Canary in the Coal Mine: A Forgotten Rural Community, a Hidden Epidemic, and a Lone Doctor Battling for the Life, Health, and Soul of the People

Kenneth W. Lin, MD, MPH

Fam Med. 2022;54(4):312-313.

DOI: 10.22454/FamMed.2022.528887

Book Title: Canary in the Coal Mine: A Forgotten Rural Community, a Hidden Epidemic, and a Lone Doctor Battling for the Life, Health, and Soul of the People

Author: William Cooke and Laura Ungar

Publication Information: Carol Stream, IL, Tyndale Momentum, 2021, 320 pp., $25.99, hardcover


In the mid-1990s, Dr Abraham Verghese’s memoir My Own Countrydescribed how people living with HIV suffered not only from the infection’s physical effects, but also from stigma in a community where it was viewed as divine punishment for deviant sexual behavior.1 Today, another stigmatized behavior continues to fuel the HIV epidemic: injection drug use of illicit opioids. In 2015, 181 residents of Scott County, Indiana contracted HIV from syringe sharing or sex with persons who had shared syringes, giving the small, impoverished rural community one of the highest HIV incidences in the world.2,3 Dr Will Cooke found himself at the epicenter of America’s opioid and HIV epidemics. Canary in the Coal Mine recounts the story of his efforts to protect the health of his patients and his community.

In 2004, Dr Cooke opened Foundations Family Medicine in Austin, Indiana, becoming the town’s first local physician in 27 years. He was initially naïve about the damage that decades of poverty and emotional deprivation had inflicted on the residents of Austin and neighboring towns. When new patients started showing up at his office asking for one or more of three drugs (Oxycontin, Xanax, and Soma) that he eventually called “the devil’s triad,” Dr Cooke struggled to distinguish patients with genuine pain or anxiety disorders from those who were just looking for their next fix. He “was astonished to discover that Austin had led the state in prescription drug abuse for years” (p 48), and that one in five residents had a substance abuse disorder.

Moonlighting in Scott Memorial Hospital’s emergency department, Dr Cooke came face to face with the results of oxymorphone abuse and reuse of contaminated syringes: increasing numbers of overdose deaths and patients presenting with abscesses, endocarditis, and viral hepatitis. In February 2015, the state health department announced that it had confirmed more than two dozen HIV infections linked to injection drug use in or near Austin. In response, Dr Cooke joined a coalition of health officials and community leaders to persuade Governor Mike Pence to lift the state’s long-standing ban on syringe service programs. As state and national resources began pouring into Scott County, Foundations Family Medicine played a critical role in community outreach and HIV testing and treatment. Although Dr Cooke appreciated the outside help, at the same time he was discouraged by the state’s heavy-handed and stigmatizing approach, which included installing flashing emergency signs at nearby truck stops that read “WARNING: HIV OUTBREAK.”

By the summer, 86% of Scott County patients with HIV infection were engaged in care2 and its syringe service program was utilized by nearly every HIV patient who was still injecting drugs. While the state health department had focused exclusively on controlling the outbreak, Dr Cooke recognized that improving his community’s long-term health depended on expanding social services to address the adverse social determinants that created the opioid epidemic. In a revealing conversation, the deputy director of Indiana’s Division of Mental Health and Addiction confided: “Nobody wants to talk about these root causes of the hopelessness and desperation that lead to the drug use and sex work” (p. 176).

Dr Cooke turned frequently to prayer and his Christian faith when his determination flagged or when he sought meaning in his patients’ struggles. Ironically, a syringe service program in a neighboring county closed when one of one of the commissioners who voted against renewing it for moral reasons quoted scripture to support his decision. Meanwhile, Austin has thrived since the outbreak due to community efforts “to destigmatize poverty and substance abuse disorder, and to create safe places for people to access help” (p. 261).

Canary in the Coal Mine will appeal not only to clinicians who treat patients with opioid use disorder or HIV, but to anyone who has witnessed the consequences of these epidemics in patients and patients’ families. The book offers an inspiring example of how one family physician can make an enormous personal and public health difference in a community. But it has a sobering message, too: the elements that ignited this outbreak persist in similar places across the country. As legal restrictions on syringe service programs threaten to spark outbreaks in other states,4 elected officials would do well to read the book’s appendix, “Ten Biblical Principles for Harm Reduction” (pp. 269-278), which includes the admonitions “seek and save,” “love others lavishly,” and “put people before morality.”


  1. Verghese A. My Own Country: A Doctor’s Story of a Town and Its People in the Age of AIDS. New York: Simon & Schuster; 1994.
  2. Conrad C, Bradley HM, Broz D, et al; Centers for Disease Control and Prevention (CDC). Community outbreak of HIV infection linked to injection drug use of oxymorphone – Indiana, 2015. MMWR Morb Mortal Wkly Rep. 2015;64(16):443-444.
  3. Peters PJ, Pontones P, Hoover KW, et al; Indiana HIV Outbreak Investigation Team. HIV infection linked to injection use of oxymorphone in Indiana, 2014-2015. N Engl J Med. 2016;375(3):229-239. doi:10.1056/NEJMoa1515195
  4. Kuehn BM. Restrictive policies threaten efforts to stop 2 West Virginia HIV outbreaks. JAMA. 2021;325(22):2238-2240. doi:10.1001/jama.2021.7404

Lead Author

Kenneth W. Lin, MD, MPH

Affiliations: Department of Family Medicine, Georgetown University Medical Center, Washington, DC

Corresponding Author

Kenneth W. Lin, MD, MPH

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