Scott County, Indiana is beautiful in the springtime, a mix of sturdy midwestern farm country and those lush, Kentucky blue-greens that spill over the border to the south.
The skies are wide and heavy and auspiciously blue, close to the ground the way flat places seem to bring the heavens down. The radio is full of DJ’s yapping with excitement: Churchill Downs is just down the road, and the magnificent spectacle of the Kentucky Derby was run there this weekend. My hotel is decorated to match, with brightly colored plastic helmets taped above the front desk, and a variety of other, incredibly specific decorations — a large cartoon horseshoe, a chandelier made of shiny horse cut-outs, starting gate labels — that herald the coming run for the roses.
The people here are proud; it’s a close-knit community of just over four thousand, and the wily kind of post-thaw excitement hangs thick in the air, thankful for warm breezes and new leaves and an excuse to drink too much all weekend.
Despite their proximity the the mint julep-fueled opulence of the first Saturday in May, though, and despite all the money flowing fast and loose right across the Ohio River, Scott County is incredibly resource poor. And it is here, among the many shuttered businesses and the struggles of small town poverty, that the story of the HIV outbreak begins.
“The health department there didn’t offer HIV testing before the outbreak.”
This is not the first time that something Jamie Roberts tells me causes a near spit-take. She’s a program director at Step Up Inc, which works to promote health in Indiana, and for the last few weeks has been coming down from Indianapolis to do HIV testing in Scott County’s matchbox-sized health department and recently-opened one-stop community resource center.
Other things I almost spray her with saliva-infused coffee over: The fact that the health department does not offer pregnancy tests or STI screenings; that community members regularly come into one HIV testing centers with no practical or useable knowledge of the virus; that any money an organization receives from the State of Indiana cannot be used to purchase condoms.
That last one took some time to process. Too bad, HIV prevention efforts: Indiana does not want its money spent on rubbers.
From across the table, Roberts gives me the tight-lipped, loaded smile of a public health diplomat. Around us, brunch in a cafe that bills itself as a “student union for adults” unfolds with the usual streams of fussy pancakes and eggs; across the street, the capitol building in the heart of Indianapolis looms large. It’s a striking piece of architecture. It’s also where laws are passed that ultimately serve to restrict access to condoms and clean needles. It’s almost unfathomable.
The story of the HIV outbreak in Scott county reads like a litany of systemic dive weights put onto a community that was just trying to keep its head above water.
A few years ago, the Planned Parenthood in town shut down; Roberts tells me that she’s seen with her own eyes an increase in pregnancies in its wake, high school girls on their second kid, the usual shit. There’s no public transportation, and the lay of things is spread out enough to isolate those without wheels from potentially life-saving services. There are high rates of unemployment (8.9 percent compared to the state average of 5.9 percent), adults without a high school diploma (21.3 percent), and poverty (19 percent), all kindling for the fire of the current outbreak.
And then there are the drugs.
Drug use here makes sense the same way that drinking one’s self to death on a desert island does. As one addict told deputy state health commissioner Dr. Jennifer Walthall, use of the injectable semi-synthetic opiate oxymorphone—AKA Opana, the drug at the heart of the Scott County outbreak — makes everything okay, just for a moment. “The feeling is that you don’t need anything else.”
The drug problem in Scott county is entrenched, multi-generational, and occurs in families; it’s a metastatic cancer, not an easily excised tumor. The CDC reports that, per user, there’s an average of 4–15 injections per day, shared with as many as six people. According to a public health nurse with the Scott County health department, it is not uncommon for a single needle to be used upwards of 300 times, until it literally breaks off in someone’s arm. Although you can buy needles and syringes here over-the-counter, you have to sign a log and besides, the pharmacist can refuse to sell them to you anyway. And even if the needles flowed freely, it’s illegal to be in possession of such drug paraphernalia without a prescription. So, you can buy them. But it’s illegal to have them.
The problems of Scott County are not new, nor are they unique. All over the country, there are small, struggling communities full of good people just trying to stay alive. The drug problem, the lack of resources, the poor education — we’ve known about all of it. It’s nothing new. Hell, the State of Indiana is in the midst of a bad hepatitis C outbreak, with statewide cases in 2013 numbering at 5,758.
Hep C is, like HIV, a bloodborne, chronic disease, often transmitted by needle sharing. And, also like HIV/AIDS, it will definitely fucking kill you if left untreated. Yet, it took HIV — a disease with a better media pedigree — for action to be taken.
The needle exchange here is temporary, a small mercy from the governor, bequeathed upon Scott County and Scott County alone. It’s currently scheduled to close before the end of the month, but has already gotten one stay of execution, so there’s hope that it will remain open longer yet. Still, the idea that Scott County could ever solve this HIV crisis without it is ludicrous, and the likelihood of them ending this outbreak by solving the drug problem — sans infrastructure, of course — is about on par with that of the chances that I will one day grow a tail.
It’s not that Scott County isn’t doing great work: there are so many people there on the ground busting their asses to help pull this community back from the brink. But when there are laws in place that make even the most basic levels of harm-reduction out-of-reach (nevermind the burning garbage heap of social problems that allowed this trash fire in the first place), it’s the equivalent of stepping on someone’s neck and berating them for not standing up.
The phrase “HIV outbreak” is alarming. It gathers attention like a laser. “Decades of flawed-to-nonexistent healthcare infrastructure, and a collection of deeply intersectional socioeconomic issues like poverty, classism, and lack of education,” is more of the kind of phrase that gets people to close that tab before they even finish reading it. But that, dear reader, is the ugly truth at the core of this outbreak.
Again: Scott County is not unique. Scott County is the canary in the coal mine. Without the eagle-eyed notice of a nurse who spotted what they considered to be an usual cluster of a few HIV cases in a county that only saw a few each year, this place would still look just like so many of the other, countless towns that share the same poor, rural American pedigree.
In this way, I guess Scott County was just luckier than usual.