Paula Maupin noticed a difference almost immediately after her patients started shooting clean. Gone were the nasty infections and festering abscesses peppering the arms of the patients who walked through her doors, sometimes leading to gruesome outcomes. “I’ve had two people who almost lost limbs because of abscesses,” she said. “Using clean needles, when you don’t have to shove the same dirty needle in your arm 30 times… It really makes a difference.”
Maupin wasn’t always so certain. A public health nurse with Indiana’s Fayette County Health Department, Maupin and her colleagues were initially skeptical about introducing a needle exchange program to their community. “We all sat and discussed it and thought ‘there’s no way we’re going to do that,’” she recalled. There was a powerful perception among many in the state that needle exchange programs — which provide injection drug users with access to clean needles — would enable or encourage addiction, and Fayette health officials didn’t have much background about their public health benefits.
But less than two hours away, the worst HIV outbreak in Indiana’s history was raging through Scott County. The outbreak surfaced in Austin, a rural town with a population just above 4,000. By March 2015, there were more than 80 confirmed cases of HIV in the county, nearly all of which were linked to shared needle use of prescription drugs. The soaring HIV rates drew widespread media attention, and reporters descended upon the quiet community to cover the fallout.
Officials in Fayette took notice. The two counties shared a number of demographic similarities, including high rates of hepatitis C, which is spread through the blood and linked to injection drugs. So Maupin began to do her own research, and was quickly convinced of the public health benefits of needle exchange programs.
Despite evidence of their effectiveness, such programs were banned in Indiana. But mounting pressure from public health experts pushed Gov. Mike Pence (R) to approve a temporary emergency needle exchange program in Scott County and later permit counties, like Fayette, to establish their own programs on an individual basis — provided they find their own funding.
Pence, now the Republican vice presidential nominee, had been known for his vocal opposition to syringe exchange programs. “I do not enter into this lightly,” he declared at a press conference after approving Scott County’s program. His reluctant acceptance of the emergency measures prompted the recent New York Times headline: “Prayer, and Then A Change of Heart.”
“If I were to sum up Mike Pence and his approach to any of this, it would be ideology trumping evidence every time.”
For many of the governor’s critics, however, that’s an exceptionally rosy characterization. In their eyes, Pence’s tepid response to the HIV outbreak was not a laudable feat of moral acceptance in the face of crisis but a confirmation of a worrisome outlook on public health issues. Many believe he dragged his feet to address a dramatic crisis that could have been preventable with a stronger public health infrastructure. Others say his response to the outbreak was entirely consistent with his approach to health — one that is governed by personal belief rather than medical need, often at the expense of his constituents.
“If I were to sum up Mike Pence and his approach to any of this, it would be ideology trumping evidence every time,” said Beth Meyerson, a professor of public health at Indiana University and co-director of the Rural Center for AIDS/STD Prevention. “Under the Pence administration there has been a very clear message that public health is not a priority and any of the moral policy issues that could be at play will rule over public health evidence and population needs.”
Although Pence did temporarily lift the ban on needle exchange programs in Scott County, he made it clear that he would not support a statewide effort. “I am opposed to needle exchange as anti-drug policy,” he remarked. “But this is a public health emergency and, as governor of the state of Indiana, I’m going to put the lives of the people of Indiana first.” He also signed legislation that left in place a ban on funding for the needle exchange programs, placing the financial burden for purchasing syringes on the often rural, cash-strapped counties.
“This governor did no favor to public health beyond the signing of the law,” Meyerson added.
Indeed, Pence is well-known for championing conservative social issues: In less than one term as governor, he has signed eight anti-abortion bills and a notorious “religious freedom” law legalizing discrimination against LGBTQ people. Pence opposed legislation encouraging teens in the state to get vaccinated against HPV and, as a congressional candidate, advocated for diverting HIV/AIDS funding to programs that promoted changing sexual behavior. He also introduced the first federal measure to defund Planned Parenthood; slashed state public-health budgets; and cut funding for smoking prevention programs after famously claiming that “smoking doesn’t kill.”
Those positions have many worried that a Trump-Pence ticket could empower the Indiana governor to export his public health approach to the national stage.
“This isn’t the kind of representation that we as a state need, and that we as a country want [in a vice president],” said Dr. Katherine McHugh, an OB-GYN based in Indianapolis.“The Scott County HIV epidemic is a great example of the ignorance of Mike Pence and people like Mike Pence, who try to stick to these lofty, utopian ideals, like ‘well if we just stop providing any kind of needles or support this opioid epidemic will just go away.’ … Not only is the opioid epidemic still going strong in Indiana and everywhere in the country, but then we had this huge and horrible public health crisis, this HIV outbreak from all the dirty needles.”
“It’s a great example of how his policies really and truly affect people on a very real basis. These people now are forever affected and infected because of his inability to see reason.”
HWith an influx of drugs into the community and a significant increase in cases of hepatitis C, community health workers saw the potential for an HIV outbreak and braced themselves for the worst. “We knew it was a only matter of time until HIV set in,” William Cooke, a physician based in Scott County, told NBC last year. “We’ve been asking for help for a long time. We identified long ago there was an undercurrent here that was very unhealthy.”
The predictions later proved accurate: By April 2015, there were more than 80 confirmed cases of HIV in Scott County, with as many as 22 HIV cases diagnosed per week at the height of the epidemic. Many of the cases were tied to the use of Opana, a powerful opioid that drug users would often grind up and inject through shared, dirty needles. By the time Pence declared a public health emergency in March 2015, two months had passed since the Indiana Department of Health began investigating 11 HIV cases that were confirmed in Scott County earlier that year.
Now, the needle exchange program has been credited with dramatically curbing the virus’ spread in Scott County. But experts say the outbreak was entirely preventable. A recent study in the New England Journal of Medicine concluded it could have been avoided with more comprehensive public health policies, including HIV testing and needle exchange programs. In spite of the risks — and a substantial body of research demonstrating that needle exchange programs effectively curb the spread of disease — a needle exchange program wasn’t introduced in Scott County until after the HIV outbreak surfaced and Pence warily approved the emergency measures.
Critics charge that the governor’s response was insufficient and unnecessarily lengthy — the effects of which will be felt for years to come.
“It’s the governor’s refusal to address this situation that I believe will result in Indiana’s most historic failure in public health,” declared Dr. Shane Avery, a family physician in Scott County, at an April 2015 legislative hearing on expanding the program statewide.
“These people now are forever affected and infected because of his inability to see reason.”
The law Pence signed in May 2015 was something of a compromise: It permitted counties to apply for their own needle exchange programs but did not lift a ban on state funding for those same programs. That limitation has presented a significant challenge for many communities trying to get their programs off the ground, particularly small counties already operating on meager budgets.
“I honestly feel like it was somewhat setup to fail given the fact that it wasn’t given any resources and there were a lot of hoops jumped through,” said Dr. Carrie Lawrence, a scientist at the Rural Center for AIDS/STD Prevention.
Fayette County’s Maupin experienced first-hand the constraints presented by the lack of resources. “It was rough,” she said. “Our councilman got approached by the state, and the state said ‘you have a really high hepatitis rate and you need to do this,’ and they basically said ‘we’re flat broke; we don’t have money to fund a program.’”
Left to cobble together the funding herself, Maupin sought help from the Indiana Recovery Alliance, an organization that operates a mobile unit and distributes syringes. The head of the organization, Chris Abert, gave her some supplies to get started and passed along a list of grant opportunities from foundations and nonprofit organizations. In total, Fayette was able to scrape together around $27,000 to sustain the program, which the state department of health recently renewed to operate for another year.
But it could be a challenge to stretch that funding if the program, which currently has 20 participants, expands. “When we have the amount of people I’m expecting, we’re going to burn through that money pretty quick,” Maupin told the Associated Press in March.
Abert’s organization hasn’t benefited from any state funding either, despite operating what Lawrence calls the most comprehensive syringe exchange program in the state.
The Indiana Recovery Alliance relies on grants from foundations and in-kind donations from other organizations to stay afloat. “Policies are only as effective as the resources attached to them,” Abert said. “Everything we’ve done — given out 3,500 doses of naloxone, hundreds of treatment referrals, distributed hundreds of thousands of dollars of harm reduction supplies — we’ve done that without any funds allocated from the state. The local health departments haven’t had any extra money allocated for their programs; they have to re-allocate existing funds.
“I just think it’s ridiculous that we are dependent on grant writing and selling T-shirts to try to meet this public health issue.”
Stephenie Grimes, who coordinates the needle exchange program for Indiana’s Madison County, says the biggest financial barrier for her program is the purchase of actual syringes. So far they’ve been able to manage, thanks to syringe donations from community members and small grants. “Just when I’m at my wit’s end, something seems to happen and it works out,” Grimes said. “I get emotional talking about it because we have residents from the community who say, ‘hey I have a whole bunch of syringes; can I donate?’ We have had syringes donated by our hospital, we have had local foundations that have given us money to purchase syringes.”
Without any financial support from the state, those lifelines have been crucial in sustaining several county needle exchange programs throughout Indiana. Many health providers, like Maupin, heard about the HIV rates in Scott County and and saw the potential for an outbreak within their own communities. “It was a big concern,” Maupin explained. “We’re really similar to Scott County. I was really concerned that we were going to have that same issue.”
And it’s not just Fayette. According to Jerry King, the executive director of the Indiana Public Health Organization, there are anywhere from 15 to 20 health departments within the state that look like Scott County’s — places with struggling economies and limited resources for public health programs — putting Hoosiers at risk for a range of poor health outcomes.
“With the exception of just two or three health departments in Indiana, every health department is underfunded, especially at the rural level,” King said.
IThat legacy has continued under Pence’s leadership. During his tenure as governor, Pence signed legislation that slashed Indiana’s public health budget and oversaw a decrease in public health funding from $17.43 in 2012 per person to $12.40 today. Today, Indiana ranks 46th out of 50 states in per capita spending on public health.
The need for a greater statewide emphasis on public health is clear: A 2015 report from America’s Health Rankings placed Indiana 41 out of 50 states in overall health, listing low levels of public health funding, air pollution, and smoking as the state’s three most pressing public health issues.
On smoking in particular, Pence’s record is noteworthy. Indiana has the seventh highest smoking rate in the nation, with the smoking rates among pregnant women nearly double the national average. And yet, Pence has gutted funding for smoking prevention programs and, as noted earlier, taken the unusual position that smoking is not linked to death: “Time for a quick reality check,” he wrote in an 2000 op-ed. “Despite the hysteria from the political class and the media, smoking doesn’t kill.”
Pence also rejected a proposal to raise the state’s cigarette tax by five cents a pack — despite a large body of research showing higher cigarette taxes can reduce smoking rates — and voted against the Family Smoking Prevention and Tobacco Control Act as a member of Congress.
Pence, who often touts his economic record as a conservative success story, has taken these positions despite their toll on the economy. According to a 2014 study, the state spent nearly $3 billion on smoking-related health costs. He did, however, get a boost from major players in the tobacco industry: As ThinkProgress previously reported, Pence has received more than $100,000 in donations from tobacco companies throughout his political career.
“He has very significantly impacted my patients and my practice. I encounter opposition and issues because of his policies on a daily basis.” — Dr. Katherine McHugh
His penchant for health-related cuts doesn’t end there. During Pence’s time in Congress, he also voted against increased funding for the Children’s Health Insurance Program, which provides insurance for low-income children who cannot afford private coverage.
Nevertheless, both Trump and Pence have highlighted the Indiana governor’s record on the campaign trail, praising the state’s balanced budget and tax cuts — a dynamic Meyerson and others are quick to point out as they evaluate his legacy on public health.
“He calls himself a fiscal conservative but at what cost? The cost is the health of the Indiana population,” Meyerson said. “There is no investment in the health of Hoosiers, and our health outcomes demonstrate this.”
“If Planned Parenthood wants to be involved in providing counseling services and HIV testing, they ought not be in the business of providing abortions,” Pence told Politico in 2011. “As long as they aspire to do that, I’ll be after them.”
He wasn’t the only one. State funding cuts initiated that same year eventually forced five Planned Parenthood clinics to close across the state, including the only health center that offered HIV testing in Scott County. The embattled county remained without an HIV testing clinic for two years even as the HIV epidemic mounted, from 2013 until the spring of 2015.
And then there is Pence’s support of a recent anti-abortion bill so extreme it garnered push-back even among anti-abortion Republicans in the state. The bill, HB 1337, which Pence signed into law in March of this year but is currently stayed, prohibited women from seeking abortions on the basis of a fetus’ race, sex, or a diagnosis of mental or physical disability — and imposed penalties on the doctors who performed them. It also required abortion providers to bury or cremate aborted fetal tissue.
Although some of these restrictions are in place in other states — North Dakota, for instance, bans abortion on the basis of genetic abnormality, and Arizona on race — together, these provisions made Indiana’s law one of the most expansive of its kind.
Elizabeth Nash, the senior state issues manager at the Guttmacher Institute, calls it “the broadest and the most restrictive” law banning abortion for specific circumstances.
“No other state bans abortion for all of those circumstances — sex, race, genetic anomaly, or the fetus’ national origin, ancestry or color,” she added.
The bill’s provisions even drew opposition from stalwart anti-abortion Republicans in the state legislature, who argued the measure represented government overreach. “It’s a sad day for me to have to vote no on a pro-life bill,” said Representative Cindy Ziemke. “I have never had to do that before. I never thought I would ever have to.”
The push-back extended to those well outside the political arena. When Sue, an Indiana resident, heard that Pence signed HB 1337 into law, she decided she’d had enough. Sue wasn’t involved in politics or local activism — “I’m just a normal person… just a wife and a mom,” she says — but the law struck her as exceptionally punitive, and antithetical to pro-woman and family values.
So Sue, who asked that her real name not be used but instead goes by “Sue Magina” in interviews, decided to do something.
“I remember I looked at my husband and I was like, ‘if they’re going to ask us all of these personal questions and they want to know as much, we might as well just keep calling and telling them when we get our periods.’ He looked at me and he was like, ‘you might be onto something.’ And I went on Facebook and took about 20 minutes and threw up a Facebook page.”
— Susurrus (@zomboid_muse) August 2, 2016
Sue wasn’t expecting many followers — maybe 150 likes from family members and friends — but the effort clearly struck a cord. In a matter of days, it had thousands of followers, eventually gaining the more than 74,000 Facebook followers it has today. The campaign, though tongue-in-cheek, reflected deep concerns among women who found the law disturbingly intrusive.
As an OB-GYN, McHugh was particularly concerned about the ways the bill would impact her patients, many of whom McHugh says come from the city’s poorest neighborhoods and would struggle to find the resources necessary to support children with disabilities.
“I couldn’t believe that Mike Pence and his colleagues would just truly turn their back on the most desperate of patients, these women who are now forced to make these choices, who would have been forced to give birth to babies who maybe wouldn’t live, or maybe would live with profound disabilities,” she said. “And of course to do that in a state that doesn’t provide good services and childcare and preschool and all of these family-friendly things, that doesn’t exist here in Indiana, largely because of Mike Pence’s influence.”
— alpha cancer 🦀♋ (@assilem665) July 24, 2016
Pence has taken a number of other controversial positions on reproductive health. Despite Indiana’s low HPV vaccination rate — less than 50 percent of teenage girls and 15 percent of boys have gotten all three shots — Pence opposed legislation encouraging teenagers to get the HPV vaccination over concerns about “government overreach.”
Similar concerns came up when the Indiana Department of Health sent a letter reminding parents to vaccinate their children against HPV. The letter drew criticism from the executive director of the Conservative Family Association of Indiana, who, in an angry email to supporters, called it “intrusive” and expressed “frustration with Indiana Government as a ‘papa bear.’” Pence agreed to look into it, and several days later, the State Department of Health changed the letter to include language about the vaccination being “optional.”
Pence’s unwillingness to support HPV vaccination is an example of what the Rural Center for AIDS/STD Prevention’s Beth Meyerson calls “moral policy.”
“What Mike Pence showed in that policy scenario was a clear position against the public health evidence, which in this case, was the safety and effectiveness of this vaccine,” she said. “His approach to public health has not been based on evidence but based on ideology… it’s about his personal belief system and that of those around him.”
That belief system, critics say, has harmed Indiana residents and health care providers and demonstrates his priorities in the face of a crisis. It also offers a glimpse into Pence’s potential policy sway as a vice presidential candidate — a harrowing possibility for many health care providers and everyday people, who worry about having an ideologue at the helm of health.
“[My patients] are not people who are politically savvy or following the news,” McHugh said. “These people are much more concerned with where their next meal is going to come from or how they’re going to fight whatever issue they’re dealing with presently rather than following politics. But they are very aware of [policies like HB 1337] and how it takes away their health care, their access. They’re very aware of this.”