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.
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