 On behalf of the McLean Center and the University of Chicago Trauma Center, I'm delighted to welcome you to today's lecture on ethical issues in violence, trauma, and trauma surgery. It's a pleasure to introduce our speaker today, Dr. Gary Slutkin. Dr. Slutkin is an epidemiologist and physician specializing in infectious diseases. He's the founder and CEO of the anti-violence organization that's named Cure Violence. Dr. Slutkin also is a professor of epidemiology and international health at the School of Public Health at the University of Illinois at Chicago. Dr. Slutkin received his MD here at the University of Chicago's Pritzker School of Medicine. He received his internal medicine residency at the University of California, San Francisco, where he trained in infectious disease at UCSF and the San Francisco General. Dr. Slutkin worked in the early 1980s as the director of tuberculosis control in San Francisco. And from 1981 to 1984 helped to reverse the TB epidemic in San Francisco. He then moved to Somalia and worked on controlling tuberculosis and cholera epidemics in Somali refugee camps. In the early 1980s, Dr. Slutkin was recruited to join the new World Health Organization's Global Program on AIDS. Let me say that again in the early 1980s, when AIDS was just being detected and just emerging, Dr. Slutkin joined the new WHO's Global Program on AIDS, where he studied the extent of the AIDS epidemic and led efforts to start national AIDS programs in 13 countries in Central and East Africa. Dr. Slutkin continues to serve as a senior advisor for the World Health Organization. In the mid-1990s, Dr. Slutkin returned to the United States and turned his focus to violence. He developed a new strategy for reducing violence by treating it as an infectious disease and founded his organization, Cure Violence, that there are two or three wonderful handouts in the back on your way out. Please pick them up that Dr. Slutkin has left with us. Dr. Slutkin's work takes a public and community health-oriented approach to violence and attempts to reduce violent behavior through health and epidemic control methods. Dr. Slutkin has won many national and international awards, including the U.S. Attorney General's Award for Public Safety, the Order of Lincoln Award, which is the highest honor in the state of Illinois, and the UNICEF Humanitarian of the Year Award. Dr. Slutkin's talk today is entitled, as you see behind me, Treating Violence as a Contagious Disease, Theory in Practice, U.S. and Global. Please join me in giving a warm welcome to Dr. Gary Slutkin. Dr. Sigler was a teacher of mine here. That's true. And I'm always thrilled to be back with the University of Chicago Pritzker School of Medicine. And I'm always particularly happy to be in this room because I was sitting way up there, yet about where you're waving, when I received my match with the University of California, San Francisco. And so I have this wonderful memory of that moment. You can be the same room on March 16th, right? Yeah, good. So sit in that lucky seat, it'll be. So how's everybody doing? Everybody good? So yes, it's true. I come from the world of managing epidemics. I did jump out of routine, as it were, medical practice, actually I never did it. I went from being a chief resident to infectious disease doctor and then learned how to do infectious disease control through tuberculosis. And then transported myself to, I was commuting between San Francisco and Mogadishu for a few years and then I moved there. And so I spent about 10 years abroad and then I came back to not really knowing what I would do next, but I came back to this country and got confronted with the violence here and saw it differently, basically because I didn't have training in it and I had a lot of training in infectious diseases, but also, most notably, I had been trained here at the University of Chicago where you are really guided to go deep and to try to understand something and to look at it anew and to look for the invisible. And what I found looking at graphs and charts and maps and talking to people was that it's behavior, that is, say, violence's behavior, is indistinguishable when you're looking at maps and charts and graphs from all other epidemic processes. And around that time when talking to people, I asked someone, what is the greatest predictor of a violent event? And the answer was a preceding violent event. So that's really when I hit my head and said that kind of clenches it because what is the greatest predictor of a case of flu? Preceding case of flu, what is the greatest predictor of a case of tuberculosis or Ebola and so on? And so, and that's definitional of contagion, that is to say it is a risk factor for itself. So aside from other risk factor issues like high blood pressure as a risk factor for stroke, stroke isn't a risk factor for stroke, but infectious disease epidemiology is defined by it being a risk factor for itself. And so, as I'll show you, we made a decision to try it out to treat violence in a different way. And at this point, this work has been expanded to over 100 communities in 25 cities in this country and on five continents and extensively through Latin America and in building in the Middle East too, and has been getting a lot of recognition. Nevertheless, it's not the way that you hear about a violence on the news. So what I'm going to ask you to do is to consider that whatever you knew before, maybe we need to start over like for the patient who keeps getting the same medicine over and over and over and over again and more of it and more of it and more of it, but guess what isn't getting better. So you have to like relook at the situation, don't you, and say is the diagnosis right? So what we're saying is to look at the person who does violence differently through a new lens, through your lens, through a medical lens, through a health lens, through a non-judgmental lens, but through an understanding lens. And we will see that the person himself or herself, not only the one who is in the hospital having been injured, but also the person who did it, think the person who just did a mass shooting that was as well known or the person in the community who did it is primarily having a health problem, a contagious health problem, having picked it up from others and having been traumatized. In other words, an untreated health problem. I mean, just think about how many times these mass shooters, but also people in the community, how many times they've shown symptoms without having the opportunity to be managed in a different way. In fact, in a harmful way, rather than a helpful way. And then a contagious problem, which basically just means that one event leads to another. So I wanna go through the contagion, then talk about the methods and the results, and then talk about what we, in particular us health people, need to do to step up a bit more to take up some of the space that's, we've frankly abdicated. Just to put a marker there, this is the only health epidemic that is not primarily managed by the health field. It's the only one. And think about all the things that we do in health, whether it's reversing, changing eating behavior or sexual behavior, think AIDS or smoking behavior, violent behavior, it's just a behavior. It's an epidemic behavior. So where we'll land on, our role. So there have been thousands of studies now that show that violence is a health problem, hundreds that have shown that it's a contagious health problem, and dozens now that have shown they're treating it as a contagious health problem, has results and very powerful results and sustained results and fast results. This is, was put out in 2013, Institute of Medicine, and it summarizes the state of the data there. And it's exceptionally strong. So what are the population characteristics of a contagious disease? Well, there are three only, and it meets them. Clustering, epidemic waves and transmission, meaning communicability, meaning that one event leads to another. So here's cholera and Bangladesh. Here's violence in Chicago. Epidemic waves. I mean, here is the wave of almost all US cities, they all seem to have mimicked each other for this period, and it's the collective wave. And what you see is a standard epidemic curve, it didn't go down right here, because there was another epidemic that added into it, and another that added into it. It's kind of like having a house that is kind of on fire and smoking, and then in one room it's a little bit hotter, and then in another room it's hotter, or an AIDS epidemic in Africa, an AIDS epidemic in Africa where there are, this is what's going on in Entebbe, and this is what's going on in Kampala, and you're just kind of adding them to each other. So all epidemics are summations of multiple epidemics. This is cholera, cholera epidemic in Somalia that I was involved in, point source epidemic, secondary wave. Here is a killing of violence epidemic in Rwanda, primary point source epidemic, secondary wave. Forget reasons, you wonder why there were secondary waves, these were people who were not exposed, and then they became exposed. The people who came into the camp who weren't there before, secondary wave, these are people who were hiding and then found, so they were not exposed and they were exposed. And then the third characteristic is transmission, which simply means that one event leads to another. So again, the definition of contagious is makes more of itself. I should also add the definition of disease, so the definition of contagious, both in the medical and in the standard textbooks, is producing more of itself, or some version of that exposure being the underlying principle. The definition of disease is essentially characteristic signs and symptoms that result in morbidity and mortality. And so it fits, so I didn't make up these definitions, it just so happens that this fits, just like a whale fits the definition of a mammal, even though you may think somehow it looks like a fish, it meets all of the characteristics. So dozens of studies, I wanna just pause for a second to show you this, because there is this thinking in theory of underlying causes other than violence itself. And this is a study of housing project, Alabama, everything's horrible, poverty, father's not around, schools are horrible, nutrition bad, all of these things. But the kids, 48 years old, when interviewing themselves and their parents, they had not been exposed to violence. And in years later, they did not have a risk of violence higher than the general population. Those who had seen it, it had been done to them, according to them and their mothers, 30 to, in fact, 100 fold more. And this is the same thing if you think about it for AIDS or TB. You know, these horrible conditions, but if AIDS isn't brought in, if TB isn't brought in, if flu isn't brought in, it doesn't just emerge. And it's dose dependent. Low exposure, intermediate exposure, high exposure. It's dose dependent, which is also the case for most of the biological things that we interact with, isn't it? I mean, how much of the flu virus? How much of cholera? What's the dose? What's the proximity? And that is also the case here. It's dose dependent. So it also, it makes sense in that way. And the closer you are to social exposure, the more likely. So you could do the same thing for TB. You know, whether you're far away or very close living in the home. You know, whether you're, it's the US rate or in the neighborhood or you have a very, very close exposure. So this shifts the whole idea of this problem from the common idea of bad people. And this is just an excuse phrase. I'm not so judgmental. They just made a bad choice, really meaning this. And it isn't really this on its own, although there is susceptibility here. And this is what the science really shows now, is contagion within these circumstances, which is also relevant for other communicable diseases is that the circumstances are relevant and can increase the likelihood. So how does this work? Well, all behaviors are in fact copied. It's principle modality of transmission of behaviors. We're set up the revolution to not need to be taught everything we can just follow. A lot of things we do don't make sense. Some of them are very adaptive. Most of them are adaptive. And there is a mirror, not only neurons, but networks that there's copying mechanisms. That's why, you know, your little child will stick his tongue out when you do and things like this. It turns out that violence is particularly copyable because it's highly salient. In other words, it causes a lot of emotion. It causes a lot of attention. And therefore, and this is work that goes back to the fifties and sixties of Bandura, it's particularly copyable or communicable. And it is the observing of it. There are brain circuits, it's observing of it, the witnessing of it in its real context. And they having been victimized, which is a very intense way of witnessing it that is transmissible. And as we'll see, this accounts for a lot of things that otherwise don't make sense in the world. So when you say senseless violence, it actually is because we haven't made sense of it. It's just like we didn't make sense of plague or leprosy till we knew about invisible microorganisms. So there's a sense to this actually in its exposure related. And there are centers that allow us or require us almost to stay down the path of doing what our friends do. And dopamine mediates this. I may have to talk about this more, but in fact, the same pathways that modulate anticipation of sex, anticipation of food, a pizza tonight when I'm all excited, or anticipation of social recognition uses the same path. And there's pain centers that keep you in line so that you're not outside of your social surrounding. So reasons are given for doing violence, but the reason that holds up is really whether your friends, you think your friends expect you to do that. So we do what our friends do. This is in fact no coincidence. Oh, you just happen to look the same as me. No, people are doing what their friends do. And this of course can escalate. And with trauma, people get more hypersensitive and hyperreactive. And therefore, it facilitates, it accelerates itself into an epidemic process and epidemic curves. And this in fact, it's contagious across syndromes. So exposure to community violence causes you more likely to infect the suicide, more likely to do violence in your home, more likely to abuse a child. Exposure in war makes you more likely to do violence in your home. Why would you do that? You're doing violence, someone, your enemy is doing violence against you. Why, what was the sense of doing violence against your wife? Or the sense of doing violence in your community? It's because this script has been picked up, you found me? What is the sense of someone who was child abused abusing their own child? For example, it makes no sense. They should be the last people to do it because they know how bad it was, right? Unless something else was going on. So this theory explains other things that otherwise, I mean, that's one of the purposes of theories is to explain things that otherwise didn't make sense. So this new theory explains things, many of these things. Suicide clusters, obviously, violent recruitment. I don't know if you've ever heard seen in the newspaper, we don't know why the violence is going up because the economy is getting better and whatnot. Or we don't know why the violence went down and so on. These are basically mathematical situations that you have to do with susceptibility and resistance in populations. The most important thing about this new theory, which is beyond a theory now, it's really established science, is that we know how to stop epidemics. And so if we do what we do for other epidemics, which is detect and interrupt a potential event, like someone is progressing towards Ebola or progressing towards having full blown cholera or TB or progressing towards doing violence, generally looking more and more like it over the last few weeks or months or tonight, if we're able to detect events early as violence interrupters do, then we're trained in how to interact with people so that their behavior is modified, which is what violence interrupters and behavior change agents and outreach workers are trained to do, then we stop an event and we therefore stop its transmission. Does that make sense? And this is all we do. And then of course there's a couple other steps and there's other layers of this work. So if you prevent, every time you prevent an event, you prevent several. Some people have already been infected or are already on their way, so they need to be interacted with as well. And if you do this to a critical mass in the right places with the right people, you get rapid drop offs of the curve to an epidemiologist, the curve. And then gradually, there become new norms. What do I mean by norms? It means that someone pulls out a gun and everyone goes, what are you doing? Or someone is thinking about hitting his wife because she came home late last night and at the barber shop, they said, what's the matter with you? Instead of saying, yeah, I hope you taught her a lesson. Those are two different barber shops. When I was a medical student here, the third of us were smoking while we were watching angiograms. Now, nobody is. Look at this beautiful room. Nobody's smoking. There's no police. Why aren't you smoking? Because if one of you picked up a cigarette, someone would look at you, what's wrong with you? This social disapprover is very, very powerful and pretty soon you don't even have to think about it anymore. It's unconscious. So the way the program looks, the way cure violence looks, the way that it's the adaptations look is essentially we map like for any epidemic. How many, where is it happening? What groups are involved? What cliques are involved? What high-risk people are around here? And you say, who can reach them? And so we look for people in the community who already live there. They're their cousins, their friends, grew up with them, spent time with them, perhaps in prison or something. Are highly trusted, highly credible, believable. The kind of people who, if this person's talking to this person, when they're mad, they can yell at each other and swear at each other, but in the end, that person knows he's talking to him in his own interest. You ever get in a swearing match with your best friend? You're not gonna hurt him or her. They can yell at you, tell you you're wrong, et cetera, et cetera, but in the end, that person is highly persuasive to you. So we hire these folks as interrupters and outreach worker and they exist in communities. There's many communities now that have had such workers for 15 years, 18 years. Some people think that interrupters have been there forever, if you're 10 years old or it's like ambulances, they've been there forever. Hospitals have been there forever. You grew up, there were hospitals. Now there's violence interrupters, a lot of neighborhoods, they've been there forever. If you have a problem, you call a violence interrupter, everyone has their number. You know, your kid has weapons in the basement. You don't want to call the police in them. Call the violence interrupter. Unfortunately for this mass shooting, no one is calling these folks and these folks aren't as available or around so they're calling people who can't do anything because the guy hasn't done anything yet. And the person just progresses in his disease being watched but not enough and not with an intervention occurring. So we continue to work with people for six months to two years to shift their course just like we work with TB patients for six months now after discharge to ensure that they don't relapse. And then there's a hospital component to this and so eventually what you have is a whole system of a health department and community groups and workers, outreach workers and interrupters and their interaction with the hospital so that this hospital is developing a trauma center where there's a ready five or seven trauma centers in this hospital, in this city. Cure Balance is working with all of them and so that when someone is shot, in other words, because there was not enough detection occurred that weren't enough workers or came from a neighborhood where the intervention doesn't occur. So someone's shot, someone shows up at the emergency room and should begins to talk to the person, should he live and be discharged, we continue to work with them. And additionally, we have to prevent the retaliation. So that's one of the new in a way ethical aspects of this. You have to also ensure that their additional ramifications don't occur. I mean, this initially started with Advocate Hospital and Cure Violence years and years ago because Advocate realized that if something happened on Friday night, the whole weekend was gonna be horrible. And the trauma surgeons really were tired of telling moms your kid died. And so they reached out to us. It was like 2004, five or so and paid for the service of interrupting to prevent more of these events coming in. So let's talk about the methods. So this was first a piloted in the year 2000 in West Garfield Park, which at that time was the most violent community in the country. And there was a 67% drop from 43 to 14 in the first year. It actually was almost in the first month. And the funder said, well, do it again. It must be a fluke. And these are all the way on the left are these are not four communities. These are an average of six. And these are a few dozen, a few dozen in the whole city as controls. So you can see in the very strong P values. The next, this is way back. The next eight communities is similar. And so here is, this is from an independent evaluation that the Justice Department did study of seven years of work, 10 year baseline, eight communities. Here's a hotspot becoming cool. Here's three hotspots becoming cool. Intervention is powerful. In addition to being fast, here's a summary. All of this stuff is on our website. There've been about seven or eight independent evaluations now of this work, CDC, Hopkins, Northwestern, U of C, Justice Department. This is on the back of one of your handouts. This is a summary of the results of multiple cities in the US. And also in several Latin American spots, getting actually an 88% drop in San Pedro, Sula, Honduras. These are the cartels. This is the famous MS-13 and 18th Street gangs. This is where the rates of violence are not just more than Chicago. They're 10 times more, not twice as much, 10 times as much, so 88% drops here. This is the hospital violence, hospital intervention program, the reduction in relapses, look at that. And this isn't our work, all the other stuff was. This is a combination of our work and other work. This is by following the person, preventing these relapses. So health intervention. How often are you hearing about violence being stopped or prevented on the news? How much are you hearing about violence as a health issue after there was a bad weekend? How often have you seen the health director or doctors talking on Monday after there was a bad weekend and so on? This is the approach that the economist called the approach that will come to prominence. This is the approach that is now listed as the 10th best NGO in the world. Listed with Human Rights Watch and Care and Save the Children and so on. Being underutilized. And I'll get to why, but in part it has to do with how we in the society see the people. And how, and who's speaking. And what words are used. The worldview is wrong. It's been misdiagnosed. This is where adaptations have occurred. I mean, funders of this work include the Justice Department, the Robert Wood Johnson Foundation, multiple foundations in Chicago, by the way, have stepped up in the last year as a result of Chicago going off the hook. The World Bank, Inter-American Development Bank, UBS Optimus, the Gates Foundation is funding some work in this area now. So this is being widely accepted as a go-to, but somehow or other it isn't out there as much, is it? Is what we see and hear about it. Just to point out also that these methods are fast. It takes a while to get the funds. It takes a while to hire the right people. But once it's in place, I mean, this is when the program started. This is in Logan Square here. And then here's when the program was between doubled and tripled and sustained. Here's Baltimore, a lot of peaks and then abrupt cutoff of these horrible times in the neighborhood and many more zeros. There are now six or eight communities in Baltimore and New York City that have gone one year, two years and almost three years down to zero. That used to be as bad as some of the neighborhoods here that you know about. And that's what you aim for in epidemic control. You don't aim for 40% drop of cholera. Let's just drop it 40% and level it. Or Ebola, you aim for getting rid of it. Or making it rare events. And this is now being shown to be doable. This is during the period when Chicago was going off the hook and Anglewood in particular and one of our staff members got enough funds to do an intervention in Anglewood at the peak of the summer and just dropped it like that, hired a couple dozen workers, dropped it just like that. And then there was only funding for this much period of time. This is a prison program in the UK, same thing. People respond to people of their own who make sense to them who are trained in cooling down, buying time, validating their complaints and giving them a new perspective and staying with them. Stopping violence is hard work for people who are doing it, but it's not hard. What's hard is sexual behavior change. What's hard is smoking behavior change. This is not as hard as those. What is also hard is changing a worldview. And that's the real obstacle here is the worldview. So this is why it works. These are the same reasons why any epidemic is managed from the inside out, whether it's cholera or Ebola, TB, whatever, detecting events, preventing spread, reaching the very hardest to reach. This, by the way, is what public health does. Public health reaches the hardest to reach. Public health works in bars, in brothels, in alleys, in basements with people who are using drugs, people with risky sexual behavior. It's working behind the scenes, it's invisible. This is our problem. No one knows what public health does. Why? In part, we're quiet, health doctors, too. In part is because we're not saying here's the tuberculosis patient, we caught him. We're just doing the work, preventing the case, preventing the spread, and no one knows what public health does. What has it done? Anyway, what's it done? Well, I don't know, we're living to 80s and 90s instead of 20s. Anything else? I don't know, half of little babies used to die. Now they don't. Anything else? Oh yeah, we don't have plague and leprosy in smallpox, in yellow fever anymore. Where do they go? Oh, by the way, what happened to SARS and bird flu in Ebola? They just disappear on their own? See, this is the problem. There's this invisible nature to public health and its methods, but it is arguably the most powerful set of methods that there are, and they're just human methods, but very highly scientifically designed, based on data, with feedback, and so on. So where we're going, and what's needed here, and some cities are ahead of others on this, of course, is a system. Because you don't control, for example, in Chicago, measles, or tuberculosis, or anything with just projects, the Cure TB program, or project, or the measles project. You have the health department oversees it, and everybody knows what they're supposed to do. The pediatricians do this, the hospitals do this, the schools do this, it's a system. We had to set this up in countries for AIDS. This is what the health department does, this is what the community groups do. This is what the health care providers do. It wasn't random, it wasn't just projects. It was the development of a public health system, and when we mean public health system, we mean community-based work in which the health department and the health professionals guide and train, monitor, and supervise. Does that make sense? And this is occurring all the time to which this hospital is part, and to which every practitioner is part. Really, do we think about it? So in order to get past this challenge of the mind view and the money and the system, we have developed ourselves and co-led by Dr. Satcher, the former head of the CDC, and L. Summer, the former dean of Hopkins, a collaboration, a national collaboration, what we sometimes call a movement, to allow violence to be more clearly seen and treated as a health issue. And the component, and there are, I think now 45 cities that are involved, and 40 national, I'm talking about the American Public, American Public Health Association, and the pediatricians, trauma surgeons, the emergency docs, and so on, are involved, and several hundred practitioners, in order to change who is speaking in the language, to change the policies, in particular, the money, and to develop the system. So these are the cities that are involved. I should tell you, New York is very, very advanced here. New York has very close to a system. This is managed by the health department. It's been in their city budget since 2009. We train almost every worker. I think we train every worker. We train every supervisor. In Los Angeles, this has been in the city budget since 2006. And we helped set that up. You can look up when Los Angeles visited us here in Chicago in 2004 and five to see how this was working, because there were so many results. And then we were called out there to help organize this. And this is managed by the health department in Baltimore and Kansas City and several other places. So these are some of the partners signed on to this collaboration, this movement. So I want to spend a minute on, I've talked about the system. The policies is about money. I mean, there is like less than a thousandth, it could be when 10,000th of the money available for this world of violence is in the health sector, in the health and community sector as compared to the other sectors. So we're working with cities and states and the federal government to, not to try to necessarily, there's another course as to what happens with the justice system. It already has pushback. But the question is, will it just come spring back or will there be something that can fill that space, which is the usual thing that fills the space of every other epidemic, which is the health sector, which is the health sector and the community working together. So these are the policy changes, but I'm going to end on the importance of health spokespersons in New York and in Baltimore. The health commissioner is commonly on television, is commonly talking about violence, is writing about it. Surgeons, pediatricians are talking about it. And so on the news you will hear health people talking about violence. And they'll be talking about trauma, they'll be talking about epidemic, they'll be talking about transmission, they'll be talking about health workers, they'll be talking about interrupters, they'll be talking about outreach workers. That isn't what you may necessarily be hearing. But it's highly relevant and important as to who is speaking to determine where, what the problem is. So when there's an Ebola epidemic, you have the health commissioner, et cetera, et cetera, measles, et cetera. So we want to change this thinking from this to that. From this old view, which has no rationale, it has no biological basis, we in health don't actually see it. I mean, there's no under the microscope badness, there's unhealthy. But there isn't like, here's the bad person under the microscope, it doesn't exist. Person comes into the emergency room, you have chest pain, oh, you're really bad. Look at the, you're rash, you're really bad. Isn't the way we frame things, is it? It's more like what's going on. And we also have this bias towards what's, who's more acutely ill, and then how to help. This is the health bias. So we need to shift this view. This on the left is intentionally in medieval script because that's the way this will be seen. So I mean, health voices are being shown, are stepping up more and more. This is important, it's very important. In other words, we need you, you know, Uncle Sam or whatever, we need you to be speaking, to be writing, to be talking. And then the public and the policy leaders, and the legislators, the politicians, the foundations, the moms, they all begin to see this differently. So this is really important. It's the most important thing, I think, that we're doing right now, is asking health people to speak and to use health language. And here is Dr. Wen in Baltimore writing. Here's Sanjay Gupta. Thinking of this epidemic of preventable deaths as an infection that can be diagnosed, treated, and perhaps cured, I feel more hopeful than I have been in a long time. I mean, I would love for him to be speaking more. Here are the words. So we have embargoed words. These are some of the embargoed words. We don't say them. And curavans, they're embargoed. We call them the scary words. But the science of this is that there are these frames. I'm gonna go back to this. So if you, for example, I was talking with the brilliant ethics group earlier today. So if you were to write an op-ed, or you were to get on television to talk about violence, you don't even have to make sense. Just say public health, health, behavior, behavior change, interruption, outreach, changing norms, changing behaviors, public health problem, trauma, it works in your mind. You say one of the scary words, ah, mind gets hijacked. This is frame. The frame, and everyone, what's so good about this is that it's true. And what else is really good about this is that health is a good. I mean, everyone's got a frame of health and everyone wants it and everyone sees it as good. So there's these brilliant, excellent, important examples. But very important, I mean, I learned this at World Health. What's really important is not the perfection of the message but the intensity of the messaging and who the messenger is. And you all are the best messengers. Community people and health people. The health people is a new frame. So, and then they begin to see violent events differently. When they see the person who did a violent event, they may begin to see that person differently. You begin to see what's called a rap sheet as a series of untreated moments. So we've talked about it as a contagious or epidemic problem. The science is there, it's solid. The Institute of Medicine has really stamped it. I mean, I have an article in that that's called Violence Is a Contagious Disease, thoroughly reviewed by neuroscientists and by the infectious disease people, including people at WHO. The methods are strong and powerful. And this is one of the main challenge now isn't the need for more data. I mean, we will continue to get more data. But the real challenge is the mindset, the framing. So the last thing I'm going to point out is that you who are medical or health people, please realize you think differently. And it took me most of my whole life to realize this. Because I thought everybody thought the way that I do or the way that I was trained here or at home or other. But we have a certain neutrality in health. If you're in a hospital, in a war zone, you take what there is. You take both sides or all sides. You're not saying, oh, you're the ones I'm going to take, you're the ones I'm not going to take. So there's a certain neutrality, there's a bias towards science. It's about understanding rather than judgment. And it's about caring for and making things be better. And we need to teach this. And if you can't teach it, just be it. But begin to insert violence into the world of health and the language of health. So I'm going to very quickly show you Chicago. This is when we started. This is when Cure Violence, which was called a ceasefire tripled. This is when there was an interruption in funding. Went up by 50 killings and 400 shootings. This is when the funds were returned. This is when there were contracting difficulties. This is when the contracts resumed. And this is when in March 2015, the state stopped having a budget. And the Cure Violence work went from 14 communities to one. This is an expanded version of March 2015 point. And this, by the way, is the only community that was not taken off the street because there were private funding. It continued to go down. And this is the community in which there was the strongest and most embedded program. And it went up the most. Subsequently, the state budget has returned. And the philanthropy really stepped up. And now there's 15 communities that have outreach workers and interrupters. Some of which Cure Violence is doing. Some of which other partners are doing. Some of which we're training, but not doing. And it, and there began to be a corner to be turned in August of last year to start to go on the street in August. It's been building since. So, I'll stop here and make way for any questions. Thank you. Thank you so much for your talk and for the work that you're doing. You mentioned that in the Parkland incident, the people had seen what was going on, going on, but they reported it to the wrong people. There weren't interrupters to report it to. They reported it to people who could not or were not willing to do something. The FBI, the sheriff, the police. If there had been a violence interrupter program there, if people had reported it to them, can you talk a little bit concretely about what those interrupters might have done? Yeah, well, let me say this. Yes, thank you for asking. And there is one of the things, the papers that is available in the back, it talks about this, about preventing mass shootings through this approach. So, it's outlined a little bit more. So, there was a neighbor who knew the course of this kid and actually you probably may have seen or heard about this. So, this kid is autistic. He has deficit disorders. He's probably been bullied. He was expelled from school. He's got foster parents. And he's been screaming out and screaming out. And yes, people came. I'm not saying they're exactly the wrong people, but they don't have the skills and tools. And in many cases, they don't have the confidence of the person themselves. So, what does an interrupter do? If this were a health department, there'd be responsibility. Responsibility for making sure that every one of those possible event people had someone attached to them. And so, what the interrupter would do would be to, okay, he probably months or years ago, and there's not just interrupters, there's outreach workers. Interrupters are something's gonna happen tonight or tomorrow. These are the next layer of this work are people who work with you for over a longer period. So, they would be interacting with him and the people around them and his family to find out what's going on with him. And if there were violence in the story, which there had been repeatedly in terms of threats and something like that, if it were an acute event, they'd be hearing it all from him and they'd be validating it and befriending him. Probably the people who had been selected would already have a certain set of skills and access to him or people like him in that environment. And again, if it's a acute situation, they're buying time to cool the person down, but what they call babysitting. So, it's not like I'm gonna see you again in a month. It's like, it's an hour by hour thing of helping this person get on a different course. Now, I don't know enough about this individual's exact psychological difficulties as to what additional needs he had or has, but the person is not let go of by our system. As a result of, there's no such thing as there's nothing we can do. There's no such thing. I mean, there's more people who can be brought in. There's a whole family thing that can be done. There's a continuity of effort to this situation. I don't know what else to exactly say about this. We get calls like this all the time, but it's not mass shooting. We get calls all the time of someone who is on social media. When Cure Balance is in a neighborhood and there's let's say 10 interrupters and outreach workers and there's about 200 high-risk people, all of them, those clients and participants and all of their friends, et cetera, in that whole neighborhood, we're watching social media. We're watching Facebook, Instagram, you name it, and as much as possible as resources allow, paying attention to and trying to cool down everything that's going on there. This, the guy who did the pulse shooting, pulse nightclub shooting, this is a really instructive one that's more ordinary because I don't know enough about the particulars of whether how to get someone who is autistic and attention deficit and also violent and all of the things that have happened to him, all the additional services that are required. This kid, he had been bullied, et cetera. His whole course is the course of watching something get worse and worse without care. The FBI followed him twice. Do you remember this? Once for six to nine months, once for nine to 12 months. They followed him, they watched him, they did what they call surveillance. There's no intervention. There's no intervention. That, from our point of view, is like watching someone, you name it, diabetes or asthma or tuberculosis if it's communicable, they'll get worse and worse and worse and worse while doing nothing. Furthermore, it takes 20 of them to watch one person. These interrupters and outreach workers, each of them can effectively manage 20. So instead of 21, it's one to 20. The independent evaluation done by the Justice Department interviewed 398 of these super high risk shooters. And they, it's confidential interviews. And what they learned was that, yes, they were the shooters. They were the worst case individuals. Many of them had a history of having shot. They were highly involved in the gang. Most of them had guns. They, with time, found that the outreach workers and interrupters became the most important person in their life other than their mom. And there's between 85 and 97% effectiveness by quizzing them and asking them themselves confidentially in either helping them get a job or helping them get back to school or helping them with their financial situation or helping them with their family situation. They were asking, what are your biggest problems? There was like 10. Whatever their problem was, there was 85 to 97% of them said that they had gotten effective help in these arenas. And by the way, none of them had had any problems once they were contacted. And if one guy isn't able to do it, they get their friends. They get the other interrupters. They get the other family involved and so on. Well, he's running up there. We're gonna come down here next. Yeah, I appreciate your talk a lot. And it seems clear that the FBI and the police are not doing a very good job of protecting the citizens. In terms of the infectious disease model, you see when you stop the intervention, you see this really large rebound phenomena, which I don't really, do you see that really in infectious diseases when you stop doing it? I mean, does that fit with your model exactly? Well, I mean, yes. I mean, for example, in this city, in the 1990s when immunization was defunded, it happened, measles came back. And the same thing happened with tuberculosis. Again, in the 90s, in this city when it was defunded. So most effective programming requires maintenance and sustained efforts, usually at a lower level. It also happened actually in the AIDS program in Uganda, which had the most dramatic and most powerful and most effective reduction in new HIV infections. I know I was involved with that program, in fact, responsible for guiding it. And it was like 10 years later, they had kind of let go and let go and it came back. Are the interrupts working through the Department of Public Health or? Are you talking about Chicago? Yeah, I mean. No, in almost all cities where this works, in the United States, the interrupters themselves and the outreach workers and the hospital responders are supervised by and hired by community groups who are trained and organized and supported, excuse me, in the management of this work. The people in the neighborhood don't know very much about things beyond that, they don't know that. And then in the cities that are doing this best, it is the Health Department that oversees, this is New York, for example, the Health Department oversees the 18 communities which they've had funding for all of this time and now they're expanding to 22. So that's the beginning of a system and then there's the hospitals. Here it is not managed by the city. We at UIC are doing subcontracting from straight money into several of the communities and the Metropolitan Family Services is also subcontracting to several communities and we're working very closely together on this. Have you tried to incorporate it? I mean, to get public health interested in doing it? It seems like it should be a public health priority, I mean, for the city. Yes, it should be. Right. You were gonna say, I want to bring it down here because she's been waiting for a while. I'm sorry, and then we'll come back. Is it all right? Yeah, it was a promise. Thank you. We'll come back to you. Any comment in those countries with the highest violence to apply, for example, in the Middle East? Yeah. In the Middle East you're asking about. So our experience in the Middle East is this, we had about a seven-year program in southern Iraq in Basra and also in Beirut in the southern city and there were about 1400 interruptions and it became so popular that mayors in and around Basra were running for office in support of it. We don't have comparative data on there. It was a little harder to get data. In the West Bank we've done multiple trainings and we're developing new partnerships there. We have a lot of contact there with people who have been working very, very hard on their own to control violence there. And in Syria we've done a series of trainings with different projects and now we have something that we're exploring now that is a lot more substantial, that we're just starting. Along with, I appreciate you looking at violence from a health perspective, but along with looking at it from a health perspective, I don't know how violence can be honestly and generally address without looking at when you speak about language some words such as government, history of violence and its impact on the world, Hollywood, sensationalism, business, profit, the same thing as sex is used for in media, Hollywood, racism, hatred, prejudice, a means of control, starting from the top and how that impacts the world to a lot of the things that we're talking about here. What you're saying is very relevant. The data is clear on is that inequity is a big variable and is somewhat predictive and also trust in government or let's say distrust in government. Those two hold up is what I refer to as the dirty water for example with cholera or other things like that. At the same time, what these methods have been able to show is that you can reduce violence by 40%, 70%, 80% despite all of that. So it's not to say that those things aren't important or relevant but what is exceptionally important to consider and this has been the case in many other epidemic problems too because I mean tuberculosis, crowding is important in a lot of vaccine preventable diseases, nutrition is important. I mean, God's sake, water and sanitation is very highly important in cholera. I was living in Somalia in refugee camps in the desert. We were completely unable to provide water and sanitation but we were able to drop the rates of deaths by 85%. So it is not an either or. I've been in a lot of these conversations at World Health. You should pay attention to A and not B or B and not A but if we're not paying attention to what can really help resolve the humanitarian crisis of the moment, we're missing the opportunity and I just want to add one other thing to this besides saying that all of the things you mentioned are important and I probably quite agree with you in terms of the way this culture comes at things. The, well, as I was going to say, if you reduce the violence, a lot of other things get better. And if you don't, but the way out of the violence isn't making all of those other things better or else we have not found the way to do that yet. And that's a really big statement that I made but this was said to me by a vice president of the World Bank which by the way is full of, as you may know, economists. And they said, we've been trying for 40 or 50 years to economically develop our way out of violence and have not succeeded. And so we have decided to, although they backed off of it a bit but they decided about 10 years ago to go advance reduction and prevention head on because they were failing. So I think you hear what I'm saying is that these are both important, but we have methods. See that's the whole business of all contagious problems exist in the context of adverse circumstances but you can reduce them tremendously by interrupting the transmission and changing the norms relevant to them. I'm sorry? Looking at what's more, I understand what you're saying, I can appreciate that, but I'm just looking at what's more genuine and sustaining, sustainable. Well, I mean, really what you're asking about what is potentially sustainable? What you'd like to see sustainable? What, the way that you'd like to see society look. Yeah, I mean, I think if we could get rid of a lot of these underlying problems, we'd be bringing about the kingdom and that is probably desirable. Realistically, that may be doable. However, I do want to kind of add onto and recognize that America has a special problem. And I know this from having been at World Health where I had a group of 40 and we had only two Americans. And when I, in my work in the international environment, a World Health Organization was not blacks and whites and some Hispanics. And then there's others I didn't mention. It was my group had people from Lebanon and Zambia and Bangladesh all in multiple countries. America stands out, Americans stand out. Black and white Americans stand out as being particularly in my opinion and basically in the opinion of the international world that I lived in for 15 years straight, not having lived here. The America and Americans are seen as particularly individualistic, aggressive and violent. The inequity is very high here. I could tell you stories. I could tell you stories. I mean, I had to, when we would have meetings at the World Health Organization and we would invite, let's say 30 consultants, there was an unofficial rule, no more than two or three Americans. Why? And this was not a street meeting. This was not a community meeting. This was a meeting of world's experts, quote, unquote. Largely people who were the best at their fields, whether it had to do with behavior change or sexual behavior or malaria or whatever it was. No matter what it was, we would try to limit to two or three, why? Because they would dominate the whole meeting even if there were just three of them. And I would, on a Sunday, meet with Americans coming in for a Monday meeting. I'm not talking black and white right now. I know they're, I'm talking, because I'm seeing it in the black and white world here myself. There's differences in opportunities, but this overall stuff. Well, I would say, you know, I would brief people and ahead I said, you know, well, there's gonna be some people at the meeting and they don't talk so much. And it doesn't mean they don't know anything. They're listening. And so this culture is particular and it was a real freak out for me returning to it. And I think I've adjusted about 50%. And for a break, I go to California. If I may, I have a couple of questions for you, but I should probably make it brief. I wonder if in terms of interruption and prevention, if you focus on victims of crime, I'm sorry, not only the victim, but also the families. And the reason I ask this is because it seems to me that at this time where people are suffering the violence, there is also a lot of anger, right? And probably been trying to seek revenge. And I know that there aren't that many resources out there to focus on everybody who needs intervention. But I wonder one, if you do any work with them and two, if you have any kind of more community type of intervention as opposed to individual interventions. Yeah, two really right on, completely right on questions. So on the first, yes we do focus on the person who's called the victim. Let me just stay on that for a minute. You have someone who has TB and he gives it to someone else who has TB and you give it to someone else who has TB. So is there a perpetrator and a victim? You see my point? Because that person, but your point within that is that person is very likely to have more for himself or to perpetrate in that jargon. In other words, to transmit to somebody else. So you're exactly right on the incredible importance on focusing on that person and the person around him or her, usually him, because there's a very, very high risk of another event to that person as well as from that person if you wanna use those words and to and from the people around him or her, usually him, who he is interacting with, whether it's his own group or it's the group who he's interfacing with. So it's exceptionally important. And that's why these hospital interventions are so critically important because you have the starting point of the person who now is showing as a word disease. Just like the hospital is important when you see someone who has TB or who has any kind of infectious process. So that's a beautiful lens and so a very important program aspect. In terms of your question having to do with community, there's tons on this. There's tons of work because there's the individual, then there's the individual longer term, then there's the stuff that he has to do with the friends and colleagues, associates. And then there's a lot of community level activities, what we call public education and training and discussion and work on shifting norms. Just as this is actually a giant part of how Uganda changed its AIDS program. It was doing focused work and broad work in the community. But it's not enough. What has been done, that part has not been realized yet. Where violence prevention is right now is where tuberculosis was in the 80s. There's a lot of refinement yet to be done, a lot of additional pieces that need to be added. And that one needs to be built more. There needs to be universal training, training throughout the whole community in short, through multiple ways. Please join me in thanking them. Yeah, thank you, Matt.