Treating Gun Violence as a Public Health Epidemic
There’s broad agreement, as noted in Part 1 of this post, that gun violence (indeed, all violence) should be viewed as a public health issue.
That idea was clearly stated by Dr. Gary Slutkin, an epidemiologist trained in infectious diseases, when he returned to the US after a decade spent in Somalia, Uganda, and other countries where epidemics of such diseases as cholera, tuberculosis, and AIDs were common. In his final assignment before coming home, he was tasked to design interventions.
As he describes in a 2013 TEDMED talk, he was looking for something to do when he began hearing stories of children shooting other children.
When he asked friends how America was addressing this issue, one response was through punishment.
But, he said, “We who had worked in behavior know that punishment was something…that was highly overvalued” because it wasn’t a main driver of either behavior or behavior change.
What’s more, it reminded him of responses to epidemics long ago—before science cast better light on issues.
The other response was what he called the “‘everything’ theory, or EOE: Everything on Earth:” fix the schools, home, community, family, etc. He said he realized from treating other problems that you don’t always need to treat everything.
Assuming violence behaves like a contagious disease, Slutkin describes three things necessary to counter it.
First: interrupt transmission by detecting and finding the first cases, which includes identifying and training special workers to locate those cases, eg, “someone who’s very angry because someone looked at his girlfriend or owes him money.”
Second: “to prevent further spread…find out who else has been exposed,” but not as severely, and manage them as well.
Third: “shift the norms.” This is an extensive effort involving community activities, public education, helping people improve communication and resolve their conflicts peacefully.
“And then you’ve got what you might call group immunity. And that combination of factors is how the AIDS epidemic in Uganda was very successfully reversed.”
Slutkin and his colleagues put all these ideas together in 2000, and tried them out in the West Garfield neighborhood in Chicago—“the worst police district in the United States at the time.” The result: a 67% drop in shootings and killings.
What Slutkin began in Chicago became an organization originally called “CeaseFire,” but more optimistically renamed “Cure Violence.” It’s now a national model, with local groups operating under various names.
And several of those local groups are in the California Bay Area, which is the subject of the year-long examination that Lois Beckett and her colleagues at The Guardian have undertaken. (See Part 1 of this post.)
The reduction in violence in this region from 2007 to 2017 is remarkable—even more so because it occurred while homelessness caused by gentrification has been rising.
Due to the impact of Silicon Valley, writes The Guardian,
“For each new millionaire household the San Francisco Bay area has produced, there are at least four new people living below the poverty level.”
Nevertheless, gun homicide was down substantially in the ten-year period in more than 100 cities throughout the region. In Oakland, a 44% decrease. In San Francisco, 49%. In Richmond, 67%. With Stockton as an outlier (98% increase), the overall drop in the region was 30%.
Writes The Guardian:
“There’s early evidence that local violence prevention strategies—including a refocused, more community-driven ‘Ceasefire’ policing strategy, and intensive support programs that do not involve law enforcement at all—were a ‘key change’ contributing to these huge decreases.”
Lest anyone conclude that gentrification resulted in the reduced gun violence, it’s noteworthy that there was no uptick in violence in the suburbs to which the people forced out of the city moved.
One local activist noted:
“The idea that gentrification is more responsible for the reduction in shootings and homicides is offensive to the hundreds of outreach workers, community members and practitioners on the frontlines actually doing this work daily.”
As Slutkin had observed, pinpointing the source of the infection is critical to containing it. The Guardian quotes experts:
“Longtime community outreach workers and violence interrupters, many of whom are formerly incarcerated, are crucial to making these public health strategies effective.”
A Richmond official, DeVone Boggan, who’s developed a nationally recognized fellowship program for men at highest risk for violence, says:
“We have to extend the idea of what public safety is beyond policing and incarceration, to include these things like intervention, outreach, and neighborhood empowerment.”
In line with using data wisely, Oakland did a 2017 study of every homicide over 1-1/2 years and found that 0.16% of Oakland’s population (about 700 men) were responsible for the majority of the homicides. That enabled more effective interventions.
Here’s something both fascinating and integral to program success: Boggan says some credit must go to the shooters who are no longer shooting, who are now making “healthier decisions…I think these individuals have to be a productive part of the solution. They have to be embraced and brought into the discussion.”
One young man, now a college graduate entering business school, sounded remarkably like Slutkin, the epidemiologist.
“Gun violence is pretty much a form of disease. Once it starts affecting one person, it starts spreading.”
He’d never considered carrying a gun until he was shot listening to fireworks one July 4th. He went to jail for illegal possession, but later entered Boggan’s fellowship program “with other young men caught up in the long-running cycle of local fights and retaliations,” writes The Guardian.
Says this young man:
“To have somebody who believes in you, and knows you’ve got the potential to go for it, stuff like that makes you want to keep going right.”
The situation isn’t nirvana at present. Throughout the region, black residents are 22 times more likely to be killed with a gun than white residents, and many residents, black and white, still don’t feel safe. Property crime has risen significantly.
But the improvements are dramatic, and the cluster of approaches seems to work.
These programs can cost tens of millions of dollars—and they require sustained attention. But consider that amount when compared with the costs of the damage done by gun violence.
Sadly, as of 2017, Cure Violence was woefully underfunded in Chicago, the city where it began, existing on just a few grants. That meant a dearth of Violence Interrupters. The group’s leaders attributed an increase in Chicago’s violence to that drop in funding, reported The Trace.
I’m not sure the program exists at all any more, though Chicago neighborhoods are in such ongoing crisis that one would think the funding could be found.
Congressman Danny Davis, testifying just days ago (September 26, 2019) before a Congressional subcommittee hearing on The Public Health Consequences & Costs of Gun Violence, cited a University of Chicago Crime Lab estimate that gun violence costs Chicago and its residents $2.5 billion a year.
“Despite the high cost of gun violence, not one penny of the approximately $624 million raised by federal taxes on guns and ammunition in 2018 went to gun violence prevention. Rather, all gun and ammunition excise taxes go to fish and wildlife conservation.”
I’m all for fish and wildlife conservation, but there seems to be a huge disconnect here.
Hospital Emergency Departments and the “Teachable Moment”
One of the most promising developments in breaking the cycle of violence is Hospital-based Violence Intervention Programs.
Originating in the 1990s in community groups in Oakland, California, and Milwaukee, Wisconsin, they resulted from hospital medical staffs’ recognition that, from their location on the “front lines,” they could work with “trusted community-based partners who were well-positioned to provide intervention to violently injured youth after hospitalization.”
The umbrella group is now called The Health Alliance for Violence Intervention. I’m quoting from their White Paper, which I found extremely valuable.
Based on the premise that victims of interpersonal violence may well then retaliate as a “natural response borne out of societal pressure,” the programs begin when the youth is hospitalized and continue well after release.
Trained Intervention Specialists serve as mentors at the “teachable moment”—a time when the youths are believed most receptive to changing their behaviors and making changes in their lives.
Follow-up includes mental health care when needed to address the psychological traumas, and broad additional assistance: academic, vocational, housing, and help in honing in on the youths’ skills and interests to guide them toward productive careers.
A number of studies have documented the effectiveness of these efforts in reducing violence and costs that result from it.
“Collaborating With Gun Owners on Suicide Prevention”
Just as Cure Violence collaborates with actual shooters to turn them away from gun violence, a program based in Salt Lake City, Utah collaborates with gun owners on suicide prevention as part of a public health approach to reducing gun deaths.
As noted in Part 1 of this post, nearly 2/3 of gun violence consists of suicides, and we know the presence of guns exponentially increases the lethality of these attempts.
In Utah, reports Morissa Henn, Community Health Program Director at Intermountain Healthcare, that rate is 85%. Henn also testified at the September 26, 2019 Congressional subcommittee hearing.
The number has increased since 1999, when Surgeon General David Satcher called for the US to “address suicide as a significant public health problem.”
Henn says the high rate is due to the country’s failure to address “the inextricable link between suicide and firearms.” Although there’s not much evidence in support of most existing suicide prevention programs, she says,
“One of the only empirically based, high-impact suicide prevention strategies is reducing access to lethal means—which, in the United States, means reducing access to firearms for people who are at risk for suicide.”
Although lethal means reduction isn’t widely discussed in the US, awareness has grown since Surgeon General Regina Benjamin called for it in a 2012 National Strategy tied to a public health approach to suicide prevention in individuals at high risk.
Henn is part of a coalition of health professionals, gun owners, and others seeking to prevent suicide by firearms in Utah. Of this unlikely partnership, she says:
“In my experience, building productive and trusting relationships with gun owners on suicide has made us all think bigger, rooted the efforts in real-world context, and connected the data with culturally relevant messages and best-positioned messengers.
“Over time, I have learned that advancing these non-traditional partnerships is not only possible, but is a critical step if we are going to move the dial on gun death in America.”
“Similar to the way that shifts in social norms around drunk driving did not require all-out bans on cars or alcohol, a shift in voluntarily putting space and time between a suicidal impulse and a gun is framed in our coalition as a preventive, not prohibitive strategy. That small shift in framing opens the door to dialogue.”
*an emergency department study found that among gun-owning parents of suicidal youth, 33% had unlocked guns at home before training; none did after training.
*with bipartisan support from the coalition, the state legislature passed a Suicide Prevention and Gun study that has gathered important data being applied to prevention. “It exemplifies how gun-related research can bring people and data together to drive collective action.”
*they developed a suicide prevention module for firearm instructors that the state adopted for permit seekers that’s won support from 79% of concealed carry instructors.
*a Safe Harbor Law permits gun owners or those they live with to temporarily store firearms with law enforcement for free if they believe someone in the home is a danger to self or others.
*They’ve joined with government, faith, business, and firearm stakeholders in a statewide media and education campaign with private dollars matched by public funds to extend awareness of suicide and lethal means reduction.
Though they don’t yet have impact data, they are optimistic because of the momentum they’ve built and what they’ve accomplished to date—and Henn recommends similar steps on the federal level. She believes it’s important to:
“Create political space in Congress for more open dialogue—engaging firearm owners and non-firearm owners in trusting partnerships can help us advance life-saving messages and behaviors.”
Sandy Hook Promise (SHP)
Our country was struck to its core by the horror of Sandy Hook, the 2012 mass shooting that killed 20 6- and 7-year-olds, as well as 6 adults. Some of those grief-stricken parents have built an enduring legacy to their children by trying to prevent similar violence through identifying people at risk and getting them help before they act.
It’s an extensive program, and I can’t do justice to it here. I encourage you to explore the website.
SHP calls itself a “modest, above-the-politics organization that supports sensible program and policy solutions that address the ‘human side’ of gun violence by preventing individuals from ever getting to the point of picking up a firearm to hurt themselves or others.”
On the website, a March 22, 2019 press release describes the impact of SHP’s “Say Something” program.
When students at a Connecticut Middle School, who had just received the training, “saw disconcerting information and behaviors coming from one of their peers“ they averted a potentially violent situation in their school.
The Missing Piece…
After discussing the hopelessness that so many Americans feel about gun violence in Part 1 of this post, I felt the need to shed light on some programs that are, in fact, preventing gun violence.
But none of this should detract from what I—and the vast majority of Americans—feel is an imperative: the passage and enforcement of meaningful federal gun safety legislation.
All the above programs may well be more effective—and less urgently needed—if we can enact sensible laws to reduce the carnage that has affected individuals, families, and our society so deeply.
I thank my friend Dennis—one of the untold numbers of volunteers and staff in gun violence prevention organizations and elsewhere who are working so hard to keep us safe by bringing such laws to fruition. Dennis has directed me to a number of the sources that I’ve used here.