In late April, the Indiana legislature “voted to let any county that can prove it is experiencing a drug-linked outbreak of HIV or Hepatitis C . . . set up a needle exchange program.” Governor Mike Pence, who had previously been opposed to these programs, said that he was “looking forward to signing [the bill] into law.”
What prompted the about face was an outbreak of HIV—more than 150 confirmed cases—in Scott and Jackson Counties in the southeastern part of the state. Austin, Indiana, population 4,200, has “a higher incidence of HIV than ‘any country in sub-Saharan Africa,’” according to Tom Frieden, head of the Centers for Disease Control. In fact, Austin “had more people infected with HIV through injection drug use than in all of New York City last year.”
Austin is far from alone. According to USA Today, “HIV is already festering in many rural places. Although no outbreak has reached the size of Indiana’s, research reveals a high prevalence of HIV in some rural counties in the South, with more than half of cases outside large metropolitan areas in Alabama, Mississippi, South Carolina and North Carolina.”
Now, shooting smack is something you normally don’t associate with rural America. It’s more Manhattan than Mayberry. Yet intravenous drug use is what’s driving the HIV outbreaks in rural areas.
What’s driving the intravenous drug use is a story that is, arguably, even sadder.
Sam Quiñones, the author of “Dreamland: The True Tale of America’s Opiate Epidemic,” calls heroin “the fallback drug.” “Fallback to what?” you probably ask. It’s the fallback to prescription painkillers like Oxycontin and Opana. As you are probably aware, abuse of these “semi-synthetic opiates,” which as Quiñones told NPR, are “molecularly very similar to heroin,” has ravaged small towns and rural communities in recent years.
Eventually, users stop taking the pills to relieve pain and start using them because they are addicted. For a while, “pill mills,” and the unscrupulous doctors who ran them, made getting the drugs relatively easy. Eventually, state and federal officials started cracking down on these operations and made what pills were available on the street more and more expensive.
Enter the fallback drug, heroin, which the Atlantic called “a cheaper and, frequently, more accessible high.” That opened the door for Mexican drug cartels. In places like Portsmouth, Ohio, the setting for Quiñones’ book, the cartels combined lower prices and “customer service”—they would deliver heroin in the same way people delivered pizza—“to this new class of addict who were white” and often unfamiliar “with the drug world.”
This, in a grossly oversimplified way, is how we wound up with a small town in southeastern Indiana with a HIV infection rate exceeding sub-Saharan African nations. It’s how we got to three generations of the same family injecting drugs together, while “frequently sharing syringes.”
The story gets even sadder. To explain how, let me tell you about a train ride that my friend Dave the Swede (not his real name) took between Chicago and Washington last year. Along the way the train went through small towns in eastern Ohio and western Pennsylvania with abandoned houses, derelict cars, and trash as far as the eye could see. Then the train would pass the boarded-up factories.
In a word (actually, two words), these towns were dying and the communities within them were, as my brother once put it, “screwed.” It’s not a coincidence that books like “Dreamland” and “Methland” by Nick Reding are set in towns like the ones Dave saw from the train, whose economic bases have been hollowed out.
Nor is it a coincidence that Scott County, Indiana, Sheriff Dan McLain told the Indiana Economic Digest, “You drive through our small towns and see a lot empty storefronts. . . . Too many people here just feel hopeless.”
The release of “Our Kids” by Robert Putnam was the occasion for a back-and-forth between conservatives like David Brooks and Ross Douthat and liberals like Jeff Sposs and Elizabeth Stoker Breunig over whether the plight of people in places like Portsmouth, Ohio and Austin, Indiana, is rooted in culture or in economics. The obvious answer is “both.” As Douthat wrote, “The American economy isn’t performing as well as it once did for less-skilled workers. Certain regions— like Putnam’s Ohio—have suffered painfully from deindustrialization. The shift to a service economy has favored women but has made low-skilled men less marriageable.”
That’s probably an understatement.
At the same time, as Brooks insisted, what’s missing from many of these communities isn’t only money and better economic policies, but norms. To cite an example, it’s true that fewer marriageable men, a consequence of the economic hollowing-out referred to above, can be expected to lead to fewer married women, but it doesn’t logically follow that it should lead to more women giving birth to children out of wedlock.
And for a long time it didn’t. To quote Douthat again: “In a substantially poorer American past with a much thinner safety net, lower-income Americans found a way to cultivate monogamy, fidelity, sobriety and thrift to an extent that they have not in our richer, higher-spending present.”
Douthat and Brooks are correct when they argue that the worst effects of the Sexual Revolution and our increasingly normless culture are felt by the “the less-savvy, the less protected, the kids who don’t have helicopter parents turning off the television or firewalling the porn.”
Thus, people in places like Austin, Indiana, and Portsmouth, Ohio, are “caught in recurring feedback loops of economic stress and family breakdown, often leading to something approaching an anarchy of the intimate life.”
Why am I going on about this? Part of the answer is that I’ve been haunted by towns like the ones Dave rode through. My own hometown is a lot closer to Portsmouth, complete with a heroin problem, than it is to the comfortable D.C. suburb I live in. I’m aware that while I got out, a lot of people who weren’t all that different from me didn’t. Gratitude, not a sense of superiority, is the only fitting response.
Another part is that when Christians talk about stories like this one they bring to mind the adage “If you only have a hammer, every problem looks like a nail.” In this case, it means an almost exclusive focus on the cultural/moral dimension while ignoring the material reasons people might feel hopeless and seek oblivion in a pill or through a syringe.
I admit that I haven’t got a clue about what to do for these people and their communities. Their plight is, as social scientists might put it, overdetermined.
Like I said. Sad.