Can we use public health models to cure the disease of gun violence?

The shrines appear every few blocks. It is a small piety to bless oneself, a habit to read the notes: “Always Remember,” “Forever in Our Hearts.” They grow overnight, started with a votive candle in a 10-inch glass holder purchased from the bottom shelf at the back of a bodega. One candle is met by another and then another until there are 15 or 20 to arrange in the shape of a heart, or the victim’s initials or the form of a cross, on the sidewalk before the apartment building of the young man who was shot.

Acrylic images are painted on the glass, like characters on jelly jars: St. Jude, patron of the hopeless; Lazarus, looking surprised, his shroud unraveling behind him; Mary, her heart pierced; or the Sacred Heart himself, bleeding out in sympathy. Above the candles someone affixes to the brick wall a photo of the handsome young man, smiling or defiant, sweet or trying to look hard, captured at a party or in cap and gown. A story ended. He is honored here for a few weeks, until rain soaks the cardboard someone erected like an awning over the candles and dissolves the poem chalked onto the concrete. But with what seems like inevitability, another little grotto will soon sprout on a nearby corner.

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There are the killings that create a low hum month after month, the ones for whom the candles accumulate.

There are murders in the United States that make the country stop—briefly—to wring hands and argue about gun laws. These tend to be the killings of many people at once, often in mostly white suburbs. They shock because, however many times we lose our innocence seeing covered bodies in a movie theater or a shopping mall or a schoolyard, we are surprised that these people would be killed.

Then there are the other killings, the ones that create a low hum month after month, the ones for whom the candles accumulate.

The violent crime rate has declined in major U.S. cities to levels that would have been unimaginable a generation ago, when residents installed multiple door locks and saw heavy traffic at funeral homes—in New York a drop of 83 percent between 1993 and 2016, according to the Mayor’s Office of Criminal Justice. There were 2,262 murders in New York in 1990 and 292 in 2017, according to the New York Police Department. This decline translates into thousands of people walking the streets today who would not be alive had homicides continued at their early ’90s pace.

Pastor Reginald Paris (left) and David Caba (center), senior program director for Bronx Rises Against Gun Violence, meet with residents of the Williamsbridge neighborhood of the Bronx. (Roy Baizan)

But in certain neighborhoods in New York and in cities like Chicago, St. Louis and New Orleans, the murders can still be measured by the candles. The death toll may be near zero elsewhere, but it is still not low enough for the handsome boys who stare out from the photos above the candles.

The neighborhoods in New York City with the most gun violence in 2017 are mostly the same that topped a much grimmer list in 1990, explained Liz Glazer of the New York City Mayor’s Office of Criminal Justice. Ms. Glazer was speaking at a forum in June on reducing gun violence hosted by John Jay College for Criminal Justice of the City University of New York and the news publication City Limits. (Full disclosure: My husband is executive editor of City Limits.) They are the neighborhoods, Ms. Glazer pointed out, that also rank highest for a different kind of violence: poverty and racism: “If I were to show you maps of where high asthma, high unemployment, low educational achievement is, it would be those very same neighborhoods.”

None of these young men died naturally, but neither was the violence random. It can be the result of a dispute involving illegal drugs, or it can come from adherence to a code of strictly regulated social expectations, “organized around a desperate search for respect,” that operate as a means of imposing order, according to an extensive body of research conducted by Elijah Anderson, the William K. Lanman Professor of Sociology at Yale University. It’s pride. An injured ego and a sense of honor. Recompense for a slight or retaliation for an injury. At the root is fear. A chain of choreographed behaviors spreads among a small number of young men, and one attack creates the next.

Treating an Epidemic

Policy makers, police and neighborhood activists wrestle with the persistence of violent crime, trying out new strategies to keep homicides down. Fashions in crime prevention emerge in cycles, from military-style tactics to the much-touted “broken windows” approach (cracking down on nuisance offenses on the idea that chaos leads to more criminality). Other methods counsel data-driven, precision-targeted patrols or relationship building, with officers walking the beat and striking up conversations. All are focused on police and on control.

But what if the focus were on the people most affected by the violence and therefore most likely to carry it on? What if the chain of violence that can change a victim into a new perpetrator could be broken? Dr. Gary Slutkin, a public health expert at the University of Illinois at Chicago, is the founder of Cure Violence, a nonprofit group that uses public health methodologies to stop the transmission of violence. Dr. Slutkin has written that incidents of physical violence are best understood as disease, as a contagion that “is spread from one person to another,” with perpetrator and victim trading roles of infected and infector until the disease becomes epidemic within a population.

The same methods used to interrupt the transmission of the Ebola or West Nile virus can be adapted to the contagion filling so many coffins in Chicago and the Bronx, argues Charles Ransford, senior director of science and policy at Cure Violence. The group’s methods have been adopted in 25 U.S. cities, including New York, San Antonio, Kansas City and New Orleans, and in communities worldwide from San Salvador to Sadr City, Iraq.

Perpetrator and victim trade roles of infected and infector until the disease becomes epidemic within a population.

“We’re often talking about the work with an epidemiological lens,” Mr. Ransford explained. “I can imagine a world without violence, and all that that would mean for everyone, especially the most marginalized. With this health approach, I can see how it is possible—with people who need help and care getting it, conflicts that naturally arise being worked out, sometimes with outside help.”

He advocated an expanded mindset that understands the link between suffering injury and committing violence. “There is no justice in waiting for a person who has been heavily traumatized by violence themselves to behave violently and then send them to prison. That is not just or fair for anyone involved.”

Mr. Ransford’s work involves surveillance of the sort familiar to the World Health Organization or the Centers for Disease Control and Prevention: identifying where the outbreaks are, who the carriers are and what the patterns of transmission look like. What appears to an outsider to be random violence, is, on closer inspection, anything but that. Cure Violence accumulates information, maps the relationships in a neighborhood, and learns the history of neighborhood resentments, loyalties and disputes.

The organization Cure Violence trains staff to be “violence interrupters,” providing social support for young people in neighborhoods with a history of crime. (Roy Balzan)

Analysts with Cure Violence review violent crime data for areas as small as just a few blocks—the same method used in statistics-driven policing of the sort initially championed by Mayor Rudolph Giuliani and Police Commissioner Bill Bratton of New York City. But instead of using the data to marshal a police response, Cure Violence uses workers on the ground to identify the protagonists and other people affected by violent crime and work with victims before they spread the violence to the next host. It is akin to sending health promoters with mosquito nets out to villages where West Nile has been identified.

In this case the men bearing metaphorical mosquito nets are called violence interrupters. They work in concert with outreach workers, education coordinators and a host of Cure Violence staff who surround a “contagious” person with social support, job training, psychological counseling and hope.

There are exceptions, but most violence occurs between people who know each other and have some kind of a relationship. The person most likely to commit the next murder, the evidence suggests, is someone who has been touched by this one. For this reason, Cure Violence and its ancillaries send emissaries to meet, listen to and attempt to influence the person hurt by a violent crime. This work requires people who know the neighborhood, for whom the code of retaliation and respect is not foreign but simply a set of expectations they no longer follow.

Cure Violence identifies the people affected by crime and work with victims before they spread the violence to the next host.

The program hires men from the specific area being targeted for Cure Violence intervention, those who know the life of street corners but have turned away from it or outgrown it. Often they have served time in prison. Usually they are still known to people involved in crime, to gangs and less formal criminal groups, and so have credibility that a social worker lacks, explained David Caba, director of Bronx Rises Against Gun Violence, a Cure Violence partner that operates under Good Shepherd Services, a large Catholic social service provider in New York.

“We identify high-risk youth and get them to change their violent mindset [away from] conflict. We mobilize to change the community norms,” Mr. Caba said, explaining that after a shooting or a killing BRAG covers the immediate area with posters condemning the crime and urging a cessation of violence. It also sends in outreach workers, literal peacekeepers, who organize a rally or vigil on the spot where the violent incident took place. They call in community organizations and churches, elected officials and neighborhood pillars, and walk the streets with a bullhorn, talking about how the violence needs to end.

Each afternoon, violence interrupters working for BRAG fan out across a sector in the mid-Bronx, a mile north of Yankee Stadium. It is a busy commercial district of auto repair shops, clothing stores and workaday restaurants, with menus printed in Spanish first. BRAG’s people work from 4 p.m. to midnight, later on Friday and Saturday, for 40 hours a week. Beneath the awnings of small groceries or on sidewalks thick with families hustling home at the end of the day, they check in with people affected by violence, those most likely to spread it. A passerby might notice a burly man walking in step with a younger man, something like a brotherly conversation passing between them. The interrupters hold brief conversations to take the temperature, assess potential tensions and suggest how the transmission of violence can be broken. The goal is to keep conflicts from boiling up.

Intervention Works

Joel Castillo still has the bearing of the boxer he was in his youth, a thinly suppressed physical energy lightened by a certain gentle sweetness unique to tough guys. A big man with tattoos written across his arms, he had his share of altercations outside the ring. Now his work is to be a peacemaker. His entreaties to lay down arms are effective, Mr. Castillo said, because people know he speaks from experience in the same community he now tries to heal.

“That’s where I did damage. I was the problem, and now I’m part of the solution,” he said. “I was able to get someone to put a shotgun away. I was able to get someone to not stab his girlfriend’s father. He’d seen the way I changed my life. He trusted me.”

St. Barnabas Hospital in the Bronx lies half a mile from the Bronx Zoo, a 10-minute walk from Fordham University, in the 48th precinct of the N.Y.P.D. There were 137 homicides in 1990 within the confines of the 48th, with many of the victims rushed through the swinging doors of St. Barnabas’s Level-1 trauma center. In 1998 there were 23 homicides. Last year: just eight. But that was still eight too many for Cure Violence and Bronx Rises Against Gun Violence. Since last year BRAG has had a direct relationship at St. Barnabas, working under its department of community affairs.

They walk into a hospital to meet grieving, raging family members, friends angry and frightened—a virus about to erupt.

Three times a week, Mr. Castillo walks the hospital halls, ducking his head into the rooms of young men being treated for assaults or gunshot wounds, the boys most likely to wield a gun when they recover. Are they interested in talking, he asks? Do they want to think about a different way, a means to stop the cycle?

In some cases the work is even more direct. The surgeon stitching up the wounded boy makes contact first, suggesting the victim might want to talk to someone who knows a way out. St. Barnabas considers BRAG part of its aftercare regime, of a piece with the antibiotics and physical therapy the medical team will order, explained Arlene Ortiz-Allende, senior vice president for community and external affairs. Mr. Castillo or other outreach workers are often called to the hospital at night, in the heat of a dispute. They walk into a waiting room to grieving, raging family members, friends angry and frightened—a virus about to erupt. They explain to the hurt about trauma, about learned behaviors and ways to change.

The work is one to one, person to person, a reversal of the trauma and the violence.

In cities used to meeting force with force, accustomed to spending money on armored gear and jails, sending hard and gentle men into hospitals in the night to tell boys not to retaliate might seem foolish. It sounds naïve and small-bore.

But Cure Violence offers reams of statistical evidence for its approach, with assessments of effectiveness conducted by the John Jay College of Criminal Justice Research, Johns Hopkins University and the Centers for Disease Control and Prevention, and Northwestern University and the National Institutes of Justice. Mr. Ransford proffers charts and tables showing declining contagion where the program is put into practice.

“We’re a second voice in their ear saying there’s another way.”

The number of shootings in Chicago neighborhoods that use Cure Violence and similar programs dropped 36 percent from the first quarter of 2017 to the same period in 2018 (from 80 to 44), after Cure Violence was reintroduced, according to Chicago Police Department records. Shootings and homicides dropped citywide that year, but the steepest declines were in the most violent slivers of neighborhoods, the ones using the program. The program was first introduced in Chicago in 2004 and showed strong promise, but a state budget dispute shuttered the program—and severely limited all other non-emergency spending in the state—between 2015 and 2017. In those years the death toll in Chicago climbed.

New York City dedicated $22.5 million in 2017 to dramatically expand its program to prevent gun violence, establishing a crisis management system informed by Cure Violence methods in the city’s 18 most violent neighborhoods. New York had seen a 63 percent reduction in shootings with injuries or fatalities in one South Bronx neighborhood that used the the Cure Violence method between 2014 and 2016, according to an assessment by the John Jay College of Criminal Justice Research and Evaluation Center. The study compared the South Bronx neighborhood with a demographically similar neighborhood that did not have violence interrupters. But perhaps more promising than the decrease in shootings were the shifts in attitudes toward violence the John Jay survey found among young men in the neighborhood.

“We’re a second voice in their ear saying there’s another way,” explained Brian Atkins, who has worked as a frontline violence interrupter. Those enmeshed in violence need to be introduced to the idea that there are other options, he said. “When you’re younger, you do things; you don’t really think about it. In one type of sense, it’s like you outgrow it and you realize that path ain’t getting you anywhere. But some people don’t know the resources. Even getting back to school, they don’t know the steps to take, and we help connect them with those steps.”

In August, New York State announced an additional $18 million to fund a similar fleet of community outreach workers and interrupters across the state.

This summer BRAG expanded to another part of the Bronx: Williamsbridge, an area of brick houses and wide boulevards, hit hard by the subprime mortgage bubble 10 years ago. The neighborhood has been plagued by local drug-dealing gangs and their attendant disputes and grievances for decades. People keep their children indoors and teenagers walk fast, avoiding unnecessary eye contact. Violence seems inevitable, normal. Mr. Caba wants to change that. This summer BRAG organized a series of block parties in the zones most affected by violence. The goal was simple: get neighbors to imagine a different normal.

On a muggy day in August, Mr. Caba and his crew set out folding tables on the street and chipped frozen hamburgers onto a six-foot long charcoal grill and chatted while they laid out cheese and rolls. A little further down the block Shareef Landsmark, who directs the young men BRAG works with back into school or into trade programs, turned the music up at a D.J. booth and hit the microphone to call the children out. There would be a dance contest.

He used to operate with one of the gangs that ply the neighborhood, finding trouble and drama on White Plains Road. He tilts his neck to show where a bullet grazed his skin. A neighborhood grotto narrowly avoided. A few years ago he came to BRAG outreach events, curious, and found a new way to marshal men.

As a propulsive bass filled the street and wary neighbors ventured contact, a young man rode into the party on a bicycle. He glided slow loops up and down the block before he slowed to look at the hamburgers and make conversation. One to one. Rain threatened all afternoon and finally burst forth like a monsoon, but the children danced and the young played. Nothing inevitable.

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Andrew Wolfe
1 year ago

The public health model is interesting, but could become a proxy for law enforcement. One could just as easily cite this "disease" as a reason for longer incarcerations of convicted criminals, given the deleterious effects cited.

Mike Houlihan
1 year ago

James Gilligan, MD James, former Director of Mental Health for the Massachusetts Department of Corrections, argued for a disease/health model for understanding violence in "Violence: Our Deadly National Epidemic" (New York, P.G. Putman, 1996) and in several sequels. His work and his insights have stood up over the year, even if they have not always moved the policy and practice of corrections in the manner he envisioned.

Charles Erlinger
1 year ago

As I commented on this subject some months ago (and claimed no originality in doing so):

“The risk profile for the epidemic-like phenomenon of “innocent casualty by gun” in the U.S. can certainly be lowered. We know how to do the groundwork of epidemiological data collection and analysis, causal factor identification (including proportional cause attribution to each identified factor), and systematic formulation of preventive measures.”

“Adoption of preventive measures against identified systemic risk is complex in a way that differs significantly from the basically rationality-dominant risk analysis process. Adoption of preventive measures, known as risk management, involves arriving at a consensus for the taking of steps to introduce community change, often to deeply embedded cultural practices and prejudices. Additionally, it usually involves cost. Finally, it usually involves choices, the future consequences of which cannot be known with certitude. The acceptance of this, in turn, requires some level of mutual good will, and a level of comfort dealing with probabilities is helpful.”

The proponents cited in this report do not claim that the preventive measures that they have implemented are the only measures possible, or the only acceptable ones. Rather, they are plainly open to trying whatever is in their power that the data suggest, without assurances that every measure will have the hoped for result. They do not claim that the measures they have tried are even potential proxies for law enforcement and they do not claim that the adaptation of some epidemiological methodologies applied to a risk management problem somehow magically turns the problem into a disease. So far as I can tell from the text of the article, they are sensible enough to not mistake a metaphor for a physical reality.

JR Cosgrove
1 year ago

The problem with this article is that gun violence is not a disease. Gun violence is a symptom of an underlying condition which one may call a disease but few ever look for this root cause of the symptom, gun violence. They never look for the actual disease. It's too uncomfortable to do so especially for the editors and authors at America.

Tim Donovan
1 year ago

I believe that a change in attitude among people in our society is important and necessary to reduce gun violence as much as possible. I do support the right to bear arms for hunting or self-defense. However, I support more stringent gun control laws. When my Dad died in 1994, I discovered that he had a handgun in his bank safety deposit box. I immediately turned it over to my local police. Perhaps a gun "but back program would be helpful. That is, people who own guns would receive financial compensation from civil authorities.

Phillip Stone
1 year ago

Short answer to the headline - no!

One of our Prime Ministers, a competent leader and Christian, made gun ownership illegal after a massacre in Tasmania focussed the body politic in unity at the time.

An enormous drop in two sorts of violent death, suicide and gun homicide followed and has persisted.

It is noteworthy that attempted killing has continued apace but knife, cleaver and blunt heavy objects cannot kill so quickly and many persons attacked in this way, mortally wounded, have been rescued by modern paramedic services, excellent surgeons and blood transfusion.

The homicidal habits of humans was not altered. It is not properly designated as a disease, illness or epidemic. It is evil, it is sin.

Making out that certain sins are actually symptoms of sickness rather than issuing from typical average normal human beings in the post-Eden state is just another way of denying the truth.

Wonderfully parodied in West Side Story, play and movie.

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