Donald Trump put Mike Pence in charge of the COVID-19 response in the United States. Pence has no background in medicine, science, public health, or any remotely related field. More importantly, he is an anti-science climate denier who is happy to put his small-minded prejudices before public health. We know this because of the last public health crisis that he was responsible for, the 2015 HIV outbreak in rural Austin, Indiana.
Austin is a town of a little more than four thousand people in southern Scott County, Indiana. When the cannery that provided jobs through the 1970s closed, it left a small depressed, isolated town. A quarter of residents live below the poverty level. The average person makes $15,600 yearly, half of the national average. And while the unemployment rate is only 3.9 percent, the true jobless rate is certainly much higher. This means that most people in Austin have low-wage jobs that provide no health care or other benefits. In this context, opioid addiction was and is widespread.
The drug of choice in Austin was the powerful painkiller Opana extended release. The active ingredient in Opana is oxymorphone, which is three times as potent as morphine. Opana is marketed as a long-acting pain killer, taken only twice daily, so each pill has an extremely large amount of drug. Since the pills could be easily crushed and snorted or injected, Opana quickly became a popular drug among intravenous (IV) drug users. Opana was reformulated in 2012, supposedly to make it “tamper resistant,” although the new formulation also extended the company’s patent protection and profits. Unsurprisingly, workarounds for the tamper-resistance soon followed. While the new drug was difficult to snort, five minutes on the internet provides step-by-step directions for how to prepare Opana for injection. It was this form of oxymorphone that Austin residents injected. Opana was later removed from the market as a result of continued abuse and the scandal in Austin.
While Opana was plentiful and cheap in Austin, IV needles were not. Indiana allows needles to be bought from pharmacies without a prescription. However, needles are considered “drug paraphernalia” and so possessing one is a felony. Buying needles from Austin’s single pharmacy was a guarantee of police harassment and arrest. As a result, needles would be passed around literally hundreds of times, sometimes being sharpened by hand to extend use. Needless to say, this is a perfect environment for the rapid spread of HIV and other blood-borne diseases.
To make matters worse, health care in Austin was near nonexistent. In 2015 there was a single physician in town and just one pharmacy. Until 2013 there was a health care provider in Scott County that did free HIV testing. Unfortunately for the people of Austin, that provider was a Planned Parenthood. Prior to being the governor of Indiana, Pence was a US congressman. He was responsible for pushing through cuts to Planned Parenthood funding nationally. In his first year as governor the Scott County Planned Parenthood closed due to lack of funding, cutting off the sole source of low-cost or free health care for thousands.
Just the next year, at the end of 2014, the only doctor in Austin diagnosed a number of cases of HIV among his patients. It would be three months before Governor Pence would take meaningful action to stop the spread of this disease.
Previously, there had been on average one diagnosed case of HIV per year in Austin. Five cases were found at the end of 2014. As testing expanded, it became clear that the disease had become widespread, with up to twenty new cases diagnosed per week. Ultimately, the total grew to 184 identified HIV cases, making 5 percent of Austin HIV-positive. Nearly all of those diagnosed also had hepatitis C, another deadly disease spread by reusing needles. Although hepatitis C can be cured, treatment costs in the neighborhood of $100,000 per patient.
Public health officials quickly identified this crisis and began to call for a needle-exchange program to prevent the further spread of disease. Needle-exchange programs provide needles to IV drug users, as well as disease screenings and offers of addiction treatment. Numerous studies have shown that these programs prevent the spread of disease while causing no increase in IV drug use. At the time, these programs were prohibited in Indiana.
In mid-January 2015, new HIV cases in Austin spiked. In late February, the governor acknowledged the crisis, but still refused to take any action. Pence informed Ed Clere, chair of the Indiana House Committee on Public Health he would still veto needle exchange legalization.
It wasn’t until March 26 that the Pence administration declared a public health emergency in Austin, allowing clean needles to be distributed. Pence reported that he’d waited so long before allowing an exception to the needle-exchange ban because he was praying for guidance. He stated, “I don’t believe in needle exchanges as a way to combat drug abuse, but in this case, we came to the conclusion that we had a public health emergency, and so, I took executive action to make a limited needle exchange available.”
Resources eventually poured into the area and the HIV outbreak was brought under control. Today Austin has a health center that provides mental health and primary care services in addition to addiction services. Although needle-exchange programs are now legal in Indiana, they can only start after a crisis is in progress. Under legislation Pence helped pass, a community has to document active transmission of blood-borne disease before they can implement a clean needle program. Furthermore, neither the state or federal governments provide any funding: all money has to come from private grants. Unsurprisingly, only nine Indiana counties currently have them.
Pence and his cronies clearly are to blame for this crisis.
Health-care cuts he championed allowed disease to spread undetected. Later testing showed that most of the cases of HIV were contracted prior to January 2015. Early interventions, provided by a robust, publicly funded health-care system, could have prevented almost all of these infections.
In Austin, Pence’s anti-LGBTQ and antiabortion religious prejudices exacerbated the spread of HIV. Refusal to allow harm-reduction strategies like needle-exchange programs guarantees health crises like Austin’s.
Pence’s insistence on putting his right-wing beliefs before public health and actual evidence will only make our current crisis worse.
The first death from COVID-19 just occurred in a nursing home in Washington state. It now appears that the virus has been circulating in the area for weeks. Considering the cramped conditions that are universal in extended-care facilities, it is almost certain that all of the other inhabitants have been infected, as well as many visitors and employees. Cuts to health-care funding (from both Republicans and Democrats) reduce the possibility that the virus’s spread can be slowed, and means that our health-care system is certain to be taxed and overwhelmed when more cases start to emerge.
Health-care disparities between urban and rural areas, as evident in Indiana, as well as between the rich and poor, make it likely that more undiagnosed cases will linger and spread. And jobs with little or no benefits make it more likely that people will be forced to come to work while sick, potentially spreading COVID-19. We need equal, universal, well-funded health care as a right. And we need competent people heading up the current fight against COVID-19, not an unqualified political appointee who happens to have nothing else to do. Especially in a crisis, the bigotry of those in power poses a life-threatening danger to the rest of us.