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CONNERSVILLE, Indiana — On the morning of Nov. 18, in this rural town in eastern Indiana, Paula Maupin sat in a trailer in the parking lot of a shuttered lumber company, hoping a few heroin addicts might turn up. She is a nurse with the Fayette County health department, and it was opening day for the county’s needle exchange program, one of three in the state. Maupin was there to offer drug users clean needles, anonymously, to remove dirty ones from circulation and stop the spread of disease. The trailer has no electricity — a generator runs the lights, a phone charger and a tiny space heater — but Maupin had bins of whatever a heroin addict might need — syringes in various gauges, aluminum cookers the size of a tea light, ampoules of sterile water, cotton pellets to absorb impurities, gauze, Band-Aids and tourniquets. “You offer them something that they will use and that they need, you get contact with them. And each encounter you mention the different other services that you have,” including HIV testing and referrals to rehab, Maupin explains. “A lot of times they're just really afraid to take that step.”
However modest, Fayette County’s syringe exchange program is a big step forward for Indiana, which banned syringe exchanges until last year. The Republican governor, Mike Pence, is a vocal opponent of the practice as condoning drug use, although it has been proven effective by years of research in preventing the spread of HIV and hepatitis. Even as 31 other U.S. states — including all four of its neighbors — opened the door to syringe exchange, Indiana kept it firmly shut. That changed abruptly in early 2015 when Scott County, another tiny rural community in central Indiana, reported dozens of new cases of HIV, all of them linked to a group of intravenous drug users who had been sharing needles. Under pressure from state and national public health experts, Pence signed an emergency measure in March 2015 establishing a needle exchange in Scott County and later allowed other counties to start their own. “The outbreak pulled it out of the realm of politics and morality and pushed people who had otherwise been more hard-line about this to a place of pragmatism,” says Daniel Raymond, policy director of the Harm Reduction Coalition, a national group advocating for more humane policies toward drug users.
But Indiana’s grudging acceptance of syringe exchanges has done little more than shift the state’s responsibility for a public health crisis to the communities that are least able to handle it. While allowing needle exchanges, Indiana has left in place a ban on state funding, requiring counties such as Fayette that need the programs to come up with the money on their own. “We’ve basically tied both hands behind our back after we said, go for it!” says Beth Meyerson, a professor of public health at Indiana University and co-director of the Rural Center for AIDS/STD Prevention.
A spokesperson for Pence said the governor’s “calendar is full” and declined to provide a comment for this article.
Indiana began investigating Scott County’s HIV outbreak on Jan. 23, 2015, and since then, public health experts in the state have been warning that other counties face similar challenges — a growing population of IV drug users with hepatitis (often a bellwether for HIV) and not enough testing, rehabilitation or primary care facilities to treat them. “Across Indiana there are 20 to 30 health departments that are seriously underfunded,” says Jerry King, executive director of the Indiana Public Health Association. “Those are all places that could experience the same things that Scott County has.” In December 2015, the federal Centers for Disease Control and Prevention identified several counties in Indiana as vulnerable to a similar HIV outbreak among IV drug users. But Pence, who faces re-election this year, has remained steadfastly opposed to lifting the ban on funding for needle exchange, despite the evidence that it works. A study published in January by George Washington University public health researchers, found that Washington, D.C.’s needle exchange program helped avert 120 new HIV cases over two years. While 22 counties aside from Scott have expressed some interest in needle exchanges, only two have managed to set them up. Advocates are calling on Indiana to lift the ban, before another outbreak hits. “The big thing that the state could do is to put some money behind it,” says Raymond. “That sends an important signal. It takes a key barrier off the table.”
U.S. counties where persons who inject drugs appear especially vulnerable to the rapid spread of HIV or hepatitis C
Based on preliminary data, this supplemental map to an unpublished CDC analysis identified the 220 counties in the U.S. that are most vulnerable (in the top 5 percent) to future outbreaks of HIV or hepatitis C among people who inject drugs. The complete study is under review for publication and has not been released by the CDC. The analysis does not indicate that the entire population is at risk, or that an outbreak is inevitable.
Fayette County is typical of the communities hit hardest by the recent wave of opioid addiction in the United States — it’s small and isolated, 96 percent white and 23 percent of the population is poor. Auto industry jobs, which once sustained the economy, have disappeared, and the population has shrunk so much that many towns in the county can no longer sustain a primary school. The auto parts giant Visteon, once the biggest employer in Fayette, closed its plant in 2007. But some things haven’t changed: the countryside is carpeted with corn and soybean farms, like the one where Maupin grew up, and teenagers still drive to the county seat, Connersville, to hang out at Kunkel’s Drive-In or the Pizza King.
Drugs, too, have been a constant. “Heroin has been around since I've been here,” says Carol McQueen, another local farm girl who took over as police chief in Connersville on Jan. 1, after more than 20 years in the police department. “There were just some people we knew who did it,” she says. “Then we started to notice that younger people were using it, then we started seeing it more frequently.”
In 2014, after a surge in overdoses drew intense statewide media attention, state, county and local law enforcement officials came together on a task force to crack down on dealers and users. “We've effectively slowed it in the last year,” says Detective Scott Phillips, Connersville’s narcotics officer. But users simply switched to methamphetamines or prescription opioids when heroin got hard to find — and then back again. “If you cut off one supply they’ll get it somewhere else,” Phillips says.
And the effort had no effect on overdose deaths: in 2014, there were 13 in Fayette County. In 2015, there were 14.
Meanwhile, Maupin was watching a parallel surge in hepatitis. In her role as the county’s public health nurse, she would investigate each case. “I could link, probably, at least 95 to 99 percent of that to IV drug use,” Maupin says. Some patients would confirm it directly. For others, she could figure it out. Connersville is a small town, and the names on the hepatitis reports were often the same ones listed in the Connersville News-Examiner police logs for arrests for drug possession or paraphernalia. Or she would find that they were Facebook friends with people who had died of overdoses. It wasn’t clear what the county could do about it. “We just kind of watched it,” Maupin says. “At that time, a needle exchange wasn’t an option. We didn’t know how to deal with it.”
In 2014, Maupin received 77 reports of hepatitis C in Fayette County; in 2015 there were more than 100.
Indiana health officials were watching too. Hepatitis cases related to IV drug use have been climbing across the state since at least 2011. The link between the two is well-established: typically, within five years of beginning injection drug use, a person will test positive for hepatitis C, Meyerson explains. In 2014, state representative Ed Clere, who was then chairman of the public health committee, pushed for a bill to study the possibility of a statewide syringe exchange program, in response to rising hepatitis rates. In the face of vehement opposition, it failed to get out of the state senate. But national advocates, including Raymond of the Harm Reduction Coalition, were encouraged that at least the issue was on the table in Indiana. Community groups and local public health officials were largely unfamiliar with how needle exchanges worked, so he started doing training and outreach sessions with them in early 2015. “They were also thinking that Indiana’s going to have a looming problem if we didn't try to advance needle exchange,” Raymond says.
That is exactly what happened.
In January 2015, Indiana disclosed Scott County’s sudden spike in HIV infections: 11 new cases in a town of 4,200 people. By April, there were 135 confirmed. Even veteran public health workers were shocked at the extent of the outbreak and the deep problems it revealed — three generations of injection drug use in a 10-block radius in one small town, where drug users were using dirty and broken needles and sharing them. But in other ways, the HIV outbreak was not surprising at all. Scott County had already seen a rise in hepatitis. “They're really just several steps away from HIV at that point,” Meyerson says. If one person in a tight network of drug users is exposed to HIV, it can spread very quickly. “The avenue of transmission is so efficient,” she says. “With sex you don't have that kind of efficiency. With a syringe, oh my God, it's a line right in.” In Scott County’s outbreak, 84 percent of the people who tested positive for HIV also had hepatitis, according to the CDC.
The response was swift. On March 26, 2015 the governor announced a syringe exchange program in Scott County, on an emergency basis, to stop HIV from spreading further. “Everybody's eyes were on Scott,” Meyerson says. “There was a lot of institutional support raining down on Scott to make this work.” The state’s public health officials brought in regional and national experts to advise the county on setting up the program, and quickly set up a “one-stop shop” to bring all the services that had been missing in the county — HIV testing, hepatitis treatment, subsidized insurance, ID cards — under one roof and easily accessible to people who needed it.
But the governor’s support was lukewarm. “I do not enter into this lightly,” Pence told The Indianapolis Star. “In response to a public health emergency, I'm prepared to make an exception to my long-standing opposition to needle exchange programs,” he said, emphasizing that he would veto any bill that proposed a statewide solution. So the legislature passed a compromise: a law that allowed syringe exchange programs to be established by individual counties, if they declared that there was a public health emergency due to hepatitis or HIV and that a syringe exchange was “medically appropriate.” The ban on state funding was left in place, so counties would have to come up with the money themselves, and could not pool their efforts to come up with regional solutions — even though 71 percent of Indiana counties have fewer than 50,000 people. Pence signed it into law in May.
When Maupin first heard the news about the drug-related HIV outbreak in Scott, she was worried. The two rural counties are alike in nearly every way, with similar populations, similar drug use and hepatitis problems and similar results in the state’s annual ranking or counties’ health outcomes— last and next-to-last. “I started thinking, hmmm, that's a problem here too,” Maupin says. “I wonder if we need to think about that.” But she was resistant — as were most in the community — to the idea of giving out syringes. “We were with the ones who thought, well that's just enabling them,” she says. But state officials strongly encouraged them to set up a program, she says, “and then you look more into it, you do your research, and you see the correlation between the sharing of the equipment and the disease and realize that there's really not any other option.” With the support of the county commissioners, Fayette submitted its needle exchange proposal last summer, and on Aug. 14, 2015, Maupin recalls, she got the phone call saying that they had been approved.
This is where the stories of these two counties diverge. While Scott benefited from top-down intervention by the state — and its “one-stop shop” is considered a model for other syringe exchanges — Fayette had to fend for itself. The county commissioner told her, “We might have a little bit of money that we could scrounge up for you to get started,” she recalls. For the rest, she turned to nonprofit grants, from the Indiana Recovery Alliance and AIDS United. When a potential spot for an office fell through, a neighboring county loaned them the trailer. The lot she found to park it in has no electricity, so the local emergency management director lent them his generator. The total budget is $22,400; she’s spent about $6,000 so far. “It took us until November to get enough funds, get everything set up and feel like we had enough to offer people,” Maupin says.
The first day she went out, she wasn’t sure if anyone would come. Rumors had been circulating, she says, that the police would arrest people coming out of the trailer and charge them with possession of drug paraphernalia. “It scared a lot of people away,” she says. “They were certain that it was being watched.” For weeks, as the temperature dropped, no one showed up except an addictions counselor who volunteered to sit with her. “It’s really just been myself and him on Thursday mornings sitting in a cold trailer for three hours.” By early January, the word seemed to have got out that this was for real. A few people have come to the public health office looking for her. “I had a woman who injects four times a day,” Maupin says. “One man has come in twice. He's our big advocate. He's really pushing it to his friends.” Another one has been talking about going into rehab.
The ban on state funding means that Maupin can’t ask the part-time nurse, whose position is funded by the state, to help her set up or move supplies from the trailer. Occasionally, the county’s food and sewage inspector or the births and deaths registrar give her a hand, but they, like Maupin, already have full-time jobs. She manages the syringe exchange program on top of her regular duties, which include everything from running flu shot clinics at local businesses to doing head lice checks for children to answering the call when someone faints at the courthouse and investigating reports of other communicable diseases. “I never realized how alone I was in this,” Maupin says.
The state also did not put any additional funds toward its broader public health needs, despite ranking 48th out of 50 states in per capita spending on public health. So, Fayette has had to patch together the services — HIV and hepatitis screening, detox and substance abuse programs — needed for syringe exchanges to work most effectively. “It’s not about the needles,” Meyerson says, but how to add all these services without additional money or manpower. “That's really the conundrum that faces rural counties not only in Indiana but all over the country. It's how do we add this on?”
In some counties, opposition from law enforcement can make needle exchanges untenable. That was not the case in Fayette, where the prosecutor’s office and the local police are largely supportive. The prosecutor recently made it clear that he would not seek to file charges against people for drug paraphernalia, as long as they were not also carrying drugs. The police, too, have begun to shift away from a purely enforcement-based approach to illegal drug use. Once a week, an addictions counselor comes in to talk to people at the station house, and officers hope to start sending referrals to a new rehab facility planned for the area. “We've kind of changed how we've thought in the last year,” says McQueen, the police chief.
Like the health department, the police in Connersville are not getting any additional funding for this. But if they don’t find help for people who are addicted, the town will pay in other ways, McQueen says. Drug use fuels property crime, as well as most of the cases they see of child abuse and child neglect. Her deputy chief, Robert Fee, has just one plea: Make more state money available for treatment, close to the places where people live. Otherwise, tiny police departments and tiny public health departments end up competing against each other for the same pool of funds. “Everyone's eating away at grants,” says Fee. “All that money can't be divided up everywhere.”
‘It’s not about the needles. That's really the conundrum that faces rural counties not only in Indiana but all over … how do we add this on?’
professor of public health, Indiana University
The irony in Indiana is that its HIV outbreak has prompted more dramatic change outside the state than at home. Two powerful Republican senators from neighboring Kentucky — Hal Rogers and Mitch McConnell — credited Indiana’s experience as the impetus for pushing to end the federal ban on funding for needle exchange late last year. But Congress has not set aside any additional funding for needle exchanges, so states and counties are waiting for guidance from the CDC and other federal agencies to see what funds are available and how to apply for them. “It's not going to be a massive infusion of new funds,” Raymond says.
Maupin, for her part, says she is sustained by her belief that she’s doing God’s work. “You get one problem solved and then something else comes along,” she says. “I have to be honest, it has been a lesson in faith.” The example of the people coming into the health department office for clean needles — passing the sheriff, the prosecutor and the probation office along the way — also keeps her going. “The ones that have come in, I think they're very brave,” she says. “They're taking a chance, I think, to come here. It gives me hope.”
Meyerson, however, worries that hope and prayer may not be enough for counties like these, forced to use duct tape and shoe string as a substitute for real investment in public health. “These communities, they're MacGyvering it. They're really trying. At that point, we've got to help them out. Don't make the counties figure this out on their own.”
Indiana ranks 48th of 50 states in dollars spent per capita on public health
Advocates say a lack of public health infrastructure, from HIV and hepatitis testing to primary care and rehabilitation services, makes poor counties in the state especially vulnerable to the effects of heroin addiction.