AUSTIN, Ind. - Johnathon Clark's head caves in deeply where his grandfather shot him.
He went to the elderly man's home four and a half years ago hoping to steal money for drugs. An argument got violent. Now, as he sits in Dr. Will Cooke's exam room, he's maimed for life at 28, a large slice of the right side of his head gone.
But while this visible reminder of his years-long addiction is horrific, a more insidious legacy hides within his body - HIV.
And if he and his doctor can't keep it under control, it can kill him as surely as a bullet.
Cooke knows this. He's cared for scores of HIV patients in his small-town family practice over the past two years, and their desperate lives raise the risk of AIDS and death. Clark's story of getting hooked on drugs at 13 and shooting up liquefied painkillers for years is not unusual. It's tough to keep patients like him in care and on meds.
Their recovery is fragile.
As is the community's.
This tiny city off Interstate 65 is the epicenter of a medical disaster. Dr. Tom Frieden, former director of the U.S. Centers for Disease Control and Prevention, confirms Austin contains the largest drug-fueled HIV outbreak to hit rural America in recent history, and "the largest concentrated outbreak ever documented in the United States." He says its 5 percent infection rate - 215 cases in a population of 4,200 - is comparable to some African nations. And like those countries, Austin has long struggled with scant medical resources. Cooke is its lone physician, caring for most of the HIV patients along with his staff and an ever-changing cadre of medical students.
Student Allison Pressimone came here after volunteering in Kenya, Tanzania and Uganda.
"The fact that every other patient has HIV is mind-boggling," she says. "That's what I saw in Africa."
Near a poster reading, "We've got your back," Pressimone and her colleagues gather around Cooke as he lays out a treatment plan for one HIV patient. Cooke - a 45-year-old wearing a Star Wars cap that matches his scrubs - peppers the usual medical instructions with a dose of humanity, advising students: "Listen to him and talk to him and show him compassion."
A deep Christian faith guides the doctor, who closes all his emails with a quote from Galatians:
Addiction festers at the intersection of hopelessness and economic ruin, making Austin a harbinger for all the nation's broken-down, drug-plagued rural communities. The only real difference is that the spark of HIV entered Austin two years ago and raged into a wildfire.
The Courier-Journal spent six months examining how Cooke, the rest of the community and the larger world has responded to this singular outbreak, interviewing dozens of health workers and experts, patients, community members, state officials and others; examining state, federal and community records; and witnessing the start of the city's recovery.
What happened here provides lessons for the entire country about preventing a deadly epidemic and stopping its spread. Studies show Indiana spends less than all but one other state on public health, and a quarter of Hoosiers live in areas without doctors. When this outbreak first hit, the state couldn't even find enough people to test for HIV. Former Gov. Mike Pence, now the vice president, opposed needle exchanges known to curb the disease, and the short-term program he finally did allow was widely criticized as too limited and too late.
All this left the community scrambling and looking within.
Seeds of a lasting recovery are now beginning to take root: Hope among the young. Stronger ties between health care workers, churches, civic leaders and charities. New outreach to the addicted, ailing and desperate. And for many, a new and more compassionate answer to the question of whether to judge the afflicted or minister to them.
And this, Cooke believes, is the true key to healing the city.
This former farming village between Louisville and Indianapolis used to be a picture of the American heartland. After the Pennsylvania Railroad laid tracks in the mid-1800s, it grew into a typical working-class town steeped in Norman Rockwell charm, where everyone knew their neighbors and kept a watchful eye on the kids.
A shop-lined Main Street branched off to well-kept residential neighborhoods surrounded by fields of soybeans and corn. Generations of locals worked at a canning plant for Morgan Foods, a company that still anchors the community. More than 30 churches sprung up in just 2½ square miles.
Bonnie Conner was born here 66 years ago in a two-room cabin on Rural Street, a road now notorious for drugs. She recalls walking 1½ miles to the nearest store to fetch milk for her mom and spending much of her childhood outdoors. She ran through the woods, played in the fields and splashed in the ditches by the side of the road after it rained - ditches now littered with spent needles.
Conner's family didn't have much money, but "we had food to eat, clothes to wear and a bed to lay in," she says. "We lived like any country kid would."
Staci Mullins, 30, felt the same way growing up in the 1980s and '90s. She recalls riding her bike up and down Rural Street without an ounce of worry, chugging Kool-Aid her mom made for all the neighborhood kids and playing pickup games of softball and baseball in a church parking lot across from her home.
But then came a series of economic blows familiar to many manufacturing-based communities. The American Can plant next to Morgan Foods shut its doors in 1986 after more than 50 years in business. A local supermarket closed. Workers left along with the jobs and poverty crept up among those who stayed. Drug use became more visible - and festered.
Clark - whose addiction would one day lead to the shooting that maimed him - recalls how drugs pulled him from God. After moving from Appalachian Kentucky to Austin as a young boy, he grew up in a local Baptist church. For a long time," he says, "it was real important." But religious teachings fell away during adolescence, which was all about "getting high, fighting and acting stupid."
Clark's addiction took hold with a vengeance in his late teens, and he used any drug he could find: meth, heroin, cocaine and OxyContin. "I woke up every day wanting to get high," Clark says. "First thought on my mind."
Mullins watched a close friend start down the same path, but would never say anything to him about it.
"I probably should have, looking back," she says. "In a sense, I think that's why we got into this situation. You know someone is doing drugs and you just turn your head."
Around that time, Mullins began to notice strangers wandering around her neighborhood, some she now realizes were prostitutes and their customers. Cars she didn't recognize lingered in the church parking lot, a short drive from I-65. One woman jumped in front of her dad's car, offering her services. Mullins began to get nervous during evening jogs, worried men might holler at her out of their vehicles.
"Parents would just say, 'Ignore it'.Our community doesn't like confrontation," she says. "We turned a blind eye, willingly."
Cooke grew up about 35 minutes away in Jeffersonville, Indiana, son of a carpenter and a nurse. He spent lots of time in hospitals because of his mom's job and got used to the medical world as a young boy.
Cooke's mom showed by example something he also learned in church - to "leave the world a better place than I found it." From an early age, Christ's life was the ultimate inspiration for him on how to do that.
When Cooke was 16, his gums began bleeding and a previously healed sprained ankle swelled. Doctors diagnosed a bleeding disorder in which the immune system destroys the blood's platelets. Cooke stayed in the hospital for five days. The temporary ailment didn't cause pain, so he spent his time observing the constant stream of doctors, nurses and medical students coming in and out of his room. Their work fascinated him.
At one point during his hospital stay, his youth pastor visited. Cooke was active in church, especially in choir, and had talked with the pastor about his interest in ministry and missionary work. But when they discussed future plans that day, Cooke told him: "I could help people by being a doctor."
After graduating high school, Cooke enrolled in Indiana University Southeast for his undergraduate studies - and his mom enrolled in med school. Cooke followed her lead, going to American University of the Caribbean's med school and then transferring to IU.
When it came time to specialize, Cooke felt drawn to family medicine. Many of his peers chose better-paying specialties. More than one classmate warned: "You're going to waste your life being a primary care doctor."
Cooke didn't listen.
After a three-year residency, Scott County officials recruited him to practice in Austin as part of a program to bring doctors to underserved communities in return for loan repayment. It seemed the perfect fit, meeting Cooke's one criteria for where to practice: Which place needed him most?
So in 2004, he opened Foundations Family Medicine in Austin.
Cooke knew the practice wouldn't make a lot of money. Scott County consistently ranked in the bottom or dead last on county-by-county measures of overall health. Many residents had no health insurance or relied on government Medicaid. Cooke would have to work in the emergency room at nearby Scott Memorial Hospital to earn enough money, and pour some of that money back into the practice just to keep it afloat.
He knew mission work exacted a price.
"To me, this is a ministry," he says. "I felt called here, and I came here to answer that call."
From day one, Cooke realized too many of his patients craved pills, in many cases the same three potentially addictive drugs: the anti-anxiety drug Xanax and the painkillers Percocet and Soma, which is also a muscle relaxant.
A long line of doctors had stayed in Austin for short stints, and he suspects some prescribed painkillers and anxiety meds too freely. Granted, there was a national push to treat pain aggressively at the time; medical experts called it "the fifth vital sign." But it still seemed odd.
Cooke got very strict about prescribing pain pills, requiring urine screens, choosing non-addictive treatments whenever possible and writing prescriptions for the shortest course of medication necessary. He developed a "banned" list for the most frequently abused pills. He hired a nurse practitioner who specialized in pain management to handle the patients who truly needed the medicines, but wound up parting ways with her because she was prescribing more painkillers than he wanted her to.
Meanwhile, drug abuse continued to rage, with residents getting pills from out-of-town doctors or on the streets. OxyContin gradually gave way to Opana, which was approved by the federal government in 2006 even though its active ingredient, oxymorphone, had been removed from the market in the 1970s amid addiction concerns.
Opana became the new drug of choice for patients such as Clark, who shot it up with friends and says, "we shared with anyone." The close-knit, insular nature of the community worked against it, with the CDC later finding up to six people shared needles at one sitting, and two or three generations - young adults, parents and grandparents - sometimes shot up together.
After around 2010, patients in their 20s and 30s began walking into Cooke's office with medical conditions linked to IV drug use: hepatitis C, skin abscesses, and endocarditis, a condition in which the inner lining of the heart becomes inflamed.
Patient Lee Shuler, a recovering pain pill addict who also got his wife hooked, nearly died from endocarditis, then lost her to an overdose, leaving their two children, 10 and 7 at the time, motherless.
"The very day they released me from the hospital, we had to bury her," he says.
Cooke knew what overdose could do to a family. When he was a kid, his mother's sister OD'd on a living room couch, leaving a cousin almost exactly the same age as him without a mom. Though he wasn't that close to his aunt, he was furious at her for "being so selfish." Few people thought of addiction as a disease back then.
But after a decade in Austin, Cooke knew for sure that it was, and that little could stop that disease from spreading HIV.
Not only did Austin have no other doctors; it had no drug-treatment centers. Dwindling government funding led Planned Parenthood in nearby Scottsburg to close in 2013 after years of providing HIV, education, testing and referrals. The nearest place offering regular HIV testing and case management was the Clark County Health Department in Jeffersonville, about 35 miles away.
Cooke was overwhelmed and outgunned.
So were local families.
Courtney Neace, a 17-year-old senior at Austin High School, lost her mother to addiction in 2012. She died in her sleep at 29 after years of drug use and heart problems.
Courtney was only about 9 when she and her younger brother would peek underneath a bedroom door in her grandmother's trailer to see their mom sitting on the side of a bathtub as someone helped her shoot up a pill. Another time when the kids visited their mom, who didn't have custody of them, Courtney woke up to find her gone.
"You left us in that trailer full of random people, who were all doped up and high off of anything and everything," she wrote in a letter to her mother after she died. "We were scared. We were all alone.....I knew that I had to get us out of there. You probably never knew this but my brother and I walked all the way from that trailer to grandma's house, the person who took care of me my entire life."
It was only after her death that Courtney realized her mom was a lost, scared woman with a horrible disease.
"You still had so much life left to live," she wrote."The only thing I wish I would've done more during the time you were here was tell you I love you."
Bonnie Conner, once the "country kid" with the idyllic Rural Street upbringing, watched addiction ensnare three grandsons.
Tyler, Derek and Scottie Combs began life much like their grandmother, hunting and fishing in the woods and playing Red Rover in the fields. When they were little, their mom, Polly Polly found a needle in a ditch line where the boys liked to jump in piles of leaves. She sat them down, warning, "Don't play out there anymore."
The boys stayed out of trouble for years. Tyler became a standout in basketball, Scottie in baseball. But when Tyler, the oldest, was 16, he had four wisdom teeth removed and got a prescription for the painkiller Lortab. He told Polly he liked the way it made him feel; it gave him courage. After the pills ran out, a friend sold him more. He got hooked.
A few years later, Derek fell in with the wrong crowd and began using pills too. Scottie moved on to pills after sneaking drinks with Tyler as a high school freshman.
The boys' drug use waxed and waned. Tyler quit cold turkey when he joined the Army, and Derek eventually checked into a Christian rehab in Ohio. But in 2012, Derek ran his Toyota Tercel off the road and it flipped several times, killing him. Tests found a small amount of alcohol in his blood. He was just 21.
Derek's death devastated his brothers.
Tyler, who was prescribed pain meds after being wounded in Afghanistan, sunk deeper than ever into addiction. Within a month, he overdosed on heroin in his barracks while stationed in Alaska and had to be revived with naloxone. When he went home for a visit, Polly found a needle in her bathroom.
She still didn't know Scottie used drugs, even when they landed him in the hospital at 17. At his grandmother's place after a family trip, Scottie spiked a high fever and stumbled on the way to the bathroom. Bonnie dragged him out to the car to drive him to Cooke's office as he mumbled: "Thanks, Mamaw. You saved my life."
Cooke's nurse took his heart rate - a sky-high 170 beats a minute - and Cooke told the family to bring him to Scott Memorial. The next morning, Cooke stopped by his hospital room and told Polly things didn't look good. He transferred Scottie to Kosair Children's Hospital, now called Norton Children's.
Polly climbed into the ambulance that rushed her son to Louisville. Doctors diagnosed endocarditis and blood clots in his heart, both lungs and an arm. They kept him for eight weeks.
They asked Scottie if he used drugs. He said no.
But in his mind, Scottie had a pretty good idea where the infection came from: dirty "works" he used before injecting melted pills.
Doctors tested him for all sorts of infectious diseases, trying to figure out what made him so sick. An HIV test initially came back positive. Further testing showed the result was false.
"I got lucky," Scottie says. "Thank God."
But for the rest of Austin, luck was about to run out.
Source: The (Louisville, Ky.) Courier-Journal,
Information from: The Courier-Journal, http://www.courier-journal.com