“I prefer a simple introduction. I am a Christian, a conservative and a Republican, in that order,” Indiana Governor Mike Pence said when he accepted the VP nomination at the Republican Convention on July 15. He is forever introducing himself with this little jingle, usually delivered with his index finger extended for “in that order.”

This article was originally published by The Influence, a news site that covers the full spectrum of human relationships with drugs. Follow The Influence on Facebook or Twitter.

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His speech at the convention, like his subsequent campaign-trail appearances, was crisp, moderate and disingenuous. The focus was on “fiscal responsibility.”

“In my home state of Indiana, we prove every day that you can build a growing economy on balanced budgets, low taxes, even while making record investments in education and roads and health care,” Pence said, to cheers.

While economic growth in Indiana is above average, the improvements follow trends that preceded his tenure. Pence did succeed in tearing up the government safety net, including the public health spend. He increased mandatory minimums for drug offenses at a time when criminal justice reform is a bipartisan issue. And he signed two of the most sadistic anti-LGBT and anti-abortion bills in US history.

But his unique distinction lies in having enabled and exacerbated the first rural HIV outbreak since the earliest years of the AIDS epidemic.

As I spoke with some of those involved—including Ed Clere, a Republican state legislator who had the foresight to pursue a needle exchange bill before the crisis hit, and was punished by Pence for his pains—a malign picture emerged of the “reasonable” half of the Trump ticket.

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The Real Extremist on the GOP Ticket

Make no mistake, the vice-presidential candidate is an extremist. Much of the media has failed to communicate this, and perhaps to understand it. They call him a “social conservative” when he is a militant theocrat.

Part of it is that Pence is a smart, disciplined and attractive man. His imitation of a down-home, plain-spoken Hoosier has become second nature. He is described as “polite,” as “humble,” as “look[ing] like a football coach.” He likes to say that he is a conservative, “but I’m not in a bad mood about it.”

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Donald Trump would make any running mate seem, by comparison, moderate. He makes Pence seem milquetoast. (Compare Pence’s generic-masculine close-cropped white hair with the orange synthetic phenomenon orbiting Trump’s skull.) The irony is that Trump appears to be the extremist when he is a hollow grifter with a personality disorder. Mike Pence is the real deal.

In March, Pence signed—“with a prayer”—a law that bans the abortion of fetuses with Down Syndrome and other genetic conditions, forces a woman to have an ultrasound 18 hours before an abortion, and forces her to bury or cremate the fetal remains, even she miscarries. Nationwide, women voiced their outrage, joining a “Periods for Pence” campaign. In June a federal judge blocked the bill, as Pence no doubt anticipated. The law demonstrated his allegiance to the “personhood” movement, which advocates giving full legal rights to zygotes and criminalizing abortion as murder.

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Pence also wants to deny full legal rights to LGBT people. In March 2015 he signed the nation’s most extreme “religious liberty” bill, to legalize anti-LGBT discrimination by people, churches and businesses. It sparked a firestorm—boycotts, protests. The bill was patently unconstitutional and indefensible. Yet Pence defended it and made a fool of himself on the national stage.

After he told the state legislature to add a clause prohibiting anti-LGBT discrimination, his theocratic backers turned on him. Up to that point, he had been a serious contender for the 2016 GOP presidential candidacy. Instead, he’s now the toady of a godless barbarian. Karma is a bitch.

Culpable for the Spread of HIV

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During all the drama around the anti-LGBT bill, HIV and hepatitis C were spreading like wildfire through a close-knit, isolated community of IV opioid users in Austin, a small town in southeastern Indiana. Austin has a population of about 4,500; 10 percent of these people are estimated by the CDC to be addicted to opioids.

Eighteen months later, some 200 people there have HIV. About 50 percent of them are on HIV treatment; about 75 percent are co-infected with hepatitis C. Very few are in treatment for addiction; even fewer have quit opioids.

Last week, The New York Times ran a story headlined “Mike Pence on HIV: Prayer, Then Taking Action” (later changed to “Mike Pence on HIV: Prayer, Then a Change of Heart”). The piece portrays Pence sympathetically as a leader who, faced with an HIV outbreak apparently from out of the blue, had to decide between two equally legitimate but competing claims: his “moral opposition to needle exchanges on the grounds that they supported drug abuse” and “an epidemic that was growing more dire by the day.”

“In recent interviews, local, state and federal health officials said Mr. Pence initially held firm [against allowing needle exchange in Austin]. So as they struggled to contain the spread of HIV, the officials embarked on a behind-the-scenes effort over several weeks to persuade him to change his mind, using political pressure, research and pleas for help from this remote, poor community.”

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On the one hand, one man’s deeply held morals; on the other, 450 lives. What would Jesus do?

“On March 23, more than two months after the outbreak was detected, Mr. Pence said he was going to go home and pray on it.”

This sentence merits a close reading. After ignoring an emergency for months, with health officials, legislators, the media turning against him, he finally “prays on it.”

Then—not one, not two, but three days later—he surrenders to the political pressure.

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The Times’ “dark night of the soul” portrayal is false. The competing claims apparently weighing so heavily on Pence are not equally legitimate. His opposition to needle exchange cannot be weighed on the same scale as the life of even a single drug user at risk for HIV.

Why? Because there is no rational debate over the effectiveness of needle exchange as a public health measure. These programs dramatically reduce disease and death.

They can also help people in their struggle against addiction; some studies show that needle exchange users are five times likelier to enter treatment than other injecting drug users.

And Pence has not had “a change of heart.” He still opposes needle exchange.

Since the Austin crisis, five more counties in Indiana have started syringe exchange programs to attempt to avert their own HIV outbreaks. Among some people on the front lines in Austin there is the conviction that Pence instructed the state legislature to provide so little support as to ensure the failure of these programs.

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“I think it was just set up to fail from the get-go,” Dr. Carrie Ann Lawrence, the head of Project Cultivate at the Rural Center for AIDS/STD Prevention at the Indiana University School of Public Health, told Politico. (Project Cultivate was central to the establishment of the needle exchange in Austin and has helped several counties negotiate the law’s many technical complications in the application process to win state approval for a syringe swap.)

The evidence bears this suspicion out. When Pence became governor in 2013, he knew about Indiana’s opioid problems. He had been warned by the CDC about fast-rising rates of hepatitis C. The agency advised him to open needle exchanges.

He remained silent about the threat of HIV until it was far too late.

“HIV is here to stay. In fact we’ve not quarantined it,” said Dr. Shane Avery, a family physician in Scott County who beseeched and hectored the governor for years to do something, anything. “It’s the governor’s refusal to address this situation that I believe will result in Indiana’s most historic failure in public health.”

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In May 2015, a pregnant 18-year-old girl died of the untreated complications of undiagnosed HIV infection, as if Austin, Indiana, were in sub-Saharan Africa.

Pence’s Progress From the Reagan-Era Right

In the late 1980s Mike Pence—born into a Democratic Catholic family in Columbus, Indiana in 1959—decided that the Reagan-era Religious Right was the crowd he wanted to run with. He changed his party affiliation and had one of those conversions to evangelical Christianity so common among ambitious young Republicans.

He graduated from law school, practiced law for a few years, ran for Congress and lost, twice, headed a far-right think-tank, hosted an Indianapolis talk radio show—“Rush Limbaugh on decaf,” he called it—and a Sunday morning TV show about politics. He interviewed politicians of all stripes, sports figures, “personalities.” He wanted to be one of them.

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In the 2000 election, Pence finally won election to the House of Representatives.

On his campaign website he stated his opposition to the five-year reauthorization of the Ryan White Care Act until an audit was done of the nation’s 2,000-plus AIDS service organizations, and all pro-gay groups struck from the rolls. Those dollars could be used more effectively, Pence said, by ministries offering “conversion” therapy—the fraudulent and psychologically injurious program of behavior modification to “de-gay” a person, often a teenager forced to submit by homophobic parents.

In Congress, Pence would wherever possible attempt to divert funds meant to assist needy Americans to evangelical “faith-based” organizations that condition their “assistance” on proselytizing to their clients, in violation of the First Amendment.

The other God Pence serves is Big Business. Reagan preached that “government is the problem” and sparked a movement to deregulate industry, privatize government functions and destroy the remnants of the New Deal and the Great Society.

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Pence and his allies have driven this beyond the wildest imaginings of Reaganomics. His opposition to FDA regulation of cigarettes epitomizes his fanaticism.

“Despite the hysteria from the political class and the media, smoking doesn’t kill. In fact, two out of every three smokers does [sic] not die from a smoking-related illness and nine out of ten smokers do not contract lung cancer,” stated his 2000 campaign website. The real “public menace,” he said, was “backhanded big government disguised in do-gooder healthcare rhetoric.”

Anti-regulation and anti-science, Pence’s extremely narrow approach to public health problems earns him “fiscally responsible” points, at least in the short term. Of course, public health problems that are left uncontrolled often develop into crises, which come with a massive price tag in dollars and human suffering.

But the central social problem for Pence has nothing to do with public health. The central social problem is morality: the prevalence of abortion, gay rights, divorce, drug use, adultery.

“When you talk about Planned Parenthood or same-sex marriage or the economy, you’re talking about one common enemy. And they do use the word ‘enemy,’” journalist and Dartmouth professor Jeff Sharlet said of Pence’s supporters.“The enemy, to them, is secularism. They want a God-led government. That’s the only legitimate government. So when they speak of business, they’re speaking not of something separate from God, but they’re speaking of what, in Mike Pence’s circles, would be called biblical capitalism, the idea that this economic system is God-ordained.”

During his six terms in the House, from 2001 to 2012, Pence checked off all the boxes: abstinence-only prevention; no rights or protections for LGBT people; no reform of drug laws or mass incarceration; no global warming; no evolution.

But it was as an anti-abortion fanatic that he made the biggest stink. Starting in 2007, he led GOP efforts to destroy Planned Parenthood, introducing six pieces of legislation in six years. In early 2011, he threatened to shut down the government over Planned Parenthood funding and came within three hours of doing so. Using fake videos made by a dirty-tricks campaign that purported to show the group participating in sex trafficking, he manufactured “outrage” and Republican support for a rider to block all federal funds to Planned Parenthood for the rest of the year, even though no federal funds can be used to perform abortions.

“He’s been called a one-man crusade against Planned Parenthood,” Illinois Democrat Rep. Jan Schakowski told theGuardian.

Even more extreme were Pence’s efforts to legitimize the “personhood” fringe of the anti-abortion movement. He introduced bills to define personhood as the instant when an egg is fertilized, to criminalize abortion as murder and prosecute the female incubator.

When the Affordable Care Act became law in 2009, Pence jumped on the Tea Party bandwagon as soon as it appeared. He helped start the Tea Party Caucus. He voted for 25 pieces of legislation and 10 amendments aimed at repealing Obamacare, including paranoid provisions like “death panels.” When the Supreme Court ruled that the individual mandate was constitutional, upholding the Affordable Care Act, Pence compared the decision to the 9/11 attacks. He challenged the Republican Majority Leader for his seat, losing badly but displaying defiance for his Tea Party constituency.

Pence was not a serious legislator. He was a far-right activist. Not a single one of the 90 bills and amendments he introduced became law. He pulled stunts and grandstanded. His votes were rated—the Christian Coalition: 100 percent; the NRA: A+; the pro-business Chamber of Commerce: 95 percent; NORML: -20; HRC (the nation’s biggest gay lobbying group): 0 percent.

Austin, Indiana: A Perfect Storm Brewing

Mike Pence did not simply allow the HIV outbreak to happen through indifference and inaction. Every detail of his record reveals advocacy of policies that created the necessary conditions.

Average life expectancy for white working-class people without college degrees fell last year for the first time in a decade, with a surge of mortality rates for those aged 21 to 54. The main causes are overdose, liver disease and suicide—all to some degree related to drug use. This demographic is Donald Trump’s base; he leads Hillary Clinton 2:1 here in most polls.

Austin, in Scott County, Indiana, lies in America’s Rust Belt. The nation’s former industrial heartland helped lift several generations of white Americans into the middle class. The idea that the next generation would be better off than their parents became an article of faith.

By 1980, growth in productivity had plunged, coal and steel were declining, and manufacturing was being outsourced. High-paying blue-collar jobs were lost to de-industrialization, automation and globalization. Tax cuts for the rich, corporate welfare, union-busting and other Reaganomics policies accelerated the destruction of America’s great middle class.

Scott County’s children have not been better off than their parents for decades. They face high rates of high-school dropouts and teen pregnancies; one third of under-19s live in poverty.

Austin is known as the opioid capital of southeastern Indiana. I-65, a major north-south highway, runs hard by Austin, ferrying pills and heroin to Chicago dealers.

Asked by NBC News why addiction is so prevalent in Austin, William Cooke, the town’s only doctor, said, “It’s really about hopelessness. When these kids are in middle school, I’m providing them care and there’s a brightness in their eyes. They believe they can be president of the US someday. But that brightness is gone by the time they’re in ninth grade. They don’t think there’s anything waiting for them. They think there’s nothing to live for tomorrow. And the drugs are so available.”

The Rust Belt’s opioid crisis was many years in the making. As author Sam Quinones writes, US sales of OxyContin increased from $45 million in 1996 to $3.1 billion in 2010, and national overdose deaths quadrupled during that period. Purdue Pharma, the maker of OxyContin, deployed its sales staff to pitch physicians in regions of the US where opioid prescribing and social security/disability receipts are high. At the top of the list is Appalachia, including West Virginia, western Kentucky, southern Ohio and southeastern Indiana. By the late 2000s, pain pills were involved in more deaths than cars.

In 2011, the CDC investigated a four-year 500 percent rise in hepatitis C rates among young injecting drug users in eastern Indiana. They advised the Indiana health department to immediately consider launching syringe exchange programs in the five-county area.

In 2012, news that 31 people in Scott County had died the previous year from prescription opioid overdose was widely reported by national media. “I worry that an entire generation might be lost to drug addiction,” County Sheriff Dan McClain told NPR.

Wherever syringe possession is illegal, drug users share needles, and once hepatitis C or HIV enter the communal bloodstream, they spread rapidly. And the specific conditions of life in Austin favor maximum risk.

Most drug users live in a single neighborhood. It is not unusual for several generations of a single family living together to share needles. In addition, the primary available opioid, Opana, is expensive, so several people typically pool money for a single pill, then shoot up the liquid form together.

But these are just the proximate conditions. Austin is also one of the poorest towns in Indiana. It has a 9 percent unemployment rate, a 19 percent poverty rate and a $16,000 per capita income. It has 35 churches and one doctor.

Indiana has the nation’s sixth-highest rate of infant mortality, and Scott County has the worst health outcomes of all 92 counties in the state. In 2014, Indiana ranked 37th in state public health spending ($17.43 per person), with the bulk paying for HIP 2.0 (state Medicaid); 50th in CDC investment ($13.67 per person); 50th in HRSA investment ($12.88 per person).

Austin is 98 percent white. Although evenly split between registered Republicans and Democrats, it has voted Republican in every presidential election since 2004. Its demographics are representative of those who have fallen under the spell of the “blue-collar billionaire.” They have done so not because he has articulated a way to create decent jobs for them, but because of “hopelessness,” because “they don’t think there’s anything waiting for them,” because “they think there’s nothing to live for tomorrow.” Trump is for them what opioids are for their children.

Many Christian, conservative Republicans have a less charitable view. “The truth about these dysfunctional, downscale communities is that they deserve to die,” Kevin Williamson wrote recently in National Review. “Economically, they are negative assets. Morally, they are indefensible. Forget all your cheap theatrical Bruce Springsteen crap. Forget your sanctimony about struggling Rust Belt factory towns and your conspiracy theories about the wily Orientals stealing our jobs.…The white American underclass is in thrall to a vicious, selfish culture whose main products are misery and used heroin needles.”

Governor Mike Pence

2016 was supposed to be Pence’s year for a presidential run. But the Fates span a different destiny.

Pence left Congress in 2012 and ran for governor of Indiana because Americans elect governors as president. A reddish state, Indiana appeared ripe for the imposition of biblical capitalism. He won by 3 percent.

Pence knew perfectly well that his state had high rates of IV opioid use and the attendant threat of hepatitis C and HIV infection. The CDC had already advised the state health department that needle exchange was the most effective emergency intervention. But giving people needles to shoot up drugs was a non-starter for the staunch drug warrior. What does the CDC know?

Soon after taking office, Pence cut taxes for the wealthy and corporations, dumping an annual tax burden of $1 billion on local governments, which had to reduce public services to meet the shortfall.

Scott County’s health spending per person was $10.84 in 2013. It had no budget for free HIV, hepatitis C or other STD testing. A single Planned Parenthood branch had long provided those services, but Pence asked the Republican-led state legislature for a defunding bill. Scott County’s Planned Parenthood, which did not provide abortions, hung on until 2013. Two branches in adjacent counties were also shuttered.

Pence did find money for staffing at the state’s prisons ($43 million) and for new prison construction ($51 million). One of his top campaign donors was GEO Group, one of the nation’s biggest private prison companies; it operates a prison in Indiana and was angling to build another—what a coincidence!

Naturally, Pence’s attitude toward people who are addicted to drugs is that they are criminals who need to be put in the new cells that the private prison industry is being paid by the state to build. In 2013, as other states were legalizing medical and even recreational marijuana, Pence signed a “tougher on drug crime” bill, mandating harsher sentences for low-level pot possession. He would have nothing to do with the growing bipartisan criminal justice reform, even though it is backed by some of his nearest and dearest, like the Koch brothers, Americans for Tax Reform, Freedom Works and the Family Research Council. Instead he signed into law both longer mandatory minimums and new mandatory minimums for additional drug use and distribution crimes.

In 2014, Pence was one of the Republican state governors who refused to implement the Affordable Care Act’s Medicaid expansion. Rather than hand Obama a victory, they turned their noses up at the offer of billions of federal dollars to cover many poor people. But Pence ultimately negotiated with the Obama administration approval for his own version of the expansion, one adapted to the conservative principle of “personal responsibility.”

Among other modifications, recipients have to pay a token amount for coverage every month or risk losing it—a requirement that supposedly distinguishes it from the Obamacare giveaway to undeserving layabouts. (Obama nixed a work requirement proposed by Pence.) Charging the premiums, priced at 2 percent of a beneficiary’s income, “gives Hoosiers the dignity to pay for their own health insurance,” Pence told The New York Times. Mr. Dignity promoted HIP 2.0 (Healthy Indiana Plan) as a model for Republican governors to chip away at Obamacare.

Almost half of the 800,000 uninsured people in Indiana are eligible for this program, and as of June 2016 about half of them had enrolled. It offers the same mental health and drug treatment as Medicaid, and enrolling Austin’s addicted people in HIP 2.0—a service associated with needle exchange—has proved critical in their accessing medical care. (In November 2015, Pence also signed a bill increasing access to mental health and drug treatment for uninsured low-level nonviolent offenders.)

It represented a typical Pence “change of heart”—moving a step in the right direction, but too little and too late.

Ed Clere, the Republican Who Fought for Needle Exchange

Indiana state Rep. Ed Clere, a Republican, is the 42-year-old former chair of the public health committee, and was responsible for winning passage of the 2015 bill legalizing needle exchange.

Like Mike Pence, Clere grew up in southern Indiana; unlike Pence, he believes in science. He is a generation younger, came of age during the AIDS crisis and, perhaps for that reason, did not imbibe the poisonous stigma toward people with HIV brewed by Pence’s theocratic allies.

“AIDS was one of the biggest issues of the day when I was growing up,” he tells me. “The risks associated with unprotected sex were front of mind. My familiarity with syringe exchange programs goes all the way back to that time.”

Indiana’s IV drug users have few advocates. They do not contribute to political campaigns. They do not have lobbyists. The Indiana state legislature, like the governor, shared the dogma that if they get HIV or hepatitis C, it is their problem, not the taxpayer’s, and that giving them clean needles enables their lifestyle.

Ed Clere did not share this attitude. And as chairman of the house public health committee, he may have been the only political leader who took seriously the catastrophic risks to this community.

In 2013 he began working with Dr. Beth Meyerson, co-director of the University of Indiana’s Rural Center for HIV/STD Prevention, on a bill legalizing needle exchange statewide. (This was not a pie-in-the-sky ask. Although only eight states had authorized syringe exchange by 2014, a total of 17 states, plus DC, now explicitly authorize it. Programs, many long-established, operate in some 200 cities and counties in 33 states.) Across the Ohio River, Kentucky legalized syringe swaps in March 2015 in response to its own epidemic of hepatitis C.

Clere and Meyerson drafted their bill based on best practices and introduced it in early 2014. In order to get it through the House, however, it had to be scaled back to being a small study of the efficacy of needle swaps on hepatitis C rates. The science on needle exchange has been settled since the mid-‘90s. Pence said that he would veto any needle exchange bill. It died in the state Senate.

“Without question syringe exchange was the most difficult issue I have tackled in the legislature in terms of resistance from the governor and other legislators,” Clere says. “There was no sense of urgency. It took an HIV outbreak to grab everyone’s attention.”

The HIV Crisis Erupts

Epidemiologists believe that HIV found its way into the Scott County drug-user bloodstream no earlier than January 2014.Genetic testing of virus samples in May 2015 found that 99 percent of HIV-positive people there have the same strain of the virus, suggesting that it came from a single source and had not had time to generate even one major mutation before burning through the community. People were in the acute infection stage, and their blood was teeming with virus.

The most likely route, according to some epidemiologists, was from a trucker on I-65. Local girls who use opioids sell sex at the numerous truck stops outside Austin. Among drug users, rumor has it that a guy newly released from prison started the fire.

The first sign appeared in early December 2014, when three people in neighboring Clark County tested HIV positive. (The county’s annual number of new cases had previously never exceeded five.) All three reported sharing needles with other Opana users in Austin.

In January the number of new HIV cases in Scott County rose to 11. The state health department began issuing public alerts as the numbers kept rising. On February 25, the head of the state health department, who opposed needle exchange, spoke publicly about the the outbreak, reporting 37 new HIV infections since December. The word “urgent” finally entered the discussion.

Between February 25 and March 25 the number of new cases almost doubled, to 68. Most of Austin’s 400-500 IV Opana users had not come forward to be tested, however, so no one knew where the bottom was.

>During these four weeks, local doctors in Scott County pleaded with Pence to authorize a needle exchange program. Advocates, academics, local, state and federal health officials and the media began beating the drum, too. It was beyond dispute that the chain of transmission in such a close-knit community could not be broken without syringe exchange—exactly as the CDC had warned.

But Pence’s attention was on a far more pressing (to him) matter: a bill called the Religious Freedom Restoration Act, which supposedly protected individuals, churches and businesses from having to offer service to the LGBT community, if to do so would offend their faith-based homophobia.

Wanting to give the haters a little something extra, Pence asked his Republican-led state legislature to draft a bill that not only gave business owners the same right to discriminate against LGBT people as individuals and churches, but protected them against civil suits brought by injured parties.

As the bill moved through the state legislature, a hue and cry was raised nationwide. It turned out that the GOP’s anti-LGBT constituency and the corporate community were on opposite sides of the issue. This was obvious to anyone who had been following the “religious liberty” news; Pence made a fatal mistake in believing it would be different in Indiana. The CEOs of Indiana’s nine biggest corporations lobbied loudly against the bill. The Indianapolis-based National Collegiate Athletic Association and the current (and four former) Republican mayors of Indianapolis all urged caution. The Republican CEO of Angie’s List said that he would withdraw a $40 million expansion of its headquarters in Indianapolis. The media editorialized against the bill.

The state legislature approved it. Pence sat on (prayed on) it for three days before signing it on March 26, a day that he will not soon forget.

It was a private ceremony, no press or public. An official photograph preserves the moment: Pence seated at his imposing Statehouse desk surrounded by 20 or so Judeo-Christian jihadists in full-on olden nun and monk costumes and lobbyists from anti-LGBT hate groups like the American Family Association of Indiana, Advance America (“Christian bakers, florists and photographers should not be punished for refusing to participate in a homosexual marriage!”), the Alliance Defending Freedom—Pence’s ties with these groups go back decades.

Only after this did Pence go to Scottsburg, Scott County, meet with local doctors, health officials and CDC epidemiologists and then don an Indiana EMS vest to speak publicly for the first time about the HIV outbreak.

Also on March 26, with a show of great reluctance, Pence has signed an executive order lifting the ban on needle exchange for one month. “I do not enter into this lightly,” he said. “In response to a public health emergency, I’m prepared to make an exception to my long-standing opposition to needle exchange programs.”

“This is all hands on deck,” he said. “I’m going to put the lives of the people of Indiana first.” A month had passed since the state health department had declared an emergency.

Meanwhile the backlash to the “religious liberty” bill was immediate and overwhelming. Angie’s List made good on its threat. Yelp, Gen Con, PayPal, Salesforce.com and other businesses said they would leave the state or not enter it if the bill was not rescinded. Apple CEO Tim Cook, who is gay, penned a Washington Post column describing the law as “very dangerous.” Thousands of protesters marched in the capital. Mayors and governors of liberal states announced a boycott of travel to Indiana by state employees. National sports leagues voiced their displeasure. George Takei, Warren Buffett, Charles Barkley. The state’s largest newspaper, the Indianapolis Star, ran a cover reading only “FIX THIS NOW.”

Pence tried to gut it out for a few days. In a now-notorious interview with George Stephanopoulos on ABC’s This Week, Pence refused to give a yes or no answer eight times to a version of the question, “Does this bill mean it is legal to discriminate against gays and lesbians?” Pence kept repeating the same hollow phrases (“Tolerance is a two-way street, George”), digging himself a deeper hole.

Within days Pence had signed a “fix” to the bill, spelling out that the RFRA could not be used to discriminate against people based on sexual orientation or gender identity. He had caved. Although LGBT people still had no state legal protections against discrimination, the “religious liberty” lobby was enraged by this perceived betrayal.

“Unfortunately, Indiana leaders yielded to the cultural bullies and the enticements of Big Business and the result is they have sacrificed the essential rights of their citizens,” Family Research Council President Tony Perkins said.

Step by inept step, Pence had walked straight off the cliff of his presidential aspirations. He had alienated his base, delivered his state an economic blow ($60 million, as a dozen conventions pulled their business) and was parodied by Jon Stewart in a Daily Show segment (“A Million Gays to Deny in the Midwest”).

Ironically, he was simultaneously being lavished with praise by media and harm reduction advocates for giving the green light to one needle exchange in one county for 30 days, in the midst of an HIV crisis provoked and prolonged by his own neglect.

The Legislative Struggle to Protect Drug Users

On April 20, 2015 Pence extended the needle exchange for an additional 30 days.

“The governor threatened to veto any syringe exchange legislation. He wanted to do it by executive order, but that was only a short-term solution,” Clere says. “I felt strongly that we needed to pursue a legislative solution that would not only offer a longer-term solution for Scott County but also for other communities throughout the state—and not just for HIV but hepatitis C, too.”

So Clere re-introduced his 2014 model legislation. He held hearings, where experts lined up to destigmatize needle exchange, saying that it is an “anti-disease” rather than an “anti-drug” measure. “He really worked very hard to make sure the science was clear so his colleagues would know how to make decisions,” Dr. Beth Meyerson said.

Clere knew that the HIV outbreak and the attendant media shit-show had put the fear of God in the legislature. His cost-effectiveness argument sealed the deal.

“Many of the folks who have contracted HIV in Scott County are going to be receiving treatment at taxpayer expense,” Clere said. “Even with the number of cases that have been confirmed so far we could be talking about tens of millions or hundreds of millions of dollars.” A needle exchange program on this scale costs about $160,000 a year to operate. The CDC estimates that the lifetime costs of healthcare, including HIV and hepatitis C treatment, for the 190 HIV positive drug users in Austin will exceed $100 million.

But the governor still refused to surrender any ground, vowing to veto any bill that authorized needle exchange statewide, as Clere’s did, empowering each county to decide for itself. Clere was forced to add one restriction after another. “I’m not sure where the goal post is now. It seems to keep moving,” he told the Indianapolis Star.

Pence appeared not to understand or not to care that the HIV crisis in Austin was years in the making and would take many years and a major investment in public health infrastructure to end. He would give whatever it took to make the immediate headlines go away. But the intractable socio-economic death spiral afflicting Austin that had resulted, for example, in three generations of a single family becoming addicted to Opana? Perhaps the Trump-Pence partnership will fix that after it gets rid of ISIS.

The final legislation authorizes any Indiana county to establish a one-year needle exchange program, but only after proving to the state health department that it is already facing a public health emergency related to drug-related hepatitis C or HIV. Rising rates of hepatitis C are the red flag alerting health officials that the conditions are ripe for HIV to rip through the community; drug arrest records, overdose deaths, opioid sales and other data are signs of extensive opioid use that will likely lead to shooting up and sharing needles.

This bureaucratic red tape, the one-year limit and other restrictions reflect Pence’s “moral” opposition to needle exchange except as an “extraordinary measure in an extraordinary situation.” The legislation he signed gives control to the state health department—effectively, to Pence himself—rather than empowering each county’s officials and medical professionals to know what they need.

More important, it defines “emergency” as the presence of infectious disease. But the emergency is the presence of addiction itself, which took hold five, 10, even 20 years before HIV emerged. Three generations of a family shooting up together is, by any measure, an extraordinary situation, but in Austin it has become ordinary. The likelihood of HIV transmission is almost the least of it. HIV is treatable. But lacking access to maintenance therapy or professional addiction treatment, this family has a moral right to clean needles.

Syringe swaps are burdened with enormous expectations. They are controversial and misunderstood. People on all sides have a stake in whether they fail or succeed Ed Clere’s original legislation maximized their potential to succeed.“I wish communities had the ability to use syringe exchange more pro-actively rather than waiting for an epidemic to come along—to prevent rather than just control infections,” Clere says. “I am also concerned with approval being limited to one year. What will that mean going forward?”

No state funds were allocated to deal with this red tape. Rural health departments do not have additional staff who can drive around in a van, which they do not have), trying to talk a hard-to-reach population of drug users into taking hepatitis C and HIV tests, which they also do not have.

Needle Exchange in Scott County, and Its Uncertain Future

Allowing a needle exchange in Austin was, for Pence, the headline. He never returned to Scott County. He never set foot in Austin, period.

For Austin’s health officials and chief of police, the fact that Pence had sat on his ass for so long meant that they had to do something that they had never done before and were ambivalent about, and had to do it at breakneck speed in a generally hostile environment under great media scrutiny.

Harm reduction workers ideally lay the foundation for a needle exchange over a period of months, meeting with local constituencies and trying to earn their trust. “[But] this was a response to a crisis. The people who were doing it had no prior experience. To some extent, it was sprung on them,” said Daniel Raymond, policy director of the Harm Reduction Coalition. “Local law enforcement was being asked to do a 180-degree turn in a matter of days. But building trust takes time.”

The needle exchange opened on April 4, 2015 in a “one-stop shop” on the edge of town. The program offered sterile syringes, HIV testing, condoms, tetanus immunizations, referrals to primary care physicians and drug treatment centers, and enrollment in HIP 2.0 to foot the bill. A door-to-door shuttle bus was driven by a church volunteer. Reporters crowded around the entrance to the building to interview people who came to use it. After four days, a total of four people had showed up.

It was more than just the intimidating presence of the media. There was a one-for-one rule—one used needle in exchange for one clean one—that required a drug user to transport a used needle (a crime) out to the one-stop shop for a single sterile syringe, which would be used and re-used (and likely shared) up to 40 times a day. The rule was self-defeating.

Local health officials quickly made some adaptations. They dropped the one-for-one rule in favor of giving out a week’s supply per person. They got a van for mobile needle exchange, becoming a familiar presence in the ramshackle streets where Austin’s drug users lived. They even began going door to door and making ongoing personal contacts. The chief of police first reluctantly, then deliberately took to the new regime. Austin itself made the best of its sudden association with addiction and disease in its own small-town American way—with free community dinners, special “AIDS” issues of the high school newspaper and church prayer walks.

Between April 25 and May 7, the number of people who got sterile syringes more than doubled, to 250. By May 14, it had grown to 326, and more than half were new visits.

Because Austin’s health professionals and volunteers are deeply committed to the health of the town, they have found a method, however unconventional, to get clean needles into the hands of those who need them. Door-to-door needle exchange is effective in a town where everyone knows everyone else’s last name. “The fact that after six weeks they had more than 300 people participating speaks for itself. They are making it work,” Raymond said. “They have the best needle exchange that works for them.” But without the town’s continued support, the exchange will become vulnerable, “and that makes the very people the exchange is there to serve vulnerable, too.”

By June 17, 170 people had tested positive for HIV, but the rate of new infections appeared to have fallen dramatically. The situation was deemed “under control” by the state health department.

The Pence administration therefore announced that it was pulling out of Austin and turning off the emergency $2 million tap. Given that Scott County had no budget for any of these emergency services, the situation was only “under control” until the last sterile syringe was given out or the last HIV test taken.

Meanwhile, on May 15, Mike Pence had announced that he would not run for president in 2016.

When asked what Scott County needs in order to mount an effective response to what remains an emergency, the health department’s preparedness coordinator, Patti Hall, laughs bitterly and says, “Everything.”

The first thing she mentions is homeless shelters, temporary housing and low-cost housing. Addiction treatment services are scarce—only 23 programs in southern Indiana. “It takes four to six weeks to get into treatment, but when someone is ready for treatment they want it immediately, not tomorrow,” Hall says.

The nearest methadone clinic is 70 miles away, a sketchy cash-only, for-profit business. Scott County needs more doctors who accept HIP 2.0, more doctors who prescribe buprenorphine, more doctors, period.

From June to November 2015 several more people tested positive for HIV. A “retesting blitz” by the CDC in November detected a few more. In February 2016 the Indiana health department reported a new total of 188 people with HIV. One is known to have previously tested HIV negative. In reviewing the HIV outbreak, CDC epidemiologist John Brooks said that as effective (and expensive) as the detection and prevention efforts were, the crisis was “devastating but entirely preventable.”

State-of-the-art public health measures focus on medication: Testing people for HIV, and getting them on anti-HIV drugs, is the best way to prevent them from transmitting the virus to others; people who are at risk can protect themselves by taking anti-HIV meds, too. Opioid addiction is best treated with the substitutes methadone or buprenorphine, which cut HIV transmission by 64 percent. Syringe exchanges are a close second, at 56 percent.

Pence has left the future of Indiana’s needle exchange programs in grave doubt. The one-year limit on each needle-exchange authorization makes them extremely vulnerable to majority rule.

Even in Austin, where one in ten people is addicted to opioids, old moralistic attitudes still prevail. Despite, or perhaps because of, the fact that most local families know someone whose life and health have been ruined by addiction, sympathy is in short supply. “Many people think, they got into this mess by themselves and they can get out of it by themselves,” Hall says. “They resent the help they are getting.”

The can-do, pitch-in spirit with which many community members welcomed the initial intensive intervention has soured as recognition of the long slog to an uncertain recovery sets in. Rather than becoming more enlightened about the public health logic of needle exchange, many people in Scott County appear to be counting the days until May 2017, when reauthorization of the bill can be voted down.

“We have been told that we will have a struggle getting it renewed again,” Hall says. “A lot of law enforcement and elected officials are hearing from constituents who have not been touched by the crisis. They are the ones who have the property, pay the taxes and vote. They are voicing their complaints. And this is an election year.”

Granted, it is not altogether pleasant, living in a town with a 10 percent IV opioid addiction rate and a 4.5 percent HIV rate and the attendant crime and needles, needles everywhere—sidewalks, playgrounds, front lawns. “Their complaints are basically we are just handing out needles without education and treatment,” Hall says. “And there are lots of complaints about all the used needles on the ground. They blame us for that.”

If there were more recovery success stories to point to, Hall says, community support might increase. “To be honest, the success stories are few and far between.” Even when people can access in-patient treatment, they have about a 90-95 percent risk of relapse. “But we are getting some people into rehab, and they are relocating, starting their lives over, getting their children back, holding down jobs. Many people in the community do not understand what an achievement that is. But to recover, a person really has to get out of Scott County.”

Pence Takes Revenge

Retaliation for doing the right thing and speaking truth to power seems to be an integral part of Mike Pence politics.

Last November, state Rep. Ed Clere was informed by the house speaker that he had been booted from his position as chairman of the house public health committee. The official reason for his removal was his “rudeness” to lobbyists and certain other legislators.

It seemed a rather perfunctory excuse. Clere had already been dressed down by the house speaker and the Republican caucus for voting against the “religious liberty” bill, for supporting same-sex marriage and for advocating ridding the Republican agenda of “social issues.” Heading the public health committee, he pushed for Obamacare’s Medicaid expansion, an HPV vaccine bill and, of course, needle exchange.

“I still don’t understand why I was removed, but I have to believe that my advocacy for syringe exchange was a big part of it,” Clere says. “There is no question that the governor was strongly opposed to syringe exchange. In the end I was grateful that the governor was willing to work with me on the final bill, but getting there was a very painful process.”

Indiana University’s Beth Meyerson called the removal of Clere a “vendetta” for his not marching to an “ideological drum.” “He is a great public health leader. We were so lucky to have him as chair,” Meyerson said. “I am deeply disappointed in the governor for removing him.”

And there is the curious case of Clark County public health director Kenneth Burke, MD.

In the middle of the HIV outbreak, Indiana state health commissioner Jerome Adams, MD, MPH, Pence’s mouthpiece, told The New York Times, “People just want to say, ‘OK, needles for everyone, everywhere.’ It’s only going to work if it allows us to connect people to the resources they need to get clean…and get their infectious diseases treated.”

This is the “official” view of the governor, and it is cynical in the extreme. First, because it amounts saying that people who continue to use drugs aren’t worth saving. Second, because there are almost no affordable treatment resources.

Clark County public health director Kenneth Burke, MD, is, by default, in charge of HIV testing in nine southeastern Indiana counties, because Clark County is the only county that gets state funding for HIV tests. Burke, who was also a no-bullshit advocate of needle exchange since before the HIV outbreak, told his boss where to stick it.

“Some of these people are going to abuse IV drugs until they die,” he said. “But I don’t think there’s any question that you decrease the risk of infection by allowing them to use clean needles.”

Clark County has some 5,000 IV drug users. Its HIV rate is 37 percent higher than the state average; its hepatitis C rate is 40 percent higher. County commissioners declared a state of emergency in July 2015 and Burke duly undertook the labor-intensive process of compiling a 50-page application to the state health department, documenting its crisis, its lack of public funds to help, and the plan to partner with a nonprofit—the international AIDS Healthcare Foundation—to establish syringe exchange, along with disease testing, supplying HIV medication and referrals for addiction treatment.

Burke sent the application to Jerome Adams in December. Adams has refused to act on it. Meantime, three other counties won approval in less than a week.

In February, the Indiana Democratic Party filed a formal complaint with the state’s public access counselor, asking for the release of all of Pence’s correspondence about the HIV outbreak.

They want to know what it reveals about why he took 65 days to respond to the HIV crisis. They have received no response.

Meanwhile, Mike Pence smiles and smiles on the campaign trail, and is a villain. He tours the country, plans to share a stage with Marco Rubio, and never has to answer for the needle exchanges he set up for failure and the misery he left behind. In every sense, he’s the lower half of a ticket that we can only hope is doomed. Pray on it.

This article was originally published by The Influence, a news site that covers the full spectrum of human relationships with drugs. Follow The Influence on Facebook or Twitter.