An HIV crisis raises the question: Should health officials be activists? – STAT

Most local health officials don’t accept their jobs expecting to be roped into political activism.

Amid Covid-19, though, politics became a central element of health experts’ job descriptions. In Washington, government researcher Anthony Fauci publicly feuded with former President Trump. In many cities and states, local health departments were forced to square off against governors who resisted coronavirus mitigation strategies like business closures or mask mandates.

The series of squabbles has raised the question of whether, to be effective, local health officials need to add politics to their list of day-to-day responsibilities. And while the fights have been most pronounced amid the pandemic, they’ve even cropped up in states otherwise lauded for their coronavirus response, like West Virginia.

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There, the dynamic has played out in the context of a worst-in-the-nation HIV outbreak linked to injection drug use. This month, as local officials scrambled to prevent further spread, the state legislature all but banned one of their most effective tools for doing so: syringe exchanges that distribute sterile needles to people whose drug use places them at high risk of infection.

“Working seven days a week on things that are outside our area of expertise, the political backlash against popular strategies — it has taken its toll nationwide on our public health workforce,” said Michael Kilkenny, the CEO of the Cabell-Huntington Health Department in West Virginia, which serves the hard-hit city of Huntington. “It is frustrating, and we see what the consequences are.”

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Willingly or not, local health officials’ involvement in local West Virginia politics has been slowly escalating since 2018, when Charleston, the state’s largest city, closed its only city-run needle exchange.

This month, several local officials vocally opposed a controversial bill aimed at tightly regulating syringe-exchange programs, but the state Senate eventually approved it on a 27-7 vote.

The new requirements make things harder for the people trying to access the services and those trying to provide them. They require that programs tag syringes with individualized bar codes, and that recipients present a photo ID and receive new syringes at a 1:1 ratio to old ones they bring back, a requirement that flies directly in the face of federal recommendations.

“We now have a state law that makes it illegal to run a program based on CDC best practices,” said Robin Pollini, an epidemiology professor at West Virginia University.

HIV-prevention advocates say the move comes at the worst possible time. The state’s HIV case count, proportional to its population, is already among the worst nationally. Kanawha County, which is the state’s largest at 180,000 residents, recorded roughly as many HIV cases in 2019 as all of New York City, where 8 million people live. The Centers for Disease Control and Prevention has warned that the known HIV cases in West Virginia could represent the “tip of the iceberg” of a much larger crisis.

Syringe exchanges have long been demonstrated to be effective tools used to prevent people who use drugs from sharing needles and, in the process, spreading diseases like HIV or hepatitis C.

Local health officials aren’t just going up against their political superiors. Often, they’ve clashed with the very communities they serve. West Virginia residents, for example, have also gone head-to-head with health officials to oppose the syringe exchange, alleging that it increases drug use in their neighborhoods or puts people at risk of stepping on a stray needle.

It mirrors a broader national theme: Throughout the Covid-19 pandemic, governors in Republican-controlled states like Texas and Arizona have sought to ban local governments from imposing disease-prevention measures like mask mandates or school closures.

In many cases, the pushback has forced local health officials to decide between honoring the desires of the community they serve, or following the science and advocating directly against their own constituents and the mayors or county leaders they work for.

Even those who push back are often fighting a losing battle. Raw emotion will always win out against data-driven arguments presented by a government official, said Kilkenny, the Cabell County health executive.

“If you are scared to death, you’re not analyzing what’s going on,” he said. “You are running or you’re fighting. While you’re running or you’re fighting, you’re not thinking.”

Amid the backlash, local health leaders say they often have little recourse, even when they’re aware that the public’s desires conflict directly with their mission of preventing illness and saving lives.

“The implications are tough, because oftentimes local health officials are either hired by or supervised by county executives or mayors,” said Oscar Alleyne, the chief of programs for the National Association of County and City Health Officials. “They have to navigate those eggshells while at the same time clearly articulating what works.”

In critics’ eyes, however, walking on eggshells isn’t enough. In the face of a health emergency, Pollini argued that working to change the political landscape is an essential part of a public health official’s job — especially if local politics are keeping them from addressing a crisis.

“If you understand the science and you’re a public health person, you have to make an effort to turn public opinion,” she said.

In West Virginia, some local officials have attempted to land somewhere in between.

Kilkenny highlighted his testimony before a state Senate committee, which he said may have helped to water down the legislation, allowing syringe exchanges to continue in limited form. An earlier version of the bill would have outlawed the exchanges entirely.

“We educated [lawmakers] that we need this tool,” he said. “It was not successful in changing the outcome. But it possibly mitigated what would have been completely devastating legislation and made it only very very challenging.”

Sherri Young, who leads the Kanawha-Charleston Health Department and serves the state’s largest county, said that appropriately weighing science against community discomfort is often impossible. Her county has not operated a syringe exchange since 2018. Two local nonprofit groups have offered limited services since, the larger of which may be forced to close in light of the new law.

“I don’t know that the right balance has been struck,” Young said. “The ideal situation, if I could design anything, is one that the public would be comfortable with, but does work for prevention of HIV.”

She also defended the department’s work, saying it has worked to combat the HIV crisis via testing and aggressive outreach to vulnerable populations, especially in anticipation of controversy surrounding syringe exchange programs.

“We knew, because it was going to be a political issue, how to prepare for it moving forward,” she said.

Pollini, however, was direct in her criticism. Young, she said, didn’t fight hard enough to preserve evidence-based strategies like syringe exchange programs.

“We will continue to have people infected with a completely preventable disease,” she said, “because no one is standing up and saying: Hey, let me have a conversation with you about these programs and why they’re so important to our community.”

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