Playing Politics with Prevention

In 2015, the small town of Austin, Indiana, made headlines nationwide: it was the site of the biggest HIV outbreak in the state’s history. Within a population of just 4,000 people, Austin saw 190 new cases of HIV infection in less than a year, the vast majority of which were linked to the town’s opioid epidemic.

Below the surface of these alarming numbers is one state policy that contributed to the rapid spread of HIV—specifically, the ban on needle exchange programs. Eventually, Indiana’s Governor Mike Pence, now the Republican Vice Presidential nominee, reluctantly approved an emergency public health measure to allow needle exchanges.

Indiana’s example shows the powerful ways that policies and politics at the state level can affect the public’s health. Laws that put ideology ahead of evidence place communities at unnecessary risk.

Morgan Philbin, newly appointed assistant professor of Sociomedical Sciences, recently embarked on National Institute on Drug Abuse-funded research to explore how state-level policies impact substance use and sexual health risk behaviors for young men who have sex with men, as well as the political factors that can help or halt the passage of new legislation.

“Politicians play such a huge role in health, but oftentimes they have no concept of the impact of the decisions they’re making,” says Philbin. “Policy decisions are often made around politics, public perception, or religious beliefs instead of science. Needle exchange is a prime example: no one wants people to share dirty needles, but politicians also don’t want to appear to be promoting drug use by providing clean needles. The scientific evidence backs up needle exchange programs, but too often they’re not put in place because it’s about a policy-maker not wanting to seem like they’re condoning drug use.”

Taking a similar approach to Mark Hatzenbuehler’s research on state policies around bullying and discriminatory laws toward LGBT communities, Philbin’s study looks at the policy climate as a whole around sexual health risk, substance use, and what it means for communities, particularly young men who have sex with men. Regulations vary wildly from state-to-state, especially when it comes to sexual education: some have abstinence-only policies, others prevent condoms from being shown in a classroom, and many don’t require that the information presented be scientifically accurate. There are other types of barriers, too: states can make it extremely difficult for minors to get confidential HIV testing and treatment by requiring parental notification or putting up roadblocks when it comes to obtaining health insurance outside of parental coverage.

When it comes to substance use, states have just begun to see addiction as a public health crisis, as opposed to a problem for law enforcement and criminal justice. State-by-state, courts handle drug cases in vastly different ways: some allow youth to be put into treatment and education programs, but others are sent to prison. Prescription monitoring databases are mandatory in nearly every state—but only about half of them require that providers use those databases. Needle exchange programs, and the crucial funding that allows them to function, also vary immensely.

Philbin, who joined the Mailman School faculty in July after serving as a postdoctoral fellow at the HIV Center at the New York State Psychiatric Institute and Columbia, has worked with adolescents in a variety of communities with high rates of HIV and substance use from Tijuana, Mexico, to Yunnan Province, China, to Baltimore, Maryland. Despite the many miles between them, Philbin came to see many similarities in the communities she worked with—and also came to realize how far behind the United States is in many aspects.

“The deck is stacked against the young black men I worked with in Baltimore,” says Philbin, “With the history of structural racism, systematic oppression, housing policies and redlining, and very low high school graduation rates, social policy and political structure affect all aspects of these kids’ lives in a way that policymakers don’t fully understand.”

Through her exploration of state-level policies and their impact on young people’s substance use and sexual health risk behaviors, Philbin hopes to find ways to bridge the gap between research and advocacy. “We’re planning to work with policymakers to better understand if and how they use scientific evidence when making decisions,” she says. “We’re trying to shift the paradigm that has plagued public health for so long, in which once research is published, it’s done. I really want to try and understand: what can we do to affect change?”