UNNATURAL CAUSES SICK AND DYING IN SMALL-TOWN AMERICA: Since the turn of this century, death rates have risen for whites in midlife, particularly women. In this series, The Washington Post is exploring this trend and the forces driving it. Read the other stories in this series here.
Late last year, Agriculture Secretary Tom Vilsack strode into the Oval Office to tell President Obama that he wanted to resign.
“Mr. President,” he said, “I think it’s time to go.”
Vilsack had survived nearly eight years in Washington as Obama’s model Cabinet secretary — a disciplined and efficient technocrat who understood the inner workings of his department, worked well with lawmakers and did not cause trouble for the White House.
Lately, though, that approach did not seem to be enough to fix the problems he was seeing in the country. Vilsack was frustrated with a culture in Washington that too often ignored rural America’s struggles and dismissed its virtues. “I just sometimes think rural America is a forgotten place,” he often said.
Vilsack sometimes felt forgotten, too. The number of consequential issues crossing his desk had dwindled. “There are days when I have literally nothing to do,” he recalled thinking as he weighed his decision to quit.
The Oval Office conversation would change the trajectory of Vilsack’s career and affect him personally in ways that he could not have predicted. Obama asked him to oversee the administration’s response to the opioid crisis that was ravaging rural America.
The new assignment would force Vilsack to confront not only the immediate drug crisis in the country but also the frustrations and feelings of economic hopelessness that had allowed the epidemic to flourish.
Each morning Vilsack’s staff passed him statistics that tracked the administration’s top priorities: its push to train physicians on the risks of opioid addiction; the latest on its effort to get the overdose reversal drug naloxone out to more communities; the status of federal grants earmarked for struggling communities.
He visited hard-hit places, such as New England, Nevada and Appalachia. Recently he was in Missouri, a state with a surging overdose death rate, where his staff had set up a meeting with doctors, police detectives and drug counselors who waited for him in a gray-carpeted conference room in Olivette, Mo., near St. Louis.
“I am here to learn and here to listen,” Vilsack told the group. “I want to make sure that when I walk out of here, I have a very good understanding of the problem.”
He pulled out a stack of index cards and a pen from his suit pocket to jot down notes.
“The last time I was on ER call at one of our local hospitals I delivered three mothers who were opioid-addicted and had no prenatal care whatsoever,” one doctor said.
“We have no resources here,” the health director for St. Charles County said.
“We see a ton of overdoses,” said the next doctor from a hospital just south of St. Louis. “This Fourth of July we had three firework injuries and 23 overdoses.”
“Wow,” Vilsack muttered under his breath. He scribbled “3/23” on an index card and slid it back into his suit pocket.
The opioid epidemic was the kind of crisis that too easily escaped the attention of powerful people in Washington. It had developed slowly, over the course of decades, in parts of rural America that were isolated, poor and often overlooked.
Its effects, though, were devastating and were a major factor in the startling surge since 1999 in the death rate for white women between the ages of 25 and 55.
For Vilsack the crisis was personal. A former small-town mayor and two-term Iowa governor, Vilsack had spent his adult life fighting for rural America. He was also the child of an alcoholic and prescription drug addict.
The story of his mother’s addiction and her suicide attempts had long been a part of his political identity; one that he had told hundreds of times on the campaign trail. Sometimes he used it to explain away his shyness and his gruff, workaholic manner.
In other instances, he told it to inspire voters, focusing on his mother’s recovery, her religious faith and transformation into a steady and sober parent.
Now, as he traveled the country, the story served a different purpose. Vilsack used it to make the case for the kind of help that Washington could provide: more money for doctors, drug counselors and mental-health clinics to treat those who were suffering.
“When I was a kid, I judged my mom,” he had said earlier that morning in Missouri. “I thought she could just decide tomorrow to stop doing what she was doing. I had no idea it was a disease. I do now.”
Vilsack walked out of his meeting and into the bright sun of a Missouri afternoon, mostly pleased at the possibilities the roundtable had offered. His shaggy hair, which hung over his ears, had not changed since boyhood. But his tall and rangy frame was now slightly stooped. At 65, he moved with the stiffness of advancing age.
He ran a sprawling bureaucracy with 93,000 employees and a $150 billion budget but knew that he did not have money for anything ambitious. An urgent request from the White House earlier this year for $1.1 billion to battle the opioid epidemic was stalled in Congress. His department’s discretionary budget, which he could use to fund clinics, was $2 billion less than it had been in 2010.
So Vilsack channeled his energy into little things: A police officer he had met complained that prices of naloxone, the overdose-reversal drug, had tripled since January to nearly $160 per dose, making it too costly for many rural police and fire departments. Vilsack promised to raise the issue with the White House.
Someone else showed him a chemical treatment bag that could be used to safely dispose of old prescription drugs. “You can’t just dump them in the sewers. The disposal bags could help,” Vilsack said.
But, he was most excited about a four-state pilot program he was developing to use USDA grants and foreclosed properties to create transitional housing for people in treatment.
Vilsack had spent most of his adult life fighting these kinds of battles. He grew up in Pittsburgh but moved to tiny Mount Pleasant, Iowa, in 1975 when his father-in-law wrote him a seven-page letter asking him to join his tiny law practice. The salary: $1,000 a month.
Some of his first clients were farmers fighting to stave off bankruptcy during the 1980s farm crisis. “They would come in and say, ‘Save my farm. Save who I am,’ ” he said. “You all of a sudden think, ‘Jesus, what are we doing here? What can I do?’ ”
After a psychologically damaged World War II veteran and former POW opened fire during a city council meeting in 1986, killing Mount Pleasant’s mayor, the deceased mayor’s father urged Vilsack to run for the office.
There was a short stint as an Iowa state senator followed by a successful, long-shot run for governor. “For the first time in 70 years, we reversed the outmigration of people from Iowa,” Vilsack said of his two terms.
Vilsack knew that the past 15 years had hit rural America especially hard. Rural child poverty rates had begun climbing in 2003, peaking at levels last seen in the 1960s. Only in the past few years had they begun to edge back down. Rural Americans were older, more likely to be obese, less likely to go to college and more likely to become pregnant in their teenage years than people in the rest of the country. And now the opioid crisis.
At a recent news conference in Missouri, reporters peppered Vilsack with questions about whether the administration was moving fast enough to address the epidemic.
“There is some frustration that it took so long . . . ,” one reporter said.
“Why wasn’t this done years ago?” another asked.
They were versions of a line of questioning that had begun to “piss me off,” Vilsack said.
He did not blame the president for the lack of attention to rural America, though his last one-on-one meeting with Obama had taken place 10 months earlier when he tried to resign.
His frustration was with the rest of the country — the media, Congress and the private sector — which he felt had ignored the struggles and contributions of a region that produced most of the country’s food and, during 15 years of war, had disproportionately filled the ranks of its military.
Publicly, Vilsack often played the role of booster, citing modest economic gains as proof of rural America’s “remarkable comeback,” after “years of stagnation.”
Privately, he let his anger and frustration with Washington show. He was sensitive to the smallest slights directed at rural America or his record. Denis McDonough, the president’s chief of staff, praised Vilsack’s effectiveness even as he referred to him as the “cranky” Cabinet secretary.
“Maybe I have been here too long,” Vilsack grumbled. He gazed up at his sprawling Beaux-Arts style office with its gold filigree columns, massive windows and stunning views of the Mall.
“I have to be cranky,” he continued, “because people don’t pay attention to this part of the country.”
Vilsack told staff organizing his Missouri meetings that he did not want to focus on stories of people fighting addiction or parents who had lost children. He wanted to hear from the people battling the epidemic. “We’re here to talk solutions,” he said.
An exception was Karla Jaques, a USDA employee from Dexter, Mo., whose 28-year-old daughter, Alicia, had died of a heroin overdose in March.
Vilsack was waiting for her in a small room at Stephens College in Columbia, Mo., when Jaques walked in carrying a picture of Alicia wearing her crisp, white sailor’s uniform, taken in 2007 just a few hours after her daughter’s Navy boot camp graduation.
“She was so happy and so proud of herself,” Jaques told Vilsack. “She always was until all of this.”
“I have some understanding,” Vilsack said.
He then recounted the story of his own mother’s addiction to alcohol and prescription drugs. Vilsack had recently started to probe his adolescent memories, trying to piece together what might have caused his mother’s addiction. He tried to recall exactly when his mother had begun to grapple with drugs and alcohol. Was it when she went in for gallbladder surgery and the doctors gave her pills for the pain? “Did she like that sensation and need more of it?” he wondered. Did her problems begin when his father suffered his first heart attack or when his father’s real estate business began to fail?
These were the same questions Jaques was asking about her daughter, who had been embarrassed by her addiction and avoided her family in the year before she died. Most of what Jaques knew about her daughter’s problems came from journal entries Alicia had written in rehab.
She wrote that her addiction began in 2010 when she had eye surgery and was given painkillers by Navy doctors in Jacksonville, Fla. “I would get a prescription every few months so if I was given a urinalysis test I would pass,” one journal entry read. The prescription provided an excuse when her urinalysis tests came back positive.
A military career that began with promotions, overseas deployments and awards faltered and then fell apart. Her first arrest for heroin possession came in October 2014, six months after she left the service. Last fall, one of Alicia’s Navy friends called Jaques to tell her that Alicia was an addict and down to a skeletal 85 pounds. There was a second arrest for heroin possession followed by a four-month stint in prison rehab.
“I want to rebuild my relationship with my mom,” she wrote during that period. “I will call her more often and share pictures of myself and what I’m doing so she can help with my recovery. . . . I want to go back to Missouri. . . . I want to go back to school. . . . I want to be comfortable with myself. I want to be able to talk in front of people and not be afraid I sound stupid.”
Four days after her release, she died of a heroin overdose. Jaques was upset that the Navy had just punished her daughter, rather than providing medical help. “If you have a good person and all of a sudden things start going down hill, they need to find out what’s going on and not just harass them and kick them out,” she said.
Decades earlier, Vilsack’s mother had written a letter to her sister in Philadelphia describing her recovery and hopes for the future. Like Jaques’s daughter, she had been sober for only a few months.
She wrote about rehab and looking for steady work and an apartment in the same neighborhood where Vilsack was living with his father.
“I simply cannot afford to take any more chances,” she wrote. “I have all the confidence in the world in myself now — something that I haven’t had in a long time. . . . I am sure if I do my part, God will help me.”
Vilsack had read and reread the 1964 letter, trying to piece together what had allowed his mother to find sobriety after so many failed attempts. Her faith had been central; she found a good job at a bank that had helped ease the family’s financial strains.
“Then you start thinking about the little things, like my dad used to be a bourbon drinker,” Vilsack said. When his parents moved back in together, his father switched to vodka. “What was with that?” Vilsack wondered. “Maybe it was his effort to help mom?” Maybe the smell or color of bourbon triggered a craving? Vilsack guessed.
Downstairs another town hall meeting had begun. A drug-treatment court judge was saying that more than 50 percent of the nonviolent offenders coming through her courtroom were hardcore heroin addicts who only a few years ago would have been sent to a criminal court. “We are dealing with people who we would never have considered taking in the old days and getting much better results,” she said. “But our funding is lacking.”
Vilsack talked about the need for more federal spending, and he outlined his “four-pillar plan” to revitalize struggling rural economies. The answer, he said, was more investment in organic farming, eco-tourism, biofuels and bio-based manufacturing.
He slid his speaking notes into his suit pocket and glanced up at Jaques, who was sitting in the front row. There had been so much that Jaques had wanted to tell him and so much that she still did not know. “I was worried that I covered everything,” she said.
When he was finished speaking, Vilsack sought her out in the crowd. His staff and security detail were hovering just out of earshot. His government SUV and driver were waiting outside to ferry him to the airport. Vilsack told her that he had already shared her daughter’s story with Sen. Claire McCaskill (D-Mo.).
He promised that he would talk about it in Washington.