Episode 117 - The Prescription to Prison Pipeline with Michelle Smirnova

Welcome to episode 117 of the Infectious Historians Podcast. I'm Merle and I'm Lee. It's October 9th, 2023. In today's episode, we're going to discuss how America responds to illness and sickness through prescription drugs, particularly, and the impact that has on people's health, along with the problems this causes that end up with people arrested and in jail. Our guest today returns to our podcast from a long hiatus, we might say, Michelle Smirnovum. She's an Associate Professor of Sociology at the University of Missouri, Kansas City, and the author of the book just released earlier this year from Duke University Press with the title Prescription to Prison Pipeline, an intersectional analysis of the medicalization and criminalization of pain. Michelle has published on a wide variety of other topics, such as women's aging, authenticity and ethics in her personal favorite Russian humor during the Soviet Union. Her next book will be on citizen scientists engaging with institutional and cultural gatekeepers, and finally Michelle has also engaged in participatory research alongside Kansas City tenants, a grassroots movement, and citywide tenant union fighting for safe, accessible and truly affordable housing for all, which is obviously a great cause. So hi, Michelle, and welcome back on the podcast. Hi, thanks for having me. So Michelle, and I checked this earlier today before we started recording, was actually on episode 6 of this podcast, way back in April 2020, so a very different world for both personal and COVID-related reasons, I think, for many of us. We discussed with us actually inequalities during the COVID pandemic in the US, which were based around the US health care system, and the Trump administration's failed response to the pandemic. Now, this is hard to remember if you think back to that time, but Lee and I had Michelle and actually my former colleague, Future Hoover, on the podcast back-to-back to discuss these questions of inequality early in COVID. And there was actually a time when, if you recall, Lee, that there were many, many op-eds from actually historians, among others, talking about how like diseases of the past, COVID would level income inequality. Now this was clearly not the case, but I would like to think Lee that if you and I are ever any good at predicting the future, we were actually ahead of the wave of economic inequality and social inequality and all these types of things that did come from the COVID pandemic. But in any case, Michelle's new book just came out, and I thought it was an ideal time to have her back on to discuss what does often pop into the news about disease, the so-called war on drugs, and the opioid crisis. Now these are not infectious diseases, obviously, as this podcast typically focuses on, but diseases of what have been called "the age of degenerative and man-made diseases" from a famous article from the 1970s. And these have become more obvious and more apparent in at least the last half century, and I should say in the United States and perhaps the rest of the world. Right, a lot happened since 111 episodes of infectious historians. And I think, Murold, to follow up on your point, that being ahead of the curve back then and was, I guess, like April 2020 or something, thinking about our own trajectory of how this podcast and our thinking on these topics has developed, I think, focusing on inequality so quickly early on during the pandemic allowed us to make this recurring theme in subsequent episodes and thinking, and at least on my side, I'm guessing on your side as well, Murold, and our teaching last year, I guess. I'm glad to have Michelle back and both see the new book and think about how things ended up on her project. And maybe to finalize, yeah, I agree with you as well on this, Murold, that the podcast is in a sense about infectious diseases, but since the beginning, we really had these side project or many arcs or like different themes that are not entirely related to infectious diseases, but I think do illuminate different aspects with different social aspects, different connections that are definitely worthwhile and influence our thinking just the same. Yeah, it's also one other point is I haven't heard the term, believe, many arcs in a long time that was like I go to phrase early on in this podcast and it's nice to know it can return, you know, like the Jedi. But in any case, Lee, I wanted to start today by checking in with you and maybe if you're willing to discuss your family and friends back in Israel and probably an extended segment. We should say these episodes as our listeners are almost certainly aware, take us some time to produce. Whatever Lee says with us is as of Monday, October 9th in the early afternoon of the United States, so by the time you listen, I imagine things are quite different. But Lee, maybe you want to share some thoughts? Yeah, so maybe I'll start with a disclaimer that yes, this is still developing event, things are still going to change, whatever I say now is going to sound completely outdated based on the fact that the things I said two days ago are already completely outdated. So that is one disclaimer. I'm very fortunate to say that both my friends, family, extended family, I mean, everyone is safe. Some people were closer to events, other people were further away from events, but everyone is physically safe. But I think more broadly, it's a difficult situation. And I think the comparison I had before I came on this episode to discuss this event right now was our episode that we had, I think right after the January 6th event, Merle, which I mean, that was like very raw for you back then. And I think both of these events, we recorded either immediately after or kind of during the event and these were rapid events that were important and influential and have shifted our shifting the ways in which we think about our place in the world and whatever is going on around us. So all this is to say, maybe that's the background, and I'm sure that people will know much more than I do right now when they listen to this. But at least as of now, I can say, as in October 9th, I can say that the situation is difficult both politically and militarily, both of it's surprisingly so. So I don't think people almost anyone expected this over there in Israel does also cultural issues of what exactly happens now partially because what I see as pretty substantial parts of the Israeli ethos have either been shattered or are in serious risk of shattering are very vulnerable right now. And obviously psychologically for everyone involved actually on both sides, there's a lot of uncertainty and nobody really knows what's going to happen. Hello, we do have our thoughts about what might happen. And maybe on a personal note, I will say that even though I am, I guess fortunate to be here in the United States as all this is happening back in Israel, it's also difficult to be far away from all this right from all the friends and family and people I know love care about over there. So that's on one hand at the other hand, I mean, I have friends there who just tell me that I mean, it wouldn't have mattered if I were there anyway, right? It's not as if I would come and save anyone or do something that would matter all that much. So I'll just chime in to say Lee, I'm glad to hear that your friends and family are all safe. And that's very good news on a personal level and obviously more broadly, yeah, that's not surprising that you feel that way in terms of you not being there in some ways wishing you could be there. And the last thing I'll say is one thing that I do, you know, think that this podcast is very useful, and we usually joke about it, these are our kids is that we do have these moments in time of you and I frozen, I guess for as long as the internet exists for all eternity on our reactions. And I should probably go back and listen to the post January 6th one now, but I do remember I think it's the only time I cursed on this podcast about the then president and I think the guest we had on at the time was extraordinarily shocked. That is true, yeah, I think that was like the most profane this podcast has been so far. Yeah, so in a sense, at least for this podcast, I'm putting aside your direct impact, it is useful for us to have a moment in time that we now can reflect upon, you know, and I wish everyone on however side that everyone stays happy and healthy and this thing comes quickly to a close, whatever this thing is when people listen to this in several weeks. Yeah, thanks so much, Marl, and I do hope things calm down as quickly as possible. And what about you, Marl? How are you doing? Hopefully, not as bad. So I will stay on a very light note in contrast to you Lee and a very Oklahoma note as well, which is to say that my older sister and her family were just out here visiting, they just left this morning very early. So they were here for three full days and I'll say two things, one is that it was great to see cousins play with each other because her kids are 10 and 7 and my kids are 6 and so it's a very nice age range in which they can all play together and they play catch. They go to the playground, they play with various toys, that was very nice. But then the other thing that was very funny is my sister wanted to do very Oklahoma things. And so we went to a giant overpriced pumpkin patch, which is more of like a game thing. Although there was a lot of fun stuff there. So there was actually an amazing corn maze, which I had never been into like an actual good corn maze before. And there was zip lines and there was, you know, all these things like that. And then the other thing we went to yesterday actually was she wanted to go to a horse show at the fairgrounds in Oklahoma City. So we went to a horse show where we saw different styles of people dressed in funny outfits, parading horses and getting judged for horses. I, of course, because thinking about inequality was asking, how does anyone afford these things because they give out ribbons that I'm going to assume the ribbons aren't tied with money. So it was very interesting to learn or to think about, I guess I should say, the economy of taking your horse from northern Vermont and entering a contest in Oklahoma and how much that would cost you just to do that. So Merle, this is your sister from New York City, right? Yeah, my sister lives in New York City. And how much of a culture shock was it for her and her family? Well, I can't answer that because I'm not her. But what I would say is, if you think about it, and I don't know maybe we can get to Michelle's thoughts on this as well, I live in Oklahoma City, which is a big city that has very gentrified areas, very poor areas, very yuppie areas, you know, very developed areas. So in some ways, a city is a city, you know, with different flavors. I think I've been to Kansas City, so it has a different flavor than Oklahoma City. In Oklahoma City is very different in the sense that it's just vast amounts of space. And so it's different in that sense. But, you know, can you like we did go and get a really nice bowl of fuff for dinner? Yeah, you can do that, right? So there's differences, but I think, you know, she would probably say it's super different in my perspective. You know, we live in this kind of metro enclave. If we drove 20 miles north, then you would see that we're literally just in the prairie. And there's little things that you will always notice. So for example, leave, if you ever come to Oklahoma, right? The dirt is literally red. It's not brown. And so you're like, what the fuck is this dirt red for? Or you're like, where are all the trees? Because there's no trees because we're on the prairie. What's the color of the roads? Is it like standard black? Because in South Dakota, I remember they were purple. I mean, as far as I'm concerned, also roads are normal color. I've never heard purple roads. Okay, have fun in the Dakota. This is all I can say to you. And you, Michelle, how are you? Has Kansas City going? Going well, I would say the same in terms of suburbs are similar. Cities are similar that I think it is the way that we characterize the coasts as being different than the flyover country. And this is part of what I'm writing about now with my work with Casey Tennant talking about gentrification and issues of housing and all the attention is to places like San Francisco and Washington DC. But Kansas City is dealing with a lot of these similar problems. People often terminus slumification rather than gentrification that these homes are increasingly uninhabitable. But anyways, all that is to say is that I think people have these notions of what these places are that they haven't been to. And it reflects what has more media coverage than others. And if you actually visit the place, people are often very surprised by how hilly Kansas City is. People imagine it to be very rural and flat. And it is actually very urban and not flat. So all of the same that moral is describing. And you're in the midst of the semester. Are you surviving or are you thriving or are you flailing? Well, I have a 10 month old and a two and a half year old. So I am treading water backwards and trying not to let any of the rotoviruses or noroviruses or any of the other infectious diseases keep me from finishing the semester. So if we make it to the end of the semester, it's success. Are you still getting sick everyone's in a while? Remove the every once in a while part. And correct. We are paying the daycare tax very heavily this season. I mean, we don't have daycare. Yeah, well, I've been there. It's passes at some point. That's what they say. It's supposed to get better. It's supposed to emphasis. So I guess at this point, we can move on to the interview itself. So Michelle, I mean, your book discusses medicalization. So maybe a good place to start as we usually do would actually kind of try to unpack that. What exactly do you mean by medicalization? Absolutely. I think it's a great place to start. So medicalization broadly refers to the process by which non-medical problems become medical problems and that they're treated by doctors, medical technologies, and healthcare systems, including prescription drugs, which the book is about. And we often think that more medicine, more science is necessarily better. This is a sign of our advancement, but there's often an underside to these issues. Can I ask a random question that comes up mostly for my own teaching, which is you must teach some of this stuff as well. How do you get at telling students that, you know, you can get out of this narrative of, yay, we have modern medicine and things are wonderful now, right? Because that's the mentality they approach things with, right? Pop to Advil, and I'm fine. How do you explain that like, you know, all medicine isn't good medicine? Absolutely. So I mean, I think it's very hard for students to understand at times. I talk a lot about ideologies and hegemonic ideologies and comparison of medicine and science to religion and that's hard for them to understand because they think, well, religion was replaced by science and medicine. And I talk about how it becomes difficult for us to think outside of these ways of thinking that more medicine is necessarily better or that there was an objective truth that we can be discovered through the scientific method. And I often talk a lot about bias in my class and see sort of things. So it's often challenging for students to understand, but I approach it always through sort of rich examples of how we get at that. So maybe you can give us some examples of medicalization that we can, you know, use and share, right? Absolutely. And I think one that resonates strongly with students is talking about attention deficit disorder. And this is something that we've seen a large increase in the diagnosis of ADD or ADHD, attention deficit hyperactivity disorder. And so these are often diagnoses that are used for children who have trouble focusing or learning in traditional settings. And this really focuses on the individual that there's something wrong with this kid or the student without focusing on the structures, without focusing on the educational system and schools and classroom settings and how they're often not designed to meet the needs of diverse students who learn in diverse ways. And so treating individual students as though they are the problem and you need to treat this through medication as opposed to changing the structures and the design is one example of we see how there's an issue here absolutely. But the medicalizing the problem implies that there is one solution versus identifying it as a structural problem leads us to a different solution. As I'm listening to you speak, I mean, the way you define and spoke about medicalization seems to me to be very close to questions that would come up in science technology studies, right? So STS. So are you working with that literature or like separate from that literature? I mean, where exactly do you position yourself? No, absolutely. This is definitely building on an STS literature. And so it's trying to understand what are the origins of these different technologies and how they are used. But also how do they maybe position as remedying harms? But how do they exacerbate and reproduce harms that exist already? And so another example of meditization I often use in classrooms is about childbirth. Before recent times, about 99% of childbirth occurred outside of hospital settings. And today's the inverse. And on the face of it, it sounds like this is a positive that we have access to these technologies that are going to help parents and children. But those interventions in hospital settings can often produce greater harms for both the people giving birth and for the children themselves. One of those things is the increase in cesarean sections. While the World Health Organization says 10 to 15% of births should end in cesarean section, the United States has over double this rate. And cesarean sections, their life saving technologies and interventions, and they're important in certain cases. But they're also serious surgeries that can result in a lot of negative outcomes. And so it's sort of treating more technology and all technology as necessarily a positive as opposed to thinking critically about where and when and for whom. Maybe with that background that we can turn to some of the discussion of your book. Although you've given us I think a bunch of really good examples. And your book is provocatively or maybe better or literally entitled the prescription to prison pipeline, which makes us, I think, think about three things and three Ps and I assume spent you a while coming up with three Ps that would work in the title, which congratulations well done. But maybe we'll start with prescription here. And I assume you mean of a drug. So why does that wear this quote-unquote pipeline actually starts? Absolutely. And I think it's hard because I think it starts in a lot of different places. but the reason that I oriented the title and the book along these ways. is because in US many of our structural problems, such as poverty, racism, sexism, are increasingly medicalized, and that medicalization often is what results in a prescription. So kind of returning to this childbirth example, mothers are often medicalized for suffering from postpartum anxiety and depression, rather than focusing our attention on the lack of paid maternity leave, affordable child care, any of the structural supports that we need to raise kids. And so they're treated with the prescription pad. Here's the way we can fix this. We can write you a script for physical emotional pain. And that script is sort of masking these structural problems, and it can end up resulting in eventual incarceration, given if women continue to use and the doctors stop refilling their scripts, they turn to other medication that they're grappling with managing all of these challenges of raising kids potentially on their own and not providing the actual support and solutions that they need. So the problem as you describe it is inherently structural. And I mean, personally, as I was reading your book, I was particularly shocked to learn that, I mean, you quote there that the seven of 10 adults in the United States use prescription drugs on a daily basis. That's obviously an enormous amount. What are some of the repercussions of having so many drugs all over the place, having it maybe so easy to come by or to get a prescription? I'm assuming that the market is being flooded by all these drugs. And what does this do to society like the United States? Absolutely. So I mean, I think it's a shocking statistic because it shows just how ubiquitous these drugs are. And it initially sort of highlights its structure in a way that presents it as a problem. We have more drugs than we've ever had before. And it presumes that we must be sicker than we've ever been before. But yet we know the contrary is also true that people are living longer than they've ever lived before. And so the fact that we are using so many of these substances, I think is indicative of a number of things, first of which is in the corollary to medicalization in STS study, we often refer to as biomedicalization. And the biomedicalization refers to the ways that our lives are enhanced through medicine. So we don't always use medical technologies to treat ailments, but to enhance or extend our life in different ways. And so the ubiquity of these substances is not necessarily a sign of a sickness itself. But also the humans have a very long history of using all sorts of substances with medicinal properties. We talk about who gets to define what is a medicine and a drug. And that is very political and protects the use of some things over others. What's considered a vitamin or supplement versus a prescription drug, even those, all of those distinctions are very political distinctions and protect the use of some things or define certain things as benign or helpful and other things as harmful. I think in terms of consuming mind altering substances, psychotropics, things that change our experience of physical sensations or mental sensations, we also see the humans have a very long history of doing so. And it's this legislation that's criminalizing the use of this is also very political. It's about who has the right to use these substances and who doesn't have the right and who is going to be policed for using these substances. And so that's why it gets made about it's this particular substance. But really what that is distracting us from is it's who is the population that is using this substance or profiting from this substance that this is ultimately about? I was actually just about to ask you about this, right? So you mentioned several times about how this is a political decision and I agree. And my question was about to be what about the economic financial implications of all this, which you kind of touched upon in like, I think the next last word, right? So can you maybe say a bit more about that? Because I think at least from my perspective, there's been much more awareness towards that angle of big pharma making money off of all of this. So where do they fit? Is our general understanding of the problems in big pharma more or less correct? Or are we missing something or is there anything else we should know? I mean, I think absolutely, I think you are hitting at a number of these issues, but I was similarly talking about how I talked to my students about these issues that well, these drugs have passed clinical trials. They must necessarily be benign or helpful. And as we're seeing a lot of the journalism and research behind Purdue pharma and the secular family that if you have money, you can rig things in certain ways. You can present data in certain ways. And so I think it really reflects just how much power something has, if it can be prescribed by a doctor, that a doctor is different than a drug dealer. And that if it's backed by science and clinical trials and all of these things, but ultimately this is about who gets to profit from it. And we hear a lot of these conversations starting to bubble up or have already been in existence about marijuana. And marijuana was illegal in the United States for a long time, both the use and the sale. And now that it's increasingly decriminalized or legalized in certain settings, who gets to profit from it versus who is serving out sentences, whose lives and communities have been decimated when they were using our profiting from this. And so we see prescription drugs as really tied to whiteness and to class establishments about who are the populations that can designate this as this isn't a drug. This is a prescription. And so there's the power in the definition, but then also the power in the development, the sales, the profiting, all of the above. You mentioned some of the people profiting on it. And I was thinking the one time that I remember taking a painkiller was when I broke my collarbone playing rugby in college. And I was prescribed, I don't even remember some kind of drug that was probably an opioid. But this is before I think people were like, oh, maybe you shouldn't take those because they cause problems. And I guess in retrospect, I was lucky enough to not have a long-term problem. I took them that definitely made me kind of drool for a bit. But you know, I said a broken collarbone. So that was a discussion. But it brings up what is, you know, we hear about this all the time, the opioid epidemic. And I think there was a new Netflix show with, was it Matthew Broderick talking about one of the families and kind of the opioid pipeline, if I recall, which I've been meaning to watch. So is this an epidemic? I mean, why is it called an epidemic? And when did this start? And why is it ongoing, I guess? I want to start by addressing your experience and that this is the power of this narrative that is constructed of, well, you must have had a strong constituency that either you are not biologically predisposed to addiction or you had the moral fortitude to avoid addiction to this very addictive drug. But opioids are used for good reason. Like you break your collarbone. There's a reason that these are used in these medical settings that opioids have a lot of utility to people who are dealing with chronic pain and acute pain. The term epidemic, which I'm sure you talk quite a bit about on the podcast is this term that refers to infectious diseases, this thing from some external source. And I avoid using the term because I think it misdirects our attention from what's actually the problem. The term opioid epidemic implies that we're dealing with a new problem that's caused exclusively by opioids. And that opioids are exclusively harmful. But we know that opioids are not new. Opium as derived by opium poppies have been used for pain for long time. And it has been used by doctors for all sorts of ailments, respiratory ailments, diarrhea, in addition to dealing with acute pain. And so when we frame it as an opioid crisis or epidemic, it's this reductionist story that says that the drug is the problem, that we simply need to remove that substance and we're all cool in the carpool. But we need opium. We need opium in certain settings. It becomes a problem when people don't have those other structural supports that they need to survive to eat, be housed, take care of their families, etc. Okay, so I guess that covers like the first period of the title, right? The prescription. Let's move on to the second part, the prison part. Now, I mean, the opioid epidemic is one maybe term that's being thrown around for quite some time now. I think another term that is maybe even longer in discourse, at least I know it longer in discourse, is the war on drugs, right? Which has direct implications for the second part, the prison part of the title, right? So maybe we can start by asking why have we framed the problem we have with drugs, prescription drugs or drugs in general as a war, right? As this other metaphor. And since I personally haven't heard that that war is over by through victory or defeat or whatever, is that still the official or semi-official or term to use or has this just been sunset at some time without it telling anyone? You know, I think that we still see this term bubble up, it gets reframed in different ways, and we've heard the war on poverty, war on drugs, and I think this frame really justifies the type of money and resources that are used to this end that we can tell from her defense budget how much money is spent on wars. And so in this case, it justifies the spending billions of dollars to fight this elusive enemy that's as you rightly identified is never really identified or defeated. And so it kind of implies that well, it's a war on drugs. So the enemy is drugs, but as I alluded to earlier, the enemy is really the people who are constructed as using our profiting from those drugs. And I say constructed because in the reality, who is actually using our profiting, these substances is often very different than how the campaigns are waged. So absolute white people use substances that similar higher rates than poorer people of color, but the wars are waged against the latter rather than the former. And so I think this frame continues to persist and whether it's in that exact terminology or not given just how our resources are directed at protecting certain groups and criminalizing others. Is there a way to get rid of the war battle combat type metaphors or are we just stuck with that as Americans, no matter what, right? I go back to kind of how it was ingrained with me as a kid was McGrath the crime dog. Remember him is the guy who fights crime from the 80s. I still remember the ad slogan involvement Kim. You know, I think that as Americans, we are addicted to this good versus evil warfare imagery that we need things to be black and white. And it justifies these systems because sort of what I talk about in the book about the label of the addict becomes even more permanent than the label of the criminal. But it justifies the same way Michelle Alexander talks about in the new Jim Crow about justifying that we can't discriminate on the basis of race, but we can discriminate on the basis of someone's criminal history that it's justifiable because that's a bad person who did bad things. And we see the same thing with the addict language of well, that's a person who is deficient in their genetic makeup. And so we argue we've moved away from this moralistic idea of someone who just is unable to control their urges to it's a biological disorder. But this is the sort of biological essentialism that you're once an addict forever and addict that it's in your genes. And so I think the reason that this warfare imagery is so pernicious is because it constructs those people as those are our enemies those are the bad people over here. We need to protect things for the good people here. But once someone is labeled in this way, they are effectively part of the enemy and the outsider. And I think a lot of our policies are oriented in this way. And they mistreat our focus for good reason for what is the actual problem. The problem is the way these structures are designed. So trying to avoid like the good bad dichotomy that you mentioned a moment ago, as far as I understand, I mean these ideas have been critiqued by academics for quite some time, right. Are these realizations among academics have these translated into tangible policy yet or are we still like on discourse level and trying to say, oh you guys maybe this war on drugs is not a good idea. Maybe you can like use some of that funding to actually deal with the structural issues or as it's just like a case of people shouting at the wind. I think there are times when it has been effective. I think there's a lot of research when we talk about social determinants of health, but that's a term that increasingly more people are familiar with that what determines your health is all of these other things your access to housing to education to a safe environment where you're not being targeted by police. But protected by your community. So I think it is happening, but I think those two conversations are happening alongside each other. We talk about these crises over here. And we still need to direct more resources over here. And so the warfare element that how much money do we spend for defense versus how much do we spend on domestic spending. I'm referring to the US education and housing all these things. And so I think it speaks to the inequality in our spending. So I think we are increasingly seeing more spending on relating to structural racism and structural inequality more broadly and these sources, but it doesn't mean that that other type of spending and orientation of resources is getting any smaller. So can I follow up on that, I guess, and do you have ideas both because Lee and I are about to go through this ourselves and just broadly from having many conversations people mean how do we connect better, I guess the academic world with some of the policy makers and actual substantive changes on the ground. I mean, one flipping solution that came to mind, which probably as sociologist, you'll be a pulp by but is, you know, is the solution that we all just get Malcolm Gladwell to plagiarize our work. And so everyone reads it and then thinks it's new with a fancy label. And you know, he makes all the money. We make no money, but at least people actually read it and maybe change happens. I wouldn't say that's wrong. And I think with the work that you all are doing is important. And this is something the way that academics kind of shoot themselves in the foot that a lot of our systems are designed to not be open access. So we write these things into these very limited spaces that no one has access to. And so increasingly, I think people like grant foundations are seeking to fund research and support it to be open access. And we see the same thing with books, which is true for my book about it's very expensive to publish something as open access, but also if we don't do it in that way, then who is our audience. And so I think there is the piece of the Malcolm Gladwell, the poll towards Ted talks and sort of engaging in public academic work, who is your audience is your audience just other academics. Well, a lot of academics that probably agree on some of these issues. But if you're actually looking to make change involves in Casey tenants and some other activist organizations supporting mutual aid funds. So participating in our own communities in different ways that can be through political avenues, but also nonpolitical avenues. How is this work happening on the ground. And I think it's important as academics if we care about translation of this into our communities that we be involved in our communities. So Michelle, I mean, I guess this connects to one of the decisions that you made in your own book, right? I mean near the end of their book, you explicitly make it an advocacy appeal, right? To appeal to try to change reality around you through your writing, which from a story and perspective, at least that is not a stance, we usually take, I think, right? So maybe you could save it more about that. We actually haven't spoken about all the structural problems that you've identified in the book. So maybe without getting into too many details, what kind of solutions or what kind of approach to solutions, would you recommend in this case? I think I'll speak first to the issue you raise about historians. It seems like you're speaking about historians and not taking this advocacy appeal. And there is a similar divide in sociology or there was in terms of this sort of whether or not sociologists should take an active stance in their work. And I come from the perspective that everything we read is biased, everything that is produced, we all have bias. This is based on standpoint theory and intersectionality, this notion that all of us come with lived experiences. And so we're raised in class and gendered in different ways and all of those things are what draw our attention to our object of study in the first place. So we recognize that something is a problem because either we experienced it or somebody we know experience it and so we see it, we see it and we can name it as a problem. And so that is the beginning of our journey into research, Max Weber actually writes about this about your bias is going to figure into how you come to identify your research project. Then you want to engage in the research project in a way that is removing your bias so that it could be structured in a way that you could be surprised by your findings that you're not forcing certain conclusions along the way. But once you design a study in a way that someone else could do it and that they can draw inferences in different ways that once you then have your results and you analyze those results in your conclusions, your biases again are going to play in because we are operating in this world. And so what you write is going to have consequence and I don't teach textbooks in my class and I tell my students this is an explicit choice because I want them to be exposed to different perspectives and I want them to learn to recognize that everything they read has bias and to be able to identify that bias and analyze it and then synthesize it that we have a more holistic understanding of the world if we are really engaging with different perspectives and biases. So that's sort of just a long aside response to that first point about an advocacy appeal that I think that's also to me it feels like part of at least the way I understand my role as an academic that I have a lot of power and I have a lot of power to write and to be heard. And that there are a lot of marginalized folk who don't have that and that's part of what I attempt to do in my research, I tried to give voice and not supplant their voice in this colonial way, but to talk to people and to use their work. and elevate their words, because how they see this as an issue. And that's how this project actually came to be, talking to people who were incarcerated about their experience and what they saw were the problems. And what they saw were the problems were different than what the people who have come up with this language of opioid epidemics are saying is the problems. And they were telling me these stories about real pain, all sorts of hardship they've experienced, and the way they described using these prescription drugs were not different than the way people are using prescription drugs with the oversight of a doctor. And they're not different than the way that people drink a glass of wine when they come home from work. So in lots of ways, it made it evident to me that there's so much hype around this problem. And there are these real problems, but it's misdirecting our focus away from what are the actual problems. So I think that's part of the reason I take that approach. So Lee alluded to it in his question there where he said we haven't talked about structures, maybe we'll use the last part to talk about structures, which the obvious structure in the book's title is a pipeline, which I guess is a closed structure that guides you somewhere, which is probably the point of it being there. Maybe you can tell me that's the case. That's just me reading into your own thinking. So in the book you interviewed about 80 people in Missouri, which is where you live. So I would suggest that you probably know Missouri better than Lee and myself, just like I guess I know Oklahoma better than you at this point. But how does this pipeline get structured, created? And is it just, you know, throw some prescription drops, throw some more on drugs together and you get more people in prison or is it more kind of complicated than that? As we know, we try and come up with pithy titles and the Malcolm Gladwell effect of how do I get someone to pick this book up? And I did not want to be reductionist because exactly as you have identified that it's a lot more complicated than this and that there are a lot of different ways that people end up in this system. But I wanted to draw attention to this relationship between increasing medicalization or treatment of structural problems with individual solutions. So a prescription pad to deal with trauma and poverty and racism often does more harm and that harm can result in incarceration through a number of different avenues. So people continuing to use a substance which they were initially prescribed by a doctor, they lose access to healthcare, they continue using it, they are someone who is more surveyed by police officers in the first place, they end up being arrested, sentenced charged for all of those reasons, other people who end up using other substances, the gateway drug model. But also when drugs have nothing to do with it, that it's their dealing with these financial, political, social problems and that they are just someone who by virtue of being under this greater scrutiny by virtue of their race class, that they are more likely to be caught with a substance that ends up resulting in incarceration. Maybe as an attempt to kind of reflect on your answers to the last three or three questions, I mean, have you received any pushback against these ideas or the story that you're telling by any of the audiences or people who've heard the ideas from your book or read the book itself? I have not received personally pushback on the book or on findings from the book, but we do see just how powerful this narrative is about the problem with drugs and how they can derail people's lives, that people can often find examples of this in their life. And when they try and make sense of their life or make sense of this person's story, they can say, well, this person, everything seemed to be going well until they started using opioids or whatever drug. But if we actually prod and ask questions further, we learned that actually they went through quite a bit of trauma. They lost a parent. They were evicted from their house and they moved between these different environments and they didn't have the social support that they needed. And a lot of those structural factors get erased from the story because it's a lot neater to have, well, it was all fine until this drug entered the picture. And this is sort of the intention to broaden the focus and to really understand how this drug misdirects our focus from these other sources of problems. Why would you think that would be the case, right? I mean, the way I see American society or culture as an outsider is that it's very individualistic, right? I mean, the individual can and should make the right decision for themselves throughout their lives. And like this personal agency is really something important. The society kind of functions around that, right? Now, if this is true, why is this narrative about drugs kind of like, oh, this person was like flying, but then they took this prescription drug and then their life changed, right? And it kind of moves the agency from the person to the drug itself. Now, structural issues, sure. And these would be like ignored in both cases, but the emphasis on the drug rather than the individual, in this case is kind of like unusual, I would say. - Yeah, absolutely. And I think that neo-liberal bootstrap's mentality is still very much there, particularly in terms of, well, we've moved towards this medicalization of addiction that, well, this person is suffering from a disease itself, that this is what caused them to start using this substance, but then they need to invest in treating themselves. And so this is where rehabilitation centers come into play that they need to engage in the effort and stick with abstinence. And often we see with the emergence of drug courts in the 90s that rehabilitation centers are often posed as a more humanistic approach to prison and incarceration. But people who've done research in this area have found that these rehabilitation centers are often structured in very similar ways as penal institutions. They're very punitive. They teach individuals that you're an addict, that you have done bad things to your children, to your parents, to your friends, and that you need to work on this project of remaking the self to be a good person out there in the world. And Michelle Foucault writes about this and discipline and punish about this shift from corporal punishment to the soul and how that's actually much more intensive project of controlling people from the inside out. And we see this happening in these rehabilitation centers that don't actually have good outcomes for helping people, but it is on this individual. So that, well, now you have these problems now, you have to bootstrap your way out of it and through this very punitive system that not only can break people psychologically, but as they reenter society, it becomes increasingly challenging to find housing, to receive education in loans and rebuild relationships and all of those things that we need in order to survive. - So can we use some of the ways in which you approach writing about this prescription of prison pipeline, which you focus very much on structural factors? Could this also replicate for other bad things that happen, for the sake of our podcast that our listeners diseases, right? We opened up the podcast by pointing out that we said back in April of 2020 that COVID seemed to be filtered through structural inequalities. And is that also the case if we hypothetically where to look at whatever other disease you wanna look at? And Lee and I obviously work as pre-modern historians, so we can't go back as far as I'm aware and interview 80 people in say a single place, at least that's not I'm aware we can do, time machine's not a thing yet, but might these things look somewhat similar in different places in different times, obviously with other factors thrown in? - Absolutely, I think the connection to COVID is apt in that these sort of crises sort of throw our axes of inequality into stark relief that with COVID, as you noted that initially, people like you and I, white privilege people, talked about COVID being the great leveler that no one can escape COVID, but it became quickly evident that absolutely people could escape it. People who have resources to work from home, who could hire nannies, who were not deemed essential workers, they could continue to protect their children and have a paycheck and escape COVID. And that instead COVID really threw into relief these pre-existing inequalities related to housing and transportation and work and health care. And we talked about this in unemployment relief that it was increased quite a bit during COVID, recognizing that you can't actually subsist on unemployment benefits. And they said, well, okay, we need to increase it because people are justifiably out of work. When people are justifiably out of work every day, whether or not you're dealing with COVID crisis and yet we did not have those unemployment benefits carry over. Same thing with the child's tax credit that we saw child poverty reduce significantly during that time. And yet we then chose to let that expire. And so I think really focusing on people who are at the margins, people who are experiencing these inequalities and centering those stories. begin with is a way that we should be writing these histories and we're not always from those places. And I think that's part of the reason why it's important to create an academic system where increasingly marginalized people, people who experience all sorts of inequalities are able to become academics and to be able to write these histories, but also the importance of this work in terms of really trying to center the margins. As a last question that would connect to that in a different way, I guess, I was really interested in the way in which you kind of moved, right? You moved from the personal level of individual stories that you got from the different people that you interviewed. I also all the emotions that are involved in it, right? Because I'm pretty sure those stories were not happy or pretty horrible, I guess. So how did you move from that into this much more abstract and a little cool, okay, these are the structure of problems. This is what we need to fix. Maybe you could say a bit more about that and kind of bring in back your own perspective, right? Your own subjective perspective that you mentioned earlier, we kind of like we're discussing earlier about what this was doing to you as a scholar, but also as a person who is interacting with these people. Maybe that would be a good place to end the interview. No, absolutely, and that's something I've struggled with in this research and I wrote a bit about in, I believe, the appendix to the book about sort of me as this researcher who comes in, collects this data and leaves about what is my responsibility here and am I profiting or benefiting from this in some way that my royalties are not very high for academic publishing, but that as an academic, our capital is publications. And so one of the questions that we asked people at the end was what should be done here. And so that was one thing that was very central about how do I really carry forward that I make this promise to the people who they shared their stories and their stories are precious and they were heartbreaking and it was incredibly emotionally challenging for me to hear. Many of them talked about how cathartic it was that they discussed this in a really positive way. I also compensated the interviewees and this is something that I previously worked at the Census Bureau and we would conduct research on diverse populations and one time there was this pushback for paying unhoused people $75 for a focus group even though they were doing the same focus group with house people for 75 and they said well that's coercive, 75 dollars for an unhoused person is just more than it is for a house person and we successfully fought back and said you can't pay someone less for the same work but it does raise these ethical issues of coercion and so similarly prisoners are exploited and they are paid nothing pennies for the work in prison environments and so coming in and paying someone $20, $30 for an interview, there was a debate we had with our institutional review board of is that coercive and yet outside of the correctional setting we regularly pay people that much and so this was something I was very attentive to in the process that I do not want coming in as this researcher even though everything was in confidence we took all these protective measures so our data couldn't be subpoenaed but I'm still this white woman who's coming in as being guided in by people who work the warden people who work at this presence so I'm effectively read as part of the institution and so well do I have to comply do I have to say yes that is this going to be good behavior and help me and so these were things that I had to reckon with and try to communicate clearly to the people I spoke to but I think also through all of this I was like if I'm going to do this I need to really do what I think the people I'm talking to want most or that they see are the problems and I need to fight for those issues instead of just exploiting their stories they entrusted me with those stories and I'm incredibly grateful that people opened up and shared the way that they did but the focus really is how do we prevent this from happening because these harms are not harms that people should endure so I think that's a good place to end the discussion today so I wanted to thank you Michelle for coming on the podcast thank you so much for having me I think all these discussions and the interdisciplinary connections I think are so important for us to be able to understand those things that we're studying so thanks for all the work you do and thanks for having me on again was a pleasure yeah thanks it was great right I think that was very helpful to think about both the prescription to prison pipeline and to tease Michelle's books title but also maybe think a bit about the structural issues that came up on several occasions in this podcast but maybe more broadly to think about different approaches that we can take in our own work to maybe extend this particular project maybe a good place to start this reflection segment is again to reiterate one of my points during the interview the extent of this problem right I mean I kind of knew that the prescription drugs were a big deal here again as an outsider but I did not know they were that big of a deal right so 70% of adults that is way more than what I would have expected yeah I thought it was a great conversation with both as you pointed out some interesting facts numbers as it were behind the scenes but also some stories and also some structural points that I think we'll get too shortly I do wonder is the US an outlier right is this a US thing or is it bad also and let's just use our neighbor to the North Canada or is you know everything wonderful in Canada I don't know right these are opening questions I have I do know that the quote-unquote opioid epidemic has become news feature of the last few years but as I think Michelle pointed out that has a lot to do with who's getting caught up in this epidemic quote-unquote now right that it's much more white people whereas other drugs right focus on other groups that don't necessarily get the same focus of attention I think it's important to point out then we did not say this during the interview that I mean a lots of people are dying because of this I think the last numbers I saw are probably somewhere around a hundred thousand people a year if I remember correctly and also life expectancy in the United States has been either kind of like stagnating or slightly decreasing even before COVID but definitely so after COVID yeah I think that's definitely the case I've seen those figures as well although you have to hold constant you know as Michelle did race class gender all those things are particularly important when it comes to those numbers this reminds me maybe it's an open question and purely anecdotally but I imagine you know when you throw around that 7 and 10 number that a lot of this is older people and I think about this say with my parents and I don't know if your parents have this as well but they have this Monday to Sunday little bucket thing that you put your pills in for the week and some of them I think are just daily vitamins I think a lot of them are just daily items calcium or whatever it might be but is that something you have in Israel right that like older people have these like weekly planners for their pills I mean as a product yes we do I think I first saw it with my grandmother but my parents have not used it as far as I know okay I mean I think you know when you start taking multiple pills a day is when people start using these things but that's obviously something that was invented created at some point because more and more people were taking more and more pills yeah there's actually a bigger one which has like seven days of the week and I think like four different times a day right it's like morning noon evening night so you can have like that's like 28 different slots in which you can put your pills this reminds me of an art exhibit I saw I think it was like in the museum of natural history in New York probably about a decade ago which was kind of like a person's life with regards to the drugs that they take like a small box or something representing each day of your life and this exhibit was I don't know probably like 10 yards long and maybe like two yards wide each day of your life would be represented with the pills in which a person would take in that day so it's like realize how much so many of us depend on these drugs for yeah I mean one could write a good history of these pill box things as a change over time narrative about American society and American history maybe we should write that article like conceptual history of America and prescriptions told through the materiality of the pill boxes yeah I mean you can start I'm not sure I'm going to be there but you can definitely start the other thing that I thought was interesting I immediately kind of thought of is I don't think I've mentioned this on this podcast but my kids are both in kindergarten as I think you know Lee and they're in separate classrooms now but they have like the same curriculum so it's interesting to track what's happening in their daily education and how much of it is structured extremely similarly right that the curriculum in these two parallel classrooms in the same school is basically identical and maybe that was always the case and I just wasn't aware of it but it's like eerily similar right as these things are very centralized now in a way they didn't use to be I think 20 30 years ago so maybe in In that respect, it's interesting to ask you because this like an actual experiment, right? Is one teacher or one classroom better than the other for that particular kid? Well, what we did because my wife is nothing if not a fantastic advocate for herself and our kids is she went in and talked to the principal last year. So last academic year and told the principal as we were enrolling the kids, here's the type of teacher each one of them needs based on their personality. And here's the types of ways in which they learn and I think that's been pretty successful in terms of the type of teacher they've actually been matched up with. So even though the curriculum is the same, they each have a very different experience because they each have different learning styles. And so in a sense, you know, that's both a good and a bad, right? It's that my wife and I, my wife, more than me, knows to advocate for our kids and to treat them like individuals or else, yeah, they would be treated pretty much like cookie cutter all the same. No, that's fair. I mean, that's also my experience here in the US system, just like having a quick meeting with like the current teacher of my daughter has been helpful and just like, I guess both showing that we care, which I think is useful to do. I mean, just like a very practical basis, but also to point out the places where we think our daughter should, I mean, get more attention or less attention to. Yeah, that makes sense to me. The last thing I wanted to bring up Lee in the context, this conversation is what we talked about kind of in the middle, which was about academics as advocates for lack of a better term. And I think Michelle, you know, is in a field in sociology, which is obviously very presentist, right? I mean, you're writing about largely constructed present things. I mean, people can do historical obviously, but most people are writing about more present things. So they've kind of ended this debate. I would say between, you know, can you be a unbiased observer of things? And I think they basically said, no, you can't. You can advocate more or less. I think historians are very much actually having this debate right now. There was a big brew ha ha for lack of a better term about the former president of American Historical Association with some essay he wrote, put that aside for now. But it's an open question, and I think about it in many ways all the time. I think, you know, all of us are interested in what we're interested in because of structural issues, interests, whatever, like I'm happy to do that. But I do wonder, right? If historians are supposed to be advocates for policy change or whatever you want to think about, how does that work for pre-modernists? You know, I could see if you're a 20th century American historian and you're writing about questions of race and gender in class and, you know, this and that in America and things that still exist. But, you know, how do you write about or how do you advocate for Byzantium if you are a Byzantine historian? I mean, are you supposed to advocate for Byzantium? I'm not sure. I mean, so as the Byzantist on this podcast, I would argue that I'm more advocating for a different approach, right, like the pre-modern approach of kind of like thinking, analyzing, that's what I would say, right? I mean, I tell my students as well, right? Byzantine is just a case study that I happen to know because of my own weird academic trajectory. I mean, but you could do the same thing with ancient Greece or with, I guess, modern United States if you choose to do that, right? Just like this down to earth, look at the primary sources of internet at the time, trying to understand the culture, especially when it's a culture that's not yours, which is to say most of the past and figuring stuff out and tackling difficult questions about it. I mean, that's what I would say. Yeah. I mean, I don't have an answer. I was just curious on your take because I think it's a much more difficult debate. I think it will be resolved in some way or the other have my thoughts on it. But as a pre-modernist, it does leave us outside many of those discussions in some ways. I think it's also more difficult to convey, right? So when you're talking to people in the present, I mean, everyone seems to know what the hot topics are, right? Well, we're interested in, right? You mentioned race, class, gender, I mean, that's the, sure. But if, for example, you are writing about the fall of Rome, right, and you want to make a point about that fall of Rome and how that fall of Rome may or may not be relevant for us or for the United States in the present, how exactly are you supposed to do that? Are you supposed to like have in your introduction a couple of pages outlining your political view and drawing this analogy between Rome and the United States today and then making your argument? Are you supposed to talk about your intellectual formation and your life experiences? I'm not sure. And I've seen a few people who actually have done it. There's like a person who wrote on the invention of race and classical antiquity. I think that's the name of the book. And there he has like a few pages, which are basically a autobiographic sketch of himself. I felt he probably felt that he had to do it back there. But that's not common, not as all as common as it probably is in sociology. Yeah. No, I think that's a fair point. And I think I've read that book too. And if I recall, that author had to write a 50 page introduction, theoretically, laying it out, which if you have to write 50 pages explaining why the topic and the idea of works and how you're doing it, that's a lot of pages, but just leave it at that. The book itself had a lot of pages as well. We could put that aside. So maybe we can move on from this, the more lighthearted segment, which is pretty neat at I think today. So Merle, I mean, here in New Jersey, especially around Princeton, I was reminded that fruit picking is a big deal, especially now in the fall. And whether you're going to like locate apples or pumpkins or whatever in some kind of agricultural setting. So are you still doing that over there in Oklahoma? So there isn't really apple picking here because the climate is not apple picking like. But what there is is they basically, from my perspective, do holidays here to like the most capitalist degree, which is actually fascinating because you know, you probably think of saying New York or some East Coast city is like, you know, the center of capitalism in America or whatever your mentality is. But actually, you know, how we do holidays here is I would say more extreme per lack of better term. So there's lots of places to go pumpkin picking. But what there also is just like every store has like a small little pumpkin has it take to use the word patch in it. So you go to like home depot and outside and part of the parking lot, there's just like a bunch of hay bells and they're selling pumpkins of all sizes that you can like get from this like hay bell patch or there's like a local athletic store that does it or the local grocery store that we have, they have pumpkins arranged by size. So there's these giant ones up at like $70 and they must weigh like 500 pounds or something ridiculous. But my son likes to visit them because they're so big. So we go to the pumpkins and what does it have to really means is over the course of October, we buy like, you know, two pumpkins a week. So by the end of Halloween time, we have like 10 pumpkins at our house because, you know, every time you go shopping, my son comes shopping with me, he gets to pick something out. Right. That's the deal. We go shopping for groceries and he gets to pick something. So what is he pick? He picks a pumpkin. So we now have, I think two pumpkins so far, it's only the first week basically of October and I mentioned we'll have 10 by the time Halloween rolls around. There's two points. One is that we actually came up with the same strategy of bringing our daughter and saying, okay, you can get, we actually said two things each time. Maybe we should like cut that down to one. But the other thing I mean, isn't it still like hot in Oklahoma? I mean, aren't the pumpkins. If you leave them outside, we'll just like start flying up. Yeah. Generally and also carve them. They're kind of okay. Right. I mean, if you think about it, people are putting these pumpkins out as I say in these faux pumpkin patches for like, I don't know, six or seven weeks before Halloween. So they must know that they're not going to like actually go bad. Open. And what about haunted houses? I mean, it's not fruit picking or vegetable picking, but is that also like big over there? I haven't seen any. Everyone likes to do extraordinarily intricate Halloween sets on their lawn. So there's one that I really like in the neighborhood where there's like five skeletons out front that are human sized and each day until Halloween over the month of October, they rearrange it in a new scene. So like one day they were playing poker, one day they were doing yoga, all these types of things. So people are spending I would say sometimes thousands of dollars on these Halloween decorations. And time. Right. I mean, just like coming up with ideas to like redesign your yard every day, that's impressive. Well, they probably like pills, they put them in a chart and plan it out with by week. I'm sure this is planned like well planned in advance. And what about you Lee? Have you taken your daughter apple picking or something else picking? I remember before you had a kid, you used to rant about how awful going to these pumpkin or other picking things were and I remember your wife basically kind of scolded you once and said, but they're fun. So where have you landed? We were hoping to go to one of these, I think last week, but then the weather was really bad over the weekend. But do you remember a turhun right turhun like the standard I mean, it used to be like a very family friendly kind of low key. The first round I was here. [BLANK_AUDIO] Now it's it's kind of like an empire. It's funny. You say that. I was mentioning this from friends this weekend that we used to go to Terhune, which was the local place in Princeton, maybe what, 10, 12 minute drive from the university. And at some point toward the end of our time in Princeton, which is like five years ago, now it became this like, yeah, empire, right? That they would charge you for every weekend that there was a cost to get in when it used to just be this local place. And now it's clear people coming down from New York. Yes. Yeah. So that definitely changed. And I think also there are other places that seem to have popped up that I don't remember them being around, which kind of offer, I guess, the same deal of farm experience for lack of a better term, fall farm experience specifically. Although I think Terhune is like year round at this point. Yeah. No, it definitely is, I think. So you got to go apple picking. Apple picking with little kids is fun. Well, definitely try. We have like tried the forage on different occasions. I think some of which I actually described them as podcasts like a while ago. But I guess that on this more optimistic note, hoping for optimistic future, at least as far as possible, we would like to thank our sponsors at both Oklahoma State University and the Hebrew University in Jerusalem for funding infectious historians. And our team, our great team, our sound editor, Amitai Barlavi and our webmaster, Veridir Kanati. Until next time, stay safe. If you're listening to this in the Middle East, get your booster and flu shots in the US. And let us know where Lee should go picking with his daughter.