What happens when you shut down health centers that provide HIV testing and ban programs that encourage drug users not to share needles during a spike in opioid use? In rural Indiana, the result was a surge in HIV infections. More than 80 people have tested positive for HIV in Scott County since mid-December, with most cases linked to intravenous use of Opana, a prescription painkiller.
The warning signs were there: Four years ago the Centers for Disease Control and Prevention advised of the rapid spread of Hepatitis C—which often accompanies HIV—among young drug users in Indiana, many of whom shared needles and other injection equipment. Indiana has the lowest per capita spending on public health of any state, while Scott County “has high rates of poverty and despair,” wrote Shane Avery, a local family physician. “Add to this a high rate of uninsured, low rates of completing a high school education, and insufficient access to public health services such as testing for sexually transmitted infections and mental services,” and you get conditions ripe for an addiction-fueled epidemic. The only clinic to offer HIV testing in the county, run by Planned Parenthood, closed in 2013, after state legislators pushed through a series of ideologically driven funding cuts.
Now, Governor Mike Pence has declared a state of emergency and is rushing in resources that should have been there all along. He’s also done something the CDC recommended four years ago, which is to suspend the state’s ban on making clean syringes and needles available to drug users. “In response to a public health emergency, I’m prepared to make an exception to my long-standing opposition to needle exchange programs,” he explained. It’s a very narrow exception, applying only for thirty days, and only in Scott County. “I don’t believe that effective anti-drug policy involves handing out paraphernalia to drug users by government officials,” Pence elaborated.
This is an incoherent position, and one that frustrates health workers and advocates. If needle exchanges are bad policy, why use them in an emergency? And if they are effective enough to warrant use now, why ban them otherwise? “Governor Pence will have to renew the emergency declaration for another 30 days, and keep renewing it indefinitely, until Indiana passes a permanent syringe exchange law,” Daniel Raymond, policy director for the Harm Reduction Coalition, wrote in an email. “There’s no medical, scientific or public health basis for a 30-day needle exchange program—it’s unrealistic to expect that within a month you can find everyone at risk and somehow get them to stop injecting.”
Research on the effectiveness of needle exchanges is neither new nor ambiguous. More than a decade ago the director of Health and Human Services conducted a review of the scientific literature and declared that such programs “can reduce the transmission of HIV and save lives without losing ground in the battle against illegal drugs.” Rather than encourage drug use, needle exchanges can have a positive impact on addiction by bringing users into contact with the health care system. The National Institutes of Health, Centers for Disease Control and Prevention, the World Health Organization, the American Medical Association, the Surgeon General, and the federal Substance Abuse and Mental Health Services Administration, among others, support their use to help prevent the transmission of blood-born infections.
A needle exchange in the Bronx, New York. (AP Photo/Bebeto Matthews)
And yet there is still a significant amount of resistance to needle exchanges. Largely it falls on party lines. Indiana is one of 23 states, most of them red, where they are illegal. The George W. Bush administration went to great and deceitful lengths to cast doubt on the science supporting exchange programs. In 2011, House Republicans reinstated a 1980 ban on federal funding for needle or syringe distribution, which had been briefly lifted in 2009. “A lot of it has to do with a focus on drugs as a criminal problem, and viewing addiction as the consequence of bad individual choices that warrant punishment,” Raymond wrote.
The politics are changing slowly, as the pressures of America’s heroin epidemic grow and conservative attitudes towards criminal justice shift. After a long debate the Kentucky legislature passed a comprehensive heroin-response bill last week that allows local health departments to set up needle exchanges. A bill working its way through the Florida legislature would green light a pilot exchange program in the Miami area. Nevada decriminalized the possession of syringes in 2013, opening the door to exchanges.
Lifting bans on needle exchanges is just a starting point. For instance, the Kentucky law directs no state funding to the programs, so the money will have to come from local coffers or donations. Preventative medicine should be a no-brainer for fiscal conservatives—at $84,000 for a 12 weeks of treatment, it’s much more expensive to treat Hepatitis C than to provide clean needles—but overall, there’s still a depressing level of petty ideological opposition to investments in public health, the most egregious current example being the refusal to expand Medicaid. Sexual and reproductive health remains a fraught battleground; in Texas, which has the third-highest number of HIV cases in the country, Republicans are currently trying to strip $3 million from HIV and STD prevention and redirect that money to abstinence education.
If lawmakers like Pence are only willing to support health care in response to crises, there will always be another crisis. Unlike the benefits of tax cuts the costs will fall disproportionately on the poor. As Shane Avery, the Scott County doctor, wrote, emergency assistance from the state “is temporary and managed by the most underfunded public health program in the nation. I wish to complement the assistance we have received from the [Indiana State Department of Health] to this point, but they must be allowed to do their job unobstructed by lack of funding, and political and religious views.” Arguing that “untold numbers” of lives are at risk, Avery continued, “I don’t wish to be alarmist, but this is our new normal.”