The Shooting Contagion: Looking at Violence as a Health Issue

Hal Conick
Marketing Health Services
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Key Takeaways
​What? Chicago-based Cure Violence is attempting to rebrand gun violence from a morality issue to a health issue.

So What? Founder Dr. Gary Slutkin likens violence to a contagious disease. Stopping it means creating a new understanding of how it spreads. 

Now What? The message of violence as a contagion is spreading, but Cure Violence is battling against old public perceptions, a lack of funding and the politicization of urban violence. 

​June 20, 2016


While most people think of violence in terms of “right” and “wrong,” for the past 16 years, Cure Violence has been trying to reshape people’s perceptions. The Chicago-based organization believes that the violence epidemic can be reversed by treating it as a public health threat.


It was an unseasonably warm, early-November afternoon in Chicago’s Auburn Gresham neighborhood. Nine-year-old Tyshawn Lee had stopped to play on the swings at local Dawes Park, his basketball to the side, delaying a trip to his grandmother’s house by a few minutes. 

What happened next, according to police, is something that happens too often in Chicago and across the U.S.: Lee was shot and killed. He was lured into an alley by a 22-year-old man, shot five times and found dead, his basketball found a few feet away from his body.

Lee was the second nine-year-old over a 15-month stretch to perish due to violence in Chicago and one of thousands affected by rampant violence across the country each year. The violent crime rate is down across the country, from a rate of 747.1 per 100,000 people in 1993 to 365.5 per 100,000 in 2014, according to the FBI. However, the FBI reported in 2012 that there is a chasm between violent crimes in metropolitan and non-metropolitan areas, with a violent crime rate of 409.4 per 100,000 in urban areas and a rate of 177 per 100,000 in rural areas​

For the past two decades, Dr. Gary Slutkin has been working to prevent killings like this. He’s formed an organization that has already built up a history of success for stopping retaliatory shootings and homicides, and looks to make sense of how violence can be so rampant in one population and nearly absent in another. 

After years of scientific research and testing, he came to a conclusion: Violence is a contagion, not unlike the flu​

Fighting the Contagion

Slutkin has seen contagious diseases across the world, but it was most shocking at home. When he came back to the U.S. two decades ago from his work with the World Health Organization fighting contagious diseases such as AIDS in Africa, he was troubled by the headlines of children shooting children across the country. 

However, as he researched the problem, Slutkin saw similar patterns between the graphs and charts of violent areas and in areas where outbreaks of disease took place, starting with a small radius of space and ballooning larger over time. When he looked into what happens to the brain when violence occurs, he saw a pattern of unconscious learning and copying of behavior, something that has long been discussed in incidents of domestic violence. The patterns of violence started to make sense.  

“The brain has mechanisms for imitation and copying, in particular for violence. It’s very copyab​le and it’s so emotionally laden,” Slutkin says. “People follow what their friends do [and] it’s also largely unconscious. This causes mobs to behave exactly like other contagious diseases.”

What makes for a contagious disease? It’s something, like tuberculosis in the lungs or cholera in the intestines, that is able to produce more of itself and spread, making the human a vessel for contagion. Violence follows this pattern, Slutkin says.  

“I didn’t make it a disease and I didn’t make it contagious,” he says. “We just connected the dots, then demonstrated that if you treat it that way, guess what? It bends. It responds a lot.”

 

An example of the similar patterns between disease clusters and violence clusters. (graph care of Cure Violence)


In 2000, after five years of examining the problem, Slutkin developed Cure Violence, then known as CeaseFire Illinois. The program’s goal, he says, is to use a health approach to reduce violence. He has worked to change the perception of violence held by public health officials, politicians and citizens across the U.S. as an unfixable social epidemic. Slowly, Cure Violence’s method has gained the trust of officials and spread across the world with a current presence in 60 communities across 25 cities and four continents

“Shootings and killings can be dropped very substantially, very quickly, with a new set of methods that basically involves health workers,” Slutkin says. “The newer way [of thinking about violence], which I think should make sense to most people, is that people can be reached by health workers who have access and trust. They can cool people down, prevent shootings and change people’s thinking just like we’ve done for other types of health problems and contagious processes.”

Cure Violence launched in Chicago’s West Garfield Park neighborhood, and shootings in the neighborhood were reduced by a reported 67%. Recent success has been no different, as the organization boasts accomplishments including a 75% reduction of shootings in city-funded sites in Chicago, 27 months without a shooting or killing in Yonkers, New York, and more than 200 days without a homicide in funded areas of New Orleans, among many others. Retaliations, which Slutkin says happen on a third of all shootings, often drop to zero in areas with prevention workers.



“When we know about a shooting, we’re pretty good at preventing [retaliation],” he says, relating the work to preventative medicine. “The workers for Cure Violence are people who are pretty well integrated into the neighborhood. They have high credibility and trust; they’re able to talk to the people and cool them down and buy some time. Whenever you start to buy some time, you win.”

Evaluations of the program by the U.S. Centers for Disease Control and Prevention and Johns Hopkins show that implementation of Cure Violence meant a reduction of killings by 56%; a Northwestern University study reports that Cure Violence achieved a 100% reduction in retaliation homicides in five of eight studied communities; and a University of Chicago study shows a 38% decrease in homicides in targeted districts. More cites have adopted the program, including New York City, which designated $13 million for Cure Violence programs within its most violent neighborhoods.

 

Cure Violence health workers, or interrupters, work to "cool people down, prevent shootings and change people’s thinking," Slutkin says. (picture care of Cure Violence)  

 

Rebranding Violence and Stopping its Sprawl

Perception and politics have been the main roadblocks in the way of Cure Violence’s path to success. Violence largely is seen as something of a morality issue: If you’re a violent person, you’re a bad person, or so the thought goes. 

Marketers and health officials alike are used to the mission of changing perceptions. Changing the perception of HIV/AIDS has saved lives across the world. The perception and opinion of Apple has taken the company from being seen as slow to market and flawed in the 1980s to cutting-edge and almost impenetrable in modern times. But change takes time. Slutkin acknowledges that the public still sees violence as moralistic, but he believes in the science, even if he knows it will take a while to fully sink in publicly.

“It took a while for people to get that there are invisible microorganisms. It took a while for people to understand evolution or that the world is round,” he says. 

William Mayer, a professor of political science at Northeastern University and author of the book The Changing American Mind: How and Why American Public Opinion Changed Between 1960 and 1988, says that changing the mind of the public is not an easy task and usually takes years of small victories.

“The general finding, at least of my work and some other people, is that public opinion does change, but, with a few exceptions, it tends to change pretty slowly,” Mayer says. As an example, he says racial attitudes in the U.S. have certainly changed, but it’s taken decades. “From the very first public opinion surveys on racial attitudes, conducted in 1944, up to the present, we’ve really kind of crested. … You can say there was this huge change, but it was over 40 years.”

Mayer, who is not associated with Cure Violence, says one example of a common perception change is that of alcoholism, which went from being thought of as a social ill to a disease over the span of many decades. 



While Charlie Ransford, director of science policy for Cure Violence, says that this kind of change in public perception can be difficult, much of it can come via simple messaging.

“Instead of looking at someone acting violently and jumping to judgment and saying ‘That’s a bad person,’ it’s seeing someone who has been violent and asking ‘What in their life drove them to do this?’ I think that’s simple,” Ransford says. “We’re not asking people every day to dive into people’s lives and truly understand where they’re coming from. [We’re asking them to] understand the effects of violence.”

Ransford likens Cure Violence to the history of 911 emergency lines. Much like Cure Violence, 911 lines deal with a complex issue, triage it and send it to whomever can handle the problem. As much as this service has become engrained in American society, it wasn’t always there. He believes Cure Violence can make a similar imprint across the country. 

“What you’ll see is these early adopters will have some early successes. After a few years, those early successes will be written about. We’ve had that over the past 10 years. Unfortunately, this process takes a long time,” he says.  

A big problem in changing the perception of violence and how it is treated is that both citizens and politicians must actively want the change. Ransford says the simple truth is that they can’t afford to ignore either people or policymakers since Cure Violence is a “small foot with a big footprint” organization, meaning it doesn’t have many people on staff while trying to create a seismic change.

Ransford says Cure Violence believes that getting at policymakers is a crucial first step. “That [means] trying to get at mayors, consulates, state representatives, state senators, governors. A lot of time that means going through partners who have meetings set up with people or they have regular conversations or connections with people. Developing relationships at that local level [is huge].”

Even so, the government is the voice of the people, so citizenry cannot be discounted. Ransford says people in their communities see and feel the effect of Cure Violence every day and they want to find a better way to have people tell their own stories. 

 
 

“The brain has mechanisms for imitation and copying, in particular for violence. It’s very copyable and it’s so emotionally laden,” Slutkin says.​ (Photo care of Cure Violence) 

Uniting the Medical Industry

Uniting the voice of the medical industry has huge potential to get Cure Violence’s message across to the public, Slutkin says. Ransford says he has been tasked with catalyzing the medical movement. This has meant reaching out to prominent doctors such as former U.S. Attorney General David Satcher and Dr. Alfred Sommer, dean emeritus at the Johns Hopkins Bloomberg School of Public Health, and forming a team of partners to promote the idea.

Ransford says that when he joined, it was clear to him that violence was what was holding his city back, something he maintains is true today. 

“It’s not really a big leap to understand that all violence works this way,” Ransford says. “That any kind of violence, whether community violence, gang violence, war violence, even mass-shooting events … people exposed to these events are traumatized. And sometimes that trauma can result in a person becoming violent.”

The key to stopping violence is the same as stopping other behaviors, Slutkin says: Limit exposure, change behavior and stop the spread as soon as possible. 

“There’s still a desire to look at this problem through emotions and morality that is still more comfortable. It’s what people are used to,” he says. “That’s why it’s especially important is to get health voices into the media. We need health spokespersons. We need health directors, public health directors, pediatricians, physicians, trauma surgeons to be speaking, explaining that this is a health issue, that the people who are doing it have a health problem acquired through trauma and exposure.”

In addition, Slutkin says he wants to see a better triage system in place that would define a relationship between what outreach workers, hospitals, practitioners and others can do, in addition to improved funding so the issue can be addressed country-wide in a more serious manner.  

The medical community has a good idea of how this change in perception happens. Consider that people once believed that individuals who had the plague were possessed. 

“What we’re doing is just trying to [encourage] influential health [professionals] who understand violence is a health problem to join together to spearhead a movement to change the way the public understands [violence] and, therefore, the way we as a society treat violence,” Ransford says. “We’re putting together a set of recommendations and an outline for a community on what a health system to violence looks like so that communities can understand what it is they can do to have a full response [system] to help prevent violence.”

 

Cure Violence funding in Chicago is currently down due to Illinois' budget struggles. The group reports that each time funding is cut, shootings rise anywhere from 50% to 70%. (Photo care of Cure Violence) 


One medical professional whom Cure Violence won over early is Joshua Sharfstein, associate dean for public health practice and training at the Johns Hopkins Bloomberg School of Public Health. Sharfstein worked with Cure Violence when he served as secretary of health and mental hygiene in Maryland. The local program, known as Safe Streets in Baltimore, was one of the only social programs he actively raised money for in his time as a public official, $2 million in all. 

Cure Violence’s landmark project in Baltimore took place in the Cherry Hill neighborhood, which went more than 400 days without a homicide with the program in place. From 2003 to 2008, the neighborhood had 77 shooting incidents with 139 victims; from 2009 to 2014, the number of incidents dropped to 34 and the number of shooting victims to 37. 

When Sharfstein was in his role as secretary of health and mental hygiene, he says the program was popular among citizens, police and the mayor, among others.

However, in the time since, the person overseeing the program passed away due to an infection, a shooting with multiple victims took place at a party and the police started turning against the program. Funding became a challenge. Even with medical support, the program’s funding can waiver in the face of politics.

Sharfstein speaks in an even-keeled way about the difficulties, But he hopes the program will shift the way violence is considered nationally. So long as the results are there to back it up, he believes change can still roll out.

“People are open to the idea that we can do things differently, but specifically if [the new way] works,” he says. “There’s a limit [that] a theoretical explanation of a different approach can accomplish. The most persuasive argument we had was if it works.”

In Illinois, Cure Violence was one of many social programs to see its funding cut in the wake of budget issues. However, it’s not the first time the funding has been cut out by the state; it’s the third. Each time, killings rise by 50% to 70% in areas they protect, Slutkin says, and drop back to baseline when they are refunded. In January and February of 2015, Chicago had 100 Cure Violence workers, or “interrupters,” and nine neighborhoods had streaks of zero killings. The Chicago Tribune reported that there have been more than 1,700 shooting victims in 2016 alone, nearly twice as many than in the same months in 2015​

Marketing for Change

Public health officials tend to undervalue the marketing of their work, Slutkin says, but much of the problem with the understanding of Cure Violence is that the results are nearly invisible. Celebrating a win publicly is difficult, but without celebrations and acknowledgement of achievement, no one knows about it.

“It’s not highlighted by exaggerated announcements or anything,” he says. “We’re quiet professionals making the communities in the cities safer and healthier. That’s what we do in health, through a lens of care with a bias toward the people who are most in need.”

Even so, he and others in the organization know marketing must be taken more seriously. Kathy Buettner, Cure Violence’s director of communications, who retired at the end of last year and now only works part-time, says Cure Violence gets a lot of earned media and press coverage. The organization was even featured in a documentary called The Interrupters, which won the Independent Spirit Award for best documentary in 2012. 

However, even with all the earned media, Buettner says that there is no marketing budget to push forth their message through other means. Making a “real marketing push” would be ideal, she says, and they’re currently meeting with firms so Cure Violence can have a partner when it does get more of a marketing budget, but for now, retweets, shares and earned media are driving the way. 

One issue that may prevent Cure Violence from being more widely known is that groups it supports and guides in different cities have their own brand, and sometimes multiple brands. New York City alone has 27 sites that follow the Cure Violence model that go by approximately 18 different names, such as Save Our City, Man Up and Operation SNUG (GUNS spelled backward). 

“It’s a marketing challenge we haven’t completely resolved,” Slutkin says, explaining that different groups take pride and ownership in their local group, right down to uniquely naming it. “Every McDonalds is a McDonalds, but every Cure Violence [group] is not [titled as such].”

Buettner says they want these groups to be local in nature, so working with local non profits, hiring local people and getting local funding is key, but it’s a challenge all the same. 

“It’s one of our branding challenges because it’s all local, so everyone thinks [they’re all] different,” she says. “For us, as an organization trying to influence public opinion to view violence a little different, it’s complicated. We can’t say [that] it’s all Cure Violence because we don’t manage those sites, we provide training and visit sites regularly, while trainers that go around and update training, but we are not actually managing them.”

The next person who manages marketing for Cure Violence will need a bit more marketing, video and social media experience, Buettner explains. It’s going to take a lot to juggle marketing on a small budget, but she says that is a must for Cure Violence to figure out: When you only have a finite and very small budget, how do you deploy resources effectively?


Finding Understanding Through Challenges 

While Cure Violence faces many challenges—marketing, funding, politics, public perception— the one that Slutkin says has been the biggest roadblock is simply understanding. It’s hard for many people to look at a situation that seems foreign and feel empathy. 

Much of this violence occurs in extremely urban areas, generally predominantly black or Hispanic. The strife is hidden away in corners of cities. However, it is now on full display via social media posts, online videos and media reports. Slutkin hopes this may help outsiders gain a greater understanding of the problem, likening it to the discovery of microorganisms, but noted that there will still need to be a vast educational process that frames the issue scientifically.

When asked if he believes that there eventually will be changes in perception of violence, Slutkin is enthusiastic: Perception of substance abuse as a health issue has changed, as has the perception of infectious diseases. Why not violence? 

“It’s one of our branding challenges because it’s all local, so everyone thinks [they’re all] different,” she says. “For us, as an organization trying to influence public opinion to view violence a little different, it’s complicated. We can’t say [that] it’s all Cure Violence because we don’t manage those sites, we provide training and visit sites regularly, while trainers that go around and update training, but we are not actually managing them.”

“Oh yes!” he exclaims when asked if he believes Cure Violence will continue to gain a greater role in violence prevention across the country. “In different cities at different speeds and different countries at different speeds. But sure. All the movement is in this direction of this being treated as a health issue.”

Politics may continue to be a problem moving forward. Budgets aren’t always going to have money for the program, even with the mountains of studies that Cure Violence gives to policymakers and the knowledge that each shooting stopped means roughly $1 million in savings. 

Money aside, he says, lives can be saved. “What is anybody doing that’s more important than saving lives or helping people get healthier?” Slutkin ponders in a bewildered tone. “I just want to know what that is … all you have to do is prevent one shooting and you’ve paid for nearly a whole neighborhood’s program.”

That brings about another challenge: So many shootings have happened over the years that people have grown numb to how they affect individuals, families and society at large.

Over and over again, Slutkin has been told, “It’s political,” and says he always responds that he has no idea what that means in the context of losing human lives. 

“Something is drastically missing. I’m not talking about Chicago, I’m talking about all of us: the whole country. The world, really,” Slutkin says, taking long pauses between sentences. “What are we valuing? What on earth are we valuing? What considerations are taking precedence over human life?”


 

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Author Bio:

https://auth.ama.org/publishingimages/halheadshotcolorcorr.jpg
Hal Conick
Hal Conick is a staff writer for the AMA’s magazines and e-newsletters. He can be reached at hconick@ama.org or on Twitter at @HalConick.
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