Sam Quinones’s brilliant investigative history of the opioid crisis, Dreamland, has two main villains. Neither of them are people: Quinones is relentlessly compassionate towards the Mexican farm boys who smuggle home-made heroin across the U.S. border and deliver it to junkies and soon-to-be junkies all across the country, and even the worst of the pill dispensing doctors he profiles, Dr. David Procter, comes across as a nastily comic weasel rather than a force of evil unto himself. Nor are the public health officials responsible for the “pain revolution” that expanded the prescription of opiates for chronic pain themselves bad guys- they honestly if foolishly believed that they could avoid spreading addiction if opiates were targeted to people in pain, and several of them revised their views and worked to stop the expanding epidemic once they realized what was going on.
Closer to a purely malevolent force is Purdue Pharmaceutical, which earned over a billion dollars in sales in 2002 on 6.2 million prescriptions for Oxycontin, the most widely-prescribed morphine derivative, and which ignored evidence for the addictiveness of their product while distributing highly misleading studies that claimed to prove opiates were safe. Purdue spent tens of millions of dollars on direct marketing to doctors- junkets and gifts and enticements that stopped just short of bribing doctors to prescribe their pill. As Quinones narrates:
And yet not only did nobody go to jail (Purdue paid fines and settled civil cases, and some executives paid fines and were sentenced to community service) it is harder to make the case that individual executives should be behind bars than that the organization as a whole behaved in a hugely destructive manner. As in the housing bubble and subsequent financial crisis, the amount of individually criminal and fraudulent behavior was far less than the harm caused by pharmaceutical companies as a group. Even more like the housing bubble, individual consumers of opiates were overwhelmingly state-subsidized; pharmaceutical companies were less destinations for private funds than conduits for public spending from Medicare, SSI, Medicaid, and the VA. Our hybrid public-private health care system, like our hybrid housing system, seems almost uniquely prone to abuse, as consumers do not bear the costs of their health care decisions while the government enjoys a kind of “plausible deniability” about the dangers and costs of the services for which it pays.
This corrupted (and ever-expanding) health care system is thus one of the main villains of Quinones’s story, I think he would agree. Where he might disagree with my characterization of his book and the story it tells is in the identification of the other main villain as the uncontrolled Mexican border. Although he sadly notes how it is easier for heroin dealers to get through customs than it is for Mexican men who want to work direcha (the right way, in law-abiding ways) in the United States, he is sometimes reluctant to examine why exactly it is so easy for individual Xalisco teenagers to make their way to the states and start pushing heroin on an American population already primed for addiction by pills, and why it is so very easy for small time producers to ship their low cost but highly pure black tar heroin to the States. The Xalisco boys are polite and friendly, fearful of violence, and without any large-scale criminal organization- they are you might say the exact opposite of the ruthless cartels profiled in Sicario or, for that matter, the black-dominated heroin gangs that are the focus of The Wire. The Xalisco boys, as Quinones names them, are amateurs who fall into heroin production and dealing because it allows them to buy Levi’s blue-jeans for their families and show off on the town plaza for a few weeks, not hardened criminals.
But ironically, as Quinones shows over and over, it is precisely this lack of hierarchical organization and avoidance of violent disputes over territorial control that made the Xalisco boys so devastatingly effective at bringing dirt-cheap heroin to the States in the quantity and purity necessary to kill tens of thousands of people. With hundreds of independently operating cells and a largely undifferentiated but highly pure product, Xalisco boys are like an economist’s dream of perfectly competitive markets:
The boys earn just a few hundred dollars a week, limit their personal costs to a bare minimum, and return to Mexico to show off for a few weeks before venturing back out again. Without barriers to entry in production, distribution, and sales, new cells of drug dealers enter the market until the price is pushed down to marginal costs- and the supply of both drug dealers and their product is in practice almost perfectly elastic, able to expand or contract easily in response to demand.
If you legalized drugs without regulation on suppliers, you probably couldn’t do a better job delivering it to junkies cheaply and at high purity than the Xalisco boys have managed to do, and (as was imagined in season 3 of the Wire, when police captain Bunny Colvin unofficially legalized drugs in the abandoned “Hamsterdam” section of his West Baltimore beat) the result is a very low level of drug trade-related violence but a very high level of overdose and increased addiction. The story that Quinones tells has none of the horrific violence associated with the cartels or the cartel-associated gangs like MS-13, but it does have lots of overdosing addicts.
Without the Mexican supply, there would still be heroin in America, but the heroin would be significantly more expensive and more difficult to obtain. The collision of this ideally competitive supply of highly pure, very cheap heroin and the demand created by our corrupted and hybrid private/public health care system is what creates the tragedy of Dreamland, and sets the stage for the explosive growth in opioid-related deaths we have seen in recent years.
I share Gabriel Rossman’s sincere enthusiasm and admiration for Quinones’s book- it is one of the most impressively researched and absorbingly written non-fiction books I have ever read, and I’m not surprised that Angus Deaton, who has been tracking the quantitative side of the explosion of white American mortality, named it as his favorite book of 2015. But it still upsets me that Quinones himself, in penning an LA Times op-ed arguing against Trump’s immigration policies earlier this year, doesn’t spare a single word for the opioid epidemic and the role of the unpoliced border and Mexican heroin and heroin dealers in spurring it on, a topic which he has just spent several years exhaustively researching and on which he is now perhaps the foremost expert. Quinones’s sympathy for the dealers and interest in the details of their operations is no doubt in large part responsible for his book’s artistic success. But without a square accounting of immigration’s costs alongside the benefits he claims in his op-ed, the country is being misled.