Tracking the Path of the Opioid Crisis
BU historian Benjamin Siegel travels to a tiny poppy farm in India to find the roots of a global crisis
When Benjamin Siegel left the BU campus in late 2017 in search of the foreign poppy fields that have helped fuel America’s opioid crisis, he landed halfway around the world in Budha, a village of 5,000 people in the western half of India.
Budha is a typical small town in the developing world, Siegel says. The air smells of diesel and fried snacks sold by street vendors. One store in the village sells agricultural supplies and seeds. “It’s pretty dust-blown,” says Siegel, a College of Arts & Sciences assistant professor of history. But what makes Budha a player in the opioid market is that it sits in the heart of Mandsaur, India’s most productive government-regulated opium farming district.
Siegel first arrived in Budha in January 2018 as part of research for his forthcoming book, Markets of Pain: A Transnational History of the United States Opioid Crisis. “How did all these small villages like Budha add up to contribute to today’s opioid crisis?” he asks. And how, starting in the years after the Second World War, did the United States acquire a glut of opioid drugs that ultimately ballooned into the opioid misuse and addiction we see in the present-day crisis, with more than two million Americans addicted?
The BU historian is traveling the world in search of answers, scouring records in Turkey, the United Kingdom, Australia, the United States, and India. Mandsaur, in the Indian state of Madhya Pradesh, is the most prolific producer of opium among the 19 Indian districts where poppies are legally farmed, generating about a quarter of India’s legitimate opium output. All told, India manufactures the largest amount of opium gum—between 335 and 556 tons per year—for the global pharmaceutical industry. Until recently, most of its opium gum ended up in drugs on the shelves of pharmacies in the United States. If you’ve ever taken Tylenol containing codeine or painkillers after surgery, especially prior to 2010, odds are that some of the opiates in those drugs came from poppies grown in Mandsaur, Siegel says.
The Demand for Opioids
For the 186 registered opium farmers in Budha, their livelihood and social status revolve around poppies. Having a poppy-growing permit, or “patta,” from the Indian government is a status symbol among villagers, and owning a patta typically increases a son’s or daughter’s marriageability.
And yet these villagers—and tens of thousands of other opium producers and their families who farm poppies under regulations tightly controlled by the Indian government—have seen few of the financial benefits reaped by the world’s pharmaceutical companies since the demand for opioids surged in the 1970s. It was around that time that American physicians and the US Drug Enforcement Administration began to worry that the American people’s need for pain-relieving opiates like codeine and thebaine would exceed the country’s supply by the 1980s and 1990s, Siegel says.
Around the same time, several studies stating that opiates were not addictive in controlled hospital settings, including one from the former Boston University Medical Center, were inaccurately represented by pharmaceutical companies to suggest that opiates did not pose an addiction risk for patients who could use them at home for chronic pain management.
“That’s when we started using opioids in new and problematic ways, and companies began to bring opioid-based drugs to Americans in record numbers,” Siegel says. “It was the moment when opioids moved from being administered solely in hospital beds, and as component parts of certain cough syrups, to drugs that could be taken at home.”
With increased demand from America, opium gum became a coveted cash crop for poppy farmers in India. Since then, the drug industry has raked in profits from opioid use and addiction; it is now paying out hundreds of millions of dollars in lawsuit settlements for its role in creating the opioid crisis. The epidemic has led to more than 70,000 overdose deaths in the United States in 2018 alone.
But now, as the use of synthetically derived opiates like fentanyl has taken off and the cash value of raw opium has tanked, poppy farmers are struggling to make it.
Most of the men and women who perform the labor-intensive poppy farming and the finger-cracking process of harvesting raw opium live in difficult financial circumstances. Many are unable to make a profit, send their children to college, or scrape together money for marriage dowries.
“People in this already marginal region of India are struggling further because they can’t make a good profit,” Siegel says. “To lift a family out of agricultural poverty, sons and daughters of farmers should be going to college and the next generation should be doing less agricultural work and instead work in industry or the service sector.”
Mandsaur is theTOP PRODUCER OF OPIUM
among the 19 Indian districts.
of India’s legitimate opium output is generated in Mandsaur.
Making a Connection with Rural Farmers
Arriving in Mandsaur, Siegel, who had worked as a journalist before earning a doctorate in South Asian history from Harvard University, fell back on old-fashioned reporting work to find his way to a poppy-farming village, where he hoped to meet the rural farmers whose crop is the point of origin for the world’s opioid market.
He had an ideal investigative partner for the job: his wife, Caterina Scaramelli, a CAS research assistant professor of anthropology and of earth and environment.
“If I had showed up by myself asking questions about opium, that would probably have coded a bit differently,” Siegel says. (Farmers may have thought he was looking for an illegal drug connection.)
Together, Scaramelli and Siegel connected archival insights with what was happening on the ground, drawing upon Scaramelli’s expertise as an anthropologist with experience working with villages in rural Turkey.
“It’s easy for historians to figure out what’s going on from a pile of old documents,” Siegel says. “But Caterina moved us toward different and more living questions, and helped us build some good trust with people in Mandsaur in a really short period of time.”
In the district seat of Mandsaur, he sought out the superintendent of police, who arranged a press conference about his research. The event attracted nearly 50 local journalists who clamored around the couple, snapping photos with their cell phones and cameras.
Although Siegel was initially caught off guard by the paparazzi, the press conference ended up being a blessing in disguise. Photos of him and Scaramelli were distributed around Mandsaur’s villages. By the time they made their way to Budha, villagers recognized them and knew about the purpose of their visit.
The epidemic has led to2 Million+
overdose deaths in the US in 2018
Budha’s farmers sell an opium crop at $21 per kilogram
to the Indian government
Opium gum can sell for up to$1,672 per kilogram
on the black market
An Archaic Method of Harvesting Opium
Growing poppies is so easy, Siegel says, you could do it in your own backyard. “You plant them at the end of one calendar year, typically in November or December, and they grow pretty quickly, ready to be harvested by March or April.”
Turning poppies into opium, however, is painstaking work. “The white poppy flowers first turn into hard, green capsules, and then you have to score them by hand,” Siegel says. In Mandsaur, women typically do this work, using a six-to-eight-centimeter-long knife. As they cut, the capsule begins to bleed latex that dries over the course of two weeks. Then, a handheld tool shaped like a scythe is used to scrape up the dried liquid, which now resembles a tarry gum. The farmers collect the gum into tins and sell this product for about $21 per kilogram to the Indian government.
All of the raw opium from Mandsaur’s farmers is processed by the Indian government in one of two old factories in the nearby cities of Neemuch and Ghazipur. Siegel visited the one in Neemuch, a worn-out building constructed in 1935. There, the opium gum, which starts off soft and sticky, is converted into a harder, resin-like form and then sold to foreign importers, formerly to mostly American buyers but now mostly to buyers in Japan.
About 10 years ago, America’s major opiate importers like Merck, Mallinckrodt, Noramco, Abbott Laboratories, and Janssen Pharmaceuticals began increasingly buying product farmed on the Australian island of Tasmania. Instead of opium gum, Tasmanian farmers produce poppy straw, a raw material that can be more efficiently converted into morphine, codeine, or thebaine, powdery chemicals called alkaloids that can be further converted into pharmaceutical drugs. Poppy straw is also a better product, Siegel says, because it cannot be turned into black market heroin.
“I don’t think these companies care one way or another about where the [raw materials] come from. It’s just easiest to buy from Australia now,” he says. If that’s the case, why is this archaic harvesting method still used in India?
“It’s the story of marginalization,” he says. Because opium-producing licenses carry such cultural prestige among India’s farmers, there’s political value for district commissioners who promise to increase the number of licenses. “It can definitely get you some votes. It’s also a question of labor and jobs: since the 1980s India has considered moving to the more secure poppy straw method, but has hesitated to do so for fear of pushing people out of the industry and losing votes accordingly.”
Depending on the year, Budha’s farmers selling an opium crop at $21 per kilogram to the Indian government can expect to make between $129 and $268 per season, according to Siegel’s research.
Meanwhile, throughout India there are many farmers who, without a permit, illegally grow opium destined for the black market. Heroin use is skyrocketing throughout the country, especially in certain northern cities and in the state of Punjab, Siegel says. A kilo of opium gum can sell for up to $1,672 on the black market, nearly 80 times what the Indian government pays.
In Budha, Siegel met Dilip Patidar, who makes a living by growing a diverse range of crops throughout the year.
“Soybeans, onions, garlic….Dilip will grow whatever he thinks will sell well,” he says. Patidar also grows opium through a legal patta that his family has held for at least two generations.
His quality of life is better than most of the other opium farmers around him, Siegel says. He has some extra family clout that he can leverage to improve his access to capital and new technologies, and he’s installed irrigation systems, an expensive investment that yields better crop harvests.
Patidar, it seems, is one of the lucky few. And although the Indian government looks to Madhya Pradesh as a success story in terms of agriculture, crop prices have gone down or stayed stagnant over the years.
“There’s a lot more irrigation, fertilizer, and credit lines opening up for farmers,” Siegel says. “But all the typical indicators of human health have gone down.”
The state, he says, has major malnutrition, low levels of formal education, poor access to clean drinking water, and high levels of child mortality.
The story of opium—and of Mandsaur farmers like Patidar—is another example of poor farmers trying to chase a potential cash crop, Siegel says. Except that this cash crop is part of a global chain of value leaving the most vulnerable communities marginalized.
“There’s so much value that comes to India’s state governments, its central governments, to the Drug Enforcement Administration in the United States, to the pharmaceutical industries, and the doctors prescribing opiates to their patients,” says Siegel. “But at the two ends of that, people are suffering: farmers in India and elsewhere, on the one hand, and Americans dealing with a new narcotics crisis, on the other. I want us to look at these two ends….They’re connected. Why is everyone in the middle getting so much more value from this commodity?”
His book, to be published by Oxford University Press, looks at many countries and their involvement in the global opioid market over the last 75 years. He hopes it will bring clarity to the tangle of factors propagating opioid misuse and addiction. “Today’s opioid crisis is rooted in policy choices that were made with the best information we had 40 years ago,” he says. “After a lot of profit and too much suffering, maybe it’s time to rethink these choices with some new insight.”