HILLBILLY ELEGY

November 9, 2017


Hillbilly Elegy is without a doubt one of the best-written, most important books I have ever read.  A remarkably insightful account of J.D. Vance growing up in a significantly dysfunctional family but only realizing that fact as he became older and compared his family with others.  As you read this book, you realize it is a “major miracle” he escaped the continuing system of mental and physical abuse prevalent with poor, white, Eastern Kentucky “hillbilly” families.  When moving to Ohio, the abuse continued.  Even though financial conditions improved, conditions remained ingrained relative to family behavior.

 I grew up poor, in the Rust Belt, in an Ohio steel town that has been hemorrhaging jobs and hope for as long as I can remember.” That’s how J. D. Vance begins one of the saddest and most fascinating books, “Hillbilly Elegy:  A Memoir of a Family and Culture in Crisis. Published by Harper, this book has been on the NYT best seller list since its first publication and has rarely dipped below number ten on anyone’s list. Vance was born in Kentucky and raised by his grandparents, as a self-described “hillbilly,” in Middletown, Ohio, home of the once-mighty Armco Steel. His family struggled with poverty and domestic violence, of which he and his sister were victims. His mother was addicted to drugs—first to painkillers, then to heroin. Many of his neighbors were jobless and on welfare. Vance escaped their fate by joining the Marines after high school and serving in Iraq. Afterward, he attended Ohio State and Yale Law School, where he was mentored by Amy Chua, a law professor and tiger mom. He now lives in San Francisco, and works at Mithril Capital Management the investment firm helmed by Peter Thiel. It seems safe to say that Vance, who is now in his early thirties, has seen a wider swath of America than most people.  The life he has lived during his adolescent years is absolutely foreign to the life this writer has lived.  This makes the descriptive information in his book valuable and gives a glimpse into another way of life.

“Hillbilly Elegy” is a regional memoir about Vance’s Scots-Irish family, one of many who have lived and worked in Appalachia for generations. For perhaps a century, Vance explains, the region was on an upward trajectory. Family men worked as sharecroppers, then as coal miners, then as steelworkers; families inched their way toward prosperity, often moving north in pursuit of work.  Vance’s family moved about a hundred miles, from Kentucky to Ohio; like many families, they are “hillbilly transplants.” In mid-century Middletown, where Armco Steel built schools and parks along the Great Miami River, Vance’s grandparents were able to live a middle-class life, driving back to the hollers of Kentucky every weekend to visit relatives and friends. Many families, on a regular basis, sent money back to their relatives in Appalachian Kentucky for aid and support consequently “keeping their boat afloat”.

Middletown’s industrial jobs began to disappear in the seventies and eighties. Today, its main street is full of shuttered storefronts, and is a haven for drug dealers at night. Vance reports that, in 2014, more people died from drug overdoses than from natural causes in Butler County, where Middletown is located. Families are disintegrating: neighbors listen as kitchen-table squabbles escalate and come to blows, and single mothers raise the majority of children (Vance himself had fifteen “stepdads” while growing up). Although many people identify as religious, church attendance is at historic lows. High-school graduation rates are sinking, and few students go on to college. Columbus, Ohio, one of the fastest-growing cities in America, is just ninety minutes’ drive from Middletown, but the distance feels unbridgeable. Vance uses the psychological term “learned helplessness” to describe the resignation of his peers, many of whom have given up on the idea of upward mobility in a region that they see as permanently left behind. Writing in a higher register, he says that there is something “almost spiritual about the cynicism” in his home town.

Mr. Vance mentions Martin Seligman as being one psychologist that aids his efforts in understanding the “mechanics” of his family life. Commonly known as the founder of Positive Psychology, Martin Seligman is a leading authority in the fields of Positive Psychology, resilience, learned helplessness, depression, optimism and pessimism. He is also a recognized authority on interventions that prevent depression, and build strengths and well-being.

Learned helplessness, in psychology, a mental state in which an organism forced to bear aversive stimuli, or stimuli that are painful or otherwise unpleasant, becomes unable or unwilling to avoid subsequent encounters with those stimuli, even if they are “escapable,” presumably because it has learned that it cannot.  This describes the culture that Mr. Vance grew up in and the culture he desperately had tried to escape—helplessness.

Vance makes the proper decision when he enlists in the Marine Corps for four (4) years.  This action took place after high school graduation.  Just graduating from high school is remarkable.  The Marine Corps instilled in Vance a spirit in which just about anything is possible including enrolling and completing study at Ohio State University and then going on to Yale Law School.  He escapes his environment but has difficulty in escaping his lack of understanding of how the world works.  There are several chapters in his book that give a vivid description of those social necessities he lacks. “You can take the boy out of Kentucky but you can’t take Kentucky out of the boy”.  This is one of my favorite quotes from the book and Vance lives that quote but works diligently to make course corrections as he progresses through Yale and beyond.

In my opinion, this is a “must-read” book. As a matter of fact, it should be read more than once to fully understand the details presented.  READ THIS BOOK.

Advertisements

The publication EfficientGov indicates the following: “The opioid crisis is creating a workforce epidemic leading to labor shortage and workplace safety and performance challenges.”

Opioid-related deaths have reached an all-time high in the United States. More than 47,000 people died in 2014, and the numbers are rising. The Centers for Disease Control and Prevention this month released prescribing guidelines to help primary care physicians safely treat chronic pain while reducing opioid dependency and abuse. Given that the guidelines are not binding, how will the CDC and the Department of Health and Human Services make sure they make a difference? What can payers and providers do to encourage a countrywide culture shift?

The opioid epidemic is also having widespread effects on many industries relative to labor shortages, workplace safety and worker performance.  Managers and owners are trying to figure out methods to deal with drug-addicted workers and job applicants.  HR managers cite the opioid crisis as one of their biggest challenges. Applicants are unwilling or unable to pass drug tests, employees are increasingly showing signs of addiction on the job and there are workers with opioid prescriptions having significant performance problems.

Let’s take a very quick look at only three employers and what they say about the crisis.

  • Clyde McClellan used to require a drug test before people could work at his Ohio pottery company, which produces 2,500 hand-cast coffee mugs a day for Starbucks and others. Now, he skips the tests and finds it more efficient to flat-out ask applicants: “What are you on?”
  • At Homer Laughlin China, a company that makes a colorful line of dishware known as Fiesta and employs 850 at a sprawling complex in Newell, W.V., up to half of applicants either fail or refuse to take mandatory pre-employment drug screens, said company president Liz McIlvain. “The drugs are so cheap and they’re so easily accessible,” McIlvain, a fourth-generation owner of the company, said. “We have a horrible problem here.”
  • “That is really the battlefield for us right now,” said Markus Dietrich,global manager of employee assistance and work-life services at chemical giant DuPont, which employs 46,000 worldwide.

As you might suspect, the epidemic is having a devastating effect on companies — large and small — and their ability to stay competitive. Managers and owners across the country are at a loss in how to deal with addicted workers and potential workers, calling the issue one of the biggest problems they face. Applicants are increasingly unwilling or unable to pass drug tests; then there are those who pass only to show signs of addiction once employed. Even more confounding: how to respond to employees who have a legitimate prescription for opioids but whose performance slips.  There are those individuals who have a need for pain-killers and to deny them would be difficult, but how do you deal with this if you are a manager and fear issues and potential law suites when there is over use?

The issue is amplifying labor shortages in industries like trucking, which has had difficulty for the last six (6) years finding qualified workers and drivers.  It is also pushing employers to broaden their job searches, recruiting people from greater distances when roles can’t be filled with local workers. At stake is not only safety and productivity within companies — but the need for humans altogether, with some manufacturers claiming opioids force them to automate work faster.

One corporate manager said: “You’re going to see manufacturing jobs slowly going away for, if nothing else, that reason alone.   “It’s getting worse, not better.”

Economists have noticed also. In Congressional testimony earlier this month, Federal Reserve chair Janet Yellen related opioid use to a decline in the labor participation rate. The past three Fed surveys on the economy, known as the Beige Book, explicitly mentioned employers’ struggles in finding applicants to pass drug tests as a barrier to hiring. The surveys, snapshots of economic conditions in the Fed’s twelve (12) districts, don’t mention the type of drugs used.   A Congressional hearing in June of this year focused on opioids and their economic consequences, Ohio attorney general Mike DeWine estimated that forty (40) percent of applicants in the state either failed or refused a drug test. This prevents people from operating machinery, driving a truck or getting a job managing a McDonald’s, he said.

OK, what should a manufacturer do to lessen or hopefully eliminate the problem?  There have been put forth several suggestions, as follows:

Policy Option 1: Medical Education– Opioid education is crucial at all levels, from medical school and residency, through continuing education; and must involve primary care, specialists, mental health providers, pharmacies, emergency departments, clinics and patients. The push to increase opioid education must come from medical schools, academic medical centers, accrediting organizations and possibly state legislatures.

Policy Option 2: Continuing Medical Education– Emphasize the importance of continuing medical education (CME) for practicing physicians. CME can be strengthened by incorporating the new CDC guidelines, and physicians should learn when and how to safely prescribe these drugs and how to handle patients with drug-seeking behavior.

Policy Option 3: Public Education– Emphasize the need to address patient demand, not just physician supply, for opioids. It compared the necessary education to the campaign to reduce demand for antibiotics. The public needs to learn about the harms as well as the benefits of these powerful painkillers, and patients must understand that their pain can be treated with less-dangerous medications, or nonpharmacological interventions like physical therapy or acupuncture. Such education could be spearheaded by various physician associations and advocacy groups, with support from government agencies and officials at HHS and elsewhere.

Policy Option 4: Removing Perverse Incentives and Payment Barriers– Prescribing decisions are influenced by patient satisfaction surveys and insurance reimbursement practices, participants said. Patient satisfaction surveys are perceived — not necessarily accurately — as making it harder for physicians to say “no” to patients who are seeking opioids. Long-standing insurance practices, such as allowing only one pain prescription to be filled a month, are also encouraging doctors to prescribe more pills than a patient is likely to need — adding to the risk of overuse, as well as chance of theft, sale or other diversion of leftover drugs.

Policy Option 5: Solutions through Technology– Prescription Drug Monitoring Programs (PDMP) and Electronic Health Records (EHR) could be important tools in preventing opioid addiction, but several barriers stand in the way. The PDMP data are incomplete; for instance, a physician in Washington, D.C., can’t see whether a patient is also obtaining drugs in Maryland or Virginia. The records are not user friendly; and they need to be integrated into EHRs so doctors can access them both — without additional costs piled on by the vendors. It could be helpful if certain guidelines, like defaults for dosing and prescribing, were baked into the electronic records.

Policy Option 6: Access to addiction treatment and reducing stigma—There is a need to change how the country thinks about — and talks about — addiction and mental illness. Substance abuse treatment suffers when people with addiction are treated as criminals or deviants. Instead, substance abuse disorder should be treated as an illness, participants recommended. High deductibles in health plans, including Obamacare exchange plans, create another barrier to substance abuse treatment.

CONCLUSIONS:  I don’t really know how we got here but we are a country with a very very “deep bench”.  We know how to do things, so let’s put all of our resources together to solve this very troublesome problem.

%d bloggers like this: