Canary in the Coal Mine - A Story from Region 6

Indiana is known as the crossroads of America.  In recent years Indiana has also become the crossroads of multiple deadly epidemics.  In 2015 Austin, Indiana was the epicenter of the worst drug fueled HIV outbreak in the history of the United States. Out of a town of 4300 people.

On this episode of the NNLM Discovery podcast, Region 6’s Community Engagement Coordinator, Darlene Kaskie, shares how NNLM is sponsoring a series of talks at public libraries with Dr. William Cooke, a physician and author in rural Austin Indiana.  Dr. Cooke wrote a book called Canary in the Coal Mine about being the only doctor in a small town that was hit by twin epidemics of substance abuse and HIV.  His story examines the social determinants of health that contribute to poor healthcare and offers hope that communities can come together to make sure that every child born has access and resources and choices that they need to be healthy and prosperous.

NNLM donated hundreds of copies of Dr. Cooke's book to all the libraries that hosted the event. The libraries then distributed the books to community organizations such as faith-based groups, rehab centers, counseling services, and public health departments.
You can view a short video about the story here on the NLM YouTube Channel.

The NNLM is the outreach arm of the National Library of Medicine with the mission to advance the progress of medicine and improve the public health by providing all U.S. health professionals with equal access to biomedical information and improving the public's access to information to enable them to make informed decisions about their health. The seven Health Sciences Libraries function as the Regional Medical Library (RML) for their respective region, with Region 6 consisting of: Illinois, Indiana, Iowa, Michigan, Minnesota, Ohio and Wisconsin. To learn more about Region 6 visit: http://www.nnlm.gov/about/regions/region6.

All of the artwork for this podcast series has been created with a generative AI text-to-image tool!  The text prompt for the episode's artwork was " a canary in a coal mine as an abstract painting.”

Join Outreach Services Librarian, Yamila El-Khayat, for new episodes of the NNLM Discovery podcast. You can subscribe on Apple Podcasts, Spotify, Amazon Music, Google Podcasts, or listen on our website www.nnlm.gov/podcast. Please be sure to like, rate, and review the show!

Transcript

00:00:03:17 - 00:00:27:15
Yamila El-Khayat
I’m librarian Yamila El-Khayat and this is NNLM Discovery, a podcast from the Network of the National Library of Medicine. This podcast series explores how NNLM is improving the public’s health by communicating in new ways. Today’s episode is, “Canary in the Coal Mine,” a story from Region #6. Community Engagement Coordinator from Region #6, Darlene Kaskie, will be joining us today. 

00:00:27:17 - 00:00:28:19
Yamila El-Khayat
Hi, Darlene.

00:00:28:21 - 00:00:30:03
Darlene Kaskie
Hello, Yamila.

00:00:30:05 - 00:00:33:13
Yamila El-Khayat
So, Darlene, tell us about today's story.

00:00:33:15 - 00:00:57:15
Darlene Kaskie
Well, as you know, each NNLM Region covers a large geographic area and our Region #6 area is almost all the states that make up the Midwest. So when you cover an area that large, the health disparities of one state like Ohio may be different from the disparities of another state like Minnesota or Iowa. So today I'm here because I want to share the program that was developed with our state advisory group in Indiana.

00:00:57:17 - 00:01:00:10
Darlene Kaskie
Yamila, I'm going to put you on the spot.

00:01:00:12 - 00:01:01:14
Yamila El-Khayat
Yikes.

00:01:01:16 - 00:01:04:20
Darlene Kaskie
What do you know about Indiana?

00:01:04:22 - 00:01:09:05
Yamila El-Khayat
I know one city there, Indianapolis, but isn't everything else farms?

00:01:09:06 - 00:01:32:19
Darlene Kaskie
Yeah, well, you're not too far off. I'm kind of surprised you didn't mention basketball. You see, I'm actually a Hoosier, and I did grow up on a small farm in Indiana, and my parents still live there. A lot of Indiana is rural with small towns, small towns with little access to health care or local doctors. And unfortunately, one big issue in Indiana is substance abuse.

00:01:32:21 - 00:01:40:01
Darlene Kaskie
From 2011 to 2021, Indiana saw substance abuse increase by 181%.

00:01:40:03 - 00:01:40:22
Yamila El-Khayat
Wow.

00:01:41:01 - 00:01:47:02
Darlene Kaskie
Yeah. With a lot of the misuse and overdose happening in these small towns that have little resources to help.

00:01:47:04 - 00:01:56:12
Yamila El-Khayat
Substance abuse is far too common, everywhere. I think we can all learn from this story. Why don't you just jump right into it. Where do we start?

00:01:56:14 - 00:02:21:22
Darlene Kaskie
Well, we started by partnering with Dr. William Cooke from Austin, Indiana, in Scott County, which is located in the southern portion of Indiana, about 40 minutes north of Louisville, Kentucky. Dr. Cooke wrote a book called “Canary in the Coal Mine” about being the only doctor in a small town that was hit by a horrible epidemic. Now, the good news is the town rallied together, provided resources, and they overcame the tragedy.

00:02:21:23 - 00:02:46:16
Darlene Kaskie
So our goal for sharing his story, what worked and what didn't work, may help other Indiana communities facing similar substance abuse issues. Then next, we partnered with libraries across Indiana and coordinated speaking events in different communities. We've already been to three locations, and today we're going to feature a few segments of Dr. Cooke's talk at Allen County Public Library in Fort Wayne, Indiana.

00:02:46:18 - 00:02:53:22
Darlene Kaskie
So here is Dr. Cooke setting up the story and sharing some information about his own family.

00:02:54:00 - 00:03:22:13
Dr. William Cooke
So Indiana, as you probably know, is known as the crossroads of America. And in 2015, we became the crossroads of multiple deadly epidemics, including the opioid crisis, adverse childhood experiences, social determinants of health and HIV. We actually became the epicenter of the worst drug fueled HIV outbreak in the history of the United States. Out of a town of 4300 people.

00:03:22:15 - 00:03:46:22
Dr. William Cooke
Most of the people that we take care of in Scott County came out of Appalachia, and my family also migrated out of Appalachia. They ended up being squatters, actually on the Ohio River, just inside of the Indiana border. And they were able to give my brother and me a better life then they had growing up. But not everyone in my family was so fortunate.

00:03:47:00 - 00:04:19:12
Dr. William Cooke
My Aunt Sally. She died in her thirties of a drug overdose. She dropped out at 14. Never found the same structure, never found any mentors. Was in and out of relationships, went from alcohol to opioids. My Grandfather and her actually drank a lot together and they found that they could go to doctors offices and get opioids, use some themselves, but they would actually bag up some and sell them to support themselves.

00:04:19:13 - 00:04:44:00
Dr. William Cooke
My Grandfather and my Aunt, father and daughter, were a team. They went to a yard sale and got my my Grandpa a walker. He didn't need it, but they got him a walker so that they could go to a doctor and get opioids from him. So that's how my my Aunt Sally lived life, my Grandfather as well. They both died young.

00:04:44:00 - 00:05:06:23
Dr. William Cooke
My Aunt Sally again in our thirties, my grandfather in his fifties. So, you know, people are losing decades of life through diseases like substance use disorder. And it's it's coming out of systemic harms, harms in our communities, that we can do something about.

00:05:07:01 - 00:05:30:15
Darlene Kaskie
And that's why we're sending Dr. Cooke around Indiana so we can identify and do something about the harms in our communities. I think one important takeaway from his message is that life expectancy is declining in America for the first time since the 1920s. And one of the main reasons behind this lower life expectancy is toxic social, economic and environmental conditions that communities face.

00:05:30:17 - 00:05:35:15
Darlene Kaskie
Yamila, do you know why the book is called “Canary in the Coal Mine”?

00:05:35:16 - 00:05:47:00
Yamila El-Khayat
I don't. But as a bird owner, I do know that canaries were taken into coal mines so the miners could tell if the air was poisonous or not. I believe it was carbon monoxide. Is that why?

00:05:47:02 - 00:06:10:12
Darlene Kaskie
Yeah, exactly. Dr. Cooke wants to make Austin, Indiana, the canary so that we can use his community as an example to help prevent future healthcare epidemics because they are preventable. So what I also like about Dr. Cooke's presentation is that he humanizes his experiences and he talks about the individuals who've been impacted by this tragedy. Here is Dr. Cooke.

00:06:10:14 - 00:06:44:09
Dr. William Cooke
So what what happened in Scott County? You know, that's why I'm here. We have multiple overlapping, you know, issues that developed into a perfect storm, the opioid epidemic, obviously, the social economic demographic, harms, public policy and then, of course, the HIV and hepatitis C. I opened my practice there in 2004 and I was immediately overwhelmed by the amount of distress and stress that I saw in people's lives.

00:06:44:11 - 00:07:13:02
Dr. William Cooke
You know, people were coming in and describing existences that I really didn't understand still existed in the United States. Again, you know, no running water, no electricity, burning trash. It shocked me. I had gone overseas. I'd been, you know, been on mission trips to third world countries. But even there, I didn't see the same conditions that I saw right here in Indiana.

00:07:13:04 - 00:07:40:23
Dr. William Cooke
And that troubled me. And I really didn't feel prepared for my medical education. You know, I was taught how to take care of diseases in medical school, not how to deal with social, you know, circumstances that were harming people. That's a complete different thing. People would come in and they would ask for Percocet, Xanax and Soma, those three in combination.

00:07:41:01 - 00:08:06:11
Dr. William Cooke
They asked for it so often I, I kind of nicknamed it the “Devil's Triad.” Patient after patient. I want Percocet, Xanax, and Soma. And it's like, “No, we're not going to do that. Let's look at something else.” Some patients, you know, they were dealing with chronic pain and I was the only doctor in town and they were on opioids.

00:08:06:11 - 00:08:32:00
Dr. William Cooke
And so, you know, there was an effort to try to help people get off of those. Samantha is one. She was in her late twenties dealing with back pain. She had gone to a back surgeon, had back surgery. He was prescribing her pain pills, opioid pain pills. But it was, you know, several counties over it was a long distance for her.

00:08:32:02 - 00:08:49:17
Dr. William Cooke
She knew I was new, to the, to her town and I was her doctor now. And she asked if I could help her. And I said, “sure, you know, we could work together. You're young. There's no reason why with physical therapy and some effort, we can't get you to where you're functioning in life without pain or with less pain. And we could get you off of these.”

00:08:49:19 - 00:09:06:15
Dr. William Cooke
So we started working together. I gave her this contract that said, you're not going to sell your drugs, you're not gonna take anything else. Blah, blah, blah. She signed it. We went on. Referred her to physical therapy. She was doing great. Had a lot of hope for Samantha. She was showing up to her visits.

00:09:06:18 - 00:09:37:04
Dr. William Cooke
She was passing urine drug screens. She was doing her physical therapy. She was improving. Until one day, I did a drug screening and got that back and it showed that she was taking other substances other than what I was prescribing her. Now, this is around 2004. At the time, you know, I had just graduated and was taught that there's certain patients that are too difficult to deal with, that it would burden down your entire practice.

00:09:37:04 - 00:10:00:09
Dr. William Cooke
And so the best thing to do in a circumstance when you're dealing with someone who's using other substances, like Samantha, would be to just dismiss her from your practice. In fact, I had been given this form letter on how to do this, and so I pulled up the form letter. I put Samantha's name in there. I sent it off through the mail, went on seeing patients.

00:10:00:11 - 00:10:23:10
Dr. William Cooke
But a couple of days later, she came in with my letter. Ripped it up, threw it at my receptionist's face, started yelling and screaming. “Dr. Cooke, cut me off. What am I supposed to do?” Started tearing posters off the wall, knocking furniture over. It's a completely different person than the Samantha that I knew. You know, we didn't know what else to do but call the police.

00:10:23:10 - 00:10:37:08
Dr. William Cooke
So they came in and took her out to the police car. And I remember looking out my my office window, at this 20 something year old woman, back of a police car, head draped down, hair hanging in her face.

00:10:37:09 - 00:10:42:20
Darlene Kaskie
So Samantha sitting in the back the cop car reminded Dr. Cooke of his Aunt Sally.

00:10:42:22 - 00:10:53:17
Yamila El-Khayat
Wow. What a powerful story. Unfortunately, this is a story of poverty in America, and stories like this can be seen and are happening almost in every community.

00:10:53:23 - 00:11:22:04
Darlene Kaskie
Um-hum. That's right. And that's why his story is so important. Now, at this point in his talk, Dr. Cooke discusses identifying the toxic stress in an individual's life, whether it's adverse childhood experiences, or not having your basic needs met like shelter, safety, or food. All of these conditions may lead to the development of harms, like substance use disorders. But it’s even bigger than that, it leads to and can be traced to all other sorts of indirect harms.

00:11:22:06 - 00:11:31:07
Dr. William Cooke
You know, you can name something like cervical cancer that doesn't seem to be even related to toxic stress in someone's life.

00:11:31:08 - 00:11:57:10
Dr. William Cooke
Right. But what we know is that cervical cancer was the leading cause of death among women in the 1800s. But now we have screening and preventative tools that will prevent any woman from dying of cervical cancer as long as they have access to screening and preventative services. So why can't we get down to zero, if no woman should ever die of cervical cancer?

00:11:57:10 - 00:12:22:14
Dr. William Cooke
What's keeping us from getting down to zero? There's some invisible force keeping us from getting down to zero. What? What is that? Depending on what insurance you have or if you have access to insurance, you may have access to certain tests and procedures that someone else doesn't, for example. Depending on where you live, you may have access to transportation to get to a doctor.

00:12:22:16 - 00:13:04:19
Dr. William Cooke
Depending on where you live, you may or may not have a doctor to even go see. Right. So the social conditions in which someone is born and raised will affect even something like cervical cancer. So it doesn't just apply to substance use disorder, you know it applies to really anything diabetes, heart disease, cancers, cervical cancer. Samantha came back to the emergency department probably about eight years after I dismissed her from my office.

00:13:04:21 - 00:13:34:11
Dr. William Cooke
She came in with abdominal pain and I walked into the room and I sat down and she recognized me, I recognized her, and it was awkward. But we get past awkward when people need help. And I said, “you know, Samantha, I'm here to help you. I'll do everything I can. You know what's going on?” She started telling me how she was experiencing this abdominal pain, and it had been getting worse over the last few months and over the last few days it had become unbearable.

00:13:34:11 - 00:13:56:22
Dr. William Cooke
And she came in and I said, “you know, we'll figure this out.” Went out, you know, for some medicine to help her feel better, ordered some labs, some studies, started seeing other patients. At some point, the guy that was with her came out and handed me this letter and said that Samantha had been carrying the letter around with her for a few months.

00:13:57:00 - 00:14:17:19
Dr. William Cooke
It was addressed to me, Dr. William Cooke, and my address on it, and he said she was just afraid to send it to you, but she's been carrying it around. I think you should read it. So I went back to my desk, opened it up, and it described how she was raised in a home where there was a lot of alcohol use, a lot of poverty.

00:14:17:19 - 00:14:41:21
Dr. William Cooke
She never felt like she belonged. Never felt safe. Around 13 years old, she went to a dentist and she was prescribed an opioid pain medicine. 13 years old. She took that and didn't just help with her physical pain. She said it changed something inside of her to allow her to feel safe for the first time in her life.

00:14:41:23 - 00:15:08:03
Dr. William Cooke
Imagine that, a 13 year old takes a pill and for the first time in her life she feels okay. What do you think she's going to do? She continues using through high school and then at some point she realizes what she's taking and she doesn't like it. You know, I don't want to be an addict, so I thought you could help me and I messed up and you found out and kicked me out.

00:15:08:04 - 00:15:37:03
Dr. William Cooke
I don't blame you, but I need help. I don't want pain pills. I just want help. Will you take me back to help me? Now, at this point, I had stopped discharging patients from my office. Instead, I would bring them in and have a conversation, figure out what was going on. Hear their story, connect them to resources. So, people like Samantha that I had already done that too, I felt really guilty for.

00:15:37:04 - 00:16:05:06
Dr. William Cooke
I would carry around this burden with me. On how I had, you know, discharged Samantha. And here she is asking if she could come back. I'm like, “yes,” you know, absolutely nothing is going to keep me from going back in there and saying, “you know, Samantha, yes, let's work together.” I pulled up her CT results and it showed metastatic cervical cancer.

00:16:05:08 - 00:16:36:04
Dr. William Cooke
So metastatic cervical cancer is a cancer that no woman should ever die of if they have access to screening and preventative services. You know, and I was the doctor in her community to provide her those screening and preventative services to her. And I told her she couldn't come to me. And because she didn't have access to screening and preventative services.

00:16:36:05 - 00:17:01:00
Dr. William Cooke
Not only did she develop cervical cancer, it’s now metastatic. And instead of going into the room and saying, “of course I'll help you.” I have to go into the room and tell her that she has metastatic cervical cancer. And, you know, she probably only has a few months, maybe a year, to live.

00:17:01:02 - 00:17:29:16
Dr. William Cooke
So, you know, the things we do matter and limiting access to people matters. Again, people can only make choices from options available to them. If Samantha doesn't have the option to get cervical cancer screening and prevention, how the hell is she supposed to? And whose fault is it?

00:17:29:18 - 00:17:49:21
Dr. William Cooke
So I brought her back into my practice and, you know, we worked together for the next couple of months, but it didn't keep her from dying in her late thirties like my Aunt Sally did. And she left, you know, two kids just like my Aunt Sally did.

00:17:49:23 - 00:17:57:02
Yamila El-Khayat
Wow, that's terrible. I can really feel his guilt. What a heavy burden to carry over all those years.

00:17:57:04 - 00:18:22:04
Darlene Kaskie
Yes, and that's another reason we wanted to share Dr. Cooke's story. Not only is he a fellow Hoosier, a doctor living in a small town, he is a compassionate man of faith, which we thought was important when connecting with communities in rural Indiana. Now, as we mentioned at the very beginning, there was a tragic HIV outbreak that put Austin, Indiana, in the national and even the international spotlight.

00:18:22:06 - 00:18:29:20
Darlene Kaskie
So here is Dr. Cooke describing what led to this attention and then how they stopped the outbreak.

00:18:29:22 - 00:19:03:09
Dr. William Cooke
So going back to the opioid outbreak and HIV in Scott County, there were certain landmarks along the way that were missed. In 2011, what we saw in our community was there was an increase in soft tissue infection, endocarditis, sepsis. This is indication that there's injection drug use in the community. And we saw this. There was a change in the way that the Opana opioid was manufactured.

00:19:03:11 - 00:19:19:01
Dr. William Cooke
They changed it. In fact, the manufacturer had done studies to show that it actually increased drug use. But they suppressed those studies.

00:19:19:03 - 00:19:43:17
Dr. William Cooke
That change resulted in an increased drug use. IV drug use in our community. People started injecting because they used to crush it and snort it. They couldn't do that anymore. It would cause it to turn into a gel, so they could melt it and draw it up into a syringe, inject it into their vein to get the same results. You know, syringe distribution was illegal at the time.

00:19:43:17 - 00:20:10:09
Dr. William Cooke
People didn't have sterile syringes to inject with, and so they would either inject with the same syringe over and over and over again or they would share syringes with other people. And when you inject with a syringe, that’s not sterile, you're injecting bacteria into the bloodstream. If you're sharing syringes, you're injecting whatever virus or bacteria that person has into your bloodstream.

00:20:10:11 - 00:20:29:18
Dr. William Cooke
So we started seeing an increase in hepatitis C cases in the community. Hepatitis C is a harbinger of HIV. This made national news. This is an article from Reuters. You can't see this, but it says Austin, Indiana, right there.

00:20:29:20 - 00:20:59:13
Dr. William Cooke
National news said Austin, Indiana needs help. This is four years before the outbreak. The Indiana Department of Health identified Scott County as one of the places in Indiana that had this hepatitis C epidemic brewing. And again, hepatitis C is spread the same way as HIV. It's a harbinger of HIV, if there's a lot of hepatitis C in the community HIV is already there or it's coming very soon.

00:20:59:15 - 00:21:20:06
Dr. William Cooke
Again, there was no testing in the community. We had one public health nurse. And so HIV actually entered into the community around 2011. And we didn't pick up the first case until right at the end of 2014, beginning of 2015. And so people had been contracting HIV for years leading up to that point.

00:21:20:07 - 00:21:47:15
Dr. William Cooke
If there had just been testing in the community, it would have prevented the whole HIV outbreak. And I'd probably be standing here talking about something else, if I was standing here talking at all. And once we found out that people in large numbers were contracting HIV in the community, multiple things happened very quickly. Governor Pence issued a emergency order to unlock resources that we would need.

00:21:47:17 - 00:22:08:14
Dr. William Cooke
I vowed that no one would have to travel long distances to get care for substance use disorder, HIV or hepatitis C. So my primary care clinic in Austin, I vowed that we would take care of anyone that walked in the door, and we made sure that we had the resources to take care of HIV. So we started treating HIV right there in the community.

00:22:08:16 - 00:22:37:01
Dr. William Cooke
And then the health department started a syringe service program so that people had sterile syringes so that they didn't inject over and over again and develop soft tissue infection, sepsis and die or share and spread HIV and hepatitis C more. And between all of these, we quickly leveled off. And between July of 2015 and December of 2015, we didn't have a single new case.

00:22:37:03 - 00:23:08:01
Dr. William Cooke
Treatment is that effective? Harm reduction? Is that effective? We went from 180 cases to none. Almost immediately. But this was a significant outbreak. It represented a third of all the new HIV cases in Indiana. It represented a third of all the new, this is a town of 4300 people, it increased the incidence of HIV in Indiana by 20%. It affected the entire state.

00:23:08:03 - 00:23:35:14
Dr. William Cooke
Predominantly people living on public assistance. Medicaid. Treatments not cheap. In my book, I say that, you know, “health care disasters don't just happen. They develop right before our eyes and we either don't see it or refuse to see it until it's too late.” We lived this story once. I wrote a whole book about it. You know, and now we're doing it again.

00:23:35:16 - 00:23:58:18
Dr. William Cooke
It doesn't have to be, Healthcare disasters don't have to occur. You know, there are things we can do to stop it in the beginning by connecting with people and giving them access to care. It's not wrong to give someone access to care. We don't have to put all the burden on someone who doesn't have access to find it.

00:23:58:18 - 00:24:36:06
Dr. William Cooke
That doesn't even make sense. To me healthcare isn't what happens in hospitals and clinics. Healthcare is what's happening in the community where people are born, raised and live. I'm only responding to what's already happened to someone when they come to me. Again, I was trained to take care of diseases. Right? But over time, I have trained myself through research and I think we're doing a better job of training the young doctors that healthcare is actually those social determinants.

00:24:36:08 - 00:24:55:06
Dr. William Cooke
There's always hope. There's toxic conditions that are harming people, but there's something we can do about it. We can come together as a community to make sure that every child born in our community has access and resources and choices that they need to be healthy and prosperous.

00:24:55:08 - 00:24:59:16
Yamila El-Khayat
Thanks, Darlene, for sharing this story and spreading this important information throughout Indiana.

00:24:59:18 - 00:25:02:07
Darlene Kaskie
You're welcome, Yamila. I'm glad we could share.

00:25:02:09 - 00:25:04:13
Yamila El-Khayat
Are there any upcoming events?

00:25:04:15 - 00:25:10:17
Darlene Kaskie
Yes. We have one more speaking engagement planned for Richmond, Indiana, on March 25th.

00:25:10:19 - 00:25:21:04
Yamila El-Khayat
That sounds wonderful. And we've also made a short video of this story where you can see Dr. Cooke in action. Check out the show's description for a link to YouTube.

00:25:21:06 - 00:25:43:05
Darlene Kaskie
Oh, and Yamila. May I add that NNLM donated hundreds of copies of Dr. Cooke's book to all the libraries that hosted our event. The library then distributed the books to community organizations such as faith based groups, rehab centers, counseling services, and public health departments. This was our effort to extend this information as a tool that led to more discussions.

00:25:43:06 - 00:25:45:20
Yamila El-Khayat
Did anything surprise you during these events?

00:25:45:22 - 00:26:01:06
Darlene Kaskie
Yes. Thank you for asking. We've had law enforcement and criminal court justices come to these events. They wanted to learn more about solving this opioid crisis, and their participation was a perfect opportunity to engage with important local leaders.

00:26:01:08 - 00:26:23:14
Yamila El-Khayat
Agreed. I look forward to hearing about what you're doing in other states in future episodes of NNLM Discovery. NNLM offers many funding opportunities for projects that improve access to health information. Contact your local regional rep or search for grants that are available now at NNLM.gov/funding. This is NNLM Discovery.

00:26:23:16 - 00:26:24:13
Yamila El-Khayat
Thank you for listening.