore, taken to be a special case, caused by conditions that were endogenous to the country and its culture Even today, China’s experience is generally thought to be irrelevant to the wider world, as is evident from the fact that the literature on the American opioid crisis very rarely mentions nineteenth-century China, and usually only in passing
It is true, of course, that the Chinese predicament was unique in many ways, and it is also true that the past never reproduces itself in an exact fashion. But as Mark Twain famously observed, History never repeats itself but it does often rhyme. It is a measure of opium’s peculiar ability to insert itself into human affairs that it has created many echoes and rhymes between past and present.
Consider, for instance, the justifications that were used by the management of Purdue Pharma in their advocacy of OxyContin and other opioid-based painkillers: that they provided miraculous relief; that they were safe and addiction was extremely rare; that there was a large unmet demand; that opioid addicts and abusers were temperamentally inclined to addiction, that the problem really lay in lax law enforcement.” These arguments echo, to a degree that can only be described as uncanny, the voices of the merchants who built their fortunes by selling opium in China and Southeast Asia in the nineteenth century. Consider also that in the United States, as in China, the demand for opioids increased at a staggering rate. OxyConti came on the market in 1996 and just a couple of decades later, in 2015 30 million people, about 3 percent of the population, were believed to be addicts. In Ohio alone, by 2016, 2.3 million people, around 20 per cent of the population, had received a prescription for opioids. During that time, opioid overdose became the leading cause of death in America, surpassing gun related fatalities and car accidents. In 2016, an average of 175 Americans were dying of overdoses every day adding up to an annual total of 64,000, equal to the entire population of cities the size of Santa Fe, New Mexico. In 2017 there was a 10 per cent rise, with 72,000 overdose deaths. It was as if, writes Barry Meier, a plague had entered one of these towns and killed every single inhabitant!!
In nineteenth-century Asia, as well as in twenty-first-century America, opiates provided relief to people engaged in hard physical labour. Like the Chinese migrants who toiled in Southeast Asian mines, mineworkers in Appalachia also took opioids because the drug made it possible to go on working despite injuries and exhaustion. And just as the retailers of opium in Southeast Asia specifically targeted those miners, so did American pharmaceutical companies focus their promotional efforts on areas like Appalachia, where there were larger concentrations of people with work-related injuries.
I have an opinion about Big Pharma and opioid medications writes Ryan Hampton, a recovering user. “To put it simply: They’re evil. I know that’s not very nuanced, but I want to just come out and say it.” We can be sure that there were millions of people in China who were saying the same thing about the merchants, Chinese and foreign, who were selling opium to drug dealers.
It is now abundantly clear that the rapid rise in opioid addiction in the United States is also closely related to a multidimensional crisis. The manner in which Purdue Pharma and other pharmaceutical companies were able to obtain federal approvals for their opioid painkillers; their enlisting of doctors and physicians in their distribution campaigns, their manipulation of the judicial systems; their success in co-opting lawmakers at both the state and national levels; and the fact that the company’s top management was able to get away with light sentences-all point to corruption on an astonishing scale. Today, American pharmaceutical companies outspend every other industry in buying political influence. As Patrick Radden Keele writes in Empire of Pain. The opioid crisis is, among other things, a parable about the awesome capability of private industry to subvert public institutions.
It is starkly evident that in the United States today, as in nineteenth century China, civil servants, doctors, prosecutors, police officers, law enforcement agents and public figures from many walks of life can be persuaded to look the other way with sufficient financial inducements. And, as with China, the profits that opioids generate are such that limitless amounts of money can be used for those purposes In the years between 2006 and 2015 alone, Purdue Pharma and other drug companies spent roughly 700 million dollars on buying political influence, eight times the amount spent by the gun lobby. To understand how opioids and their purveyors are able to seek out and exploit pre-existing weaknesses in the system we have only to look at the example of Qing China.
Again, in the United States, as in nineteenth-century China, the expansion in the use of opioids has also been accompanied by a steady erosion of trust in figures and institutions that had long commanded authority and respect. How was it that 400,000 American lives, more than all American military deaths in World War II, were lost in an epidemic without anybody taking notice? Chris McGreal writes:
As grief gave way to anger, the families of the dead and the survivors wanted to know why opioids were so easily prescribed, and why doctors told them these pills were safe.
They asked how it was that those who Americans expect to protect them – the medical profession, the government, the federal regulators – to stand idly by, or worse, as the bodies piled up year after year.
The involvement of small town pharmacists and doctors (like the principal character in Dopesick) is particularly shocking in this regard because they are traditionally the most trusted people in their communes. This is how Ryan Hampton, whose life was upended by pills prescribed by a doctor, puts it: ‘I was given the prescription in doctor’s office place we are all taught to trust. My “dealer’ was a source we are taught to believe has our best interests at heart.
The actions of the rural doctors and pharmacists who vouched for opioids and doled out prescriptions affected many beyond those who fell victim to addiction. The damage seeped deep into communities often in exactly those parts of the country where, like in China, the family was regarded as the sacrosanct cornerstone of social life. For these Americans, the ease with which opioids were prescribed and chained represented a betrayal not just on the part of individual doctors and pharmacists but also of the sciences that lent them their authority. By giving their imprimatur to opioids these widely trusted figures helped to make opioids socially acceptable. The same could be said of the Food and Drug Administration (FDA), which had long been one of the most trusted institutions in the country, it conducted only cursory, two-week trials on OxyContin before approving it. Two of the examiners involved in the FDA’s approval process later went on to work for Purdue Pharma. In 2002, when the FDA convened group of experts to examine the harms from OxyContin, eight of the ten had ties to pharmaceutical firms. The link between the regulatory body and the corporations it oversaw was a prime example of ‘regulatory capture.’ All of this resulted in an erosion of trust that would have bitter consequences during the COVID-19 pandemic.
The opioid epidemic, it is worth recalling, unfolded against the backdrop of other massive institutional failures, like the financial crisis of 2008. Opioid use surged in the wake of the crash not only because it thrust large numbers of people into poverty, but also because of the revelation that banks, once the most dependable of institutions and the bedrock of many small communities, had become predators that sought to profit from the systematic duping of their clients. Rising inequalities and disappearing jobs in sectors like mining and manufacturing, which had provided secure employment for generations of Americans, compounded the crisis further.
As the journalist Sam Quinones, among others, has shown, many of the communities that have been worst affected by prescription opioids are in regions that were severely impacted by post-industrial blight, with factories closing, tax bases shrinking and cities sinking into abandonment and neglect. The changing economy and extreme rates of unemployment have left rural populations in the heartlands of America devastated. In 2012 15 per cent of rural residents had more than one opioid prescription.” Nor is it a coincidence that some of these regions send disproportionate numbers of young people into the military, to fight overseas wars from which they return traumatized in mind and body. Not for nothing have overdose fatalities been described as ‘deaths of despair.
In many parts of the United States, the opioid crisis has overlapped with a more general loss of faith in political institutions, including the electoral process, which is the very foundation of democratic systems of governance. Since 2000, when the presidential election was decided by hanging chads, trust in the electoral system has declined steadily, hitting new lows after the elections of 2016 and 2020. This has contributed, in no small measure, to the deepening of political rifts to an extent where it has become commonplace for political pundits to lay odds on the likelihood of a new civil war. In all of this there are echoes of nineteenth-century China.
There is another, very important, way in which the contemporary American experience thymes with the situation in nineteenth century China: the loss of people’s sense of their place in the world, and the dissipation of long-held beliefs in the centrality and primacy of their country, not just as the world’s paramount economic, political and military power but also as a model of good governance Why this feeling should be widespread in the United States is not easy to fathom, since the US still is, unquestionably, the world’s foremost economic and geopolitical power. Yet, the fact that many Americans believe their country is in decline was made evident by the slogan that carried Donald Trump to power: “Make America Great Again’
It is no coincidence that the need to believe in the continuing superiority of the United States is felt most strongly in precisely the regions that are the epicentres of the opioid problem, where the idea of decline is perceived as a threat to national, and even racial, identity Evidently, despite America’s vaunted traditions of individualism, the necessity for a collective sense of primacy is powerful for many Americans, much as it once was for countless Chinese. Indeed, what the United States is experiencing today is, in many ways, a reversal of the civilizational shock that traumatized China in the nineteenth century
There are many other parallels. In nineteenth-century China, as in the United States today, there was an outpouring of noir literature related to the opioid crisis, there too drugs came to be associated with nightlife and partying. In both countries drug addiction did not spare the families of the highest in the land, mandarins and emperors senators and presidents. In nineteenth-century China, as in the United States today, the inflow of opioids was often described as a security threat and a national emergency. But the strangest aspect of the crises, in Qing China as in contemporary America, was that on the surface everything seemed normal, so that it was possible for visitors and even large sections of the population to be completely unaware of the very existence of a problem.
That these parallels have gone totally unnoticed in the United States is itself another way in which contemporary America rhymes with nineteenth-century China.
Excerpted from Pages 290 to 297 of Smoke And Ashes: A Journey Through Hidden Histories by Amitav Ghosh