Hospitals: Essential Partners in Violence Prevention Work

Supported by the California Endowment, this post is part of a series, “Galvanizing the Civic Sector to Reduce Gun Violence.” The series focuses on what several sectors – parents, teens, schools, hospitals, law enforcement, the faith community, the philanthropic and business sectors, civic leaders and others – can do, independent of state and federal legislative activity, to reduce violence and the number of gun-related injuries and deaths.

“We can’t just patch up folks and send them back. When they show up in our emergency rooms, we have the opportunity to discover what’s really going on, what led to these wounds in the first place.”  – Yvonne Madlock, Director, Shelby County [Memphis, TN] Health Department

Where there is violent crime, there are hospitals; and where hospitals exist, there stands in the wings an essential partner for violence prevention work.

What hospitals can and do bring to the table ranges from basic medical services to provision of data, from tattoo removal programs to hosting intervention programs to neighborhood involvement – even neighborhood reclamation.

At the most basic level, hospitals can provide data that tell the story of patients who are victimized by violence.  And the story they tell is graphic, grim and, sadly, no mystery.  Except for several highly publicized school shootings, most of the victims of violence, via stabbings or shootings, are poor.  Many victims come to the hospital with little education, scant family support, a great deal of anger, fear and pain, bleak prospects for the future and a desire for revenge.  They are more often than not boys or young men of color with obscenely easy access to guns.  They have grown up in a culture of violence often at home, usually in the neighborhood and sometimes on the way to school.  Fear has inhibited their ability to learn.  As Shawn Dove of the Open Society Foundations has said, “These kids can’t get out of Vietnam.”  Once shot, many victims will return from the hospital either permanently injured or dead.

If a hospital only provides data, it has already given the crime and violence prevention community a gift, a prism through which prevention and intervention services can become clear.  Yet, there is much more that hospitals are doing to stem the violence that sends so many Americans to their emergency rooms.

This post, based on interviews with top public health officials in communities across the nation, explores some of the factors motivating hospitals and their personnel to engage in violence prevention work, highlights promising strategies that hospitals throughout the country are using to reduce violence in their surrounding neighborhoods, and describes notable examples of intervention programs that are hospital-based or involve hospitals as key partners.

Why Hospitals Partner in Violence Prevention Work

For a host of moral and practical reasons, hospitals are often highly motivated violence prevention partners.  Some of the key factors that are spurring hospitals to be involved in this work are described below.

Moral: Doctors who have served in the military and who now serve in trauma centers cannot believe that they’re seeing and treating wounds they’ve seen on the battlefields of Iraq and Afghanistan.  Some opine that if our trauma room responses were not so good, our homicide rates might double or even triple.  Grievous wounds, the deaths of many young men and women, and the families and communities that are deeply and sometimes forever scarred have brought increasing numbers of hospitals and city and county health departments into the violence prevention arena.

“We’ve gotten really good at the ambulance end of things,” said one public health official.  “We’ve now got to turn our energies and talent way up the road to see why we’re picking them up in the first place.  We’ve got to start shutting this down at the source.”

“We are aware of the recidivism rate,” points out Dr. John Sherck of the Santa Clara Valley Medical Center in California.  “We know they’ll be coming back, and we want to avert future harm or death.”  Dr. Phil Leaf, Director of the Johns Hopkins Center for the Prevention of Youth Violence, says that many trauma room doctors have become advocates for prevention, “because after sewing up the same person two or three time, they say, ‘I’m angry.  This is not what I signed upup for.'”

Economic:  A recent study by the American Public Health Association (APPHA) estimates that the cost of hospital care for firearms-related injuries was over $2 billion per year between 2003 and 2010.  The study indicates that the average medical cost for each individual treatment was $75,884.  An article in The Crime Report notes that, according to the report, a staggering “275,939 individuals were victims of gun violence [who] received 1.7 million days of hospital charges” and that 80 percent of the costs are borne “by taxpayers through Medicaid or other public-funded programs that subsidize hospital care.”

The APHA article also stresses the importance of an alliance between the law enforcement community and hospitals:  “Benjamin Hayes, former chief of the law enforcement branch at the Bureau of Alcohol, Tobacco and Firearms’ National Tracing Center, said it’s important for the law enforcement community to see health professional as allies in curbing gun violence.  ‘Most people don’t associate medical costs with gunshots,’ said Hayes.”

Dr. Daniel Webster, Director of the Johns Hopkins Center for Gun Policy and Research, points out that the direct, measurable costs within the health care system “miss some of the biggest social costs relevant to gun violence.  Gun violence causes tremendous fear, disruption and angst in daily lives and greatly depresses property values, which, of course, have great relevance to revenue that local government has to address a broad range of citizens’ needs.”  Taking into consideration medical and mental health costs, lost wages and other related costs, Dr. Ted Miller, Principal Research Scientist at the Pacific Institute for Research and Evaluation, puts the overall cost to society in 2010 at an astronomical $174 billion.

Trauma Room Priorities: Deane Calhoun, recently-retired founder and director of the Oakland-based violence prevention program Youth Alive and Caught in the Crossfire points out that victims of violent crime instantly alter emergency room priorities.  “Staff, sometimes as many as 10, immediately turn to someone who is ‘bleeding out.’  Their job is to stop the bleeding.  This can take away from car crash victims or the person suffering from a heart attack.”

Legal: Dr. LaQuandra Nesbitt, Director of the Louisville Metro Department of Public Health and Wellness, indicates that hospitals “once felt that their obligation to meet community needs consisted of taking in charity cases…Now there is a legal requirement that hospitals as a ‘community benefit’ must be aligned with a salient community issue.”  Gretchen Musicant, Commissioner of the Minneapolis Health Department says that, “In Minnesota, most of the hospitals are nonprofits, and as such, are required by the IRS to involve themselves in community health improvement.”

A Redefinition of Violence:  “We’ve misdiagnosed it,” asserts Dr. Gary Slutkin, a physician, formerly with the World Health Organization, and founder and CEO of Cure Violence.  “Violence is not a criminal justice issue.” According to Dr. Slutkin, violence is “not an issue of ‘good’ and ‘bad’ people who need more punishment.  Violence is fundamentally a health issue – an acquired contagious behavior – a result of witnessing, observing and victimization.”  Citing a recent report of the Institute of Medicine, Slutkin points out that “violence fits the dictionary definition of contagion and of disease, and should be now known as a ‘contagious disease.’…We must have law enforcement and we also need ‘interrupters’ as health workers to detect it and ‘interrupt’ its spread, and provide professionally trained behavior change outreach.”  His aim is high, striving to change community norms, “just as this country did with smoking and other behaviors.”

What Some Hospitals Have Done

As noted above, trauma care and provision of data are among the major roles that hospitals play in addressing violence.  Hospitals are also raising awareness of the problem, convening key partners, enacting new protocols for responding to violent incidents, and providing employment opportunities to local residents.

Raising Awareness:  Dr. Aimee Reedy, Division Director, Programs, at the Santa Clara County Public Health Department, asserts that the first task is to convince the public that “violence is a public health issue, and as such, can be avoided.”  Yvonne Madlockpoints out that “we must look at those in trauma rooms as super-victims, not super-predators.”

In an era characterized by high mistrust of people in authority, the medical community seems to have retained its standing.  “We have credibility, can serve as an early warning system, and we should speak out,” asserts Louisville’s Nesbitt.  Madlock says, “We’re out there talking to various boards, local health departments, county commissioners and to key stakeholders.”  Calhoun reports that doctors and nurses connected to Youth Alive’s hospital-based peer intervention program, Caught in the Crossfire, speak to “schools, sports, faith and community groups, and at community hearings and as public witnesses at legislative hearings.”  Some hospitals make available literature on the “environmental issues,” the dangers of guns in the homes, the links between guns and suicide and between and guns and homicide, in addition to describing safe gun storage practices.

Johns Hopkins’ Phil Leaf points out that at a minimum, hospitals can train trauma room staff to talk to family and friends gathered at the bedside of a victim about the negative results of trauma and what they might do to avoid further victimization.

Convening Other Stakeholders:  Universities and hospitals are “anchor institutions,” says Dr. Leaf.  As such, they can bring people together.  “We can be the interlocutors.  There may be some issues with police, faith-based organizations, even schools, but we are seen as neutral.”  Leaf asserts that hospitals can help violence prevention planners by providing a public health perspective, namely, clarifying the intended goal or goals, identifying the target population, and establishing benchmarks for success.

Changing Protocols:  Gretchen Musicant asserts that if hospitals and their affiliated clinics ask more questions beyond the presenting gun wound, “they must have a protocol, must know what to do, how to intervene. We’ve done this with child abuse and more recently with domestic violence.”  Dr. Sherck has changed trauma room protocol at Santa Clara Valley Medical Center, launching a modest-sized initiative in which the hospital social worker interviews the victim and family, and if consent is secured, connects the victims to a pastoral care worker (often through the faith community).  “We also help with medical reimbursement and in some cases even help with groceries,” says Sherck.  Even though young, Sherck’s program reports that, of the 83 percent who have agreed to join the program, none have recidivated.  Costs, which are minimal, include added duties for the hospital social worker, and helping to coordinate volunteer services from the faith and family services sectors.

Providing Jobs:  Another often unheralded role for hospitals is that of employer.  Health care is among the nation’s fastest growing industries.  Hospitals can provide entry-level jobs and job training in a wide variety of career fields.  Linkages among hospitals, community colleges and the community can lead to job opportunities for those living in neighborhoods experiencing high unemployment.

Hospitals and Violence Intervention Programs

Below are some notable examples of promising violence intervention programs that are either hospital based or rely heavily on the participation of hospitals.

Caught in the Crossfire: “Without a Caught in the Crossfire staff member there, your family and friends think healing means retaliation,” says Sherman Spears, co-founder of Caught in the Crossfire.  “They stand by your bed and make a plan to go get the guy who put you in here to show how much they respect you.” (see http://www.youthalive.org).  Caught in the Crossfire, which started at Oakland’s Highland Hospital in 1994, is a “hospital-based peer intervention program that hires young adults who have overcome violence in their own lives to work with youth who are recovering from violent injuries.”   Specialists are highly trained to provide long-term case management and linkages to a variety of services.  Without intervention, hospitals discharge patients to the same hostile environment without providing skills needed to spurn retaliation and gain job and educational skills needed to survive without violence.

Results published in the Journal of Adolescent Health, later corroborated in a study published in the Journal of the American College of Surgeons, showed that “youth who participated in Caught in the Crossfire were 70 percent less likely to get arrested and 60 percent less likely to have any criminal involvement than injured youth who were not involved in Caught in the Crossfire.”

Cure Violence: “Violence interrupters are asked to go into the most dangerous neighborhoods, in the most dangerous cities in the U.S., at the most dangerous time, to get people to stop shooting each other,” says Dr. Daniel Webster in remarks published on the Cure Violence website. “And they’re going in unarmed.  Yet, they go in, and they do it.  And it works.  It’s really changed my view about what’s possible.”  Cure Violence, which treats violence as an infectious epidemic that can be stopped, is based on detecting and interrupting violent events, determining those most likely to spread the disease and changing the underlying social conditions that produce violence.

Cure Violence engages public health departments, local hospitals and the community. Workers, trained in persuasion, behavior change and changing norms, come from the community.  Many of them have served time in prison.  In studies commissioned by the U.S. Department of Justice, the Centers for Disease Control and Prevention, and Johns Hopkins University, Cure Violence reports “reductions in shooting and killings of 16 percent to 34 percent that are directly attributed to the strategy, and from 41 percent to 73 percent overall.”

The National Network of Hospital-Based Violence Intervention Programs (NNHVIP) asserts that hospital-based intervention programs provide “a powerful way to stop the revolving door of violent injury in our hospitals…engaging patients in the hospital during their recovery is a golden opportunity to change their lives and reduce retaliation and recidivism.” (see website http://nnhvip.org). NNHVIP reports on a variety of programs, such as “Healing Hurt People” in Philadelphia, a trauma-informed approach that begins in the emergency room.  Philadelphia’s violence prevention work, coordinated by Hahnemann University Hospital in conjunction with the Drexel University College of Medicine, fields a team that includes a physician, psychiatrist, social worker and psychologist with extensive experience in violence prevention and trauma.  Mentors work with victims and families on issues related to school, housing, substance abuse, recreation, job training and the law.

NNHVIP describes similar models such as Healing Hurt People in Portland, Oregon, and Project Ujima in Milwaukee.  NNHVIP’s website identifies key components to the effective implementation of hospital-based violence intervention programs, from “securing hospital buy-in” to “setting funding goals for sustainability.”

The Massachusetts Violence Intervention Advocacy Program.  Led by Catherine Fine, Director of the Division of Violence Prevention at Boston’s Public Health Commission, the violence intervention program serves communities through the emergency departments at three hospitals.  Its tiered services, including both recovery and development, fall into four categories:  injury and recovery; basic needs such as housing, food and child support; personal development including educational assistance and job training; and maintenance such as check-ins, maintaining jobs, etc.

But Fine would go further to change policies and practices, aiming to “create a trauma-informed city that understands trauma and its impact…to create trauma awareness in agencies serving children and youth… trying to weave all of this into how folks do business.”  As violence can be learned, so can its prevention, she maintains.  She has started social/emotional learning curricula in schools, helping to develop language that would resolve conflict, and has helped train teens, “our best messengers,” as peer leaders in dating violence prevention and conflict resolution.

Acknowledging that residents are a community’s primary asset, and that social cohesion is a protective factor against violence, the Health Commission has launched the Violence Intervention and Prevention Initiative in five Boston micro-neighborhoods with elevated rates of community gun violence.  See the Prevention Institute website to find lessons learned from the initiative.

From hospital intervention, interventions in schools, community mobilization and awareness campaigns, the Boston Public Health Commission seems well on its way both to helping create an awareness that “28 percent of Boston’s children have been exposed to some form of violence,” and to helping develop a broad-based capacity to respond to and prevent violence.

Along with a community’s other “anchor” institutions, local hospitals must be included as an essential partner in comprehensive violence prevention work.