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Brian, a patient at my clinic in Scott County, Ind., is one of many who helped me learn the difference between “do no harm” and “protect from harm.”

I met him years after he had given up trying to rise above his family’s poverty, toxic stress, and substance use. Having succumbed to despair, his substance use brought only fleeting relief. “This ain’t living, man,” he once told me. “Every day is like dying and going to hell.”


Medical school had convinced me that the U.S. was the best place in the world at keeping sick people alive. But meeting people like Brian, who grow up surrounded by sickness, disability, and early death, confronted me with the grim reality that our nation hasn’t done enough to protect and foster healthy people.

The Subcommittee on Primary Health and Retirement Security of the Senate’s Committee on Health, Education, Labor, and Pensions met in late July to discuss the national crisis of declining life expectancy due to the health disparities experienced by people like Brian.

Sen. Bernie Sanders (I-Vt.), the subcommittee’s chair, Sen. Susan Collins (R-Me.), its ranking member, and other members of the HELP subcommittee all agreed that more must be done to keep safe and alive the country’s citizens who are most at risk of deaths of despair, including those who use drugs. Sanders pointed out that a child born in Fairfax County, Va., can expect to live 14 years longer than one of my patients in Scott County, Ind.


I had the honor of testifying about my experiences and successes working at the epicenter of the national opioid crisis.

I shared how, like Brian, I had grown up surrounded by poverty, toxic stress, and substance use. Those factors contributed to my grandpa’s death in his 50s and my aunt’s overdose death at 39. Although my parents escaped that fate, providing my brother and me greater opportunity, our family remains an example of how deaths of despair profoundly lower the overall life expectancy.

After graduating from medical school as a family physician, I felt prepared to care for an entire community and, in 2004, opened a rural health clinic in Scott County in southeastern Indiana. But nothing could have prepared me for the suffering I found in the nation’s heartland. Young people with the kinds of complications from diabetes usually seen only in much older people. Women dying from cervical cancer. A man with a tumor on his tongue so large he couldn’t close his mouth. All of these, and more, could have been prevented with access to primary health care.

These encounters with people harmed by the circumstances of their birth convinced me that health and prosperity are not solely dependent on effort and choice. As the surgeon general’s report on Community Health and Economic Prosperity indicates, certain U.S. communities are at health disadvantages due to inequitable access to vital conditions that shape health and well-being such as clean air and water, nutritious food, safe housing, reliable transportation, a livable wage, and a sense of belonging and civic power.

Children don’t choose to be born and raised in these low-opportunity neighborhoods. Yet their life chances are diminished all the same. After all, people can only make choices from the options available to them.

My community in Scott County has been on the frontlines of the national overdose crisis. In 2012, Reuters shined a spotlight on the deaths of despair snatching people from far too many families in this rural community. Even with the national attention, nothing was done to reduce the harm that health disparities and substance use were inflicting on residents, inevitably leading to the worst drug-fueled HIV outbreak in U.S. history in 2015.

It took that tragedy to bring change. Today, Scott County has the best HIV treatment rates in the state and incredibly had only one new case last year. The local recovery community has expanded and become a resource for others. All this was done by providing access to care in ways that feel safe to people in need, moving beyond “do no harm” to “protect from harm” through the use of harm-reduction programs.

Harm reduction honors human life by developing practical strategies to reduce the negative consequences of people’s circumstances and behaviors on their health and the health of their communities. Examples include bystander CPR classes, syringe services programs, and providing individuals and families with naloxone, a medication that can rapidly reverse an opioid overdose.

I connected Brian to the local substance use harm-reduction program, which worked to keep him safe from infectious diseases and overdosing until he was ready for help, and then connected him with the resources he needed when he was ready to quit using drugs. That’s when his life began to change.

“One day it struck me that if these people care about me, maybe it’s OK to start caring about myself,” Brian told me. “That’s when I decided to get help.”

Brian’s story isn’t unique. I’ve heard people in recovery across the U.S. tell similar stories of rediscovering hope and life through harm-reduction programs. As substance use and overdose deaths surge across the nation to historic highs, we need these life-affirming and disease preventing programs more than ever.

Increasing access to hope and life-affirming care is something everyone should be able to get behind. Yet there is a national push to restrict access to harm-reduction programs, and many have even been forced to close in the places where people need them the most, including Scott County, West Virginia, Atlantic City, N.J., and elsewhere.

For too long, our nation has tolerated — even advocated for — a system that blames people who are suffering. That ignores the cumulative effect that every person’s health has on our nation’s health.

The American dream requires that every child, regardless of social class or circumstances of birth, has access to the vital community conditions we now know are required to be healthy and prosperous. By taking on this crisis of health inequities and declining life expectancy now, we can reestablish the United States as the best place in the world to live.

William Cooke is a physician specializing in family medicine, addiction medicine, and HIV medicine. A recipient of the Ryan White Distinguished Leadership Award, he is also the author of a book about the Scott County HIV outbreak, “Canary in the Coal Mine” (Tyndale Momentum, June 2021).

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