Why we shouldn’t allow Mike Pence to decide public health policy

gov-mike-pence-r-ind-photo-bill-clark-cq-roll-call-newscom
Gov. Mike Pence, R-Ind. (Photo: Bill Clark/CQ Roll Call/Newscom)

By Joseph Lachman, 9/9/2016

Mike Pence is the current Republican Vice Presidential Candidate, and also himself a threat to U.S. public health. Why? He allows his moral idealism to prevent him from implementing effective public health policy, resulting in many unnecessary cases of illness as well as deaths.

I am referring to Mike Pence’s response as Governor of Indiana to the state’s opioid addiction crisis and HIV outbreak. Mike Pence is part of a large group of conservatives who voice strict opposition to needle exchange programs (NEPs, or syringe exchange programs, SEPs) as a method of combating the spread of infectious disease, particularly hepatitis and HIV. Despite the proven effectiveness of the programs, they rely on gut feeling to argue that needle exchange programs only serve to encourage drug abuse. This resulted in an HIV epidemic in Pence’s home state of Indiana.

To better understand the situation, I spoke with multiple professionals in this field. This first was Dr. David Vlahov, Dean and Professor at the University of California, San Francisco School of Nursing. Dr. Vlahov previously helped run a needle exchange program in Baltimore, and has conducted years of research on the subject. The second was Dr. Carrie Ann Lawrence at Indiana University. She helps run Project Cultivate, an organization that helps various counties in Indiana combat the spread of HIV through syringe exchange programs. I was very fortunate that both of these individuals shared their time with me to explain the importance of SEPs as a part of public health policy to prevent the spread of HIV.

Before we get into their perspectives, let’s first look at how this public health crisis emerged in Indiana.


Indiana’s opioid crisis and HIV outbreak

In spring of 2015 a small county in Indiana suddenly faced nearly 200 diagnosed cases of the virus out of a population of only around 5000. Intravenous drug users began abusing a powerful prescription painkiller called Opana. In 2012, Reuters reports that at least nine people died of prescription drug overdoses in Scott County, Indiana, alone, most being from Opana. Users would crush the pill and snort the contents to bypass the slow release mechanism and feel the full effects immediately.

After the company producing Opana realized that cases of abuse were rising, they altered the pill to include a coating to make the drug almost impossible to snort.  However, users soon discovered a way to get around the coating by injecting the drug instead, which is where the real danger begins. Disturbingly, many people who were abusing Opana never considered the dangers of needle-sharing. On top of that, some female abusers of the drug turned to prostitution to get the money to get money buy the drug on the street, only increasing the risk of HIV transmission. As people continued to abuse the drug and share needles, new cases of HIV suddenly jumped, reaching nearly 200 in the previously mentioned Scott County. Dr. Lawrence correctly pointed out that this crisis defied stereotypes, affecting not urban minority populations, but rather mostly white rural counties that never imagined they would face this kind of emergency.

When a public health crisis emerges, it requires immediate action. However, the crisis could also have been averted with smart preventative measures to combat opioid addiction. So, what went wrong?

Needle exchange programs have never been popular with conservative politicians, who claim without evidence that they will only encourage drug abuse. Mike Pence was among the conservatives who staunchly opposed implementing this kind of program out of moral indignation, and so, needle exchange programs were banned under Indiana law. Federal law at the time also banned funding for needle exchange programs.

It was only after Scott County Sheriff Dan McClain and a host of local, state, and federal health officials all spent months trying their hardest to persuade Pence to change his mind that he caved. He authorized a 30-day amnesty from the NEP ban for Scott County in March of 2015, but eventually was forced to extend that time limit and lift the statewide ban on NEPs. But the new rules still required county officials to declare a public health emergency and submit a plan requiring state approval for a NEP of up to one year.

This was more than two months after officials detected the outbreak, giving public health officials limited options to contain the virus over that time, and a much more difficult task even after Pence compromised.

When he finally capitulated, the New York Times reports that at a press conference Mike Pence said, “I will tell you, I do not support needle exchange as antidrug policy, but this is a public health emergency.” Why should you have to wait for an emergency to start implementing this policy?

Despite eventually bowing to pressure, it’s important to point out that Pence’s decision to un-ban SEPs doesn’t ensure that they will be funded properly. In addition, Dr. Vlahov emphasized Indiana’s overall lack of funding for public health, meaning that the state lacked much of the basic infrastructure needed for creating a response to a public health crisis. Dr. Lawrence explained that Pence’s compromise has had limited effectiveness due to the lack of financial help offered to small rural counties with limited resources, as well as a host of restrictions on the needle exchange programs they create. Many rural counties facing a sudden public health crisis were already low on funds. According to Dr. Lawrence, this is why more than a year after the change in policy, only four counties have been able to implement needle exchange programs, despite at least twenty-four counties taking steps to do so, including a county that was approved for an SEP, but did not have the funds to implement it. On top of that, counties must also reapply each year, making it difficult to maintain the programs.

Dr. Lawrence also pointed out that not only did the state government not allocate funds for SEPs, but state public health officials appointed by former Governor Pence have also made it difficult to receive funding through the Centers for Disease Control and Prevention. Furthermore, the state has not decriminalized possession of syringes, meaning that many drug addicts fear being charged with a felony, making them less likely to use public health services.

Gregorio Millet, director of public policy at the Foundation for AIDS Research, offered thanks to Pence for finally capitulating, but called the HIV outbreak in Indiana, “entirely preventable.”

Some people have questioned the actual effectiveness of needle-sharing programs, and so I took some time to analyze as much relevant historical and scientific literature as I could find, and of course asked Dr. Vlahov and Dr. Lawrence about the results of their extensive experience in this field.

A brief history of needle exchange programs

In 2001, Dr. Vlahov worked with other experts in his field to create an overview of the history of syringe exchange programs. The first SEP opened in Amsterdam in 1984, the same year that HIV was discovered. This approach to disease control was originally developed to combat hepatitis B, also transmitted through blood. The UK and Australia began implementation of programs in their respective countries by 1988. Furthermore, public support in the US led to needle exchange programs in several major US cities, despite some opposition, particularly from African-American communities that feared increased drug use.

However, moral opposition to this method of fighting HIV/AIDS during the Reagan Administration led to a federal ban on funding for needle exchange programs on November 4, 1988, stating that the programs would not be funded “unless the Surgeon General of the United States determines that a demonstration needle exchange program would be effective in reducing drug abuse and the risk that the public will become infected with the etiologic agent for acquiring immune deficiency syndrome.” This effort was led by major conservative Republican voices, including North Carolina Senator Jesse Helms, who, according to the American Medical Association’s Journal of Ethics, claimed that allowing funding would essentially be a federal government endorsement of intravenous drug use.

The Comprehensive Alcohol Abuse, Drug Abuse, and Mental Health Amendments Act of 1988 went even further, with a comprehensive ban on distribution of clean needles or bleach for sterilization. The Ryan White Comprehensive AIDS Resources Emergency Act of 1990 included similar language. All together, the federal government severely limited public health authorities’ ability to use needle-sharing programs to combat the spread of HIV/AIDS, as well as any research that would prove the method’s effectiveness. Private organizations such as The American Foundation for AIDS Research and Robert Wood Johnson Foundation funded a limited amount of research to evaluate the effectiveness of this approach.

After several years running these programs and analyzing the results, more data were becoming available to evaluate the effectiveness. The US General Accounting Office and University of California released reports concluding that needle exchanges do not increase drug abuse and reduce HIV ratesIn fact, the results showed evidence that the programs helped bring drug addicts in contact with treatment services, and did not lead to an increase in crime. 

Despite the growing evidence in favor of SEPs, President Clinton also failed to lift this ban after being pressured not to do so by the Republican-led congress, including Republican Representative Dennis Hastert, who made a similar argument to Helms.

Since then, the ban on funding for research and implementation of needle exchange programs has gone back and forth multiple times. President Obama lifted the ban in 2009, but it was then reinstated once again by the Republican-led Congress, only to finally be lifted again in early 2016 out of dire necessity in response to the public health crisis in Indiana and Kentucky. It was only after the crisis began to directly affect Kentucky Congressman Mitch McConnell’s home state that he allowed legislation to go through that would partially lift the ban. Strangely, funding would not be allowed for the needles themselves, but was instead limited to every other aspect of the program, such as personnel, vehicles, gas, and rent, which represent the vast majority of costs.

In some ways, this can be seen as a conflict between public health goals – the “War on Drugs” and the HIV/AIDS epidemic, despite the fact that early research suggested it might even be possible to take on both issues with this type of program. An important question is, has the evidence supporting SEPs held up over time?

Do needle exchange programs help combat HIV?

The short and plain answer is yes, needle-sharing programs have been shown to reduce HIV transmission in communities facing public health crises. Furthermore, syringes are inexpensive, meaning that these programs are also cost-effective as a public health strategy. Do these programs increase drug use? Again, the short and plain answer is no, needle-sharing programs have not been shown to cause statistically significant rises in drug abuse in communities where such programs are in effect.

Dr. Vlahov himself summarized his conclusions about the research on SEPs:

[Research] showed that needle exchange does not increase drug use; it does not increase needle sharing; it does not encourage starting drug use; it does not increase crime; it does not increase needles on the street; it does decrease needle sharing, and it does increase people going into [drug treatment] services.

Dr. Lawrence noted that they have found important and sometimes unexpected allies in this fight to prevent the spread of HIV. Local sheriff’s departments even in small conservative rural areas have played an important role in bringing SEPs to their counties. She stressed the need to help the public understand that we need to treat this not simply as a criminal justice issue, but rather a public health issue if we want to really see improvements.


 

In short, needle exchange programs are a vital part of fighting the spread of HIV, and politicians should not allow their personal beliefs to interfere with the implementation of smart public health policy that saves lives and prevents communities from being torn apart by preventable outbreaks of disease. If Mike Pence becomes the vice president, he will have a central role in determining the future of public health policy in the U.S. The question is, can we really trust him to do what is best for the health of our citizens?

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About jslachman381

I'm a Yale graduate who majored in History of Science, Medicine, and Public Health.

View all posts by jslachman381

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