As the United States is collectively gripped by the reappearance of measles and other childhood diseases caused by poor vaccination rates — a direct consequence of disinformation campaigns aimed at a population that seeks ready opportunities to fear and distrust the medical community — there’s another issue currently flickering in the background that’s likely to burst onto the public sphere. While the public health community is aware, the average civilian isn’t, and there’s a note to the situation that’s strongly reminiscent of the early days of the HIV/AIDS crisis, when no one cared about a mysterious and looming illness because it only involved gay men and injection drug users — the dregs of the population.
Earlier this year, Indiana experienced the largest HIV outbreak in the state’s history, despite the fact that many people in the United States view HIV as a distant issue somewhere in the rearview mirror. HIV is considered a limited problem in the United States and when people are infected, the popular assumption goes, the disease is fully manageable — they just need to take some medications and everything’s fine. A surprise outbreak of this nature, however, illustrates that HIV is not gone in the United States, and it has the potential to simmer up anywhere, anytime, devastating communities.
Meanwhile in Appalachia, communities are being devastated by Hepatitis C, with public health officials fearing that HIV isn’t far behind. Like HIV, Hep C can be treated, but it requires extremely costly medications — and even with new developments in the field of HCV treatment, the process can be grueling. Some patients are treatment resistant and may struggle for an extended period of time as they battle their medication side effects and the risk of liver failure. It’s not as infectious as HIV, being passed only through direct blood to blood contact, but it’s no less lethal.
In both cases, these diseases are being spread primarily through dirty needles. Drug use is up in rural communities within the United States, and though meth is a common sight (and killer), numerous other drugs are ravaging the country’s far-flung regions. The small populations of these regions doesn’t make them any less important, and it doesn’t reduce the impact of sudden outbreaks. In fact, it can make them worse, as an outbreak can cascade quickly through an entire community.
Certain issues make the management of public health in rural communities particularly challenging. One might believe that it would be easy to provide testing and treatment to a smaller population, and to track contacts when there are fewer people to look at. Moreover, it would appear easier to offer preventative options like needle exchanges (harm reduction) or methadone and therapy (for those who want to quit using). However, those advocating for such measures can forget the stigma that reigns in rural communities, and the fact that accessing treatment or seeking preventative options is complex for those who live somewhere where everyone knows who they are.
A respected businessman knows that if he goes to a needle exchange, people will notice, and he’ll likely see a decline in customers. An employee at a grocery store knows she runs the risk of being fired if she seeks treatment at a methadone clinic. A teen knows someone will tell her parents if she gets condoms at Public Health or asks for advice on safer sex practices. There is a peculiar, painful stricture in rural communities that makes public health very challenging because the existing stigma is magnified, and it’s even harder to overcome. No one wants to be seen as one of them.
One result of that isn’t just that people are slow to pursue options for harm reduction. Many also actively avoid seeking information about their HIV and HCV status. Even when private and confidential testing is provided in settings that make it possible to get tested without broadcasting the fact that one is seeking testing, people are reluctant to actually see their results. One in seven people in the United States with an active HIV infection hasn’t been tested. In a town of 7,000, that means a minimum of 1,000 people could have active infections, and likely more, because magnifying interpersonal contact is very common in small towns. Think of the problems with a dating pool that includes 7,000 people — minus children and monogamous couples along with people who aren’t interested in dating. Once infection arises, it can spread like wildfire.
This is a huge public health issue. Rural communities on their own deserve access to good public health services and shouldn’t be living under the constant threat of a severe infectious disease outbreak. They also interact with suburban and urban communities and have the potential to infect and reinfect their contacts — the exact nightmarish situation that spread HIV so quickly once a handful of patients developed the infection. Rural communities could become the vectors of the next epidemic, especially with many people fleeing for urban environments as a result of economic depression. Rural communities are shrinking and all those people have to go somewhere — taking their HIV and HCV with them.
The solution to the public health problem of infectious disease in rural communities is challenging, as these diseases continue to be heavily stigmatised. ACA might have provided some possibilities by improving access to health care providers who could offer a discreet method of testing and accessing treatment, but rural communities remain without health care because they can’t afford ACA plans and there’s a distinct shortage of doctors — and those very doctors are part of the community, making it difficult for shy patients to ask them for assistance.
It’s clear that agencies need to come up with an approach quickly for the sake of rural people, and for the sake of the nation as a whole. They ought to start by consulting community leaders directly, as they know their communities best and can offer the most useful insights into disease prevention and control.
Image: Clean Needles Save Lives, Sean Hoyer, Flickr