How can we put a stop to violence? Gary Slutkin, MD, believes the key is treating it as we would any contagious disease. The epidemiologist and Founder/Executive Director of Cure Violence recently spoke at TEDMED 2013 about utilizing public health and science-based strategies to prevent violence in communities.

“The greatest predictor of a case of violence is a preceding case of violence,” said Slutkin.

And as with an epidemic such as cholera, the way to stop violence is to find those “first cases” and interrupt the transmission. Cure Violence’s model involves violence interrupters who play a similar role as health workers during epidemics, going into communities to help re-frame issues and cool down situations that could lead to violence. At the same time, outreach workers help people change their behavior and—in time—change the social norms of a community.

>> Watch the full TEDMED presentation.

>>Read more about the public health approach to public safety from Cure Violence.

Crime and violence in U.S. inner cities has a profound impact on public health. The question is how best to combat it. According to recent studies, one answer could be as simple as assigning more police officers to foot patrols in crime hotspots.

With funding in part from the Robert Wood Johnson Foundation’s Public Health Law Research program, researchers from Temple University worked with the Philadelphia Police Department to conduct a study on the impact of police foot patrols on inner city crime. Findings published in Criminology in 2011 found foot patrols helped reduce violent crime — at least temporarily — by 23 percent in high-crime areas of the city. A recent follow-up study in Policing and Society revealed a qualitative look at how the participating officers developed extensive local knowledge and formed community relationships — both of which contributed to the cuts in crime.

These and other results demonstrate the need to involve officers on foot patrol in the development of violence prevention strategies, according to researchers.

>> Read more about the study.

Tuesday, January 8, from 12:30 to 1:30 p.m. EST, the Harvard School of Public Health, in collaboration with Reuters, will present an hour long live webcast on gun violence, in response to the too many recent gun massacres.

The webcast is part of the school’s ongoing “Forum” series,  whose aim is to provide a platform to discuss policy choices and scientific controversies by leveraging participants' collective knowledge. Tomorrow’s forum on gun violence will look at the legal, political, and public health factors that could influence efforts to prevent gun massacres.

Participants include Laurence Tribe, professor of Constitutional Law at Harvard Law School; Felton Earls, MD, professor of child psychiatry at Harvard Medical School; David King, senior lecturer in public policy at the John F. Kennedy School of Government at Harvard, and chair of Harvard’s Bipartisan Program for Newly Elected Members of Congress; and David Hemenway, PhD, Director of the Harvard Injury Control Research Center.

In advance of tomorrow’s Forum, NewPublicHealth spoke with Dr. Hemenway about ongoing research efforts aimed at preventing gun violence and gun massacres. Dr. Hemenway is the author of Private Guns, Public Health, which demonstrates how a public-health approach—historically applied to reducing the rates of injury and death from infectious disease, car accidents, and tobacco consumption—can also be applied to preventing gun violence. Dr. Hemenway’s book was supported by a Robert Wood Johnson Foundation Investigator Award in Health Policy Research.

NewPublicHealth: What is the overall goal of the Forum? 

Dr. Hemenway: The Forum series focuses on how public health can help impact many major issues in the U.S. We are able to gather experts at Harvard who are working on these issues to provide information about what we know and to share ideas on approaches to help address these problems.  

NPH: On tomorrow’s panel, you’ll be discussing the issue from a public health approach. What are some of the concepts you’ll be sharing?

Last week at the American Public Health Association (APHA) annual meeting, a number of presenters took on an important, but often overlooked topic in the public health world: violence. Violence is often primarily considered a criminal justice or public safety issue, but there is a growing movement of public health practitioners that recognize that the health of vulnerable communities cannot be improved without first stopping shootings and killings.

When violence is present in a community, it impacts the physical, mental and emotional health of all residents. Violence also often prevents other positive changes from taking place. According to Greta Massetti from the Centers for Disease Control and Prevention, the current economic impact of youth violence is an estimated $14.1 billion in combined costs from medical care and work loss.

During the APHA meeting, speakers from organizations such as Cure Violence, UNITY and the Centers for Disease Control and Prevention discussed the latest research and strategies to prevent disease.

Treating violence as a disease

For many vulnerable communities, violence is the most pressing health issue. For children growing up in violent communities, the health impact is more than just the physical threat. As Benita Tsao from Urban Networks to Increase Thriving Youth (UNITY) pointed out, growing up in a community plagued by violence can often feel like being in a war zone.  That constant fear results in real health consequences, as evidenced by the increasing number of children who have grown up surrounded by violence and are now showing signs of chronic traumatic stress disorder. Experiencing ongoing trauma impacts young people’s physical, mental and emotional development, and has the ripple effect of making it harder to focus and succeed in school. 

The city of Philadelphia and the Pennsylvania Horticulture Society are seeing positive results as they continue to grow their Philadelphia Green program. The program has taken on the vacant lots in Philadelphia neighborhoods and transformed them from embarrassing eye sores to points of pride – and made the community safer in the process.

“The city owned the problem even if we did not own the land” said Robert Grossmann, Director, Philadelphia Green. “We decided to use horticulture to build community and improve the quality of life in Philadelphia’s neighborhoods and downtown public spaces.”

The goal was to help build equity for the people living in the neighborhoods so they felt a sense of pride – the result was crime prevention through environmental design.

With the help of community activists and landscape contractors the program has “cleaned and greened” more than 7,000 lots. The impact is a reduction in gun crimes, lower rates of vandalism and residents even report experiencing lower stress rates and an increased urge to get out and exercise.

>>EDITOR'S NOTE: On 9/13/2012 CeaseFire changed its name to Cure Violence.

Sheila Regan manages hospital partnerships for Cure Violence, formerly CeaseFire, an organization based in Chicago that has pioneered a public health approach to stopping shootings and killings. A grantee of the Robert Wood Johnson Foundation, Cure Violence has been successful at reducing violence in cities across America.

This week at APHA, Cure Violence shared how violence presents all the same characteristics of an infectious disease. Like tuberculosis or cholera, violence appears in clusters; it spreads and can be transmitted. By changing the frame on violence, Cure Violence is able to use proven public health strategies from other epidemics to stop shootings and killings. Hospital partnerships are a key part in stopping the spread and transmission of violence.

NewPublicHealth: Can you explain how Cure Violence’s hospital partnerships work?

Sheila Regan: We have a number of partnerships with level I trauma centers that are committed to the public health approach to violence prevention. We serve patients who are violently injured, typically shootings, stabbings or beatings and work to prevent further violence, retaliation or re-injury, which are seen as normal in our culture. There are the doctors, police, nurses, social workers, and everybody you’d expect to see in the hospital. What we’re trying to do is introduce a third party—our workers—who can impact behavior and mindset around violence at an opportune moment.

NPH: When someone has been injured, what is the goal of Cure Violence working with them in the hospital?

Martin Fenstersheib, MD, MPH, director of the Santa Clara County Public Health Department in California led a session on safe outdoor activity for kids and adults at the 2012 Public Health Law Conference. NewPublicHealth spoke to Dr. Fenstersheib about what is keeping our communities from safely getting outside to play—violence, blight and communities built for cars—and solutions grounded in evidence-based public health law.

NewPublicHealth: You presented at a key session on making outdoor physical activity opportunities safer. What makes this an important issue for you?

Dr. Fentersheib: Often when we talk about physical activity, we hear people say that all we need to do is convince kids to go outdoors. A lot of us then say, “when we were kids, our parents let us out of the house in the morning and we came back at nighttime and all was well.” There wasn’t any problem with that. But, of course, we’ve all become aware of safety as a barrier to outdoor physical activity. And the issue has to do with not only criminal or violence safety, but safe streets generally. Do cars in an area make it less safe for example? And, is our environment built in a way that it is safe for kids to walk to school? My presentation will be an overview of the benefits of physical activity, and what some of the barriers are.

We’ll also look at the legal side of the issue, including a study on mixed use land zoning. I think the bottom line is that safer neighborhoods will have more of a mixed use flavor so that you don’t have to go far to get to work or play or to recreational areas. In such neighborhoods, there are stores and other places for you to go, and you’re closer to public transportation. The data to be presented will show that the crime rates in those areas are lower than in pure industrial areas or areas where there isn’t mixed use. Mixed use is helping to improve the built environment in the communities in which we live by having more eyes on the street, by having people basically looking out for one another and be more of a community.

NPH: What are examples in Santa Clara of new plans to create safer outdoor spaces for children and adults? 

>>EDITOR'S NOTE: On 9/13/2012 CeaseFire changed its name to Cure Violence.

A group of impassioned attendees of the National Association of County and City Health Officials Annual Meeting attended a screening of The Interrupters, a documentary about the CeaseFire violence prevention program that began in Chicago and is now a prominent, effective program in other U.S. and international cities. CeaseFire takes a unique public health approach to stopping gun violence in communities. Findings from a study conducted by researchers at the Johns Hopkins Bloomberg School of Public Health show that shootings and killings in even America’s most violent communities can be reduced using the CeaseFire model—a model that employs disease control and behavior change strategies to reduce violence. CeaseFire employs ex-offenders who have unique credibility with community members and effectiveness in getting people to rethink the impulse to resolve disputes using guns.

Safe Streets Baltimore was launched by the Baltimore City Health Department in 2007 as a CeaseFire replication site. Speakers at last night’s screening included Ricardo “Cobe” Williams of CeaseFire Chicago and Oxiris Barbot, MD, the health director of the city of Baltimore in Maryland.

A health officer from Cambridge, Mass., asked the speakers about one thing they’d like to see changed in their communities. Dr. Barbot said: “We need a health in all policies approach with better housing, education [and other social changes] to improve the environment.” NewPublicHealth recently spoke with Dr. Barbot about the impact the program has made in the city.

NewPublicHealth: How does the Safe Streets program build on the CeaseFire model?

Dr. Barbot: We replicated what was done in Chicago, but our implementation differs in that the Baltimore health department houses the Safe Streets program–our name for the CeaseFire model—and we provide technical assistance for that community-based organization to actually carry out the model. We think that that works for us because it helps to create community ownership of the model, and it also allows us to focus on administering the program and making sure that the fidelity of the model is adhered to. We oversee the program and community groups implement it.

We’ve got staff on board that work intensively with the community-based organizations to make sure that they are tracking the number of mediations that occur, that they are tracking the number of face to face meetings, and if those numbers aren’t at a particular level, we do retraining so that the interrupters that are working in that particular neighborhood feel more comfortable in what they’re doing. Similar to any other chronic disease intervention model, the folks who are actually doing the work need to have ongoing professional development to make sure that their tools are as up to date as possible.

NPH: What has your success been since the program began?