When Do We Politicize a Death Count, & When Do We Simply Resign Ourselves to One?
According to survey research, among self-identified Independent voters who listed Covid-19 as their top concern in the November 2020 election, less than half cast a vote for Trump. Tied to his disastrous handling of the pandemic, Trump lost a significant share of college-educated voters, including those living in large suburban counties in battleground states. By virtue of this voting pattern alone, the administration’s response to the pandemic may have swung the election to Biden. Among Democratic loyalists, condemnation of Trump’s handling of the pandemic is even more pronounced.
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Clearly, for millions of American voters, responsibility for the extraordinary number of Americans who died as the result of contracting Covid-19 rests with Donald Trump.
Those who hold this view — myself included — understand that a terrible number of fatalities would inevitably result from a new, contagious, and dangerous viral strain no matter who guided the government’s response. But we disdain Trump’s record nonetheless, knowing that his shocking mismanagement added to the death count. As The New England Journal of Medicine put it, leaders in the United States took “a crisis and turned it into a tragedy.” Researchers at the University of Oxford attempted to quantify this failure, estimating that, out of a quarter million deaths, 57,800 Americans would still be alive today had the United States managed the response to Covid-19 as well as Europe.
This judgement is widely known, and widely shared. Less noted is the fact that this is not the first contemporary election with a “political” death count. In 2016, large portions of the United States viewed the opioid crisis — by that time responsible for tens of thousands of deaths — in a similar fashion.
Were they not justified? Certainly many overdose deaths would happen regardless, but policy failures in the over-supply of both legal and illegal opioids, as well as the insufficient delivery of lifesaving and evidence-based interventions like medication-assisted treatment, overwhelmed public health systems throughout the steel belt, filling morgues beyond capacity. Most of all, voters who lived in communities wracked with despair found it difficult to place themselves in triumphant Democratic campaign narratives. Hospital staff who checked parking lots periodically for overdose victims dumped on their doorstep — to cite one shocking example — would be unlikely to endorse the triumphalist Democratic mantra that “America is already great.” Immediately following the 2016 election, I tracked how Democrats bled voters in opioid-ravaged communities, to the benefit of Donald Trump, who saw a resurgence of Republican voters in many of those same areas.
Once elected, Donald Trump went on to disappoint those communities in a more egregious fashion, most notably by threatening life-saving health insurance. He also failed to curb supply. Though Trump had the opportunity to demand reductions in illegal opioid traffic in trade talks with China and Mexico, he satisfied himself with only the occasional rhetorical flourish. Just as noteworthy, the Trump administration could have confronted the surge in overdose deaths — by insisting on science-backed opioid prescribing, pressing criminal charges against corporate wrongdoers, or evincing even basic concern for intravenous drug users — but failed to take meaningful action.
Rod Rosenstein, the Deputy Attorney General Who Traduced Safe Consumption While Letting Walmart Off Criminal Charges
When it came to responding to the opioid crisis, the Trump administration was all talk; even the talk did not do much that was helpful. Typical in this regard was the public posture of Deputy Attorney General Rod Rosenstein, who published an editorial in The New York Times denouncing safe-injection sites by claiming — without evidence — that they encouraged teenage drug use and led to more overdose deaths. At the very same time, as ProPublica later reported, he quietly steered the Department of Justice to settle its case against Walmart for irresponsible opioid prescribing on generous terms, leniency that went against the recommendation of the Department of Justice prosecutors assigned to the investigation. One of them later resigned, stating in his official comments: “we must be willing to prosecute all facets of the expansive network that feeds these destructive drugs into our communities. Players both big and small must meet equal justice under the law.” The Trump administration, like those before it, saw it differently.
Truly, the opioid epidemic is also a crisis “turned into a tragedy.” Yet, unlike Covid-19, we rarely encounter this or any other explicit charge of government failure when we learn about it. For instance, no one has spoken of an investigation into the government’s actions during the opioid crisis, as they frequently do with Covid-19. To the contrary: the agencies most implicated in it, like the Food and Drug Administration or the Drug Enforcement Administration, emerged unscathed, conducting their operations much as before.
The discrepancy in how we view these public health crises results in part from some features that distinguish Covid-19 from opioids. First, in the case of the opioid overdose deaths, we have a public health crisis caused by (a class of) drugs; when it comes to Covid-19, we hope for the opposite: that drugs will save us. By necessity, this alters how we view the role of the pharmaceutical industry in each instance. Second, though sometimes likened to a contagion, drug use is not the same as the indiscriminate and terrifying danger of a novel respiratory virus. Nor is it as lethal: although at this point Covid-19 has killed, in total, fewer Americans than opioid overdoses, we have been exposed to it for only a few months, as opposed to the nearly two decades of spiraling drug overdose deaths. Had more people resisted public health measures intended to counteract the virus, its death count would be more unbearable. Finally, and perhaps most crucial of all, Covid-19 and the response to it made demands on every single American, lending terrific weight to the stakes involved in evaluating government performance.
On the other hand, opioid overdose and Covid-19 deaths share other characteristics in common. Foremost among them is the radically disproportionate burden borne by disempowered communities. Despite impressive numbers of exceptions, opioid overdoses and Covid-19 exact their steepest cost in places already crippled by disadvantage. In a strange coincidence, both also feature motivated voices who seek to dismiss risks and discount losses. For Covid-19, such voices came directly from the Oval Office; in the case of opioids, there remains a formidable, industry-supported apparatus in place dedicated to the broad prescribing of this class of drugs, one that is as unburdened by evidence or human feeling as its Covid-19 counterpart. Recently, another distressing similarity has emerged: the kind of stigma that haunts how we consider substance use disorders has started to factor into discussions of the risk obesity poses to suffering severely from Covid-19. In both crises, many people tend to blame the victim.
It is strange that these obvious connections have gone begging, especially given the likelihood that each public health crisis, in its turn, could be credited with swinging a presidential election. A simple reason for that may be that journalists typically perform their work in a context structurally incentivized in favor of issues that affect privileged people on both coasts — overlooking those unfolding in “flyover” country, where the opioid crisis first inflicted its worst damage, or those that continue to wreak havoc in parts of the city they rarely visit, filled with people they don’t know.
Saying so does not account for the particulars of whom we hold accountable for these public health tragedies, or how we do so. In the case of opioids, one company in particular — Purdue Pharma — has been vilified, while the government failures of several administrations have largely been spared. The reverse is true for Covid-19: praise and prayers rain down on companies racing to formulate a vaccine, while the Trump administration stands convicted of heinous crime. Yet the reality of modern medicine is that drug development happens in partnership with the government. If you believe pharmaceutical companies perform well, then by necessity you extol certain government agents — who, in the case of Covid-19, presumably operate at some remove, beyond the reach of political interference from President Trump. Likewise, if you denounce any particular company, then you condemn the very same tier of government, perhaps even the very same people. Janet Woodcock, Director of the Center for Drug Evaluation and Research at the FDA, was lauded when she moved to the White House to direct the Covid-19 vaccination effort. No one mentioned that a former member of the FDA’s Drug Safety and Risk Management Committee called for Woodcock to be replaced as a result of her refusal to adopt the National Academies’ recommendations for safer opioid prescribing.
Examples such as this suggest that, rather than compare Covid-19 and opioids side-by-side, we should consider their stories together and tell them in sequence. Though not identical, they are in fact deeply intertwined. No one familiar with the opioid crisis would be surprised to learn of institutional failures at the World Health Organization, nor would they be shocked to discover that the refusal to invest in public health yielded ruinous results. Any person affected by the opioid crisis would recognize the pattern when, in the absence of meaningful outreach and appropriate levels of care, the public narrative shifts toward blaming those most afflicted, facilitating invidious distinctions designed to discount the humanity and suffering of others. Any community devastated by the opioid crisis carries in its collective knowledge that, while politicians may deplore inequality in speeches, they rarely disrupt wealth in order to rectify it in policy. All of these bruising truths of the opioid crisis form a part of a Covid-19 reckoning that, in crucial respects, still awaits us.
To embrace the notion that these public health crises occupy different positions in the same catastrophic abandonment of a government functioning on behalf of ordinary Americans is to acknowledge our interconnectedness — and the refusal to do so, the true author of our national tragedy. Psychologists refer to the inability to fuse different components of reality into one encompassing narrative as “splitting,” a disorder that results in an incomplete, often extreme version of reality. One danger apparent in this sort of simplification of complex reality is the inclination to make reference to only those events that malign what our worldview already regards as odious, and recognize only those facts that can be summoned to support views we already hold.
In this light, it would be fair to say that we have been “splitting” the story on public health in America. Rather than moderate what we hate, or qualify what we love, we use another’s death in an expedient fashion, spurning them if their loss stubbornly refuses to tell us what we want to hear.
Still the deaths mount. This year will be a record-setting one for drug overdose deaths, shattering all previous numbers. Not only did the opioid crisis audition the institutional and political failures of the Covid-19, it stands to inherit much of its despair. As we preside over yet another chapter of national calamity, it is time for us to see that how we eulogize the powerless tells us something about power itself, and that when we tell a better story, we begin to make possible a better world.
