Register of the Kentucky Historical Society

Introduction

The War on Drugs' effects are varied through time and space according to the cultural constructs of substance-use and people who use drugs as well as to the institutions that manage people who use drugs.¹ The most recent iteration of the War on Drugs has targeted the so-called "opioid epidemic," with Appalachia characterized as the epicenter.² Appalachia is othered in national discourse, representing a place that is culturally incongruent with the broader United States.³ This othering engenders models that blame Appalachia for both the suffering within the region as well as for national suffering that is [End Page 373] seen as emanating from the region.⁴ Yet not all Appalachians are treated equally. Discrimination based on race and gender are abundant in state policy, community discourse, and local actions. This section analyzes Appalachia as an othered region where the framing and implementation of the War on Drugs was raced and gendered in particular ways in the 2010s.

The sources for this section include state policies, participant observation in communities, interviews with people who use drugs and service providers, and program evaluation for a variety of programs for people who use drugs. All research is focused on eastern Kentucky and eastern Tennessee from 2012 through 2021. This was a time of intense fluctuation in health and access to healthcare in the area, including continually increasing rates of overdose death, implementation of the Affordable Care Act (ACA) and Medicaid expansion in Kentucky, and the COVID-19 pandemic.⁵

The methods for all interviews and participant observation in eastern Kentucky are described elsewhere.⁶ All participant observation and program evaluation in east Tennessee was conducted as part of my role as the research director at Choice Health Network Harm Reduction in Knoxville, Tennessee. Background information and original data are integrated to organize around themes rather than results versus discussion.

Appalachia as Othered

Although squarely in the continental United States today, Appalachia holds cultural characteristics of an "othered" region. The resources extracted [End Page 374] from Appalachia, whether timber, coal, or the culture itself in the form of Dolly Parton and ramps, are integral to the national identity, but there is a generalized discomfort with the region, often based on perceived ambiguity. Appalachians are assumed racially white, but a devious sort of white that is inherently poor and violent. Constant jokes about Appalachian children born from incest reveal a deeper concern with gender roles and sexuality in the mountains.⁷ Many of those I interviewed in eastern Kentucky felt stigmatized because of where they were born, one pastor saying that the region is stereotyped as "backward."⁸

I spent time with forty women who had experiences with substance-use disorder treatment in eastern Kentucky. When I asked about being Appalachian, most had positive remarks, but did see their birthplace as setting them apart. They viewed themselves as more connected to the outdoors as compared to their non-Appalachian counterparts and as partaking in work that is coded as masculine, such as driving tractors and fixing cars. Civic leaders and program administrators who were raised in Appalachia shared pride in being from a naturally beautiful area with tight-knit communities, but they spoke extensively of how stereotypes negatively affected them, especially in terms of economic opportunity. Similar to outsiders, many Appalachians held ambiguous feelings toward the region. [End Page 375]

The ambiguity in regions that are othered may be seen as threatening and thus elicit discrimination. There is a tendency in the United States to blame individuals for their poverty and poor health outcomes.⁹ For example, the "culture of poverty" model was first used to attack Black families and communities in the Moynihan Report.¹⁰ It has since been applied to Appalachia and ignores the structural factors behind social issues such as overdose deaths and homelessness.¹¹ Individuals, families, and communities are instead pathologized and blamed for causing poor outcomes.¹² Appalachians are framed as particularly diseased, whether from parasitic infections, tooth decay, or mental health crises.¹³ A mix of individualism, classism, and Appalachian exoticism have created a "geography of blame" around the region. Appalachians are blamed for their own suffering, and accused of starting the opioid epidemic, which has spilled into the entire country.¹⁴

That blame was evident in my interviews. People from outside the region avoided being identified as Appalachian, one woman saying that she could not be Appalachian, because she "liked to work."¹⁵ [End Page 376] A mental health and substance-use disorder treatment provider from the Midwest blamed substance-use disorder on the inherent boredom of living in Appalachia. Local leaders bemoaned poverty, which they saw as unique and unconnected to structural forces. When I asked a local politician about living in Appalachia, she argued that her county was not Appalachian, because Appalachia is "uneducated" and has "a lot of drug abuse."¹⁶ While this Appalachian blame is displayed in national and local discourse, blame is both targeted towards specific communities within the region and tempered by racial privilege.

Appalachian Whiteness and the War on Drugs

Part of the existence of Appalachia as a culturally othered region originates in the racialization of white Appalachians as "pure whites" in the late-nineteenth century who became not quite white enough in the twentieth century.¹⁷ The first charitable missions into the region at the turn of the century were based on the idea that white Appalachians were one of the few white groups in the United States to be free from procreation with non-whites, and thus they were alleged to have "superior" racial stock. Yet white Appalachians were framed as needing saving from outsiders because they had developed a "degraded" and impoverished culture compared to elite whites in the urban United States.¹⁸ [End Page 377]

This framing of Appalachian whiteness has affected regional implementation of the War on Drugs in several ways. First, politicians and policy makers are softer towards drug use associated with white communities as compared to use associated with Black communities. There is more talk of substance-use disorder treatment, drug take backs, and naloxone distribution to whites than purely punitive efforts.¹⁹ Despite this, incarceration remains heavily used in Appalachian counties that are majority non-Latino white.²⁰ It is evident in speaking with judges and substance-use disorder treatment administrators that they think white Appalachians who use drugs, perhaps because of their racial privilege, are eligible for treatment, but because of discrimination based on drug use, class, and place, Appalachians who use drugs are only seen as eligible for coerced treatment within detention facilities or under court supervision. For instance, drug courts, where individuals with drug charges are mandated substance-use disorder treatment in lieu of incarceration, are touted as a silver bullet solution to substance-use in Appalachia and across the United States.²¹ Coercive substance-use disorder treatment is used to justify high incarceration rates.²² This link between incarceration and the provision of substance-use disorder treatment is not new, and was championed at the Kentucky-based Lexington Narcotics Farm. The Narcotics Farm was opened in 1935 as a joint venture between the United States Bureau of Prisons and the Public Health Service and aimed for programming that was therapeutic, rehabilitative, and punitive.²³ [End Page 378]

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Patients supervised by staff at the Lexington Narcotics Farm in Lexington, Kentucky, ca. 1960. Image courtesy Lexington Narcotics Farm Collection, MSS 222, Kentucky Historical Society.

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Patient in a cell at the Lexington Narcotics Farm, which served as both a prison and treatment facility, ca. 1960. Image courtesy Lexington Narcotics Farm Collection, MSS 222, Kentucky Historical Society.

[End Page 379]

Prison building has boomed in Appalachia for over three decades. Much like land speculation, coal extraction, and other capitalist enterprises, prisons are billed as economic development for Appalachia, despite their negative effects on local ecologies, economies, and communities.²⁴ By building prisons in Appalachian states or counties, state and federal governments may claim they are investing in economic development in the mountains, while simultaneously shipping poor, Black, and Latino people out of urban areas to Appalachian prisons. Proponents of prison building play on racial fears to promote incarceration.²⁵

Working within prisons further amplifies racist beliefs, as shown in the stories of two Appalachian counties. I spoke with a longtime substance-use disorder treatment provider who had worked in the community and within several state prisons in their county. The state prisons primarily held Black inmates, while the majority of corrections officers were white Appalachians. She said these racial disparities "set the prisons up for disaster" from the beginning.²⁶ Racism within the system was abundant. The warden displayed a large Confederate flag over his desk. Corrections officers used racial epithets toward Black inmates and white inmates who were seen as being too friendly with Black inmates. Spanish-speaking prisoners were sent to fill vacant prison beds, despite there being no Spanish-speaking corrections officers. A subsequent investigation revealed that tasers were overused on these inmates. The treatment provider I interviewed detailed the deaths of several men who were refused medical care or beaten to death by corrections officers. [End Page 380]

While the prisons were obviously brutal to those incarcerated, employees also reported negative social and health outcomes. Corrections officers described working in the prisons as "war zones." The prisons hired young people, offered them little training, and installed them in a racist system. Once they had worked for some time, my interviewee saw them become virulently racist. Even divorce rates increased in the county. My interviewee recounted speaking with a corrections officer about substance-use among the staff. She said, "The first thing they did with anybody who had any experience in the prison would say to them, get a drug prescription right away. Because you're not going to be able to handle the stress without some drugs."²⁷ They recommended benzodiazepines for anxiety. Corrections officers increasingly sought the help of my interviewee to address their own substance-use disorder.

Knowing these negative effects, white Appalachians and families of Black prisoners from northern states built a coalition to improve conditions in the prisons. While attempts to change conditions within the prison have been limited, there have been some successes. For example, they worked together to provide transportation to the families so they could visit their incarcerated loved ones. This coalition also assisted activists in a nearby county to prevent the construction of a federal prison atop a mountaintop removal site.

In another central Appalachian county, locals mourned the closure of a private prison. The prison had been the largest employer in the county, resulting in the loss of over three hundred jobs when it closed. The prison did not house any inmates from Kentucky. Instead, it had contracted to imprison over eight hundred inmates from other states. City and county officials felt devastated by the loss of the prison. The county seat lost a quarter of a million in city revenue, which limited the city's ability to maintain water and sewer services. Enrollment in county schools plummeted, resulting in fewer state dollars. Community members expressed anger at a planned prison building project [End Page 381] in a neighboring county, not out of moral concerns, but because they wanted the prison jobs to remain in their own county. Even women I spoke with who used drugs and described the inhumanity of incarceration saw the prison closure as a loss. One woman, who had been previously incarcerated, said, "They hired a lot of people in a small town like this where there ain't jobs."²⁸ Another formerly incarcerated woman wondered about the county's future after the prison closure, "What is here for the children?"²⁹

Gendered "Otherness"

Bodies that have the ability to become pregnant are politically contested.³⁰ Reproductive abilities are a site of cultural conflict in issues relating to bodily autonomy as well as imaginings of future generations. Some bodies are more contested than others and become sites of othering and blame, which is especially true for people of color and people who use drugs nationally.³¹ There is a long history of outside intervention into Appalachian women's fertility and parenting.³² For example, the Frontier Nursing Service was founded in [End Page 382]

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Frontier Nursing Service nurse monitoring a pregnant woman in Hyden, Kentucky, 1937. Image courtesy Mary Marvin Breckinridge Patterson Collection, Graphic 45, Kentucky Historical Society.

the 1920s to provide Appalachian women access to wanted services for maternal and child health. Yet the lines between medical care and moral crusading were blurred as only some women were deemed "worthy" of aid.³³ In the 2010s, individuals and policymakers blamed Appalachians who became pregnant and who used drugs for producing "damaged" generations.³⁴ [End Page 383]

Violations of bodily autonomy are inherent to the War on Drugs and intersect with violations of the bodily autonomy of people who may become pregnant. Policymakers and clinicians throughout Appalachia often portray pregnant people as nothing more than "incubators," a term one nurse in east Tennessee used to critique her hospital's policies that place heavy surveillance on patients who were known to have used drugs. An emergency medical technician (EMT) said the only time she broke consent for medical treatment was for pregnant people, because a pregnant person "isn't just one person, they're two." After a pregnant woman was in a minor traffic accident, this EMT forced the person to undergo a medical evaluation against their will.

Community-wide discrimination against pregnant people who use drugs is publicly displayed in Appalachia. Interstate billboards throughout Knoxville in the late 2010s from a coalition of national and local non-profit organizations proclaimed, "Your baby's life shouldn't begin with DETOX." Two tiny white baby feet held in a white hand, one foot wrapped in a monitor, accompanied the statement. This billboard shames parents whose neonates are substance-exposed and implies that all newborns who are substance-exposed will have negative health consequences. Not all neonates who are substance-exposed display symptoms and even those who do display symptoms do not always require treatment.³⁵ Less than 20 percent of cases of neonates displaying symptoms of substance-exposure in Tennessee are from only illicit substance-use; the majority (52.5 percent in 2016) of cases are from licitly prescribed medications.³⁶

Violations against the bodily autonomy of people who may become pregnant and people who use drugs have coalesced in programs that push long-acting reversible contraceptives (LARC) onto vulnerable [End Page 384] populations. The targeting of LARC towards poor people, people who use drugs, and people of color follows a history of eugenic involuntary sterilizations in Appalachia and the United States.³⁷ The control of people's reproduction via LARC is touted as the solution for poverty and low educational attainment.³⁸ In presentations about LARC provided to marginalized populations, misinformation about the effects of substance exposure on fetal, neonatal, and child health outcomes is used to coerce people to attain LARC. Since LARC generally requires a medical professional to be removed, a research study categorized LARC provided in these coercive formats as "soft sterilization," and as the most current form of involuntary sterilizations.

Pregnant people face punishment if they partake in certain behaviors that the state legislature and local organizations, such as children's services, have categorized as dangerous, but their bodily autonomy is also limited when they seek healthcare. One pregnant woman attending the syringe services program in Knoxville struggled to access wanted prenatal care. She lacked transportation and identification. Without identification, she could not access prenatal care or TennCare, the state's Medicaid program, at the county health department. She was referred to a social services non-profit to assist in obtaining identification, but she did not have a birth certificate from her home state of North Carolina. She was unable to receive prenatal care throughout her pregnancy.

Within regions that are othered, as shown in the activism against new prison building, there is room for ambiguity, for reaction against inequality, and for actions that push forward new possibilities.³⁹ For example, a coalition of activists fought Tennessee Senate Bill 1391, [End Page 385] which allowed for the prosecution of pregnant people on assault charges if they engaged in any unlawful act, including illicit substance-use, that knowingly or unknowingly caused harm to an embryo, fetus, or infant.⁴⁰ The bill went into effect, but was allowed to sunset, and recent reiterations of the bill have been successfully stopped.

Conclusion

The War on Drugs has most recently targeted opioids. National media sources and policy-makers have rooted increased opioid prescribing, use, and overdoses in Appalachia. Blame for the so-called "opioid epidemic" shrouds a region that has experienced hundreds of years of exploitation and stigma. Appalachia's erroneous portrayal as an all-white region has complicated its relationship to the War on Drugs. Appalachians who use drugs continue to be incarcerated or court supervised at high rates, but they are more likely to have access to substance-use disorder treatment in carceral settings as compared to people of color who used drugs during earlier periods of the War on Drugs. In the name of economic development, Appalachians have been offered unprecedented employment in these carceral settings. But this form of employment, much like other capitalist endeavors, is harmful to the worker, the community, and the environment. As blame is spread throughout the region, it is targeted in gendered ways, with parents, and mothers in particular, seen as particularly harmful to children and broader communities. Within an othered Appalachia full of ambiguity lies opportunity for both resistance against regressive policies and for building connections across different social positions to champion economic and social justice. [End Page 386]