AUSTIN, Indiana — She looks for the addicts every Friday on the north side of town, in a neighborhood that has crumbled into an apocalyptic landscape.
They are camped, more than 10 at a time, behind shattered windows, boarded-up doors, inside houses with no electricity or running water. Sometimes they huddle inside garages or sleep in cars.
When Brittany Combs pulls up in the white minivan with the health department logo on the side, she often sees no one at first. They’ll find her.
She parks the minivan in a gravel driveway. Two years ago, before the outbreak, she would have been terrified to drive into this neighborhood. Now she calmly leans against the side of the van, crosses her arms over her red windbreaker and waits.
Three people approach her a minute later, each holding a bright red box labeled “BIOHAZARD” full of used syringes. She takes the boxes from them, stacks them in the back of the van and hands them packages of clean needles. She looks each of them in the eye.
“What do you need?” she says.
She’s trying to convince one of the men to accept a few doses of naloxone, an antidote for opioid overdoses. He gives them to his friends who are too nervous to get them from the health department themselves.
“Well, you can be my middleman, then," Combs suggests.
“Well, sure,” Fred says. “But I ain’t no drug dealer.”
At the house next door, a couple sitting on their porch glare in their direction. A police car rolls by.
Combs hands him the package of 140 new syringes and three naloxone kits.
“Of course you’re not, Fred,” she says. “We’re saving lives.”
Brittany Combs drives every Friday into a part of town everyone avoids, doing a job few people want done, helping people no one else wants to look at.
When Combs, 38, started her work as a public health nurse eight years ago, the job was mostly handling disaster preparation, running health screenings for the elderly, giving immunizations and checking kids for lice.
Combs still does the disaster prep and the lice checks. But that’s only half the job now, because two years ago, everything she knew about her work changed. In February 2015, 30 people were diagnosed with HIV in Austin, Indiana, a city of about 4,000 people. Just one month later, the number rose to 55. Within a year, nearly 190 people had tested positive for HIV. The Centers for Disease Control called it the worst outbreak in the United States in at least two decades. HIV infection rates in Scott County have rivaled those in sub-Saharan Africa.
Scott County has the highest early death rate in Indiana. The coroner orders autopsies for about 90 percent of deaths. Even with the prevalence of naloxone, which keeps many overdoses from becoming fatalities, plenty of people in Austin die from their heroin addiction. They are often young. Those mourning them are usually young, too, and at risk of dying next.
“This town has been through far too much in the last two years,” Combs said. “I don’t know what else I can do besides going out there and just asking what they need.”
Now Combs runs the county’s needle exchange, handing out packages of clean syringes and disposing of used ones in the hopes of keeping the HIV epidemic contained. Combs can’t cure HIV, reverse an overdose or bring the dead back to life, but she’s doing her best to slow it all down.
“The drug-using population in Austin has been neglected for so long,” said Jackie Crane, Scott County’s second public health nurse who usually rides with Combs in the needle exchange van. “And Brittany was really the first person to take her concern for what was happening to them and put it into real action.”
In Austin, about 500 people are enrolled in the needle exchange program and about 200 people have HIV. But in the first year of the outbreak, there were 188 HIV diagnoses; that number has risen to only 215 since the needle exchange began in April 2015. Thanks to Combs' work, the spread of HIV has nearly stopped.
Combs grew up in Scott County and still lives here on 10 acres of land with her husband and two children. Her husband works for the local gas company. Her son is 8 and her daughter is 6. She always knew she wanted to work in healthcare — she just likes to take care of people. She was an assistant in a veterinary clinic first, then a floor nurse in a hospital, and now she works for the health department.
She never thought that would mean trawling slowly down pothole-ridden streets to look for addicts. Her husband worries she might get hurt. She is so busy that she doesn’t know who is going to stay home with her kids when they’re too sick for school.
Combs has become consumed by the needle exchange. She read that the relapse rate for heroin addicts is about 80 percent. She learned that fentanyl and Opana, also opioids, were flooding the county, too. She listened to people say that before they could get clean needles, they would use a syringe up to 300 times, filing it down sharper and smaller until it broke off in their arm.
“Nobody in their right mind would do that to themselves,” Combs said. “When you hear those stories or see that happen, that’s what’s hard to get out of your head.”
Combs doesn’t pretend that all her clients are getting clean. She takes the used needles, hands over the new ones and leaves.
Some of the people she helps don't even know her name. They just call her "the lady in the van."
When she leaves the van, she goes home and tries to forget what she has seen. She plays with her dog. She helps her kids with their math homework. Sometimes they ask her about her job.
“Mommy helps people who are very sick,” Combs tells them. She does not get more specific.
Combs is exhausted. She keeps forgetting to move the bins of dirty needles out of the back of the van. The naloxone kits she ordered weeks ago still aren’t here. She runs out of clean needles in the middle of a trip. She hears that someone else has overdosed. She watches a police car drive by and knows it’s following her van.
“Looks like they’re on a mission,” she says to Crane, who is sitting in the passenger seat. “Maybe one of these days we should follow them.”
Crane tells another story about the city’s treasurer badmouthing the needle exchange. He stood up at a public meeting in front of the rest of the city council and some representatives from the health department. He said what Combs was doing was making Austin’s drug addiction problem worse.
Combs is sure she’s making things better, but she wishes she could do more. She helps some addicts once and then never sees them again. She doesn’t know if that means they’ve gotten clean or if they’ve overdosed and died. She begs strangers to get tested monthly for HIV. She wishes she had the time to drive someone to a rehab center each time they inevitably ask.
One Friday last fall, she got out of the van and slammed the door shut behind her. For a second she stood alone inside the health department building.
A man had overdosed earlier and the people with him had not wanted to call an ambulance. He would later die in the hospital.
“I am so tired of going to funerals,” she said.
Not even Indiana’s governor wanted Scott County to try stopping HIV's spread with a needle exchange.
Until the approval of Scott County’s program, all needle exchanges in Indiana were against the law. Possessing a syringe without a prescription was a crime. Former Gov. Mike Pence, now the Vice President, proclaimed that passing out needles encouraged addicts. It took a year of watching the HIV epidemic spread, a year of health experts around the country growing more and more alarmed and nearly 200 diagnoses before Pence decided Scott County could give it a try.
Even at the local level, addiction in Austin is viewed as a crime, not a disease. Combs herself thought at first that a needle exchange wouldn’t work.
“I’m a nurse, so I know addiction is a health problem,” Combs said. “But I still wondered whether a needle exchange would just enable people.”
Despite the program’s progress fighting HIV, many are still suspicious of it and the people it aims to help. A mailman in Austin calls Combs personally every time he sees a needle in a ditch.
A couple sits on their porch, next to the houses of those struggling with addiction. When asked about the needle exchange, they say they don’t want their tax dollars to pay for drug habits. They gripe that legal punishments for drug users aren’t tough enough.
“Druggies and hookers walking up and down the street all day and night,” the man says. “That’s all we ever see here now.”
The local police chief didn’t respond to interview requests from an Indiana Daily Student reporter. But the receptionist at the police department’s front desk laughed when asked about the needle exchange.
“Now, there’s a big ordeal,” she said. “That’s not going over too well.”
And Austin clerk-treasurer Chris Fugate keeps standing up at meetings to denounce Combs’ work.
He argues that the needle exchange doesn’t deserve the credit for preventing the spread of HIV.
“I think HIV just ran out of drug users to infect,” Fugate says. “I think it stayed within those circles, and nobody else has been exposed since they’ve been infected.”
Studies show, however, that needle exchanges are the most efficient way to stop diseases spread through needle sharing.
It seemed to Fugate that filling the market with even more needles would just make things worse.
“And quite frankly, I don’t think these people care if they’re using clean needles,” he says. “They will beg, borrow, steal, whatever just to get their high. So if they don’t care if they get HIV, I don’t know."
His voice trails off.
One evening in late December, Combs walked into Buchanan Funeral Home yet again. It was the fourth visitation she had attended that year for an addict she knew.
Combs didn’t recognize many of the people who had come to pay their respects. But she knew the man they were mourning — a man she had known for a year and a half, as she took his used needles and gave him clean ones. He was in his late 20s. He usually showed up at the needle exchange van with his brother. He was the shy one.
Combs looked around the funeral parlor, filled with flowers and photos. In some of the photos, the man was hunting with his brother and other relatives. She hadn’t known that he liked to hunt, that he even knew how.
The room was full of people. Many were friends, all young, some in danger of overdosing like him. Combs heard someone say the man’s two kids were here. She looked at the few small children and wondered which were his.
When Combs saw the flowers, the photos, the mourners, the children, she knew, suddenly, that even though she had known the man for a year and a half, his whole life had been hidden from her. He had been more than addiction. He had been loved.
Combs walked up to the open casket. She didn’t look at his arms or his hands or his feet. She kept her eyes on his face.
Kevin Collins was Scott County’s coroner until 2012. But when overdose deaths began flooding the morgue, he quit.
“You start to get callous when you see it so often,” he said. “You start to think, ‘It’s just another drughead.’”
He didn’t want to stop thinking of them as mothers and fathers, sisters and brothers. And he could find no way to stop the endless march of death or the erosion of his own capacity to care. So he left his job as coroner.
He has been relieved, he said, to see the needle exchange picking up speed. He thinks the city should try everything possible to keep the bodies of young, addicted, infected people off the coroner’s cold table.
Another Friday afternoon, another afternoon in the heart of the epidemic.
Nearly every house has a NO TRESPASSING sign taped to the siding.
In one window, another sign offers a warning:
JESUS COMES FOR US ALL
ARE YOU READY IF HE SHOULD COME TODAY?
On many Fridays, people approach Combs’ van before she can even put it in park. But on this February afternoon, Combs is parked on Paulanna Avenue and can’t figure out why nobody is coming outside. She squints through her glasses and twists around to look behind the van. Nobody. She sees one frequent client on a nearby sidewalk, but instead of stopping, he tugs the hood of his sweatshirt up onto his head and jogs away.
“What is he running from?” Combs asks. “What’s going on?”
She glances around again and then she sees it, in a nearby driveway: a black police car, an officer watching.
Combs ignores the officer. She walks briskly to the back of the van and opens the trunk. Slowly, uncertainly, her people show up. Some emerge from the abandoned garage. Some climb out of a nearby car. Many are looking over their shoulder toward the patrol car still idling nearby.
Combs smiles and calls out to each of them by name. She asks what she always asks.
“What do you need?”