Friday, May 06, 2016
medicalxpress | Jessica and Darren McIntosh were too busy to see me when I arrived at their house one Sunday morning. When I returned later, I learned what they'd been busy with: arguing with a family member, also an addict, about a single pill of prescription painkiller she'd lost, and injecting meth to get by in its absence. Jessica, 30, and Darren, 24, were children when they started using drugs. Darren smoked his first joint when he was 12 and quickly moved on to snorting pills. "By the time I was 13, I was a full-blown pill addict, and I have been ever since," he said. By age 14, he'd quit school. When I asked where his care givers were when he started using drugs, he laughed. "They're the ones that was giving them to me," he alleged. "They're pill addicts, too."
Darren was 13 when he started taking pills, which he claims were given to him by an adult relative. "He used to feed them to me," Darren said. On fishing trips, they'd get high together. Jessica and Darren have never known a life of family dinners, board games and summer vacations. "This right here is normal to us," Darren told me. He sat in a burgundy recliner, scratching at his arms and pulling the leg rest up and down. Their house was in better shape than many others I'd seen, but nothing in it was theirs. Their bedrooms were bare. The kind of multigenerational drug use he was describing was not uncommon in their town, Austin, in southern Indiana. It's a tiny place, covering just two and a half square miles of the sliver of land that comprises Scott County. An incredible proportion of its 4,100 population – up to an estimated 500 people – are shooting up. It was here, starting in December 2014, that the single largest HIV outbreak in US history took place. Austin went from having no more than three cases per year to 180 in 2015, a prevalence rate close to that seen in sub-Saharan Africa.
Exactly how this appalling human crisis happened here, in this particular town, has not been fully explained. I'd arrived in Scott County a week previously to find Austin not exactly desolate. Main Street had a few open businesses, including two pharmacies and a used-goods store, owned by a local police sergeant. The business with the briskest trade was the gas station, which sold $1 burritos and egg rolls. In the streets either side of it, though, modest ranch houses were interspersed among shacks and mobile homes. Some lawns were well-tended, but many more were not. On some streets, every other house had a warning sign: 'No Trespassing', 'Private Property', 'Keep Out'. Sheets served as window curtains. Many houses were boarded up. Others had porches filled with junk – washing machines, furniture, toys, stacks of old magazines. There were no sidewalks. Teenage and twenty-something girls walked the streets selling sex. I watched a young girl in a puffy silver coat get into a car with a grey-haired man. I met a father who always coordinates with his neighbour to make sure their children travel together, even between their homes, which are a block apart. Driving around for days, knocking on doors looking for drug users who would speak with me was intimidating. I've never felt more scared than I did in Austin.
The mystery of Austin is only deepened by a visit to the neighbouring town of Scottsburg, the county seat, eight miles south. It's just a bit bigger than Austin, with a population of about 6,600, but it's vastly different. A coffee shop named Jeeves served sandwiches and tall slices of homemade pie, which you could eat while sitting in giant, cushiony chairs in front of a fireplace. A shop next door sold artisanal soap and jam. The town square had a war memorial and was decorated for Christmas. The library was populated. The sidewalks had people and the streets had traffic. There were drugs in Scottsburg, but the town did not reek of addiction. The people didn't look gaunt and drug-addled. No one I asked could explain why these two towns were so different, and no one could explain what had happened to Austin. But a new theory of public health might yet hold the answer. Known as syndemics, it may also be the one thing that can rescue Austin and its people.
The term syndemics was coined by Merrill Singer, a medical anthropologist at the University of Connecticut. Singer was working with injecting drug users in Hartford in the 1990s in an effort to find a public health model for preventing HIV among these individuals. As he chronicled the presence of not only HIV but also tuberculosis and hepatitis C among the hundreds of drug users he interviewed, Singer began wondering how those diseases interacted to the detriment of the person. He called this clustering of conditions a 'syndemic', a word intended to encapsulate the synergistic intertwining of certain problems. Describing HIV and hepatitis C as concurrent implies they are separable and independent. But Singer's work with the Hartford drug users suggested that such separation was impossible. The diseases couldn't be properly understood in isolation. They were not individual problems, but connected.
Singer quickly realised that syndemics was not just about the clustering of physical illnesses; it also encompassed nonbiological conditions like poverty, drug abuse, and other social, economic and political factors known to accompany poor health.