Meet the Disease Control Expert Who is Curing an Epidemic of Gun Violence

Lisa Hamilton: We know that for young people to succeed they need strong families and thriving communities. A key indicator of a community's health is its safety, and without it barriers to opportunity begin to grow. One of the most significant risks to neighborhood safety is gun violence. Today's guest is here to help us better understand community violence and possible solutions. Doctor Gary Slutkin is an epidemiologist and innovator in violence reduction, and the Founder and CEO of Cure Violence. He's a professor of epidemiology and international health at the University of Illinois at Chicago, and a senior advisor to the World Health Organization.

As a physician, Dr. Slutkin began his career working Somali refugee camps where there were tuberculosis and cholera epidemics. He went on to work for the World Health Organization to reverse epidemics across Africa. Upon returning to the United States he began to see gun violence as similar to the types of epidemics he had been treating. He has applied the lessons learned over a decade of fighting epidemics to the creation of Cure Violence, a proven approach to reducing gun violence. Cure Violence has been called a pioneering violence reduction model. The Casey Foundation has supported the City of Baltimore's efforts to bring the program to its west side communities, where it is now firmly entrenched. We're delighted to have Dr. Slutkin with us today. Hi. How are you? Welcome to our podcast.

Gary Slutkin: I'm very happy to be with you, and thank you, Lisa. It's great to talk to you today.

Lisa Hamilton: Wonderful. Well, let's start by talking about how gun violence threatens the safety and stability of communities.

Gary Slutkin: Well, violence is really the blocker, the inhibitor, of all progress in any neighborhood, or city, or country for that matter. When people don't feel safe they're unlikely to progress in almost any aspect of their life. For one, there's the deaths themselves. For two, there's all of the trauma that deaths down the street or in your own family caused, which we know is devastating. Causing people to worry about their own lives, and having all kinds of trauma that interferes with thinking, and interferes with school, and interferes with concentration. School performance goes down enormously wherever there's violence in a neighborhood. IQ scores go down an average of 10 points, and reading scores drop just for having been exposed to violence. Kids frequently feel that they don't really believe they're going to live, so this is also inhibitory to proceeding in school. It's a number one cause of dropout, and all kinds of problems like this.

Then, of course, people don't really use the neighborhood. They're not playing. They're afraid to be outside at night. Then the businesses don't come either for the obvious reasons of it costs too much in every way. They themselves feel unsafe in starting a business, and insurance costs, and everything else that are very high. Essentially the grass can't grow when there's a fire going on, and the most important thing to do is to remove the violence for any kind of human progress, or community development, or any survival to really be occurring.

Lisa Hamilton: You used your background in public health to develop the Cure Violence program. Tell us how you developed the program, and how it helps to address these issues.

Gary Slutkin: Your introduction I think was very helpful. I'm an infectious disease doctor. I don't come from the world of criminology or any of these fields. I really come from having many experiences in preventing things that spread from spreading more, like tuberculosis, or cholera, or AIDS. Also, I learned a lot about behavior and behavior change in the course of doing a lot of this work in the field. Especially with AIDS, being sexual behavior, which is a lot harder to change than violent behavior. I'm an epidemiologist, and when I came back to the US after being abroad for 10 years I was astounded by the violence going on in this country. I really was not so aware of it, and I was asking people what they're doing about it, and what was being proposed didn't make a lot of sense to me in terms of the way I understand behavior.

In other words, punishment's not really a main driver of behavior. Also, all of the social problems exist in all kinds of other epidemic settings. I just start to look at graphs, and charts, and maps, and I saw the violence behaving exactly like the other contagious diseases. It clustered. It spread in epidemic curves. One event led to another, led to another, led to another, just like flu, or TB, or colds, or any contagious process, so we designed an intervention that would treat violence as a health issues. Very specifically as a contagious health issue with interrupters, and outreach workers. New categories of workers who could stop the spread, and there have been extraordinary results to this. Of course Baltimore is one of the strong examples, but this is working now in about 20 or 25 cities, and about 50 communities, and even overseas. This method of looking at violence as a contagious health problem and treating it with specialized health workers now is becoming a standard practice.

Lisa Hamilton: Could you say more about how the program works? You mentioned the violence interrupters. Explain a bit about how they help address this issue.

Gary Slutkin: Well, we have to imagine what's occurring every night in many of our cities and neighborhoods is that there are people who are intending or planning to shoot somebody. Those events are being stimulated by people having friends who think that's what they should do, and having grown up with it a lot. When there are all kind of small insults happen, whether it's someone slept with somebody's girlfriend, or someone owed somebody money, or someone was just insulted, they picked up the idea that they're to supposed to shoot. It's just something that got picked up by the brain.

The workers are specialized workers. They're workers who have the contacts, the access, to the people who are doing it. They're generally people who come from the same neighborhood, same clique, same group, same background, same families, same histories, and we find those persons who can reach those persons who are doing it, and hire them, and train them to cool somebody down. To find out what's going on in the neighborhood and cool someone down. They're out there, these interrupters, and they say, "Okay. How's everything?" "Well, this guy's mad someone slept with his girl," or "This guy, someone smashed his car, and broke the window, and he was going to go shoot somebody." Well, nothing's happened so far. The police don't care if someone slept with someone, or someone owes somebody money, or something, but the interrupters will then go talk with that guy.

The person who is talking with him, the interrupter, is someone who he already knows, and he knows he's an interrupter. "Listen, I know what I've got to do," or they may swear at each other, but this guy has so much training, and so much insight, and so much experience that he can buy time. He can cool the guy down and say, "Listen, I understand this is awful." He'll self-validate everything he has to say, which buys more time. Then as he buys more time, and does more validation of his complaints he's able to cool him down, and then gradually, and this may take hours or it may take days, allow him to see that he's better off not to do it, and his friends likewise are better off not to do it. Then things get settled rather than another shooting happened, or any shooting happened.

Lisa Hamilton: This process of having neighbor essentially mediate conflict in the community is having tremendous success. Could you talk a bit about the reduction in violence you see through this program? It's really amazing.

Gary Slutkin: Just to add one more thing, and thank you for that. It just any neighbor. It requires a lot of specificity as to who the worker is. Yeah, he or she may be a neighbor or be someone in that community, which they usually are, but these are specialists like emergency medical technicians, or AIDS outreach workers. These are violence interrupters. They're specialists in cooling down conflicts.

The results on this, and there have now been 5, and almost 6 independent evaluations, and between 40 and 70% drops in shootings and killings are what's usually seen. There have been three neighborhoods in Baltimore that have gone over a year without any killing at all, and these are areas that had very substantial rates of shootings and killings. These were some of the most violent areas in Baltimore. There are several places where it goes down even more than that.

There's all kinds of very special things that have been found in the evaluations besides this 40 to 70% drop in shootings and killings. Retaliations in five neighborhoods in Chicago were shown to be completely stopped, like 100%. People are helped in very strong ways towards jobs, or school, or getting out of the gang situation. This also measures up to the 85 to 97% range. The norms are changing. The evaluation that Daniel Webster and John Hopkins did, the first evaluation in Baltimore, showed that people who we're not even talking to, just in the neighborhood, the high risk people are starting to change their thinking about whether they would do violence. Of course, just like in public health some people who you're talking to are reducing their smoking, but then others in the neighborhood start to get it, and start to stop smoking as well. It has a very strong diffusion effect that helps the neighborhood more broadly than even the people who we're talking to.

Lisa Hamilton: Those are really impressive results. I know that Cure Violence in lots of communities across the country, and I can imagine that many of them have their own set of dynamics and challenges. How does the program adapt to take into account the specific challenges in any given community?

Gary Slutkin: That's a great question. Even within Baltimore, or Chicago, or New York City, or New Orleans, each community is different. Of course there are mostly similarities. That's why the approach is adaptable in places even as far away as Honduras or South Africa. Even from one neighborhood to another within, say, Chicago or Baltimore, we have to go through a very systematic, what we call epidemiologic exercise of mapping out where the violence is occurring, where it's occurring the most, and what groups or cliques are involved. Are there three of them? Are there six or seven of them? Are they large? Are they small? Are there particular individuals who we need to be able to interact with? Then we need to go into all of those neighborhoods with the neighborhood community group and the health department, and find out who are the people who are most credible and have the most access, and go about our recruitment process, and a training process then.

There's a lot to figure out in terms of the where and who that allows us to guide where we work, as well as who needs to be recruited in order to reach the people that need to be reached. Then, of course, there's always cultural, and language, and other issues, and then issues related to, do you need four workers or ten, and all these kinds of things. It's a scientific mapping and design phase that the Cure Violence central staff training team goes through in concert with the local community.

Lisa Hamilton: The violence in many communities is often rooted in economic inequity, and the disinvestment in those neighborhoods. How does the Cure Violence approach incorporate an understanding of inequity and disinvestment as it goes about addressing violence in communities?

Gary Slutkin: That's also a really important question. Some of this is kind of chicken and egg, and some of it you can deal with the egg without dealing with the chicken, or vice versa. What I'm saying is that the violence is occurring mostly because of the violence itself. This is not really what a lot of people want to hear. If you go into very difficult circumstances, and there's a researcher who did this in housing projects in Alabama, and you find that where there's poverty, and there's inequity, and the fathers aren't around, and the schools are horrible, and there's tremendous poverty, and all of this, if the kids have not been exposed to violence, and it hasn't been done to them they don't then do violence. Whereas if they were exposed, the kids who were and the kids who had it done to them, they're more likely to do it, and it's dose dependent.

In a way it's like flu. That if you have horrible conditions and no flu, or horrible conditions and no HIV/AIDS then no HIV/AIDS appears. The conditions are important in and of themselves, and they are facilitators, but for these contagious processes the principle risk factor for them is themselves, so when you prevent violence you prevent more violence, and you prevent more violence. Then guess what happens? The conditions get better.

Lisa Hamilton: Thank you. That's an interesting perspective of how one relates to the other. When we think about community safety we often imagine the police playing an important role in stabilizing communities. How does the Cure Violence work interact or intersect with what the police in communities are doing?

Gary Slutkin: Well, it's a parallel set of interventions. There are points of interaction, and there's points at which the interaction would not be helpful. In other words, at the street level there's police that are doing what they do, and it may be important for them to be highly present when there's a lot of violence in a particular area. At the very end of the periphery of the model of Cure Violence there's interrupters and outreach workers, and they need to ensure that they have maximum access and credibility, so they are not interacting with law enforcement themselves. They have a different job. They have two different jobs.

The jobs of Cure Violence is to keep people from doing a shooting. In other words to keep people from crossing that line. It's more the job of law enforcement to do what it does when someone has crossed the line and a shooting has happened. Our job is to keep the shooting from happening, and to keep people from crossing the line. Then to move them further, and further, and further from that line. All that having been said, both are important. Both add to each other. At higher levels it's worthwhile to talk about overall strategy.

It's very, very common in precincts or districts for law enforcement to be calling Safe Streets, or Aim For Peace, or whatever Cure Violence is called locally, and saying, "Can you prevent the retaliation?" In other words, "There's shooting here. Can you guys go and cool everything down?" Then for us to say, "Everything's cool. We've got it." The police will say, "Can you guys go over the side of the expressway and make sure everything is all right over there?" There's cooperation at higher levels because everyone has an interest in trying to make the neighborhood safer, but these roles are different.

Lisa Hamilton: Based on what you've learned through this program and your experience in public health do you have suggestions of public policies that could better support violence reduction in communities?

Gary Slutkin: Well, the main thing is that the health sector has really been underutilized. Public health has been one of, if not the most successful sectors in improving the life of humans historically, as well as right now. As a result of public health life expectancies are longer. Children are no longer dying when they're very young. Water is cleaner. Sanitation is cleaner. The air is cleaner. Leprosy, plague have gone into the past. All kinds of things epidemic diseases have gone into the past because of public health. Smoking's going into the past, but for some reason this particular problem, which is obviously a contagious behavioral problem and health problem of the people who are both doing and had it done to them, the health sector is working about a hundredth of the capacity that it can.

The main thing is activating the health departments. Activating the hospitals and health sectors to be doing their parts of this. Frankly, to get money into the health sector so that we can have more interrupters, and outreach workers, and Cure Violence like models, but there's much more to it than that. There's all kinds of other aspects of the full public health approach that can be applied. I think when this is done, when these policies and practices are changed, and the health sector is more actively able to do what it can do then you're going to really see the communities being healthier and safer as a result of healthier behaviors. The health people doing basically its bread and butter; preventing spread, changing behaviors, and so on.

Lisa Hamilton: Well, that's wonderful advice. Thank you so much for your work, and thank you for joining us today.

Gary Slutkin: Thank you, Lisa. It's wonderful being with you and your listeners.

Lisa Hamilton: I want to thank our listeners for joining as well. If you've enjoyed today's conversation rate our podcast on iTunes to help others find us. To learn more about our podcast and for show notes visit our website, AECF.org and follow the Casey Foundation on twitter @AECFNews. Until next time I wish all of America's kids and all of you a bright future.