On Monday afternoon just before lunchtime, Foundations Family Medicine in Austin, Indiana, was deserted. One patient came in to schedule an appointment at the check-in window, surrounded by comfortable leather chairs and sterile taupe walls painted with sayings such as: “The greatest wealth is one’s health.”
However, behind the ordinary doctor’s office walls, marked with signs pledging that the practice serves people regardless of income, staff were ramping up for a full-state medical intervention.
Indiana Governor Mike Pence last week declared a public health emergency in Scott County because of an HIV outbreak that began in December last year and is tied to at least 84 people, primarily intravenous drug users in Austin — a city of nearly 4,300 people.
Illustration: Yusha
Sherry McNeely has been a nurse at Foundations Family Medicine for the past four years and was born and raised in Scott County. Two weeks ago, she began testing patients for HIV for the first time, after receiving state-sponsored training to help respond to the crisis.
“Every time someone comes in with an addiction problem or tests positive for HIV, it could be your next-door neighbor, or your cousin, your brother, your sister,” McNeely said.
Most of the people affected can only get to the doctor’s office — the only one in town — by walking, and do not have access to televisions or other media that show how deeply the outbreak is affecting the community.
“People aren’t standing out on the streets, at the stop sign, shooting up,” she said.
However, the town is attracting a network of clinicians — including addiction and infectious disease specialists — working to contain the outbreak and to figure out how to stop something similar happening in other rural communities. Many health workers from Indiana and surrounding states traveled to Austin on Tuesday, some picking up colleagues along the way, to help the city open its first HIV clinic.
“It’s not just a health risk to the using population in this case; it is how did the system miss it? Well, in southern Indiana, there is no system,” said Beth Myerson, an assistant professor of applied health science at Indiana University and codirector of the Rural Center for AIDS/STD Prevention, which is centered at the university.
While public health officials said they did not know such a crisis would hit Scott County, Myerson said there were clear signs that an infectious disease outbreak was brewing in the rural drug-using population, and she and other health experts believe the extent of the Scott County outbreak is much greater than is known.
Indiana’s nickname is “the crossroads of America,” because of the many major highways that pass through the central part of the state. This means it can also be a conduit for spreading disease.
Studies show how the spread of sexually transmitted infections like syphilis and HIV can be tracked along highways and based on what is known about at least one patient, who works in the sex trade at truck stops, Myerson expects the same thing could happen in Scott County.
“If we learn anything from this outbreak, I hope that we learn that we need to invest in this system and build it so it is much stronger,” Myerson said.
There are opportunities to do so. Pence is one of a few Republican governors to accept federal funds to expand his state’s Medicaid program, and under US President Barack Obama’s Affordable Care Act, preventive services such as HIV testing are covered by insurers.
Yet the amount Indiana spends on public health funding puts it at 37th in the US, and of every state it receives the least amount of money from the US’ Centers for Disease Control and Prevention and the Health Resources and Services Administration, according to the American Public Health Association.
Indiana ranks so low because the state’s public health structure lacks sufficient staffing and resources to qualify for federal funds from agencies that are facing budget cuts.
“We’re fighting the good fight with two hands tied behind our back because we’re not able to respond,” Myerson said.
Until the state intervened, Scott County residents were wholly reliant on local practitioners who, while hard-working, often lack the resources, training and specialists needed to prevent and respond to a crisis.
“Not only is there the HIV outbreak with IV drug use, but we’ve got high-risk sex situations that need to be taken care of too,” McNeely said.
She said when the city’s Planned Parenthood health center closed in 2013, it left the small town’s many pregnant teenagers with fewer resources for care and support, including its only source for HIV testing.
McNeely said part of her job has been explaining to people why they do not need to worry about catching HIV in an examination room or while shopping at the grocery store.
Foundations Family Medicine plans to address this at a town hall meeting this month but, in the meantime, the office has seen a small decline in the number of patients visiting the office since the outbreak — and their role in caring for people affected by it — became public.
Medical workers therefore have had to plaster the city with posters to let people know about the wealth of resources the state has dispensed to the county in response to the outbreak.
One area public health workers are hoping to make progress on is needle exchange programs in an attempt to limit the spread of disease. These type of programs, combined with addiction counseling, have been found by the WHO and the American Medical Association to be effective methods of reducing the spread of HIV.
“It’s not just about trading needles, it’s about getting people into a system of care,” Myerson said.
However, Pence has remained obstinate about his opposition to needle exchange programs, which public health workers say are key to mitigating this crisis. Opponents believe that these programs encourage people to continue using drugs.
“I don’t believe effective anti-drug policy involves handing out drug paraphernalia,” Pence said on March 26, when he announced that he would allow a needle exchange program in Scott County for 30 days.
Public health experts said this would help the crisis, but it is clear that the 30-day timeline will not offer a long-term solution to the problem.
Dan Bigg, cofounder and executive director of the Chicago Recovery Alliance, went to Austin on Tuesday to help set up a needle exchange program. He hopes that if the program is effective while it is legal in Scott County, the governor could be convinced about how it could help other parts of the state experiencing similar issues.
“I can’t tell you the amount of times I’ve heard from caregivers in northwestern Indiana who’ve wanted to do something but their hands were tied,” Bigg said.
Well before this crisis, Indiana House of Representatives member and chairman of its Public Health Committee Ed Cler, a Republican, was pushing for legislation that would expand access to needle exchange programs.
“The fact is that the situation could repeat itself anywhere else in Indiana at any time,” Clere said.
He has been working with people like Myerson to develop a comprehensive plan to reduce harm from drug use by breaking up the state into four areas, and introducing needle exchange programs according to the anticipated risk the area has of attracting a crisis similar to the one in Scott County. While he wants needle exchange to be legal for the whole state, he narrowed the plan because of the governor’s concerns.
“The governor has declared a public health emergency in Scott County, but we can’t just wait for the next emergency because then it’s too late,” Clere said. “If we find a way to introduce needle exchange in high-risk areas, then we have the potential of preventing the next outbreak before it starts.”
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