H.I.V. Is Coming to Rural America

And rural America is not ready.

Comments: 264

  1. Lack of good education, jobs and accessory to affordable healthcare. All significantly part of deep Red West Virginia. And most of rural America. It’s not just that they vote against their interests. The republicans do not do anything to help; actually the policies hurt them. I don’t see any way out of this in our present situation.

  2. @Concernicus: That's an argument that Trump made for himself in 2016. It was out of date then and is even less relevant now. I don't think it can do anything to help Sanders.

  3. @LFK Somewhat agree. Now lets turn it around. Lack of good education, jobs and accessory to affordable healthcare. All significantly part of deep blue inner cities throughout America. It’s not just that they either don't vote or continue to vote for corporately owned democratic candidates that provide nothing beyond lip service. The corporate democrats do not do anything to help; actually the policies hurt them. I don’t see any way out of this in our present situation. Actually, I do. Stop voting for pragmatic, middle of the road, do nothings that propose more of the same useless policies that led to the hollowing out of so many inner cities. Vote for change. Real change. Not Me. US SANDERS 2020!

  4. Exactly!!

  5. It's incredible that death itself is now a Blue/Red issue. We naturally gather into tribes, but this is not the time for that. Thirty years ago, when my friends were dropping like leaves in Autumn, we looked to the powerful, but they often looked away. We need to be better. Why not use this opportunity to help, not just the sick, but the sick society that we've created? Death doesn't care, it gets us all in the end.

  6. @Sera Thank you for sharing that perspective. It's so important for us all to remember that we are all one human family. I'm so sick of red and blue states.

  7. @Sera It’s always been a Red vs Blue issue since the early 1980s when HIV/AIDS was first brought to public attention. Remember that St. Ronnie, as President, was all to willing to obey conservative religious leaders and to ignore HIV/AIDS. Conservative religions were cheerleaders for blaming those affected by HIV/AIDS, and Republican politicians agreed with them in order to maintain political support from religious conservatives. Policy proposals for proactively addressing HIV/AIDS did not come from the Red-side of the political continuum... the exception being some members of the Log Cabin Republicans. These proposals, overwhelmingly, came from and were supported by people on the Blue-side.

  8. @Sera the people who looked away lived in West Virginia. It was exactly their demographic that fought against HIV awareness and blamed the victims the most vocally.

  9. More rural people have been dying from opioids than HIV, at least until now. If this report is accurate, the decimation of rural America is happening right now, specially if you add the growing suicide rate. The country is demoralized from the feeble economic recovery that helped the Michael Bloombergs and Leon Coopermans, not working families. US oligarchs and corporation don’t pay taxes, nor reinvest in the economy which would help develop a preventive network

  10. @Ted Where are the Comgresspeople in their states? And governors? Especially the Republicans. And the Evangelicals. All talk and support of Trump. The poor, addicted and those with HIV, ad Ebenezer Scrooge would say, can die and decrease the surplus population. If they don't actually come out and say it they mean it since they supply no help or compassion. FAKES all of them.

  11. Check Michael Bloomberg’s work after he left NYC. You may be surprised what the kid from Medford has done for our country.

  12. West Virginia and many of other "rural" states confronting potential and actual HIV outbreaks are among the red states currently using their resources to have the ACA declared unconstitutional. There are some great public health ideas put forth by Dr. Thrasher which, unfortunately, will never be implemented by states that have a track record of not only not caring, but actively sabotaging the health care available for their most vulnerable residents.

  13. @Dan88-What's missing from this article is that West Virginia's AG has filed two lawsuits against pharma giants Mallinckrodt LLC and Endo Health Solutions Inc. and their subsidiaries. The lawsuits claim the companies helped incite the opioid crisis in West Virginia by utilizing deceptive marketing practices to misinform prescribers as well as obscure the massive risks involved in taking opiate painkillers. https://www.wdtv.com/content/news/WVa-Attorney-General-sues-two-major-opioid-manufacturers-565229372.html Also: https://news.bloomberglaw.com/health-law-and-business/proposed-48-billion-opioid-deal-could-cut-out-west-virginia

  14. @Ann And how does or will that help the W.V. citizen who is addicted to opioids? Has the A.G. pledged to use it for that purpose? Can he under W.V. law? Or, if and when such a judgment materializes, will it simply be plowed into the state's general fund, and inevitably and disproportionately land in the pockets of corporations those who own them? Moreover, that is a potential and prospective judgment, many appeals/years down the road. Meanwhile, the same W.V. AG is pursuing a case currently before the Supreme Court, asking the ACA be declared unconstitutional and thousands of his fellow W.V. constituents be stripped of their access to healthcare, with a decision expected by the middle of next year.

  15. @Dan88 Here’s an idea: let’s REALLY implement state’s rights —- how about all the blue states keep all the revenue they actually generate from taxes and which they’ve had to share with the ne’er-d-well red states that keeps them afloat and grousing about all them “libs” and their evil-doing ways. Let them fend for themselves for a change. Then they can keep re-electing the likes of McConnell (Kentucky) and see how much they like that. It’s easy to be arrogant when you’re not paying your own way.

  16. The author states “two cities in West Virginia — Clarksburg and Charleston — have recently moved to close or limit their needle-exchange programs. Negative press, business worries and conservative approaches are among the reasons the programs have been reduced.” How exactly are policymakers supposed to help these people when they and the politicians they elected will neither acknowledge the problem nor help themselves?

  17. @Surfsider The economic decline of the region—which is years in the making but has felt steeper in recent years—combined with the large amount of energy-industry propaganda has helped put in office officials who care little about their constituents’ needs. However, Charleston last year did elect a mayor who favors the needle-exchange, which was a focal point of the race after the previous mayor closed it.

  18. Upon first reading this piece, I immediately thought of the lack of available and adequate health care and with it all-important education. I also thought of the resistance of government leaders to expand Medicaid in too many of our states, e.g., West Virginia. There seems to be a deliberate effort to keep people ignorant to science. With that are conservative religious ideologies which trigger crippling guilt in matters of sex. Indeed, this is medieval to control another to the point of making one vulnerable to diseases which can be treated and to death itself, either through drug abuse, AIDS, or other sexually transmitted diseases. This is not okay. In fact, this is amoral and cruel. No matter one's color, ethnicity, religion, gender, or sexual identity, he and she are deserving of respect and dignity.

  19. @Kathy Lollock In fact, WV was one of the first states to expand Medicaid. WV’s Medicaid expansion went into effect in January 2014. That said, the expansion only ensured that payment would be easier; it doesn’t make services any closer.

  20. @Marcus J. Hopkins and let's not forget to point out /why/ WV expanded it's Medicaid rolls; this was done under the leadership of a Democratic governor, against all efforts to block said expansion by both houses of the R-controlled state legislature

  21. @Kathy Lollock - Oh, didn’t you know? Science is our enemy because it challenges faith the word of God as written in the Bible, especially Scripture which should be your guide; supreme. The World was created in six days, because it is written. Lot traveled into the land of Canaan to the place of Sichem and his wife was turned into a pillar of salt, because it us written. And Cain went out from the presence of the Lord and dwelt in the land of Nod, on the east of Eden. And Cain knew his wife. Because it is written. All that’s needed to cure anyone of any malady or scourge is True Faith — and a long hot soak in the Bible; and sincere prayer; and a laying on of hands. If one of True Faith isn’t healed it’s because they aren’t really of True Faith, which has offended God and his agent, President Trump, sent by God to Earth, part of His Divine Plan to bring all of us The Rapture and The End of Times. How do I know? I read it on the Internet ... .

  22. It's in stories like this that the inanity of the term "opioid crisis" is clear. The phrase deliberately conflates everything from heroin addiction to patients taking a short course of Percocet as prescribed for pain. But no one is infected with HIV by using or abusing pain pills. The HIV problem among drug users is a crisis of addicts who inject drugs and share needles, and/or who have unprotected intercourse. It is not credible that HIV is new to the countryside, since we know that drug addiction is widespread and longstanding in rural America and has been for ages—and so is sex. Maybe the problem is something more specific, like communities with right wing governance that withhold sex education and HIV education; and which forbid public health initiatives like needle exchanges; and where HIV positive people may remain highly infectious because they lack access to medications that would render them non-infectious.

  23. @Mike HIV is not new to the countryside, but the spread rate is much higher now that drug injecting is so much more common. No, opioid addition in the form of pills does not spread HIV directly. The problem they are experiencing is a delayed effect of opioid addiction that has been supplanted by heroin addition as the crackdown on prescription opioids cut off the supply of their original addiction. Attempting to resolve the pill problem without effective addition treatment has resulted in a much more serious public health problem.

  24. @Mike You may have overlooked it, but Dr. Thrasher did link the opioid addiction crisis in these rural settings to the potential and actual HIV outbreaks: "And when prescription highs can’t be sustained, people often turn to using — and sharing — needles to inject heroin and then fentanyl, leading to hepatitis C and H.I.V."

  25. @Dan88 The headline says "HIV is Coming to Rural America—and rural America is not ready." The implication is rural America has been, pardon the expression, immune from the scourge of HIV but now there is a breach in their defenses that was made by "the opioid epidemic." It sounds like rural America wants to blame its HIV problem on a scapegoat, "the opioid epidemic," a self-flattering view that is easier than facing the facts. From the beginning, HIV has been spread by drug addicts sharing needles. There have always been huge numbers of drug addicts in rural America, and HIV has been there from the beginning as well. Let rural America take a second look at its politics and views of morality and see the extent to which that plays a part. If the story is that more drug abusers are starting with oxycontin and fentanyl before going straight to heroin, that's a different story. Tell it. But framing it as HIV being a problem that has just now migrated from the city to the country because "opioids" is inaccurate and unhelpful.

  26. Reminds me of the barriers to care and local prejudices described in My Own Country by Abraham Verghese. I'm curious - because I don't know - how vaccination patterns look in this same geographic area. Is preventive health generally a successful model in this geographic region?

  27. Yes, when it’s free.

  28. No one should be willing to accept that our neighbors will die from HIV. Longer term, evidence-based prevention that goes much further and deeper will be more cost effective and offer the best chance of disrupting the toll of misery, suffering, and death. That should be something we can all agree on.

  29. @Seth Eisenberg I used to think like you. That was before the faith-based conservatives gave us Trump. They have always voted for parsimonious tax scolds working for the 1% no matter how bad it was for them economically, medically, and educationally. They can pray for salvation now. Trump was the last straw for me. Let them deal with their voting habits on their own.

  30. @wcdevins Appreciate the perspective. The passing of years has definitely taught me humility. I'm curious to see if I end up where you are now. Thanks again!

  31. And yet these people will vote for Trump. They will support policies that stigmatize and marginalize the very people most prone to acquire HIV. They will support politicians who fail to extend Medicaid benefits to people who could use those benefits to obtain Truvada or Descovy, medications will markedly reduce the chance of acquiring HIV. Many people do not realize this, but the people with some of the highest circulating viral loads are those newly infected who probably don’t even realize they are infected. By the time they are diagnosed, they have often infected others. Intravenous transmission is particularly effective for HIV. How many clean needle exchange sites does West Virginia operate? Not many I would wager. So yes, a public health crisis in the making. But will West Virginia do anything about it? No they will not. Sad. Deplorable even.

  32. With Kanawha County closing their's down within last month or so (due to pressure), I'm not certain how many programs are left in WV. Thankfully our Cabell County's program is still going. Every week (give or take), buses take addicts who are in recovery to the Health Dept for HIV tests. If clean, they celebrate (who wouldn't?), if not, they immediately start protocols to help said patient. Because we already had an exchange program in place, someone reported this cluster would have been a while lot worse

  33. With Kanawha County closing their's down within last month or so (due to pressure), I'm not certain how many programs are left in WV. Thankfully our Cabell County's program is still going. Every week (give or take), buses take addicts who are in recovery to the Health Dept for HIV tests. If clean, they celebrate (who wouldn't?), if not, they immediately start protocols to help said patient. Because we already had an exchange program in place, someone reported this cluster would have been a while lot worse

  34. @Max Yes I get it, you're angry at Trump. So, so angry. But blaming the poor and marginalized for the tragedies that shatter their lives is just low. There's life (and compassion) outside of partisan warfare.

  35. I'm sure that Trump will care deeply about his supporters in these areas. He's a giving, humane man who rejects human suffering. Help is on the way.

  36. @David Henry - hey David, thanks for making this a Trump issue. It’s clearly his fault these people choose to share needles to shoot heroin.

  37. @David Henry I can't tell if this is sarcastic or not. On a more serious note I don't understand ,even if this comment is serious,why you would have this opinion. Enlighten me.

  38. @David Henry Is this a serious post or is it snark? It could go either way.

  39. While this news is hardly surprising, given the ravages of opioid addiction and its aftermath in some U.S. rural states, it's also something voters and supporters of Donald Trump should take into consideration as one hospital after another closes, and the window of obtaining affordable healthcare continues to close. This is where one should ask Is America Great Again?

  40. So what are the Democrats going to do? Only Bernie and and Elizabeth have medicare for all plans.

  41. @Zejee Reality check: Medicare for all is a dream plan. It's never going to happen -- and having to support hundreds, if not thousands of drug-addicted people in rural America is just one of the reasons. Why? Because it's not cost effective. PERIOD.

  42. @Zejee We don’t need Medicare for all. We need ACA with appropriate subsidies for people that can’t afford.

  43. We, America, have done a poor job of moving from an agriculture-based economy to manufacturing, from a manufacturing-based economy to a service-based economy, and now those jobs are under threat as well. We have allowed corporate leverage to acquire too much control over our government and our elections, and people who work are suffering. The resulting inequality is destroying communities across the nation. These problems will not stay confined to rural America, and we will all pay the price. Bigger solutions are needed, bigger than providing care or even jobs. Our entire social structure needs rebalancing, these deaths of despair are more than tragedy, they are an alarm. No matter where you live, ignore these problems at our collective peril.

  44. @Hank Linderman Service jobs require that wealth be created to spend on service. When only the top 1% have any surplus funds to spend, you're going to see most of the 99% in 'service' jobs starving.

  45. @cynicalskeptic It is not true that only the 1% have surplus funds to spend.

  46. I just got done reading two articles in the N.Y. Times. The first was about the dismal progress we are making on reducing the drivers of global climate change, and how this will degrade the world for my children and grandchildren. The second was about how people in Trumpland are subject to increasing levels of HIV and AIDS due to their pain-pill addiction issues and their own decisions about closing clinics and blocking needle exchanges programs. I'm experiencing concern overload. I've decided I'll concentrate on the first problem, and let people in Trumpland deal with the second.

  47. While I have a lot of compassion for the addicts in rural West Virginia and similar locales, and my heart breaks for those afflicted with HIV, I think tough love is in order. Vote for those who will help you. Otherwise, you’re on your own.

  48. @Icy It's not working... banning needle exchange, closing clinics, and defunding health education is "TOUGH LOVE" and the HIV rates are rising.

  49. They’ve BEEN on their own. Turning our backs won’t make it better.

  50. Well, between the nation’s progressive and world class public health policies and the compassion and expertise of our President in advocating for the concerns of the most vulnerable Americans in rural areas I’m sure there’s no cause for alarm. And to the degree those things don’t help, the invisible and all knowing hand of the free market economy will sweep in and eliminate any suffering.

  51. @Mickey I admire your faith.

  52. @Mickey Very nicely said.

  53. @Mickey You need the SARCASM FLAG. Some people are taking this seriously, and literally.

  54. Over the next 11 months, Democrats in states like West Virginia need to affix blame precisely where it belongs: on Donald Trump. In 2016, he made West Virginia the center of his campaign for bringing back jobs in the coal industry. He hasn’t delivered on that, and the continued economic distress felt in the state has exacerbated the opioid crisis and by extension the gravitation to injectable drugs and thus Hep-C and HIV. Second, he promised the repeal of the ACA and its replacement with healthcare that was better and cheaper. Again, he has failed. Voters in these states must realize that Donald Trump is the cause of their economic, medical and social woes, and for that reason, he must be replaced.

  55. West Virginia’s problems predates Trump by decades. I detest Trump and for sure Trump made false promises to all Americans, but Trump is not t blame for West Virginia’s problems.

  56. @Ockham9 : the problems in W. Va. LONG pre-date Donald Trump....you seriously think that poverty, lack of jobs, drug abuse, etc. just started 3 years ago?

  57. @Ockham9 . how will this happen?

  58. What is the role of the CDC and policies that may in some cases over-restrict prescription pain medication -- forcing individuals to seek street heroin to address severe pain? If these agencies were concerned about opioid abuse the evidence-based responses include needle exchange, treatment and medication for substance use disorder. Otherwise this creates the public-health equivalent of Lucy yanking the football away from Charlie Brown leaving him to slam onto his back.

  59. West Virginia is what near total corporate control of government looks like after the systematic targeting and destruction of labor unions so that no one is left to fight the oligarchy. Folks that have fought back end up black-balled and ostracized by mob-like business owners and sometimes crippled, dead, or imprisoned (see the Battle of Blair Mountain to know just how long this has been reality). The irony of low-tax, business friendly low-regulation West Virginia is that they are 43rd in terms of fiscal health and 26% of all income in the state is federally funded. Most folks that make a decent living are either at WVU, employed by the Federal government, or live in the Eastern Panhandle (the richest part of the state) and commute to work in super-blue and prosperous Northern Virginia for good paying government or federal contractor jobs. If you want the whole country to look like West Virginia then just keep voting Republican - it’s the ultimate example of Republican policy outcomes.

  60. @Jason Could it be that the real economic problem in West Virginia is that it depended on coal mining and related industries -- and that those are going away. A labor union cannot protect workers in a defunct industry.

  61. @Joel The corporate oligarchy in place in West Virginia actively fights against proposals for solar and wind power projects in West Virginia as well as other nearby states so they also share a lot of the blame for the reason that the only jobs in some parts of West Virginia are coal industry jobs. Moreover, the Republican party has been engaged in a never-ending effort to basically defund public education to lower taxes even more for the richest West Virginians. Never mind that a quality public education system might make their workforce a good candidate for the majority of current and future work. Right now most folks that are capable either move, join the military, or they commute to a blue area for work.

  62. West Virginia only recently went Republican. Many of the problems are decades old and thrived under Democratic administrations.

  63. Even though these communities have in the past resisted our efforts to control these public health threats, I am supportive of helping them control theirs. Public health has a large helping of self-interest so I believe helping them helps me, even if on a moral level they may not have earned it. Maybe the current crises these communities are experiencing will allow them to understand what we already understand from our past experience. I expect they will adapt to the mitigation methods after watching their relatives suffer and die needlessly, although that adaptation will probably be slower than we hope.

  64. Charleston and Huntington WV discontinued their needle exchanges because it attracted a lot of outside people with SUD to the area, who left used needles on sidewalks and playgrounds and city parks. People without SUD were concerned for the safety of their children. Needle exchange doesn’t work when injecting “families” share a spoon and push the plunger to release their own fluids back into the spoon. Even if they all use their own clean needle, the shared spoon defeats the purpose. So, needle sharing is a nice hypothetical idea that doesn’t work out so well in reality, because people with SUD aren’t known for being motivated to follow clean practices. Addiction is a powerful thing and gets around the reasoning brain. It is all appetite in the primitive brain. (I live in the county next to the town pictured.)

  65. @Elizabeth Cole - You are right. Someone with diabetes can be trusted to use the hypodermic needle appropriately, those with Substance Use Disorders (SUD) probably not. Their drug use should be supervised.

  66. Since HIV exploded in 1981, we have learned that the virus does not care who you are or where you live, but it takes advantage of behaviors and circumstances. The challenge of HIV in a rural region is not only relative income, but the lesser availability of clinical resources. Not only are there fewer HIV specialists, but the distances patients need to travel for care are greater. Unfortunately, the solution is not going to come from the President. It will start when local communities get the message out to their state governments to support Medicaid, to fund clinics for HIV and opioid treatments, to attract providers of care. Regional and state efforts to bolster training for primary care providers, physicians and nurse practitioners, is of major importance. Finally, states will bear the responsibility to support and pay for pharmacotherapy for this continuing epidemic. For many years, certain groups, mainly in urban areas, were scapegoated regarding their risk for HIV. Rural areas and their state governments need to understand, quoting Pogo, "We have met the enemy and he is us."

  67. @Jeff The solution to addiction is ultimately the responsibility of the individual who is trying to beat it. One way is to get a driving interest in a worthwhile goal, work hard toward achieving that goal and keep one's mind off of things, which if thought about would temp one to slide backward toward that addiction. Clinical help is great but it is not full proof.

  68. @Bill N. Your solution reminds me of "Just Say No." Both so-called solutions are easier said than done. No solution fits all.

  69. @Bill N. "the" solution. You BELIEVE there is only one answer to one medical problem. Yet there are many answers for cancer illnesses. The Sacklers worked diligently to hook Americans into opioids. These end-stage capitalists SHOULD have ultimate responsibility for opioid addiction in America. But they will escape with billions. Cynical Sacklers sure aren't working for the "solution to addiction."

  70. You can't help but wonder what the trillions spent on the last two decades of war in the Middle East could have done if spent at home. Many of the problems we face in this country are due to a lack of jobs. We've shipped must industrial jobs overseas but the coal industry has been largely (and rightfully) killed off for environmental reasons. What do you do when an area already short of jobs loses the ones it has? I suspect that the opioid crisis was allowed to happen as a way to keep people devoid of hope passive. The number of addicts in this country has grown astronomically. With a crackdown on prescription abuse many of those addicts have turned to heroin (a substance many never would have touched in the first place). It's interesting how opium production was at an all time low under the Taliban in 2000 but is now much improved after 18 years of the US in Afghanistan.

  71. @cynicalskeptic also fentanyl, its cheaper and many times stronger than heroin. Leading to more overdoses.

  72. @cynicalskeptic Side note: the coal industry was not simply "killed for environmental reasons." There was an environmental component but employment data shows that most coal jobs were killed in the 1950's and 1960's by the shift from shaft coal (mostly eastern) to strip mining (Wyoming and the west) where the shaft coal workers were replaced by a few operators of very large machines. What finished coal off was the advent of natural gas fracking which produced cheaper and cleaner fuel for a comparable cost. In the interim, coal was hit by the exit from high sulfur coal over acid rain, the cost of site clean-up requirements, and pressures over air quality but these were compensated for by sales overseas up until fracking started.

  73. @cynicalskeptic We all need the Second Coming or some other Messenger from the Creator of All to help us understand why our species exists and what we are supposed to do to remedy our Dire Situation. Strangely, the Creator of All is silent, and we scurry about with theories and dysfunctions, killing one another, destroying our beautiful planet, blabbering about our fictional ideologies, denying and distorting and I wonder WHY? WHY. When The Creation is so perfect, so beautiful, it defies description?

  74. It is really sad that so many people have self destructive tendencies and addictions. As a person without an addictive personality and one who has a deep appreciation for what can not be cured, I do no understand this type of behavior. What is really frustrating and tragic is that these people jeopardize the health of their spouses and intimate partners with this behavior.

  75. Hand wringing/crying over spilt milk is not productive, though. This is our collective reality.

  76. @Lyn Robins Addiction is not a "behavior choice". It's a disease of mind, body and environment. Educate yourself: "Dopesick" by Beth Macy "In the Realm of Hungry Ghosts" by Dr. Gabor Mate

  77. @Lyn Robins As a person without an addiction to self-righteousness, I cannot understand the incurable propensity of some to wag a boney finger of blame at others.

  78. Today I heard a segment of "Hidden Brain" on NPR: https://www.npr.org/2019/03/15/703445509/counting-other-peoples-blessings It discussed recent research about the positive and negative effects of the dark human emotion of envy. Listening to the program, and reading some of the comments here (and all of our political news) was/is a sobering experience. As many people as possible need to become more aware of the causes of some of our darker attitudes and behaviors. Being forewarned is being forearmed, and only by understanding our indifference to, and indeed, our hatred of the "other" can we begin to reverse our sad state of affairs.

  79. You are right, but I am done doing that. I am sick of the left trying be be good to society while the Trump/Fox lovers just stomp all over everyone’s rights. I have no interest in getting along or doing good for red state people who made their own beds.

  80. With bad harvests, bad economies, drug abuse and now HIV headed to rural areas, I wonder if they will favor government intervention. The farmers took their bailouts, $28 billion. But that's just from the trade war. Climate change is producing soggy harvests. Their economies are only 1/3 of the American economy, whereas cities and suburbs represent 2/3. Will they finally accept government intervention?

  81. @David the food industry in its entirety is the largest and most dispersed industry, from farming, picking, logistics, food prep, grocery, restaurants (including fast food thru fine dining), and food retail (sandwich shops). You're underestimating very much rural contribution.

  82. @David With all due respect, they have been accepting same for decades without calling it such. Senator Moynihan used to document how much Federal tax $ is transferred from blue states to red states, well before these terms were in use.

  83. @David The farm bailout, as with most subsidies, went primarily to wealthy farmers.

  84. "...the misguided impression that members of these groups..." It is not 'misguided' - it is supported by empirical data. The rate of HIV infection for injection drug users is about 6% according to the CDC. Gay and bisexual men still accounted for two-thirds (66% or 25,748) of all new HIV diagnoses. There may be an awakening crisis in rural white America but we do it a disservice when we ignore the actual data available from respected national sources.

  85. @SteveRR Yes, certain practices have higher risks. But if anyone thinks, gee, I am not gay, I am not an addict, I don't have to worry, I am protected, you are inviting the inevitable crossover of HIV-Aids into your community. Cities and states that face the problem head on without demonizing or stigmatizing the victims find their rates dropping. Those who are pro-active, emphasize education beyond simplistic "just say no" bromides, will bring this scourge under control. Those who focus on 'it's just gays and addicts' will see their rates skyrocket.

  86. The complaint of the GOP to the need for better health care and the means to pay for it has been that we can not afford it, but when push comes to shove it is their voters suffering in rural communities from HIV, failing hospitals, limited medicaid, drug overdoses and shortening life spans. And yet they will continue to blame Democrats who have fought tooth and nail for better health care. The GOP has made health care a political issue while it has always been that all people as a right should be given the best health care possible. The cities can not help the rural communities make this a reality. Those suffering in outlying communities must wake up and demand reform from the a now broken system, but it will not be from the heartless empty headed GOP.

  87. @just Robert, I’ll guess that rural people, with opioid dependence, are inclined to vote for Trump.

  88. @Karen Lee It doesn't matter what a person votes, as a human right, they deserve healthcare. America can afford to do this. The current results cost more.

  89. @Karen Lee Nothing bigoted about your opinions. What would make you believe that opioid drug abusers vote? Since the rural population makes up 10% of the population, it takes a Democrat to believe that they elected Trump. Perhaps if Democrats had any interest in solving problems, rather than blaming Trump for an epidemic that Obama initiated and were capable of rational thought and conversation, we would have seen conditions improve. Instead, the Democrats in Congress are focusing on impeaching Trump rather than solving problems. To date, we have spent $1.5 trillion on Obamacare and American life expectancies have declined. Big medicine got much wealthier and all Americans are paying more for fewer medical services. The residents of DC and surrounding areas got much richer, in addition, under Democrats. But they can't afford to pay more than 50% of the operating costs of their mass transit.

  90. It's roughly the same problem we now face on many fronts: the private/public balance of power has shifted decisively toward the former. The power of government (which is the outcome of the political process) to effectively regulate the exercise of private interests is more imaginary than real. As other countries show, there are effective ways to hold medical costs down through legislative action. In principle, we could do the same. But we won't because our political class is completely undermined by our system of legal bribery. Yes, there are many regulations still on the books, no thanks to the Orange Buffoon, but their enforcement has been dwindling for years. This is, somewhat incredibly to me, true even of the IRS, which is after all the agency with primary responsibility to keep the federal government funded. Other examples are pharmaceuticals, finance, airlines, and of course our good friends over there on Tech Island. Up to the time of Reagan, we retained the time-tested idea that some profit-making activities impact the public welfare enough to justify serious regulation. When necessary, in the public interest, we simply made the activity a public utility: a legal monopoly, with prices controlled by a public regulating entity. Them days are long gone, bro.

  91. HIV is really an education and awareness problem. It was hard enough to get urban America educated on this. Rural America is going to be much harder - especially since they don’t trust government or civic institutions.

  92. The U.S isn't ready for any multi-ply health crisis, and won't be until we at least braid together our five or six main coverage/care processes better. The Affordable Care Act started to do this, but some GOP governors put ideology above the health of their states' residents when they refused Medicaid expansion dollars. Ironically, those states rend to be more rural. Of course it would also help to pay primary care physicians better, reduce the number of reimbursement hoops they, pediatricians, psychiatrists, and "broad specialists" such as gynecologists and OBs go through. And will anybody be surprised when enterprising West Virginians start growing opium poppy crops?

  93. @grennan "Of course it would also help to pay primary care physicians better, reduce the number of reimbursement hoops they, pediatricians, psychiatrists, and "broad specialists" such as gynecologists and OBs go through." Medicare for all, anyone?

  94. @grennan the ACA is very far from a serious response that west Virginians could see as helping such communities. You lose your job or don’t have one? Too bad. Co-pay, premiums, prescription prices? Out of their reach? Add to that local political resistance to ACA and one understand why over there ACA did not make a serious dent at reversing republican gains.

  95. @grennan Medicaid expansion states had a faster expansion of the opioid addiction epidemic than non expansion states. Obamacare did nothing positive for health care delivery and resulted in the closures of rural hospitals and clinics. The plan insured 10 million able bodied childless adults and cut finding for SCHIP and hospitals that serve a high proportion of Medicaid patients. More money for people who had the least need and less funding for the most vulnerable.

  96. ‘By 2017 in Jefferson County, one in four people had a controlled-substance prescription.’ Why is that? Do residents of Jefferson County have some unusual conditions that cause severe pain? Or, are they just Donald Trump supporters, who aren’t aware that their Medicaid coverage is related to the Affordable Care Act?

  97. Yes, they are in pain from working overtime in the coal mines. The mining companies set up pain management clinics to prescribe opiods to them and keep them working. Then the mines were closed, but the workers were addicted.

  98. ...and now they can add $1500 a month opioid withdraw blocker.

  99. As I read pieces like this, I try to test their reliability. This piece talks about the difficulty rural Americans have in getting to nearby health services. I had my doubts, so I checked and found that car ownership in rural America exceeds car ownership everywhere else. 91% of the rural population has access to a car. And that makes sense because they lack public transportation. Moreover, the suggestion that those without cars are needle users seemed dubious to me. But I could not find out whether the poorest of the poor use fentanyl. The poor surely do, but the poorest of the poor are different. Writing an op ed doesn't take much time. And fact checking is always a good idea. But I'm not a fact-checking service and I may have found an important but isolated inaccuracy. All the same, if the only thing I check is inaccurate I disregard the rest and looked forward to learning about HIV in rural America from a piece that passes the test.

  100. @michjas Could they have a hard time getting to a health care provider because they can’t get time off of work, can’t afford to drive their 15 mpg pickup 100 miles, etc?

  101. @Djt Don't know about work. But your second supposition is wrong. I got my information from a commuter study, which found that the rural population drives relatively far to work. If they can drive 50 miles round trip every day, they can drive 100 miles for health care.

  102. Not necessarily if one’s budget is already stretched as thin as can be. That extra 100 miles and the bill or co-pay could be too much. Also, there’s the additional time it takes, perhaps making it impossible to get to a medical appointment after work.

  103. We need to legalize recreational drugs, and educate against their abuse. We need to cut all welfare to these dead-end parts of the country and subsidize people moving to low unemployment areas. (This might include "purchasing" their now largely worthless home as part of funding their move -- this would be cheaper in the long-run than maintaining rural ghettos.) And we cannot allow any impediments to quality sex education of the young. In short, support good choices, facilitate good choices, and, at some point, let the able-bodied drug users "root, hog, or die" as Lincoln put it. Finally, the enabling concept of "addiction" (which has no scientific basis apart from proof of some cravings and flu-like symptoms when quitting a drug) has to be returned to the ideological shelf. People make choices, and all we can do is create a pathway to better choices. And the first choice that matters is to move out of the rural ghetto.

  104. Addiction being a well known and scientifically proved fact, I wonder where you got that idea that it doesn't exist.

  105. @Craig Mason You have no idea to the extent to which people addicted to opioids suffer withdrawals. For some of the longer-term users, they can outright die if they quit cold turkey. Further, addicts are at higher risk of death after relapsing because they often go back to the same dose they were on when they quit.

  106. @Craig Mason Legalizing the use of opioids is not a clever solution to the problem of drug addiction.

  107. Interesting that no mention is made of the expansion of Medicaid to able bodied childless adults and its role in the prescription opioid epidemic. Thank you very much for providing profits to the drug manufacturers by having drugs supplied free of charge.

  108. But no blame to the doctors prescribing the drugs or the very aggressive campaigns of the drug companies to have those drugs prescribed? You are right, it is the victims who are to blame. They should know everything about drugs and medicine instead on relying o on professionals.

  109. @ebmem You need to do some evidence-based research and adjust your attitude, which is just plain wrong. The opioid epidemic began with doctors who broke their Hippocratic oath and oversupplied their patients, and with criminal storefront "pharmacies" that received drugs from an enterprising drug cartel that targeted the Appalachian region. Medicaid has nothing to do with it. Drug companies accommodated the drug runners and outlet and marginal "doctors" enabled people who were hooked.

  110. Your argument is illogical: because opioids can be prescribed (along with antihypertensives, diabetic agents, and antibiotics), let’s kick off Medicaid the young, poor individuals so they don’t get addicted to oxycodone. There’s no question we prescribers were lied to by Purdue, etc. about opioids and their potential for causing addiction, but we have learned and instituted laws that have helped to prevent new cases (only a 7 day supply for acute pain, I-STOP systems for finding records of prior opioid Rxes filled, etc.). Don’t blame Medicaid for a crisis it has not caused. It saves lives every day by giving the poor, many of whom are employed, access to critically needed medications.

  111. Disappointing to hear needle exchanges are being closed in any community. People who self-medicate are failing. They need assistance to prevent their lives getting worse. Needle exchanges help prevent dangerous infection and offer an opportunity for counselling and education.

  112. Each Fall in speak in eastern Kentucky on the topic of diversity, equity & inclusion to attorneys. That takes me to places like Ashland, Pikeville, Prestonsburg and London. I have lost track of how many times I've been told that I'm the first gay attorney these other attorneys have ever met. = While it is easy to make observations and generalizations regarding how these folks vote, the sad reality is that the brightest leave constantly. Harlan Co., Kentucky used to have 5 high schools 20 years ago. It has 2 now. The collapse of good paying jobs in the coal mines (it was not difficult to earn 60K a year as a miner), has sent folks scrambling for the exits. Yet many cannot leave because of care giving responsibilities or other connections. They hope now for a full time job at Wal-Mart, which pays perhaps half what they made before. = Finding health care and affording medication is a major challenge. 25% of the children in this state live in poverty and that only increases as you go east. There is a significant shortage of doctors in this region and a large portion of the doctors are foreign born, and that is another issue. Of course, it goes without saying that the percentage that do not have insurance is quite high. = For many of these folks, there is a deep sense of fatalism and hopelessness. You can find similar despair in any economically deprived area. These are inherently decent people who need a sense of hope and encouragement along with respect,

  113. @Bruce Kleinschmidt, the sad fact of the matter is that Americans have been bombarded with so much misinformation and out-right lies about health care, that they will simply not vote in their own best interests. When the mere thought of a universal/nationalized health care system is rejected out-of-hand because it's "socialism," then a lot of Americans will simply have to live without help, stewing in their resentment over their predicament. This means, of course, blaming liberals or "identity politics" or illegals or someone else.

  114. You can be certain that the government will come to the rescue. Beginning with George W. Bush, America was there with Africa to fight HIV and AIDS. The funding has been impressive and the achievements are great. And the money has kept on flowing under Obama and Trump. Whether it is right-minded Democrats or America Firsters, there is no possible justification for helping Africa but not West Virginia. And the fact that this obvious fact is not mentioned here brands the writer oblivious.

  115. @michjas : not to mention...we know how to fight AIDS and HIV after all these years. We've made remarkable strides in treatment & prevention and turned a once-fatal disease into a treatable chronic condition.

  116. @michja Trump's attempts to slash the CDC budget and foreign aid was thwarted by the US Senate. Let us give credit where it's due.

  117. @Wise Woman Wise indeed. So many people have either forgotten, or were never educated on the fact that a diagnosis was once a death sentence but today it is virtually preventable & manageable.Knowledge is power people. One just needs to educate themselves & their children.

  118. I’m happy to hear HIV rates are falling in some parts of America, and hope that we as a country can confront the epidemic as it moves to less populated areas. I hope we can find a national will to equalize health care across urban and rural, rich and poor in this country. The loss of productivity we permit in this country by our antiquated health care system is immeasurable. Rural Americans need access to healthcare, just like they needed access to electricity once upon a time.

  119. I never understand why programs like this don't reach out to churches instead of newspapers. Dems could address climate change in two years with a campaign of educating the country's pastors. The networks these people live by are direct, face-to-face, human networks, not abstract, depersonalized, informational networks like newspapers.

  120. @Robert Well said sir. Applying this logic to the current topic- prevention of HIV & AIDS- could prevent countless suffering.

  121. @Robert I used to live and work in the mental health field in Kentucky and many of our clients came from Eastern Kentucky. My experience is that the amount of cooperation you get from churches in the area is dependent on the type of church. Many of the churches will resist outside help if there is any hint that they will have to compromise their fundamentalist values. There is a lot of emphasis on abstinence and prayer as solutions. The concept of needle exchanges was resisted in many counties because of the belief it would give addicts a "free pass" to avoid the consequences of their habit, as well as burden the tax payers. Heaven forbid that churches perceive that they are somehow giving permission for illicit sex, homosexuality, or continued drug use. The resistance to change is strong. The suggestion of making changes is to be regarded as suspect, and perhaps an insult to their cultural values. State government has not been of much help. This January, 2019 quote from Republican state senator Damon Thayer: "I am philosophically opposed to needle exchanges. I don't believe it's the proper role of government to use taxpayers' money to provide needles to people to engage in an illegal activity."

  122. @Iris Flag, Yeah, I completely agree with where the issue stands. I just mean that liberals tend to undervalue traditional networks, whereas they're actually organized around trust. Consider, for example, whether you'd rather find a babysitter through the recommendation of a friend or by sifting listings on Craigslist. So, what you're telling me is that churches have preconceived ideas about these issues. Definitely. But you know, they're not completely closed off. I had a conversation with a pastor about abortion where he trotted out all the usual lines. Then I asked him about a friend who got in vitro. They fertilized a dozen eggs and used two. I asked him then about the other ten fertilized eggs, which according to his theology are abortions. I can tell you he found a completely different language to describe this woman's desire for motherhood and how complex these issues are, etc. No doubt he continues to oppose abortion, but with me, he takes a different tone now. He recognizes that his theology is flatly inconsistent and that he merely approves of one woman's sexuality and another he disapproves of. When he comes to recognize that all women are pursuing motherhood and what is best for their families, he'll have taken the final step. We, liberals, have to prepare the ground and stop sneering at where people are. For me climate change is more important that needle exchanges, and there is no obstacle to addressing the issue through faith-based communities. Yet we don't.

  123. Modern ways of dealing with HIV and AIDS violate the moral values of these people. Many of them do not want help if the help is structured to deliver an implicit rebuke to their way of life by an educated, outsider elite. Moral issues should be fought out as moral issues, issues of personal responsibility, and not changed into public health issues that are addressed within a utilitarian framework that downplays talk of guilt, judgment, shame, or responsibility. Trump will defend them from having elite, outsider values forced on them, and they will respond to having these values urged upon them by voting for Trumpsters. If we want to respect their values, we have to let them deal with HIV and AIDS the way they want to. If part of their way is to ignore and deny the problem as long as possible, that is their choice. Of course, their values include Christian love, which can be interpreted as not judging but just being there and helping, and implies the nonjudgmental public health approach. But their implementation of Christian love often leaves much to be desired. Other sorts of Christians are trying to change the way the approach the problems, which amounts basically to converting them, but this is difficult. The whole situation is tragic.

  124. @sdavidc9 I'm reminded of a slogan we had in the '80s when first combating the public health crisis of AIDS with community organisation, activism and eventually forming and funding our own research groups when the Reagan administration refused to even acknowledge that a crisis existed because it pleased their voters: AIDS DOESN'T DISCRIMINATE. PEOPLE DO. Health care is only concerned with behaviours not beliefs because diseases like AIDS or cancer or countless others do not care about your beliefs. What you're suggesting here is Darwinian in nature, an extinction of an entire people. What you're forgetting is the way the disease will transform people in other ways, through their suffering, they will realise that the petty ideas that ruled their existence are meaningless once they are faced with reality. At least they have medications now that will allow for their condition to be manageable but the resources required to deal with and eventually prevent this crisis will be immense.

  125. All of WV is in Appalachia, so what does the author mean by “Appalachian WV?” 50 of our 52 counties produce/mine coal, so what does it mean when he says the part of WV near the coalfields? Those coalfields intersect the entire state. This is the second NYT article about WV I’ve read in the last couple of days that leaves a bad taste in my mouth. People have been angry about how this area has been covered for a long time. I’ve been more forgiving, but I’m feeling that less today. Also, can you stop sending in photographers from out of state? There are people here who can do the work.

  126. 53 of 55 counties have coal.

  127. @Rebecca Kiger Talk about not seeing the forest but for the trees, there's but one picture accompanying this story (probably stock), along with an over sensitized response as to the number of counties producing or mining coal. Actually it's but 43 counties that have recoverable reserves but this is all besides the point.. You've not commented whatsoever in your response as to the emerging crisis that is HIV in WV. It's totally ignored in fact. That's telling. Is it a willful ignoring of the pending crisis? is it the inference that conservative policies are contrarian to helping your fellow West Virginians? or the possibility that those who indulge in certain behaviors deserve it? WV is a beautiful state. It's one that I look at as a possible place to retire (preferably near the state university for health care delivery and hopefully arts/culture). Relative to a nascent anger as to outsiders perception of the state, I suggest that you look no further that the current occupant at the White House. There was a bill of goods sold to the citizens as to how coal was coming back. That there is a correlative to the HIV/opioid crisis and economic well being is without question. As for his Majesty's recently publicized initiative to end this disease, he has very uneven track record - went a year after firing his HIV/AIDS advisory panel before new members were sworn in, and the administration consistently turned back health protections for LGBT Americans.

  128. @Rebecca Kiger check out the counties that don’t have coal in WVA. They are the counties that you can drink the clean water and it doesn’t flood every time it rains. They are the counties that you can live in and go to work in a good job in western Virginia. ( Roanoke , Blacksburg area ) Also , the eastern counties of WVA have access to great healthcare in Virginia by Virginian doctors and Virginian dentists.

  129. I think the use of "Conservative" and "rural working class white" ,is code, a way to say 'religious' and specifically 'Evangelical'. The compulsion to not criticize or even examine the content and conduct of religions, all in the name of 'respecting religious freedom', is societally and possibly globally suicidal. Not everything that calls itself a religion, even if it claims to be a Christian religion, is inherently benign.

  130. The problem of the spread of the AIDS virus that Steven W. Thrasher describes in rural areas resembles the situation in urban areas decades ago. Understanding that pattern would help illuminate the way toward preventing similar situations in the future. This would require digging deeper than Prof. Steven W. Thrasher has done.

  131. @Josephine S I worked in a federally subsidized health clinic in inner city Philadelphia in the early '90s. Many of my clients were IV drug users. One of our focuses was HIV testing. Every patient was offered, encouraged to test. We identified many HIV positive people and were able to begin treatment. This article list obstacles that we didn't face, like lack of funds, transportation, and Conservative resistance.

  132. No worries. As long as they keep voting for politicians who will take away their health care they'll be fine.

  133. The article ends with a call for change. But look at the voting pattern in West Virginia, non-urban Virginia, and Kentucky. The citizens are overwhelming electing politicians who will block almost all of the changes needed. This has been discussed now for decades with no end in sight.

  134. They voted for Trump on promises made. What's he doing to help the situation?

  135. @Larry Trump is steadfastly trying to take healthcare away from tens of millions of American by challenging ObamaCare in the courts and in every way imaginable. The US "president" is not only illegitimate and incompetent, he's utterly immoral and there are few examples better at illustrating his immorality than his total lack of policy on health care and his determination to make sure that tens of millions more American go completely without it. "Repeal and Replace" was a total lie by Trump and his Republican lemmings. But then everything that comes from the mouth of Trump and his Trumpists is nothing but lies.

  136. I have brushed up against the opioid crisis numerous times in my limited radius of peregrinations. Reading about it and witnessing it has led me to conclude that this nation is far from being Christian, in my understanding of the word. As an atheist, I ask forbearance in that my knowledge consists mainly of tenets gleaned from Peanuts cartoons, especially ones absorbed from the childhood viewing of tv specials. They held an enduring attraction and still do. It’s hard to reconcile that world with the one we all live in today. Burning at the stake is an apt metaphor for what passes as Christian values today. The Crucible comes to mind as an equally valid cultural touchstone. The mystic chords of memory are so weak and debatable that it is my conclusion that the house divided must fall.

  137. We all have our personal (values) views ... but if we dealt with cold facts, we might find better solutions. My first choice is education from a young age. Show younger children the ravages of opioids and the other diseases related to hedonism and discuss how they are drawn in before they are exposed to peer pressure; give them tools. Even kids can be helped to reason and make better choices for themselves. Every life saved is worth the least costly method of prevention: hard but factual eduction. Everyone is talking about the cost of healthcare. Any reduction in the need for the most costly treatments would be so much better. “The average cost of HIV treatment is $14,000 to $20,000 a year,” "The total cost for a Hepatitis C 12-week course is around $84,000.

  138. While I agree that early education is important some of those addicted to opioids are much older having originally been given the drugs for things like arthritis.

  139. Education. Period. In every way. That is what is missing.

  140. In 2016, Trump won every single county in West Virginia, winning a total of 68.7% of the vote state wide. Will West Virginia vote for a candidate that supports Medicare for All? Not a chance. Not while Donald Trump is running for President. West Virginia may cry for Federal healthcare funding, but they will not vote for it.

  141. @Purple Spain I think many people in these areas feel that they made choices. Many have been taught from childhood to believe that choices have consequences. Many may not believe that others should take the responsibility for those consequences they brought on themselves. Cultures and mindsets are not the same around the world or the US. The people of Appalachia may not be so easily compared to the populations of some urban areas. Solutions also need to be adapted to those being addressed.

  142. @Si Seulement Voltaire Yet these same people are the largest percentage of public assistance users, so I'm not buying that philosophy. I say give them what they are asking for. Let the red states opt out of all public programs. Spend that money in the blue states that pay for it any way. I lost any semblance of sympathy for them DECADES ago after living amongst them.

  143. @Purple Spain Please bear in mind that West Virginia was the most solidly blue state in the union until the early aughts. North Carolina was a predominantly blue state until a few years later. Ohio was by any metric a swing state. I am a democrat living in Appalachia and I am absolutely telling you democrats willfully lost these places. You can't let whole regions wither and die on the vine, show up for elections asking for votes, endorsements and money and expect to keep an area. Most voters here switched pretty recently because frankly, the massive decline of Appalchia can be laid squarely at the feet of democrats - not republicans. If you are on the ground here its very hard to convince people to vote democrat.

  144. I live in the Blue Ridge in Appalachia. Health care is a nightmare. Public Health has waiting lists which means you cannot get an appointment for seven to eight months. Staff is overworked and utterly abusive. Stigma. Suicide. That's us. The Public Health pharmacy tells you to come back because they do not have the meds. Many people have to find rides. They can live 300 miles away. Coming back another day is more than most of us can do. World AIDS day is a farce. How are we supposed to perceive being greeted with slick ads by people like Elton John who tells us what great progress has been made. Not for us. Bank of America has a big presence. We do not have accounts at Bank of America. Public Health is all over the place at World AIDS Day. Public Health has failed. Big Pharma smiles. Government treats us with contempt. The head of the NIH will giving a speech does not abrogate the fact that we have been lied to again. A cure is right around the corner or a vaccine trial show big promise. Patience. 35 years of lies. It's all promises. If there ever is a cure, it will not mean us. Our lives are connected to the system working. Platitudes abound on World AIDS Day. The rhetoric preaches inclusion. This does not mean us. Addiction. Hopelessness. Getting labs means another 300 mile drive. And then back again. Many of us do not have cars that are going to make it 300 miles let alone 600 miles. Care is for other people. It always has been. Sexual abuse. That's us.

  145. @Tim Barrus President Trump will fix this with something terrific, better, and cheaper than Obamacare that will cover pre-existing conditions.

  146. Trump got 69% of the vote in WV in 2016. He has gone on to try to sabotage the Affordable Care Act, and the GOP has done everything possible to make the Supreme Court lean toward corporations and fragilize government program. It would appear that WV is happy with him and the GOP. Elections have consequences. As Obama used to say, don't boo, vote.

  147. @Tim Barrus Yet, somehow, inexplicably, the people in the state voted overwhelmingly for the candidate of a party that wants to dismantle Obamacare and the Medicaid option in it. They really believe that the a Republican Party has their ‘ back’.

  148. Yes, it’s hard for us to empathize with the people who gave us Trump. But what is really sad is they are in a trap with no recognition of it. And the trap they are in, affects us, everyday. We’ve got to find a way to learn from the right - they are far better marketers than we have ever been - to tell a hear warming story of the real truth. I really don’t know how. But perhaps we can hire some ex Fox News people to help us craft the narrative.

  149. @Shyamela These areas may be waking up some, at least about healthcare. Kentucky and Louisiana elected Democratic governors because Medicaid issues were a high priority among voters... Republicans always want to cut back.

  150. @Shyamela Leave it to Fox and we'll soon learn that rural Americans have a built in immunity to all known communicable diseases with no need to vote for any progressive ideas that may actually benefit them.

  151. @Shyamela then they should stop voting for the people making the Traps. Fox news just told them what they wanted to hear. Stop pretending Fox wasn't just holding up a mirror to their true personalities. They fought to block help for HIV for years, years, years, and years. They asked for it, let them have it.

  152. Living in Seattle, there seems to be still a misguided view regarding how the needle exchange assists. There has been a push to cut the program, the ability for a rise in H.I.V. and AIDS is tremendous. The rural community may have a massive problem. Getting assitance is a small step in the program. Getting people to see through the misconceptions of what H.I.V and AIDS is; and how it is treated and how it is spread; may be extremely complicated. Once past the misconceptions, getting someone to a health clinic, taking medication and beyond is very difficult. The entire process takes dedicated caring people, with terrific communication skills, and with knowledge of the people and area. Not to be a wet blanket, but considering how long it has taken to reach people in the cities, there may not be a lot of ways to get the rural community ready.

  153. "It can't be ignored any longer?" Really? The opioid crisis unfolded right under our noses and what has been done for that other than shaming the prescribers and dispensers of the drugs? Has a fully funded comprehensive drug and mental health treatment system been implemented? The coal miners voted for a guy who told them exactly what they wanted to hear....coal will make a huge comeback. And it hasn't happened and it won't and they still will vote for him. The same guy who promised on day one to get them great, cheap health care. The same guy who promised to make pharmaceuticals cheap. That guy. He will ignore them. And they will vote for him. And Mitch will smile at them. Copy this article and publish it again next year. Maybe that will make you feel better. Or better yet, send Jared in to fix the problem. There now don't you feel better?

  154. I am totally sympathetic to the plight of anyone diagnosed with HIV, particularly in culturally conservative and medically underfunded rural areas. But there is a statistic in the article which is utterly jaw-dropping. Over a 10 year period "nearly 21 million opioid pills were sent to a single West Virginia town of 2,900 people." That's 7242 pills a decade or 2 pills a day for every man, woman and child. This was not a misguided medical policy. It was worse than drugs for profit. It was a medical act of war on our own people. And worse yet... One has to look at things in combination, not in isolation. Reduced economic opportunity, deprived educational and cultural resources, bad diet, a failure to inculcate physically healthy life styles, diminished medical facilities all coupled to a policy of fomenting drug addiction is a crime as destructive as waging war. Beneath the surface story of HIV/Aids, lies the story of the heartless promotion of addiction for profit. And beneath that story lies the horrible, unspoken reality of government and private enterprise working in tandem to commit *civicide* on an entire region. Restorative justice demands many things but it demands at least that all responsible at every level pay and pay again for the complete and total rehabilitation of these areas in all aspects of their civic existence.

  155. @Chip I don't think you go far enough. It wasn't just 1 or 10 rogue pharmaceutical companies... any more than 10 or 20 big banks nearly torched the US economy 10 years back. In an era of multimillion dollar salaries for close to one million corporate employees in the US - but ONLY in years when profit and growth are "on target," the temptation to turn a blind eye to VERY ANTICIPATABLE consequences is huge. (It's impossible to separate the individuals from the companies here, because speaking up is suicidal!) A few times each week, the handful of news organizations in the US who still have a soul come out with stories of corporate malfeasance - past or present - that illustrate a very real US vs. THEM war, where it's corporations solely focused on their own profitability vs. the overwhelming majority of US citizenry. How else to view Facebook's "We'll keep selling political ads and absolutely REFUSE to consider their truthfulness!" Or Amazon's "We'll allow/foster the sale of counterfeit books!" [On this cyber Monday, one does well to imagine the charge sheet that could be brought against this exemplar of "We broke it - YOU fix it... if you can!] Or every insurance company's spot in the circled wagons protecting their profitable healthcare operations from a proven move efficient (Medicare) competitor! Most of Europe CAN view government as a check on most corporate rapaciousness. In the US - quite the opposite - and it's been altogether bipartisan for at least 30 years.

  156. @Chip During the AIDS crisis in the 1980s, the world blood banks knew they had infected blood. Eventually, two of the blood bank officials in France were jailed because of their negligence. Needless to say, nothing every happened to anyone associated with the blood banks here.

  157. @Chip "...That's 7242 pills a decade or 2 pills a day for every man, woman and child..." That's if the pills stayed in town. Most of them were sold to out of towners that went to the "pain clinics" that were allowed to spring up on every corner.

  158. Everyone should regularly get tested for HIV at least one a year, during routine or even unplanned healthcare plans.

  159. It seems that Planned Parenthood has played a large part over the years in diagnosing and treating sexually transmitted diseases. Yet another way that people's cultural biases are hurting themselves.

  160. Let's be very clear about one thing. If we want to stop the spread of HIV, we must stop voting for Republicans. Their war on Planned Parenthood has shut down the clinics where people can go for testing and other health services. (That had a lot to do with the outbreak in Indiana - under then Governor Mike Pence.) Their blocking of Medicaid expansion and war on Obamacare has closed hospitals and left people without healthcare. Their punitive approach to crime at the expense of rehabilitation and support is both ineffective and expensive. Their insistence on abstinence only sex ed has left people seriously uninformed on health risks and even basics on sex. Their attitude towards deregulation of corporations has allowed drug companies to profit off human misery. Their tolerance of increasing inequality, resistance to living wages, and overall disparaging of government has crippled our ability to respond to crises like this. It's hard to think of any problem facing us today that Republicans are not making worse.

  161. @Larry Roth I suppose we could use a Democratic California as a shining example of how things should be done. Despite all of the access to Planned Parenthood we still find ourselves dealing with the problem of HIV. It would seem that we are dealing with a behavioral problem as much as with a health problem and there are no pills or shots planned Parenthood can give out for that.

  162. @jerrybeavers57 No one is denying that behavior is a problem; people do have to take responsibility for their actions. But that also includes politicians who ignore science and pander to the prejudices of their base. It goes all the way back to Ronald Reagan, when HIV first began to impact the US. https://en.m.wikipedia.org/wiki/And_the_Band_Played_On On health, climate, inequality, race - the GOP is consistently on the wrong side.

  163. @Larry Roth Well said! I am reminded of Alan Grayson's interpretation of the Republican health care plan: Don't get sick; if you do, die quickly.

  164. i agree that because these rural states (as my own state of missouri, sadly all republicans) are populated by people of lower education, i.e. high school diplomas, if that, they tend to be trump supporters who simply do not know that voting for him is not good for them. it's hard to understand people like that, who simply have no common sense in the political arena. so my tax dollars go to medicaid trump supporters. do they not see that the man lies like a rug?

  165. @buskat It is easier to tare things down than to build things up. And the GOP as the party of NO is an expert at the latter. Our political divide makes it almost impossible to act. Even if we do not get Medicare for all there is plenty we could do to fix the ACA, but Trump and the GOP intent on destroying democrats trumps working for the American people on any level.

  166. @buskat it’s interesting to me that Trump voters consist of rural lower educated voters AND highly educated voters who want low taxes and no regulations. It’s a complex mix of people who vote for Trump. Anecdotally , I know several highly paid and highly educated people who will vote for Trump again.

  167. Today is the world's AIDs day. The fight against HIV spread and progression to AIDS continues without a vaccine and without a cure. But the good news is that the spread of Human Immunodeficiency virus (HIV) has diminished due to an effective treatment against HIV infection. The bad news is the opioid crisis, the sharing of infected needles and mother to child transmission of not just HIV but also hepatitis C virus (HCV) is unchecked and on the rise. Many in rural America probably do not have access to the same on demand state of the art prevention counseling and treatment centers. Is rural USA not ready? Of course not. Rural USA has been somewhat insulated from the spread of HIV due to the higher level of monogamous safe sex relationships than urban America. But with increased IV drug use and sharing of needles, the dynamics is changing. A multipronged approach to HIV eradication is needed. Prevention is better than cure and until there is a vaccine to prevent the spread of HIV, mass education of the masses for safe sex and prevention of IV drug abuse has to be administered from high school level to adult education. Widespread testing of HIV infection should be undertaken and Highly active anti retroviral treatment (HAART) administered to those who could benefit from being treated and compliance enforced. Billions of $s have been spent on vaccine research that has failed to deliver a vaccine. It is time to run with what we know works elsewhere and apply it to rural USA.

  168. Red state / trump’s America leads the way in opioid abuse, social security disability, poor education, low wages, underemployment, poor access to healthcare including reproductive services But at least they have their guns and religion. Sorry, they’ve made their choices.

  169. Highly concerning the number of "reap what you vote" comments. Yes, red states are frustrating and maddening (I live in one). But 1) they are not 100 percent red (there are many Dems fighting the good fight, and children can't vote!) and 2) we cannot turn our backs on fellow citizens. We must be better than that. Not only because it is the right thing to do, but also because our country is only as strong as our weakest links. We are no better than the Fox News crowd and craven Republican gangsters if we do not continue seeking solutions.

  170. @Bh The problem is that we have effective strategies to address the issues cited in this article, but communities and states refuse to adopt them for political and religious reasons. It's very frustrating. What else are we supposed to do?

  171. There was a recent article in the Times about how we tend to blame society for the individuals who self destruct. HIV and drug addiction issues would go away if individuals led responsible and careful lives. Grow up, get married and don't stray, and stay away from abusive drugs. Its not that difficult, as millions do just that and lead happy and successful lives.

  172. It’s not exactly an informed choice when you are an addict because you had an accident, surgery or arthritis and your doctor prescribed them for you which got you addicted. Because the doctors were told by the pharmaceutical companies that the drugs were non addictive or highly unlikely to be addictive.

  173. And Mr. Thrasher is being polite in saying rural America is not ready for the coming HIV crisis. Medically, rural America is barely ready to give flu shots. Once again propaganda coming from Fox News has convinced lock step Republican Governors to not accept Medicaid expansion entirely on the idea that it was tied to the ACA. And now we, as rural Americans face the consequences of the right wing fanatics. Food deserts are being talked about in the cities. Rural America now is facing the twin crisis of not only food deserts but now health care deserts. Maybe "Buffalo Commons" wasn't so far off base after all.

  174. It’s a crime that critical care for at risk individuals in these rural communities has gone from bad to worse as a result of stigma, religious beliefs and just plain ignorance, and the costs will just continue to grow. “ Negative press, business worries and conservative approaches are among the reasons the programs have been reduced when they urgently need to be expanded ...”

  175. A simple solution seems to be unlimited access to clean needles Quote: 21 million opioid pills were sent to a single West Virginia town of 2,900 people between 2006 and 2016 That is insane, 21M / 10 years / 2900 people / 365 days = 1.98 pills per person per day for 10 years. How much of that was paid for by Medicare and has anyone investigated these doctors for Medicare fraud?

  176. @Prudence Spencer The FDA had a database of exactly what quantities when where! If you need any evidence that your government is not interested in the health of the public but only profits of corporations, that is it.

  177. It’s hard to feel too sorry for these communities when they consistently vote against their own interests and against policies that would better their communities.

  178. I think it is more complicated than that. Like any group of people, Appalachian communities are complex. The way those communities vote reflects a lot of different influences, concerns, desires, etc. One important factor to keep in mind: many former coal communities have been manipulated into voting against their self-interests by corporations seeking to exploit them. This not to say that the individuals involved are powerless or blameless, but there are some legitimate (and historically complicated) social and economic grievances in Appalachia. We should try harder to understand.

  179. @Awells great insight! Many Politicians on both sides of the aisle in WVA worked to keep good jobs out of the area. White collar jobs in science or IT are non existent in WVA . Politicians sold to WVA men that going into the underground mines was patriotic and godly and if you were killed that was God’s will. Many generations of West Virginians have been brain washed. Southern WVA is so impoverished that it doesn’t look like it is in America.

  180. Thank you for your excellent response!!

  181. "...fueled by drug companies’ promotion of pain medications beginning in the 1990s..." What? Drug companies are allowed to promote practically any drug they manufacture. What has that got to do with anything? A Doctor has to prescribe these drugs, you can't just walk into the Quickie-Mart and buy them. There are only two problems here. 1) Corrupt Doctors exchanging drugs and prescriptions for cash or sex (as has been widely reported on). 2) Low tax States, as is the case particularly through the South, who believe taxes are theft, and the only healthcare needed is the Bible (as it notes: God blesses the righteous with good health). Taxes are the price paid for civil society. Are taxes in States like New York high? Absolutely, but at least New Yorkers (and I'm proud to be one) understand this concept. New York State spends almost $200 million dollars a year promoting the arts. This is greater than the entire amount some States in the South spend on their education systems. Low tax States = No proper government services. Plain and simple.

  182. — “There is no way [the opioid epidemic] doesn’t wind up as an H.I.V. outbreak in the state,” Ms. Young says. — I can think of one way: Make clean injecting equipment available no questions asked. I work as an infectious diseases specialist here in Australia and treat HIV as well has hepatitis C and other infective complications of IV drug use. In stark contrast to my native USA, in Australia, injecting drug use is not major risk factor for HIV infection. The reason is not that Aussies don’t inject. They do. I rather suspect that until Americas opioid tsunami, heroin injection was more prevalent here than there. The reason is that since the earliest days of the HIV epidemic, sterile syringes have been available cheaply at any pharmacy without prescription and without identification.

  183. What I'd like to better understand is rural - or the different types of rural communities in this country. This may sound simplistic but what mining companies have done to their laborers over the decades is astounding. So is what people have learned to tolerate. Like doctored x-rays. It's a pernicious form of exploitation. I haven't driven through the deep South and don't plan on doing so any time soon but driving through WV was unnerving.

  184. Thrasher's premise has a number of problems. The major one is that HIV has not followed opioid use into rural communities on a consistent basis. There have been clusters including the one mentioned in West Virginia, but these have been relatively isolated. We have not seen the rapid dissemination of HIV among injectors that has been observed in urban areas around the world in the past. The 220 county modeling study is driven by two factors--white non-Hispanic race and poverty and CDC quickly realized that it missed places with significant problems and it included places that were poor and white but not impacted. Modeling is not destiny and, in fact, it has a rather poor track record in forecasting HIV epidemics. CDC has subsequently funded situation reports that look at available administrative and disease surveillance data to help states plan better. The real infectious disease epidemic associated with opioids is Hepatitis C and resources for it lag far behind what is needed. There is tremendous stigma attached to opioid use in rural areas and scarcity of resources for specialty care, public health, and social services is the norm. These conditions have made it difficult to implement policy changes in rural areas even in forward moving states. You underestimate the risks and courage that local people take in supporting unpopular policies or seeming to support them while services for other conditions languish.

  185. @Rich According to the book "Dopesick", heroin was brought to these communities from urban areas (NYC, Philadelphia) by intermediate drug runners who work for major drug operations. Heroin is cheaper than rx opioids and more likely to be available after pill mills were shut down. Some of the drug runners had sex with the locals and shared needles with them.

  186. Regarding opiod addiction, it's interesting that drug companies receive the brunt of criticism in news articles. The companies are closely monitored until the opioids leave the distribution facility. After that, they have no control. Few articles blame the physicians who over prescribe the drugs or the pharmacists who sell them. Why is that?

  187. @Daphne Less we forget, the FDA had a database which recorded exactly where every shipment went in the US. This has recently been made public. Who knew in the FDA that certain stores in small towns were receiving massive quantities, etc., etc. How many knew? Dozens, hundreds? Kids are dying and nobody cared. Nobody in the FDA anyway. If you sell drugs on the corner, 10 to 20. Sell tons of it, nothing. Not even a mention.

  188. @Daphne, the drug companies misled the physicians on the addictive properties of the medication while marketing aggressively...that’s why. Look up Purdue pharma.

  189. @Shyamela It seems improbable that anyone who completed medical school and internship and who has been alive during the past 50 years would be unaware that opioids are addictive.

  190. Someone should let them know it will take approximately 40 years of educating their communities and much involvement by all to stem this wave and to see the decrease we are now seeing in the cities. Thoughts and prayers...always more helpful than funding!

  191. Said to say, but once again religion, and the small male minds that dominate organized religion infect their congregations with fear and hate that manifests itself in the general population. In a nation that declares its allegiance to Christian values, rather than demonstrate compassion, love and help thy neighbor, we look to demean those who are not like us and seek punishment rather than redemption. Until the people can act upon true Christian values and band together to assist those who are afflicted and less fortunate, then the crisis will get worse before it gets better.

  192. When it comes to HIV infection U = U. Undetectable equals Untransmittable! There is no reason whatsoever for this epidemic to continue in the US, except for the immoral denial of basic health care to tens of millions of American citizens, of course. Current medication regimens are as simple as 1 pill a day now. These medications are highly effective in bringing serum viral load down to undetectable levels. And undetectable means you cannot spread the infection, period!

  193. @NY Times Fan Seriously? I assume you're speaking of PreP. I've seen many ads on tv for it, so I looked it up online. Effective, yes, and with a list price of roughly $20,000 per year. (In contrast, it costs a few hundred dollars a year in civilized countries.) Big pharma is perfectly okay with pricing drugs so high that it literally becomes Your Money Or Your Life. (And please don't trot out the canard that because many / most health insurance companies will pay most of the cost that this outrageous sum is somehow "okay".)

  194. @dtm " Seriously?" Totally! "I assume you're speaking of PreP." Nope! I'm talking about treating people who are already infected with HIV. If you keep them "undetectable" then they CANNOT spread the virus to sexual partners. There is over a decade of global data proving this. It should mean the end of HIV globally. PrEP (Pre Exposure Prophylaxis) and PEP (Post Exposure Prophylaxis) are also very useful tools, but that is NOT what I was talking about at all. I'm talking about 1 pill a day making already infected people unable to transmit their infection... because if the amount of virus in their blood is so extremely low that the most sensitive tests cannot even detect it, much less measure it, there is no chance of spreading the virus to others (regardless of pre or post exposure prophylaxis which are also very useful tools).

  195. i guess elections do have consequences afterall.

  196. These are the same people who support Trump's drive to eliminate ObamaCare. It would be inhumane to say they are now getting what they deserve, but tempting none the less. Now we of the blue states along the coast will pour millions to save their lives so that they can continue to support those that would destroy them. Sad.

  197. God forbid we miss an opportunity to blame something else on the (fake) opioid crisis. Maybe let's start talking about the lack of personal responsibility for those afflicted.

  198. @RJ Thank you for making this important point. Victims everywhere; personal responsibility nowhere.

  199. @RJ So, the fact that big pharma told doctors that the medications had low addiction potential, encouraged them to prescribe increasing amounts, and shipped millions of pills to small towns, had nothing to do with it.

  200. Rural America, is not "ready" for HIV? What have they been doing for the last thirty eight years? How much more time do they need, to get "ready"?

  201. I’m sure The Donald will make things right, if only those downtrodden will believe in Him.

  202. I mean no disrespect to those suffering from this crisis, but didn't many Christian leaders say AIDS was God's punishment of the gay community. I just wonder how are they going to explain this impending health crisis to their community. Can you imagine how powerful the churches could be in educating those members?

  203. What a beautiful looking place, Williamson, West Virginia.

  204. Every time there's an article about rural America a flurry of commentators angry at Trump appear in a rush to blame the rural poor for their own problems. It's sick and toxic. You know nothing about these peoples lives or struggles, yet you gleefully condemn them and laugh at their deaths. Try having an ounce of compassion for people you barely recognize as human. And remember, Trump is not a product of their world, he's a product of wealth and privilege in New York City.

  205. @Arctic Vista "You know nothing about these peoples lives or struggles, yet you gleefully condemn them and laugh at their deaths. Try having an ounce of compassion for people you barely recognize as human." Not sure who is "laughing" and "gleefully condemning," however, even if you don't like it, they have a right to their own opinion and their own feelings. I might point out that you are pretty much the pot calling the kettle black and being judgmental yourself.

  206. If you've been voting for Republicans and are sorry that you, your friends and neighbors are suffering, try voting for Democrats, and contribute to voter registration efforts. Don't look to Republicans to help you; if you are not a major donor, they are only interested in you until the clock strikes midnight on election night. Republicans won't acknowledge that they helped Big Pharma turn you into addicts, or try to make up for profiting off of your illness and death. You have to change who you vote for.

  207. Let's be real clear. The American health care system is not created for the people. It is created for the profit of the health care industry and "people" can just get sick and die. Take this one example: Truvada, a pre-exposure prophylaxis (PrEP), is an anti-viral drug and largely prevents people from getting infected with AIDS. In France it is free for all who want it. In the US, it can cost nearly $2,000 per month. Rural.... urban.... same robbery.

  208. These are the same people who complain about "Lazy minorities on welfare in the cities" but who then promptly pop pills or fake illness for disability, and stick a needle in their arm when the factory closes. Why don't they pull themselves up by their bootstraps and move to California like poor rural farmers in Oklahoma did in the 1930s? Notice that none of those vulnerable counties are in the dirt poor "Black Belt" in the south, or heavily hispanic areas in the southwest, or even in rural areas in more progressive states in the Northeast like New York, which despite deindustrialization are not facing an HIV crisis. Conservatives are toxic and destructive, even to themselves, and their rhetoric about self sufficiency and being good, god fearing folks who look after each other is complete nonsense.

  209. Needle exchange programs are a significant component of harm minimisation and reduction in HIV, hepatitis B and hepatitis C transmission. There are around 200 needle exchange programs in the US: https://drugfree.org/learn/drug-and-alcohol-news/states-cities-consider-needle-exchange-programs-reduce-spread-infection/ In Australia, with a population of just over 25 million, there are over 3500 needle exchange programs: https://kirby.unsw.edu.au/sites/default/files/kirby/report/NSP-NMDC_Report-2016.pdf From an economic perspective alone, Australia’s needle exchange program represents one of the highest returns in investment of any public health program. Not to mention the individual suffering, reduced productivity, loss of role functioning, that people face. And PrEP and hepatitis C treatments are provided at subsidised rates to citizens. Such are the ‘horrors’ of a universal health insurance scheme.

  210. Interesting that Charleston, West VA has been the focus of 2 NY Times articles so far. The first recent article regarding Mayor Amy Goodwin’s failed attempt to change the name of their Christmas Parade to Winter Parade. The link to that NY Times article s provided below. “…the coal industry in the region collapsed, jobs in chemical manufacturing disappeared, shops closed and large numbers of people moved out of town altogether…” https://www.nytimes.com/2019/11/29/us/politics/christmas-parade-charleston-wv.html?searchResultPosition=1 So it seems that Mayor Goodwin, in her misguided efforts to appear “progressive”, has opted to ignore far more dire and difficult issues at hand such as a decimated local economy and rising death tolls directly resulting from rising opioid addction and HIV. Criticisms of the mayor’s competency aside, it will be revealing to see how all of the aforementioned horrors affect how their citizens will vote in the upcoming 2020 Presidential election. Chartleston desperately needs to understand that the present (Trump) administration is doing them in; as this article states, “…rural America is ill-prepared at best and antagonistic at worst.”

  211. I’m sorry, but I thought conservatives are all about rugged individualism; I thought they believed in personal responsibility and the power of their own bootstraps. Not to mention the power of prayer. And a punitive attitude such that people who fall on hard times deserve it (which logically follows from the message of the popular Prosperity Gospel). Having pointed out the hypocrisy above, I know that individual people, and small communities, are helpless against powerful forces, and need major help from the outside. I sincerely hope they can come together as a statewide community to work out innovative solutions, and accept federal help if they need it.

  212. Way too many readers turn their ire on the downtrodden in West Virginie for bringing Trump to power, even though presumably Trump policies hurt them. Please refrain from this impulse, and stop believing this population is so stupid and look at the bigger picture. It’s just one of the many communities that have enormously suffered from decades of economic change and free trade bringing wealth to more cosmopolitan centers while leaving more rural and small towns communities behind. Plenty of economic littérature, start with Piketty. People always forget that free trade maybe a national win/win but you need corrective tax policies to account for the fact that most gains go to a select few while others lose their jobs. And, if you understand that, you understand that the communities have a lot of reasons to distrust democrats, who brought them 40 years of free trade and economically conservative tax policies. Want them to vote Trump even more massively? Very easy: select a Biden, Booker, Buttigieg, Bloomberg, more of the same. Want a shot at reversing that? Medicare for all and policies that they will actually see for themselves actually helping them. Nothing less. The rest is political speak.

  213. @R Very much appreciate your thoughtful post! Which Democrat politicians do you think would be successful against Trump and implementing the policies you say are critical?

  214. @R Your comment is full of contradictions. - Yes, over the past 40 years, Dems drifted towards supporting free trade. But your assertion that this drift is what caused the election of Trump isn't based in logic, because during those 40 years, Republicans always supported free trade. Thus, it wasn't the Dems that caused places like WV to shrivel up; it was the underlying Republican philosophy of free capitalism that destroyed these areas. - And you blame the Dems for "economically conservative tax policies"; huh? Every time the Dems tried to pass somethign progressive, the Republicans blocked it. Who deserves the blame? - You cite Medicare for All as an example of a policy that would help. You think that Republicans would EVER support that? You seem to have forgotten that when Pres Obama adapted the concepts of Romneycare (which originated in the Conservative Heritage Society), the Republicans hypocritically screamed bloody murder. You expect us to pass Medicare for All when the Republicans have a knee-jerk reaction to rejuect anything that the Dems support? Your comment might make sense in France; but it has little to do with the political realities in the US.

  215. @Jen Italia I don’t really care who but in my view any free trade moderates who pretend to defend the less well-off and the middle class will simply accelerate the slide of middle class towards republican. Particularly if that moderate is socially liberal. And I find myself at odds with most readers on this and I actually find myself in agreement with Ross Douthat. Republicans have stopped since Romney talking the language of reason and free trade policy and are now speaking in terms of values, principles and cultural issues. And let’s face it, they are winning. Unlike democrats though, they never even pretended to care about the downtrodden and so the accusation of hypocrisy sticks much more with democrats. Either way as far as healthcare is concerned they will oppose any plan no matter what so one might as well shoot for one with as much popular support as possible in the rust belt and swing states. I will support any common sensical economic patriot who will support Medicare for all while shifting towards the middle on cultural issues. Warren or Sanders is fine by me. And i will distrust the language of platitudes.

  216. I recall a quaint, friendlier West Virginia of the past, before its people, especially its poorer and uneducated, became the enablers, and then the property, of the WVA Republican Party. A week ago we read of the naive mayor of the state capital, Charleston, innocently changing the name of the Christmas Parade to “Winter Parade,” to promote inclusivity. Promptly, the full wrath of God was visited upon her. Or, rather, the wrath of the GOP-controlled State Senate, in the form of its leader, a Mr. Carmichael. The state GOP head, a woman, piled on, demonstrating that the radical politico-religious right in West Virginia welcomes both genders (but nothing in between). Seeing no biblical hypocrisy in his words, the city’s leading African American pastor, a Reverend Watts, jumped in, proclaiming the name change an affront to Jesus himself. (Never mind that Jesus was deleted from America’s celebration of His birth decades ago.) A small town radio jockey named Hoppy, a media star if ever there was, took to the web and attracted Fox News, the world’s single greatest Defender of the Faith (sorry, Queen Elizabeth). Bing how many times Carmichael, Watts, the state GOP, any elected Republican, Fox, or Hoppy himself, railed against big pharma’s attack on WVA society. Good luck. Try to imagine any of them acting on, speaking about, or even thinking about the coming AIDS crisis. To the witless whoopies who turned WVA Trump red: the crisis you voted for is at the door. Merry Christmas!

  217. That's a shame. Those of us living in blue metro areas try to get them health care with our votes and our money, but they consistently refuse to vote for it.

  218. @Frank That's because they don't want "socialized" healthcare...they want capitalist healthcare...sadly, they don't realize that means only if you can afford it.

  219. How many gay and lesbian volunteers don't help because of the community backlash in these communities? The gay community took it upon itself in the 80's to educate their members, Reagan left them to their own resourses. Yet these rural places still think that climate change is a hoax and Trump is the "chosen one". How can you help when they refuse to listen?

  220. @Martin Poor things.

  221. You drive through western Virginia and you see how America is great . Shanty farms with tin roofs and 3 broken cars from the 80's still in the front, barking chained dogs, Hamish ultra conservative stores every 20 miles, never anywhere in Europe, in the not so rich country side areas in Portugal, or Italy or Spain you find such desolation. Lack of sense of community, no culture, and guns in every house.

  222. Millions of Americans have no health insurance - or inadequate insurance. In order to halt further spread of HIV, those newly infected will need diagnosis and treatment with the medications that allow people with HIV to live long lives. These communities will suffer, HIV will spread and people will die because of the mess in this country where many people are uninsured. Those who allowed the spread of opiods should be held accountable. Most importantly, those who manufactured the opiods and made fortunes thru Big Pharma must be held accountable - their money seized and these people sent to prison. Everything in this country is about those in power harming, exploiting and neglecting normal Americans to squeeze as much profit out of them as possible. The people harmed are cast aside like peanut shells. This starts with Trump and extends through the cabinet, the legislature, the pharmaceutical companies and the giant insurance companies who fought the ACA and are fighting Medicare expansion because = $$$$$. This is shameful.

  223. Interesting that Charleston, West VA has been the focus of 2 NY Times articles so far. The first recent article regarding Mayor Amy Goodwin’s failed attempt to change the name of their Christmas Parade to Winter Parade. The link to that NY Times article s provided below. “…the coal industry in the region collapsed, jobs in chemical manufacturing disappeared, shops closed and large numbers of people moved out of town altogether…” https://www.nytimes.com/2019/11/29/us/politics/christmas-parade-charleston-wv.html?searchResultPosition=1 So it seems that Mayor Goodwin, in her misguided efforts to appear “progressive”, has opted to ignore far more dire and difficult issues at hand such as a decimated local economy and rising death tolls directly resulting from rising opioid addiction and HIV. Criticisms of the mayor’s competency aside, it will be revealing to see how all of the aforementioned horrors affect how their citizens will vote in the upcoming 2020 Presidential election. Charleston desperately needs to understand that the present (Trump) administration is doing them in; as this article states, “…rural America is ill-prepared at best and antagonistic at worst.”

  224. @Larry Chan I don't think it's fair to use one article (about a different issue) to decide that she's "opted to ignore" other problems. Renaming a parade is not a full time job.

  225. It's crisis after crisis for rural America. What do you do for those who won't help themselves? Who look at you with scorn until they personally are affected and then ask for aid? Do you educate? Can you educate? This is a cultural crisis that will reach a head at some point.

  226. @Andy Hill What are you saying exactly? What do you mean by "they won't help themselves." What does that have to do with HIV? Is that what you said about the initial outbreaks of AIDS in San Francisco bathhouses in the eighties... that they "won't help themselves?" That you scorn them because they dared to "ask" for aid when they are personally affected? If that's what you really mean, then you are a scary person. I hope you never are in charge of anything.

  227. @david Based on successes in a number of urban areas, we know strategies that work to reduce the number of new HIV infections. The areas cited in this article refuse to adopt those strategies. It's not blaming the victims, it's blaming the political and religious establishment in these areas.

  228. The GOP sees an opportunity in this. They will leverage the HIV crisis in Appalachia, use it to drum up homophobia, which they'll use in turn to draw voters to the polls. There is no strategy too depraved it is about winning at all costs.

  229. The odds that rural America embraces the lessons learned by urban America over the last forty years = very low

  230. HIV is an unexpected mutation away from a new strain with perhaps greater virulence and drug resistance. We've learned a lot about HIV's disease process and that includes its high mutation rate. Lot's of testing is one of best first line approaches to contolling this basically STD disease.

  231. Ask your GOP representatives all the way from the County good ol' boys to the Statehouse and congressman, they alway help those in need and care about public health and welfare.

  232. Social, religious and political conservatism are the bane of many types of progress. This is another example.

  233. In 2011, when Mike Pence was governor of Indiana, that state began experiencing an AIDS/H.I.V. outbreak. Until 2015, despite pleas from healthcare officials and law enforcement, he refused to approve a clean-needle exchange program which went against his conservative Christian beliefs and led to many more infections. Even after “praying” on the subject and finally giving permission for a limited needle exchange program, he pushed for “possession of a syringe for illegal substance use” to be upgraded from a misdemeanor to a felony, when every scientific study showed it did not encourage drug use. Since coming to power, the Trump/Pence administration has been gutting funding to fight spiraling rates of AIDS/H.I.V. and Hepatitis C caused by the opioid crisis and vulnerable rural areas in economic decline are paying the price

  234. @Susan I always have to remind myself, there is a difference between a dog fawning, and a dog truly liking someone. That military dog was fawning over Pence. Pence is a VERY dangerous man.

  235. When there is a recession, let alone of the largest global ones to affect us in history, usually it is the rural regions who take the longest time to recover and are the hardest hit. It would help if all urban and rural dwellers could imagine being young, and without much of a future to strive for. An Elder has just told me of his twenty-five year old nephew, who had his leg amputated, complications from taking fentanyl. There could be a vigorous national advertising campaign, showing graphic photos of young victims of substance abuse, overdoses and infected needles. The word 'young' is key, because one usually feels at that age, more immune to ills that afflict and impact on everyone. While great progress has taken place to combat AIDS since 1982, there may be a feeling that it has been eradicated, and for instance one rarely hears of herpes these days. 'Rural America cannot be ignored'; the policy-makers to get to the roots of these problems via more Life options for all ages, while launching a blunt and realistic photographic campaign of the painful skeleton road to self-destruction.

  236. "This avoidable crisis has been exacerbated by unemployment, declining coal mining production and economic pressures on regional press to act as effectively as a watchdog." There's something confusing in the last part of this sentence. Maybe just eliminate the 'as' between 'act' and 'effectively'? Or is the writer asserting that the regional press in WV does not cover important news because advertisers do not want to place ads alongside depressing stories?

  237. And they'll keep voting against healthcare.

  238. Reading a lot of the comments here today, especially from those living in West Virginia, I have the impression that people in Africa have more access to HIV information, prevention, diagnosis and especially TREATMENT than those in rural America have! The attitude of Trump and Republicans on health care is immoral and nothing illustrates that better than the rural HIV epidemic in America. There is ZERO excuse for failure to ELIMINATE all new HIV infections completely in America, much less is there any reason for new epidemics to become the rule. Currently HIV treatments are not only highly effective, but treatments nearly always result in undetectable virus levels in the blood and Undetectable Equals Untransmittable! U = U, and that means there is ZERO excuse for any more new HIV infections. Universal health coverage is the answer to this and many other health issues in America today. ALL the Democratic candidates are in favor of it. All American should be, too.

  239. This column views HIV infection in rural communities as a problem, but many people in those communities will see it differently: as God’s punishment for drug abuse and sexual “immortality.” They may regret the human suffering, but accept it as God’s will, the price to be paid for God’s cleansing of sin from their communities. This view will influence public health efforts against HIV, or lack thereof.

  240. Haven't these rural folks, the GOP base, heard that the economy is at the highest in all of history? The stock market and IRAs are skyrocketing to the highest in all of history. Haven't they heard the news??

  241. Forty years in to a public health crisis, and after countless premature deaths, local and state government’s are devoted to maintaining institutional bigotry and systemic discrimination. Sadly those policies will kill people. The H.I.V. pandemic in West Virginia and other rural areas is both sad and maddening. Infuriating even. We’re supposed to learn from our mistakes, and the current epidemic reflects abject ignorance and stupidity on the part of policy makers. Where are the conservative pro-life activists running the state now? What are they doing to address the crisis? Their hypocrisy is stunning. Needle exchanges and public health campaigns work. In West Virginia and other places like it, you reap what you sow. The people deserve better.

  242. Those who believe that expanding medicare will solve this problem would read this NYT article: https://www.nytimes.com/2019/10/04/opinion/sunday/trump-arkansas.html. It's the best (perhaps only) explanation I've ever found for why people vote against their own interests. If it's true, then the problem of HIV in the areas described in this essay goes far beyond poor access to healthcare.

  243. If addicts could readily get opiod pills they would not inject heroin (or anything) and would not transmit HIV or hepatitis. Addiction itself is a comparatively minor evil. There are many high-functioning addicts who contribute to society. It's easier when they know where their next fix is coming from. That also dries up the illegal opiod trade.

  244. Mark from Berkeley comments, "It is difficult for me to empathize with these communities as a majority of people in these communities are responsible for giving us Donald Trump." As a long-time medic at the Berkeley Free Clinic, it is clear to me that what Mark writes is essentially a comment on him, not on H.I.V. carriers or anyone else in West Virginia.

  245. How ironic that many of Trump's supporters will now be caught up in the dysfunction he and fellow Republican governor's and legislators have created in rural healthcare.

  246. What I would say to Professor Thrasher is: yes, this is true for West Virginia, North Carolina, and a lot of places with fairly substantial rural populations. And then I would say: this isn't new. It's not just a matter of drug addiction and needles, it's also a matter of sex education, substance abuse education, income inequality, prejudice against homosexuality, and men on the down low. It's been going for decades, at least. It goes on in Southeastern Florida too, for the same reasons. Against all these prejudices and despair we have defenses: PREP at an affordable cost, needle exchanges, and (what we all pray God for) a vaccine or some genetic therapy through CRISPR. And please, folks, don't castigate these people for their politics. Disease knows no preference, Republican or Democrat, gay or straight, Protestant, Catholic, or Jew, rich or poor. We're all in it together because we're all human beings.

  247. Yes, we’re all human. But some of those categories of humans do things that help the problem, and some do things that exacerbate it.

  248. @Wiltontraveler It is a direct result of their politics that promotes the spread of these diseases. I think we can castigate.

  249. @Wiltontraveler With regard to your last paragraph, I know disease can strike any community. I know that part of being a member of society is to understand that we're all in this together. The people we're talking about here in the comment section -- the anti science, anti sex education, homophobic, virulently conservative people -- do *they* know those things? If Dr Thrasher is correct, and they're in for a wave of HIV infections that they're tragically unprepared for, will they come together to support their loved ones? Will they understand that AIDS isn't something people can fight all by themselves?

  250. I remember a New Orleans AIDS worker telling my class at Loyola University in the late 1980s that the greatest rate of increase of new HIV infections at the time was among White rural women who provided dealers sex for drugs. This isn't really a new problem, just one rural America has not wanted to face.

  251. 2016 Election results from West Virginia Donald Trump 67.9% Hillary Clinton 26.2% Trump isn’t very interested in helping people out with HIV unless it involves handing out fresh lumps of ‘beautiful clean coal’. Sad.

  252. @Socrates, What did HRC have to offer West Virginians? The possibility, not the promise, of training in low skill data entry jobs. Sad

  253. @Southern Boy, True, not many good options for rural West Virginians. But a low-skill desk job is less physically taxing than mining or stocking shelves at Walmart, so contracting HIV from heroin use to manage chronic pain would be less likely.

  254. How about decent healthcare? Hillaey offered them that. You think digging coal is going to be there for the kids and grandkids of adults in WV today? And killing people with black lung disease in the process? Coal and no healthcare are not answers.

  255. So this is article #28104872 since the 2016 Election in which I - a liberal, well educated, well paid, coastal city dweller - am supposed to find compassion and empathy for rural Americans and the problems which they caused for themselves. (Funny, that was the same election in which I essentially voted to raise taxes on myself in order to spread healthcare benefits around the country.) First the opioid epidemic, and now HIV/AIDS. Nope. Not happening. I hate what a stone cold heart I have developed, but here we are. 10 years ago, I would ask what I could do to help. But today? After three years of watching these same people gleefully brag about how their candidate is sticking it to people like me? Of cheering on his every illegal, disgraceful move as he works tireless to make their lives, and this country, worse? (All while they benefit from their extraordinarily disproportionate federal benefits, flowing like burst dam from blue states to red states, of course). I pray that one day we can return to caring for our fellow man in this country. I fought the demons of cynicism and spite as long as I could. But I too cracked. Let these people take all of that nonsense the GOP sells them about personal responsibility, states rights, small government, private healthcare, etc., and sort this mess out for themselves. I am sure it will be a tremendous success.

  256. When you ain't got nothing, you got nothing to lose. These rural areas are their own worst enemies and its no surprise that the populations are shrinking and that the communities are doomed. Too bad the NY Times had to cover West VA again when this is a problem in rural areas coast to coast.

  257. It looks like the red states need to invest in intelligent public health education--they could save lots of lives with all the people suffering from obesity, lung disease, opiate abuse, alcoholism, and STDs. Maybe the Republican leadership should prod the states to wake up and improve education for their people.

  258. The return of all those coal industry jobs should make West Virginia a paradise! LOL!

  259. Don’t worry people of West Virginia and related rural areas, your president is going to fix everything. Moreover, your Republican representatives in Congress are fighting for better healthcare and education and job opportunities every day. Not. Fools.

  260. "..in 2017, St. Charles County closed its only clinic for sexually transmitted infections, which provided nearly 1,000 exams a year. " Might that have been due to "Christian" activists who objected to the fact that the clinic also provided family planning services?

  261. This is an example of how denying access to health care to tens of millions of American results in illness, disease, and death, not to mention greatly increased health care costs. Spending money on prevention saves lives and it saves money, too! HIV-positive people with access to health care are almost-always able to achieve such low level of HIV in their blood that the virus is said to be "undetectable". Being “undetectable” means that they CANNOT spread the infection through sex. There is well-over a decade of global data proving this. All the tools are in place and well established: how to reach and educate the public, how to diagnose, how to prevent the spread by treating those infected (U = U), how to prevent infection using PEP (Post-Exposure Prophylaxis), etc. There is no reason the HIV epidemic cannot be eradicated completely from the entire globe, much less is there any excuse for HIV to spread into rural communities in America! All it takes is access to basic health care for prevention and diagnosis, and access to treatment. Denying universal health care to ALL people living in America is immoral and costs more in terms of lives and money in the long run. It's both immoral and stupid.

  262. @NY Times Fan Actually, while PEP is an important intervention, the best prevention measure is PrEP (Pre-Exposure Prophylaxis).

  263. HIV has always been and remains a disease associated with the idea that sex is dirty, rape is acceptable, and the social sickness of homophobia. The virus thrives on denial, self loathing, and the rapaciousness associated with such attitudes: a commonality with addiction. The compassionate (hello Jesus) understanding of the human condition combined with rational policy can easily defeat this scourge. It is only the human weakness of avarice, shame, and self righteous superiority based in the lie of religiosity that allows the epidemic to continue. The idea of purity is a lie and a disease of the mind. We are al born in the swamp of nucleic acids which shares its womb with potential disease. Our rational minds devoid of hateful prejudice can solve this problem if bigotry can get out of the way.

  264. This is not new. Abraham Verghese, an infectious diseases physician now at Stanford, wrote a beautiful memoir about the years he spent training and practicing medicine in Johnson City, Tennessee in the early 1980's: 'My Own Country'. His story is richly nuanced and filled with keen observations about the people of this rural area coming to terms with HIV, as sons and daughters returned to their families to die. No urbanite can read this story without losing layer after layer of prejudice and stereotypes of rural dwellers.