American Overdose by Chris McGreal; Heartland by Sarah Smarsh – review

Books examining the US’s opioid crisis and its neglect of so-called ‘white trash’ reveal the extent of class prejudice in an increasingly divided country

Our enduring fascination with America is born of a mixture of vanity and self-interest. As we turn up our noses at its vulgarities – the Louis Theroux world of guns, religious fundamentalism, and the mountebank President Trump – we also defer to its political and popular cultural might.

It’s to America that academics and pundits look for news from the future. But it’s not the first place that jumps to mind when we think about the working class. That’s changed a bit in the Trump era, with many blue-collar voters rallying to his cause. But the conditions of the working poor are not widely understood or appreciated

Two new books may help shift that perception. American Overdose is written by the veteran Guardian foreign reporter Chris McGreal. It’s a detailed and compelling account of the spread of opioid addiction across the so-called rust belt, said to be the deadliest drug epidemic in American history. US consumers, writes McGreal, account for 80% of the world’s opioid painkillers.

The book focuses largely on West Virginia, in particular the town of Williamson. It has a population of 3,191 , but earlier this year it was announced that just two of its pharmacies had dispensed more than 20m prescription painkillers in the course of a decade. That’s roughly 6,500 pills per resident.

How those astonishing figures came to be is a complex story of corrupt doctors, poor drug regulation, mendacious big pharma, ruthless marketing and a depressed and alienated working class, largely white and, certainly by their own lights, politically and socially neglected. It’s a tale littered with deaths, suicides, familial destruction and homelessness, and it starts, as with so many tragedies, with good intentions.

For many years there had been a prohibition on morphine in the US (and in the UK), which, doctors protested, prevented terminally ill cancer patients from receiving pain-free palliative care. But what might work for someone in the last weeks of their life isn’t necessarily appropriate for ongoing pain management for chronic conditions. However, owing to aggressive proselytising by several influential doctors, some of whom were later employed by the pharmacological industry, restrictions on opioids were lifted for both the terminally and the chronically ill.

That’s when a former undertaker, gay escort and fraudster called Henry Vinson latched on to a commercial opportunity. He rented a warehouse in Williamson, hired several unscrupulous doctors, and began dispensing huge quantities of opioids, in particular OxyContin, a slow-release and extremely powerful drug. OxyContin was produced by Purdue Pharma – which misled the public over the drug’s addictive qualities – and it made billions of dollars. The company has since been the subject of multiple law suits.

In many ways, McGreal’s book reads like a white-collar The Wire, with a cast of characters determined to exact as much money as possible regardless of the human cost.

That the large majority of its victims were white was not due to any kind of racial targeting; but that they hailed disproportionately from the impoverished towns of Appalachia, where OxyContin was known as “hillbilly heroin”, does account for why so little interest was taken in their plight by the authorities.

These are the people, as Sarah Smarsh writes in Heartland, who are often referred to as “white trash”, the American version of “chavs”, that underclass whose suffering, because it’s not the result of racism, and because it can often breed racism, does not fit into the modern rubric of worthy causes.

Smarsh writes: “If a person could go to work every day and still not be able to pay the bills and the reason wasn’t racism, what less articulated problem was afoot?”

trailer park
The labelling of poor white Americans as ‘trailer trash’ is interrogated by Sarah Smarsh in Heartland. Photograph: Getty Images

Smarsh is from Kansas, and grew up in a family built on a long line of single mothers. She and the people she knew as a teenager – the kinds of people casually consigned to the designation “trailer park” – lived lives that felt cut off from the successful version of America, “distasteful” to a middle class that was embarrassed by the economic failings of people from “their own race”. As she puts it: “The middle-class-white stories we read in the news and saw in movies might as well have taken place on Mars.”

It’s a good premise for the examination of a prejudice – class – that dare not speak its name in America, and increasingly in the UK. But Smarsh’s book never coheres into either a vivid memoir or a damning indictment of America’s growing social divisions. It tries to do both without fully achieving either.

The problem is partly because Smarsh, now an academic and journalist, adopts a sentimental structure of addressing the book to the daughter she might easily have had (but didn’t) as a teenager. And it’s partly because the story’s terrain – poor girl works hard and makes good – is dense with cliches, many of which Smarsh doesn’t make enough effort to avoid.

There’s a self-romanticising element to the prose that can read like a Bruce Springsteen lyric – all Chevy Caprices and wide-open highways – and men tend to be characterised as either women-beating thugs or salt-of-the-earth heroes. Perhaps because she’s theoretically talking to a nonexistent young daughter, she is also prone to simplistic analysis, such as: “Economic inequality is one cultural divide that causes us to see one another as stereotypes, some of which allow the powerful to make harmful decisions in policy and politics.”

However, she makes a strong case that it’s both wrong and counterproductive to dismiss the white working class of America’s heartlands as Trump-supporting deplorables.

If American progressives really want to fight populism, the battlefront is not going to be Brooklyn coffee bars or campus safe-spaces. Liberal America is going to have to look to the country’s interior and re-engage that large stratum of society that feels – because it has been – left behind.

• American Overdose by Chris McGreal is published by Guardian Faber (£12.99). To order a copy for £9.99 go to or call 0330 333 6846. Free UK p&p over £10, online orders only. Phone orders min p&p of £1.99

• Heartland by Sarah Smarsh is published by Scribe (£14.99). To order a copy for £13.19 go to or call 0330 333 6846. Free UK p&p over £10, online orders only. Phone orders min p&p of £1.99


Andrew Anthony

The GuardianTramp

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