Dr. Anthony Ryan Hatch is a sociologist and associate professor of Science in Society, African American studies and Environmental Studies at Wesleyan University, who studies how medicine and technology impact social inequality and health.
Professor Hatch is the author of two books. His first book, Blood Sugar: Racial Pharmacology and Food Justice in Black America, critiques how biomedical scientists, government researchers, and drug companies use the concepts of race and ethnicity to study and treat ‘metabolic syndrome,’ a biomedical construct that identifies people at high risk of heart disease, stroke, and diabetes. His second book, Silent Cells: The Secret Drugging of Captive America, examines how custodial institutions like prisons, nursing homes, and the U.S. military use psychotropic drugs to manage mass incarceration and captivity in the United States.
His 2018 Wesleyan TedX talk is entitled “How Social Institutions Get Hooked on Drugs.”
The transcript below has been edited for length and clarity. Listen to the audio of the interview here.
Anthony Ryan Hatch: I had just graduated from graduate school and joined a small group of other self-identified Black assistant professors in this really small postdoctoral fellowship at the Morehouse School of Medicine in Atlanta. That fellowship was designed to have us focus on issues of HIV/AIDS, mental health, and substance use inside “correctional settings.” I joined this group of Black scholars, and we were all trying to get a foothold in the academy and get our careers going. We were visited that first summer in the program by a whole range of experts in corrections and health policy. And the whole point of this fellowship was to professionalize us, to get us ready to enter into the “grant mill,” to get funding, publish papers, and develop our careers.
The logic is pretty simple: it’s kind of a bribe. You take this money and then, in some ways, you have to compromise on the kinds of questions you want to ask. You have to ask the kinds of questions that institutions of power want answered. So if you’re asking questions that have to do with the least among us, it’s harder to get funding for that. We were all encouraged to pursue a relatively safe, clear, and clean research project in the area of re-entry.
It’s not to say that social science and health research that is institutionally funded can’t be important. I certainly have had my own institutional funding. But I just saw it as hugely contradictory that we were trying to study and understand mass incarceration “safely,” from the safe shores of liberal science. You’re producing information and knowledge that can be used to reform institutions. That’s the basic idea of the liberal approach to government. We produce science that is supposed to help us make the right decisions about policy.
But as I uncovered in this book, sometimes you don’t have all the information you need. Sometimes people haven’t been asking the right kinds of questions. And so, you really have to sit back and think about what questions need to be answered.
It seemed to me that there weren’t enough health researchers looking at the prison and thinking about incarceration from a critical point of view. From a point of view that wanted to liberate people from the prison, as opposed to simply reforming those institutions. Not just to challenge their logic, or to challenge the ideas, but to be a tool that can be used toward abolitionist ends. I didn’t want to do a project that kept the prisons going, that made the prisons smarter or stronger, or gave them greater capacity for holding people captive. That was part of my thinking in making that claim. It’s very difficult to adhere to that, but I tried to do that in this project.
Hatch: In the summer of 2009, our group of young scholars were all visited by a woman who had a brand new job at a for-profit prison healthcare company called Geo Care. And for some time prior to that, she had been, I believe, the head psychiatrist at the Georgia Department of Corrections. She had given us a presentation about the insider’s view of what was happening in terms of prisoner mental health and prisoner mental health care.
I had already been thinking about ways of bridging my previous work on racism in medicine, in mental health and metabolic health. That was part of my dissertation that became the book Blood Sugar. I was trying to think about ways to connect what I had been doing in that world to this world that I was now in. One of the things I looked at in my first project was pharmaceuticals that treat metabolic disorders and pharmaceuticals that cause them. In that book, I was looking at second generation antipsychotic medications and the fact that they essentially cause the condition known as metabolic syndrome.
I wanted to follow these drugs into the prison. So I asked this former prison psychiatrist what she thought about the use of psychotropic drugs inside the prison. She rocked back on her heels, smirked, and said, “Well, let me put it to you this way. Each year the warden sends me and my staff a nice bottle of something, because he knows we keep the prison quiet.”
It was a remarkable thing for her to have said. On one hand, it fed into the conspiratorial framework that has, in some ways, been justified by the ‘massiveness’ of our system. The New Jim Crow by Michelle Alexander certainly describes the massive system of mass incarceration as a conspiracy to re-enslave Black people, other people of color, and America’s poor.
I wanted to know if the good doctor was right. Was it the case that psychotropic drugs were being used to keep the prison on a “psychic lockdown?” There was so little published about this practice, which is why I even asked her.
That was in 2009, and that began for me what became a ten-year investigation of the relationship between psychotropic drugs and institutional captivity in the U.S. It began with this focus on prisons. But as soon as I began looking at the prison, I began to see connections to other institutions that function much like prisons.
On one hand, we know that psychotropic drugs, when used properly and carefully monitored, ideally under very short term conditions, can be helpful to people who are suffering forms of psychic trauma and life trauma. But the rules, the laws, and the regulations of these institutions, when given this powerful technology, create perversions of power. People who are held in these institutions are not always getting “care” as such. The drugging isn’t always just about their mental health, and improving it. Sometimes these drugs can be used to subordinate. I wanted to try to investigate that boundary between when we’re using a drug ostensibly for the right reasons, and when we’re using it for the wrong reasons.
Hatch: One of my fixations over the years on this project was trying to document what we knew and what we didn’t know. Why don’t we know these things, if prisons have been using psychotropic drugs since the 1950s? One of the things that I talk about in the book is the fact that for decades in the United States, prisons were the testing site for pharmaceuticals. Psychotropics entered the prison as ‘experimental medicines,’ not necessarily as things they were going to use for control. I became focused on understanding why we didn’t know certain things. We didn’t have survey data or health data. We only had legal cases to give us information about what was going on inside the prison, in terms of pharmaceuticals in general, and psychotropics in particular.
I didn’t want to have to seek permission from the prison to study the prison. That was an important political commitment, and methodological commitment, in doing this book. First of all, there are very rigid ethical rules regarding what you can do, such as getting access to prisoners, to prisoner health records, or any of the other things. Even getting inside would have to be framed as “wanting to improve prisoner mental health” or other kinds of liberal goals which may be worthwhile, but weren’t quite getting to the critical issue that I thought was important. In the book, I used only publicly available evidence, that any reasonably technologically savvy citizen could find.
I think it’s kind of lucky that we stumbled upon government audits of prison pharmacies. Because states, departments of corrections, and jail systems were spending so much money on pharmaceuticals through the 2000s in particular, the state and federal auditors were enlisted to go into the prison and to figure out what was going on. Over a period of years, my colleague Renee Shelby and I gathered thirty-three publicly available audits that show you what they’re doing. They document what the state sees itself doing with respect to these practices. You can get a sense of the entire economic and political system that facilitates the distribution of pharmaceuticals into the prison. It was a world that I hadn’t seen described anywhere. I felt it was important to try to describe how these different institutions work together to get drugs from pharmaceutical companies into the prison.
Hatch: The central idea to start with is pacification. When an institution faces a crisis, it’s got to solve the crisis somehow. The three institutions that I explore all have faced serious population crises in recent decades, due to really inhumane social policies. The sociology frame here is that you have institutions that have bad policies that don’t support people. They get into crisis and then the crisis has to be pacified. The crisis has to be solved. It has to be put down. The crisis has to be managed somehow.
Take, for example, active duty, U.S. military volunteers. In 2003, when the United States and the so-called “coalition of the willing” decided to invade the sovereign nation of Afghanistan, and then soon after, Iraq, they soon realized that they faced a real problem, which was that they didn’t have enough volunteers to actually people this new war on terror. And so, they changed a longstanding Department of Defense policy regarding who could volunteer. If you had had a serious mental health problem or were taking psychotropic drugs, you couldn’t volunteer for the U.S. military. They would turn you away. They were concerned about suicide risk, about all kinds of things. They changed that policy. The Department of Defense began shipping psychotropic drugs out into the live war zone, across the globe, for soldiers to use.
Again, they had never done this before. They had this inhumane and unjust policy, this war policy, that created a population crisis. They needed soldiers. And so then they figured out a way to keep soldiers on the battlefield. And that is literally the language that the Department of Defense uses: they say they want to “conserve the fighting strength.” Through multiple deployments, at any cost, they want to make sure that they’re keeping these soldiers on the battlefield.
The other institution I consider in this chapter is the U.S. foster system. Anyone who can perceive or has empathy knows that the foster system can be a dark place for young people who’ve already experienced much higher rates of sexual violence and trauma, other forms of abuse and neglect. And then they enter into this foster system, including the group home system. There they are administered psychotropic drugs at three, four, five times the rate of children in their local comparable communities. There’s just countless stories of overmedication in these settings to keep these kids “managed.” No one wants to deal with them. Systems aren’t in place to help them connect to family, to build family in new ways. And so they’re “managed” in this way.
And the same thing is true for elders in nursing homes. For decades, government regulators and activists have tried to get a handle on the ways that elders in nursing homes and assisted care living facilities are drugged. This is literally a cultural trope — the elder in the nursing home. You can’t watch a cultural representation, a movie, or a TV show about the nursing home and not see an elder in a chair somewhere, “Thorazined out.” It’s part of the cultural zeitgeist of this moment. Many of these elders are put on psychotropic medications soon after arrival, with no medical justification whatsoever. Up to a quarter of nursing home residents who are on these drugs don’t actually have a reason for being on them. As I write about in this chapter, part of the reason for this is the aggressive practices of pharmaceutical companies, who are actively promoting their products — in one case, through major fraud — in these institutions. Johnson and Johnson paid a huge $2.2 billion fraud settlement for pushing antipsychotic medications on elders for the treatment of dementia.
Taken together, these are all institutions that you can’t just leave. If you volunteer for the service, you can’t just walk away from that. If you’re held as an elder — some of those facilities are locked down, closed-door facilities. You can’t just leave. Similarly, for the kids in foster care, you’re a ward of the state. The state literally has possession of the body, legally.
It seems to be the case that the U.S. carceral state extends far beyond the prison. These institutions are all working very much like prisons do. The sociologist Erving Goffman called them “total institutions.” He said that they were society’s “dumping grounds.” Strong words, but they seem to apply in this case.
Hatch: This is one of the areas where I feel like it’s difficult for the science to speak to this question. I write about this a little bit. It’s difficult to know, from an empirical or scientific standpoint or through quantitative analysis of the data on mass shootings, gun violence, and psychotropic drug use. It’s very difficult to be able to say that these drugs are a causal factor in America’s mass shooting epidemic. When you look at our death rates from gun violence, both for suicides and homicides, it’s profoundly sad. But it’s very difficult empirically to prove this.
When you don’t have all the information, you’re forced to theorize. How do you explain what I see is a pretty troubling linkage between predominantly young men who commit gun violence of both the “mass” and “not mass” variety. So many of them reportedly were taking psych meds at the time of the shootings.
But we don’t exactly know how psych meds work. We don’t actually know what their specific mechanisms of action in the brain are. We know what effects they create, but we don’t know how they achieve those effects. And so in some ways there’s this little black box in terms of what these compounds are doing to our brain chemistry. People like Robert Whitaker and many others have written extensively about the clinical trial research, and the basic biological research into how these drugs work. And it seems to me to be hugely troubling that we don’t exactly know how they work yet, but we see these patterns of violence in our society to which they are linked. Outside the United States, however, this linkage has been made in several European countries, where they’ve identified that certain compounds are linked to suicide risk in youth and other forms of violence and death in society.
I think that efforts to try to keep guns from the hands of people who are identified as having serious mental illness, efforts to monitor their access to this constitutional right — whether or I agree with it or not, it is a constitutional right — are ill-conceived. They’re not considering another possible root cause that I think needs to be investigated further. So in some ways, this is one of the areas in the book where I think that more research needs to be done to try to figure this out. Because this combination of widespread societal psychotropic drug use and the mass availability of weapons is creating a situation where far too many of us are dying and being injured. Although it’s very difficult for me to say that A causes B.
Hatch: That is the big question that I tried to answer: Can we have this system of mass incarceration without these drugs? In what ways is our system of mass incarceration and mass captivity reliant or dependent on these drugs, these technologies, to function? We didn’t even talk about the use of psychotropics in privately run immigrant detention facilities, particularly among youth, which is hugely problematic, that is happening right now at the border. These institutions couldn’t do what they are charged with doing if they didn’t have these drugs to keep at least some people silenced.
They’re not doing it to everybody. I don’t want people to walk away with the misconception that prisons, and these institutions, are drugging every single person that they possibly can, with lines of people getting pills every day. That’s not exactly the picture that this book draws. It seemed to be that the “magic number” was twenty percent. You need to keep a fifth of them down in order for things to function.
This is a problem of them being too big. There’s far too many people held in captivity. The systems of captivity need to be much smaller and much more highly selective in terms of what they’re trying to do. You could have a system of incarceration in this country that is vastly smaller. Just contributing to decarceration would be one way to solve this problem. But these institutions have to rely on these drugs, because that’s the only way they can keep things going. It’s very simple: business as usual requires that they be able to manage both people who they believe have, and who do in fact experientially have serious mental disorders, as well as that other “fringe” element, that other random unruly element that is just taking up too much labor.
For example, in nursing homes they’re drugging people not because they’re causing fights, but because then they don’t have to attend to them as much. Like an alcoholic will spend their last dime for the next drink, these institutions are spending enormous amounts of money on pharmaceuticals generally, and on psychotropics in particular.
One of the facts I tried to evidence in this book was that the United States government, in all of its institutional diversity, is the single largest purchaser of psychotropic drugs in the world by far. As a citizenry, as a people, we have to ask: Why? This is supposed to be our government. We’re basically funding our government to incapacitate many of us.
The brilliant legal scholar Patricia Williams uses language I draw on in the book to describe this. She uses the language of “spirit murder.” Spirit murder involves a disregard for those people whose lives qualitatively depend on our regard. So these are people whose lives depend on us caring about them, because they’re in a position of vulnerability. They literally are held captive. We have to care for them. And our constitution, to the extent that you adhere to it, demands that. Basic human decency demands that. Social justice demands that we care for these people, and not subordinate them.
At Wesleyan, I teach a class on anti-psychiatry, which explores the intellectual and social history of that movement. One of the things I’ve learned from teaching that class, from researching this work, and from staying connected to what’s been happening in community settings, is that it is not to say that these medications aren’t helping people survive. For many people, they are. And it is not to say that every person who is using a psychotropic drug is a pawn in this grand conspiracy to subordinate society psychically. But it is to say that we can’t allow that meaning of psychotropics as therapy, as medicine, as healing to keep us from looking at ways in which they’re being used for harm. And so we’re looking carefully at those harms, and they are institutionally patterned.
The other point that I make in that concluding chapter is that just as the individual addict may be wreaking havoc in their own life, these institutions are also creating effects. We can document them and see them. Those patterns have effects on people’s lives, related to these drugs and how they’re used. That needs to be investigated. What I call for in the book is a “sobering” moment: a moment where we stop and really think about what we’re doing with so much pharmacopeia. Do we have to have this much pharmacopeia? It seems to me like a huge experiment. This is the worst kind of experiment, because it’s the one where no one knows who no one’s watching. The scientists are off the clock. And that, to me, needs to be fixed.
Hatch: In 2017 Otsuka Pharmaceuticals formed a partnership with Proteus Digital Health. This was a remarkable event in my mind. They sought and won FDA approval for Abilify MyCite. The pill itself contains a sensor, and the consumer of the pharmaceutical wears a patch on their skin that receives this transmission from inside the body. There are bioenzymes that are registered when the pill is consumed. So it’s a sci-fi, futuristic kind of enterprise designed to treat “adherence.” The idea here is that you’re going to take this Abilify MyCite so that the doctor or your family can know that you took the drug.
Proteus Digital Health is in financial trouble. They’re not making enough money. Abilify MyCite, which came out two years ago, is not really taking root in community settings. It seems unnecessary, partly because we know that adherence to a drug regime is not just a digital problem or technological problem; it’s a social one. From the research, we know that people have to have adequate family and social support, if they’re going to take medication on a regular basis. And they have to have the financial means to take that medication regularly, if that’s what their treatment plan indicates.
So maybe this Abilify MyCite was destined to fail. They should have perhaps done better market research before they put it out there. My colleague Ruha Benjamin, who’s been writing brilliantly about race and technology and ethics for years, raises this question. Just because we have the technological means and wherewithal to do something new, should we? I think many of these new developments in digital health and digital therapeutics raise that question for us. Why do we have to be transformed into these kind of ‘cybernetic figures’ in order to receive care and to be cared for? Why do we have to essentially bind with, fuse with, and hybridize with corporate technology?
There are many other health conditions for which technologies like this are currently being deployed. I think this was a new development, and one I feared at the time would be a problem. But just because Proteus Digital Health isn’t doing well, I wouldn’t assume that means we’ve seen the last of these kinds of technologies. I think people really ought to think carefully about what they mean.
Hatch: I looked at the RESPONSE Act, and it is a curious thing. On the one hand, it seems to provide much-needed resources and societal focus. But it also comes with this other side — this expansion of the state’s efforts to surveil, coordinate, and monitor the citizenry. To monitor the psychological well-being of the citizenry, and to control it. That is done in the name of ostensibly reducing risk, of reducing harm, increasing safety, creating a sense of security, a feeling of security. At the end of Silent Cells, I wrote that what’s being produced through the application of technocorrections is a feeling of “affective security,” a feeling that we’re safe from this “dangerous other.” It’s not really security. And that’s not the danger. The danger comes in the mechanism of control used to create this feeling.
And so it’s this magical kind of process where somehow we lose sight of the technology. It’s acting on us, but we don’t quite see what it’s doing to us, and how it’s ordering society. And how the technology is building a world that we have to then inhabit. The RESPONSE Act, and any effort to extend the boundaries of carcerality, has to be viewed in this context. The argument in Silent Cells is that you no longer need the physical cell of the physical prison, if you can create the prison in a person’s mind. So if you create a psychic prison, a mental prison, you no longer need the jail itself.
What is at stake is what it means to be institutionalized. If we extend these technologies out into the so-called “non-correctional world,” they’re expanding that domain of captivity. People often make this distinction between being in the prison and being so-called “free.” But I think there’s a kind of a coercion and institutionalization that happens “out here.”
On one hand, the RESPONSE Act, by extending what you might think of as “care,” is just changing who gets paid. It’s changing who benefits. Pharmaceutical interests have long known that the prison is a central site for profit-making.