As improbable as the Scott County outbreak may have been, health policy in Indiana helped enable it, and eventually stopped it. Mike Pence, Indiana’s governor and the Republican vice-presidential nominee, took stances against clean-needle programs and in favor of criminalizing drug use. These positions have been cited as contributing factors in the creation of an HIV “hot zone” of high incidence and prevalence as the opioid-riddled county and the tiny town of Austin have seen spikes in risky intravenous drug use. Pence eventually went against his deep convictions and allowed clean-needle distribution programs to operate, a decision which seems to have ended the outbreak despite the persistent lack of funding for those programs.
Pence’s initial positions are typical of most Republican lawmakers and of some centrist-leaning Democrats. The outbreak in Scott County could happen in any one of the 17 states—mostly with Republican governors or Republican-controlled legislatures—that don’t have syringe-exchange programs. If anything, Pence’s capitulation on clean-syringe programs and his eventual tepid embrace of Obamacare indicate a sense of pragmatism that goes beyond party dogma.
Most of his positions, however, are firmly within the conservative tradition of health policy, favoring a hands-off policy of few government-sponsored interventions and leaving individuals to their own health-care choices. For many Republicans like Pence, the few exceptions to this rule are for programs for children, retirees, and people who can’t work, and in strictly preventing individuals from making choices, like using drugs, that they see as prohibited on moral grounds. Pence’s decision to defund Indiana’s smoking-prevention programs and slash state public-health budgets are representative of this tradition. His initial stance against syringe exchanges was based in both the market and morality: These programs involve state-sponsored intervention and treat drug abuse as a public-health issue instead of a moral one.
Pence’s conservative vision of health policy contrasts with that of his counterpart, the Democratic vice-presidential nominee Senator Tim Kaine. As governor of Virginia, Kaine presided over an aggressive and controversial public-health policy agenda. One year after Seung-Hui Cho killed 32 people at Virginia Tech, Kaine unveiled an aggressive mental-health-policy plan that provided millions of dollars in funding for expanded services and monitoring for people with mental illnesses. In his first year in office, Kaine was also an ardent supporter of vaccinating girls against HPV with the prescription drug Gardasil. His most significant public-health achievement as governor—in a capital just miles away from the Philip Morris headquarters and in the middle of Big Tobacco heartland—was a 2009 ban on smoking in most bars and restaurants in Virginia. That measure had bipartisan support, but the Republican opposition was characterized by classic conservative anti-intervention public-health rhetoric. “I believe very strongly in the power of the free market to resolve the collective wishes of our society,” said the Republican state delegate C. Todd Gilbert in opposition to the ban.