Despair is powerful. Desperate people do desperate things. Troubled lives can drift into full tailspin.

As the HIV outbreak in Scott County shined a spotlight on Indiana’s intravenous drug abuse problem, the scene in the background of this disturbing situation demands attention, too. The headlines reflect culture shock: There are 136 confirmed cases of HIV — the AIDS-causing virus, transmitted primarily by infected drug users sharing needles and through sexual contact — as of midday Friday in a rural county of 24,000 Hoosiers.

People wonder, “Isn’t that a big-city problem?”

It can be, but its roots grow just fine in the countryside, too. And that brings us back to that word: despair.

In a letter to the Jeffersonville News and Tribune last month, a Scott County family physician — thrust into the public eye as he tried to respond to the worst HIV outbreak in state history — explained that the predicament’s cause transcends the mere availability of prescription drugs to people inclined to abuse them.

Dr. Shane Avery wrote that his “community has high rates of poverty and despair. I can tell you stories of patients, because of lack of transportation, [who] have walked miles to my office to see me. Add to this a high rate of uninsured [residents], low rates of completing a high school education, and insufficient access to public health services such as testing for sexually transmitted infections and mental services.”

The HIV at-risk lifestyle may seem distant to many people, but most Hoosiers are well aware of the poverty the doctor described. It’s all around us, including right here in the Wabash Valley.

A busy highway, Interstate 65, cuts through Scott County and the town of Austin, and that traffic increases the possibilities for imported drugs and prostitution. But the low-opportunity, low-wage, poor-health atmosphere for locals provides the fertile ground for dangerous activities.

The reality that the rash of HIV cases has, and will continue to, spread beyond the borders of Scott County has jolted the rest of the state.

Ed Clere, a Republican state representative from New Albany, has pushed for the General Assembly to allow, at least, high-risk Indiana counties to implement needle-exchange programs to contain the public health emergency and offer HIV and addiction treatment to drug abusers.

Gov. Mike Pence issued an executive order last month to allow a temporary clean needle exchange in Scott County only, but has threatened to veto an expansion of that policy.

On Friday morning, Clere told the Tribune-Star he’s continuing to work with Pence and Statehouse leadership to enact a broader program. That may include a limited needle exchange program subject to review after one year, Clere said, involving the 23 counties with the highest rates of hepatitis C — a blood disease that can precede HIV. That group includes Vigo and Parke counties. Those and many other counties on the list share socioeconomic similarities with Scott.

Nineteen percent of Scott County residents live below the federal poverty level. Vigo stands at 20 percent. Per-capita incomes in Scott, Vigo and Parke are $20,000 or below, well shy of state and U.S. levels. Twenty-five percent of Scott County kids live in poverty; in Vigo, it’s 30 percent. Unemployment rates in Scott, Vigo and Parke counties all exceed the Indiana and national levels. Like Scott, major thoroughfares — Interstate 70 and U.S. 41 — bisect Vigo and Parke, opening them up to the world, its virtues and its ills.

As the comedian says, there’s your sign.

“The growth rate of Hoosiers infected with HIV in Scott County and beyond is not only a public health issue. It is also, at its root, an issue of resources and access to care and treatment,” Susan Jo Thomas, executive director of Covering Kids and Families of Indiana, told the Tribune-Star on Friday.

Said Clere, “It certainly appears that one of the underlying factors here is lack of opportunity.”

Though the immediate need is to curtail the spread of HIV by expanding the clean-needle distribution, Indiana must change the quality of life in communities outside the Indianapolis suburbs, where 80 of the state’s 92 counties are experiencing flat-lining or declining population.

Clere emphasized the HIV outbreak could spread into any Indiana county, not just the 23 with the highest hepatitis C counts. The factors that made Scott County its high-profile starting point exist throughout the state. This could happen anywhere.

If there is anything positive emerging from Scott County’s situation, it might be that those “underlying factors” will receive serious attention.

“It’s horrible that we have to have a crisis in order to bring attention to certain issues, but it’s also good that that’s likely to be an outcome of this crisis,” Clere said. “There’s no question the crisis in Scott County has brought a lot of attention to a number of critical issues that previously were not receiving much attention.”

Mark Bennett is a writer for the (Terre Haute) Tribune-Star. Send comments to [email protected].