 It's now my pleasure to introduce today's speaker, Dr. Rochelle Dicker. Dr. Dicker is at UCLA and serves as the Vice Chair for Critical Care and the Chief of Surgical Critical Care and the Associate Chief of Trauma and Emergency Surgery, all at UCLA. Dr. Dicker graduated Summa Cum Laude from University of California, San Diego, received her MD from the University of Vermont College of Medicine and she also stayed at Vermont to do surgical residency. Dr. Dicker then moved back to UCSF and completed her fellowship in critical care and trauma and also completed a fellowship in violence prevention at the California Wellness Foundation. While at UCSF, Professor Dicker led the nation in developing youth violence prevention programs. That's important to remember, led the nation in this effort. Professor Dicker was the founding director of the Wrap-Around Project, a hospital-based violence prevention program that aimed to reduce violent injury recidivism. Dr. Dicker's Wrap-Around Project, which is now operated in San Francisco for 11 years, has received funding from multiple sources including an annual line item in the San Francisco city budget and an R01 grant from the CDC. This program, the Wrap-Around Program, has been replicated at other trauma centers, many other trauma centers around the country. Dr. Dicker is published widely in the fields of trauma surgery and violence prevention and directed a multi-center study of hospital-based violence intervention programs. She also has done work with injury vulnerable populations around the world, especially in East Africa, and was the founding director of the Center for Global Surgical Studies. Recently, Dr. Dicker moved from UCSF to UCLA, continuing her work in trauma surgery, critical care, and violence prevention. Today, Dr. Dicker's talk, as you see behind me, is hospital-based violence intervention, closing the revolving door of violent injury. Please join me in giving a warm welcome to Professor Rochelle Dicker. So it's a really exciting and wonderful opportunity to be here. I really appreciate the invitation, and I just want to say this is not going to be as lively as that ethics conversation, which was just phenomenal. I wish, you know, in California, like, well, that would be all right over here, and this is okay, but you are at it, and I really appreciate that discussion. So I'm going to talk today about something that's really very timely because the American College of Surgeons right now, the Committee on Trauma, I'll discuss that towards the end, is very interested in hospital-based violence intervention, and if you look at the American College of Surgeons bulletin this month, it has four different articles surrounding violence prevention and a position statement by the COT, and as I mentioned, we'll go into that a little bit more. So it's just serendipitous because this was planned so far ahead that that actually came out just now. So we're going to go through a little bit about why we do this work as surgeons, emergency medicine physicians, public health professionals, and its bearings on our population, not just the vulnerable populations in front of us, but really our population. It is us. It's never really them. So we think about a typical scope of practice in medicine and particularly in surgery that focuses on an individual's acute needs, but then really you want to focus on a broader context, especially if you're thinking about public health. So you want to ask the bigger questions, and that's what we tell our medical students and residents all the time. Apply principles of public health, and believe it or not, even though we're talking about surgery, chronic disease, because trauma in particular is a chronic disease, and it's important to observe patterns with an eye on the population in need. So how is surgery compatible with public health? Since the perception of surgery is that it's curative, focuses on the individual, you need high-tech, high-skills, and it's not that cost-effective. That's the rap that we get a lot of times in surgery, whereas public health is something that's population-based, there's a prevention approach. A lot of low-tech type things will work for it, and it's cost-effective. But we're going to talk a lot about how it's really critical for the surgeon and for the emergency medicine physician, and those of us interested in violence prevention, that the marriage takes place with equity. Not equality, but equity, and that's absolutely critical if we're going to crack open the issue of violence, the public health issue of violence. In terms of injury, just itself, injury takes about six million lives annually. It's probably just the bit that we know. In low and middle-income countries, all we really have still is a lot of modeling, so probably the statistic is much higher than that. But if we approach it from a public health standpoint, we can get our arms around this problem by looking at the typical way that we look at other public health issues, other chronic diseases. We do surveillance, research, prevention and control, evaluation, policy, services, and advocacy, and we're going to go through each of those and how we can embrace this issue of violence using that public health approach. But first, a little bit of a background, because you, of course, need surveillance. How many of you have seen this graph before? This is something that the WHO published some time ago now, but it brings to our attention that in the United States, we're 17 times more likely to die from homicide, from gun violence in particular, than the next high-income country in that Finland. 17 times more. But that's really just the broad tip of the iceberg, because it doesn't affect all of us equally. As with other chronic diseases, there's inequity. So the severity and disparity of homicide in youth and young adults looks like this. It is the number one cause of death in young African-Americans, and it's number two in Latinos. It takes 53 per 100,000 African-Americans annually, and 20 per 100,000 Latino. It's totally unacceptable, totally unacceptable. It has become normal somehow, but that is not acceptable, and that's the paradigm that we have to work so hard to change. Oftentimes, it's an urban story. It can be a suburban story. The San Francisco story is just a microcosm of that, where the wraparound project started. And then, who owns it? Well, traditionally, all of us in this room think, okay, violence, that's a criminal justice issue. But it was way back in the 80s that a really smart surgeon general, C. Everett Koop, and the Department of Health and Human Services at that time, came out with this publication that was a bit of a bible for several of us that were starting in this work, and then those that were thinking about it early on, like Deborah Prathrow-Stiff in Boston now in Los Angeles. But they came out with this idea that youth violence is indeed a public health issue, and they published this that sat on my desk for years as I was coming into doing this kind of work. So we first needed to do the detailed injury surveillance. And for San Francisco, it looked like this. So 76% of the homicide and assault victims had criminal histories. African-American men were 13 times more likely to be injured. And today, 4% of the population in San Francisco's African-American, they make up 60% of the gunshot victims in that city. So it was very clear that microcosm of disparity was just what we see in the rest of the country, really. And you'll see that in Chicago as well. And this is what the homicide situation looks like in Chicago, a little more specifically to where your trauma center is going to be. And a lot of the gunshot victims are right around here. So this is exciting for somebody like me who knows that having a trauma center within 10 minutes of where people are shot, you're going to be saving a tremendous amount of lives. And it's really exciting to see that this is happening here. Simply because, like in San Francisco, for example, our transport time are only seven minutes because the city is only seven by seven miles. It's a very small city. We have a different issue in Los Angeles that I still have to wrap my head around. But there was a positive here. And now you're feeling that really important need. And then you have a cumulative shooting victims by day. And these statistics have been running for Chicago since 2012, just to give you an idea of what the issue is. Again, you have to understand the baseline surveillance so that you know what your target population is. So more specifically, there were 762 homicides in 2016, which a lot of you know. There was a 58% increase from 2015. And 75% of the victims are African-American whereas 33% of Chicago's population is African-American. So the story repeats itself a lot in this country. And again, the young victims are catamount to what's happening elsewhere as well. And then the five neighborhoods. Well, you're near one here. Again, you're going to be playing a really essential role. The opportunity here is that you're going to see these people and be able to figure out a way to do an intervention so that they don't come back to your trauma center again. So what's the next step after you've defined the problem and you know what your target population is? It's identifying the risk and protective factors. And this is what's really important and for a trauma surgeon or even for a medical physician to think in terms of social determinants is still sadly a little bit of a new breaking ground. But it's absolutely critical if we're really going to start to get our arms around the problem. So social determinants of health is a complex interplay of social and economic systems. Well, what does this mean in terms of the structure? And we'll see that in just a minute. But let me just mention again, as I did up front, that this is about our population. It's not about them. It's not about they. It's not about that group. It's us. If we don't do something about this from a population standpoint, the interplay between health and wealth, our country will sink under a lack of equity in our healthcare system, not just from the chronic disease of violence, but others as well. Some of the social determinants of health, if you look at just food, for example, why is hunger happening in the United States? There's an economic bust if there's violence in the community. So stores won't go there. What ends up going up is corner markets that don't have good nutritional capacity. Potato chips, cookies, beer, that's what's served at those places. There isn't a whole foods. There isn't Trader Joe's anywhere near to be able to really support adequate nutrition. And then you look at the community and social context. I'll bring up one thing in particular. If you look at communities that are socio-economically deprived, there's a lot of pavement, and there's not a lot of green. And we know that psychologically, that is an extremely anxiety-provoking sort of a situation and picture. All these factors play in to the vulnerability of not just violence but other chronic diseases such as diabetes and heart disease. So you get health outcomes as a result of these social determinants. And I think this is really the most important way to look at the social determinants. We do a lot of phenomenal things, again, on a day-to-day basis with our individual patients. And those individual patients motivate us to go back and look at the bigger solutions. And if you look at what some of the bigger solutions are, they're wrapped up in the bottom of that pyramid. This is socioeconomic and the social determinants of health. They're poverty, education, housing, inequity. We keep revisiting those issues. So if you're going to look at the largest type of impact of populations, you need to go to the base of the pyramid. These are not mutually exclusive endeavors, right? They inform each other, but it's important to remember what's at that base of that pyramid. One last thing I want to bring up, as I mentioned a little bit ago, about social determinants is normalization. And we're going to start going into the programmatic aspects now. And keep in mind about that normalization. Sometimes normalization of violence is happening within the groups of people in a hospital. You least think are going to fit under that mode. So people you think of as very sympathetic groups that you think of typically that are most sympathetic may have that sense that it's normal for Joe Smith to keep coming back through that revolving door in the emergency department. Violence is never normal for anybody. And that's the nuts that we need to crack. That's the education part that we need to do in hospitals. So on the flip side, what are some of these protective factors that we need to focus on in order to be able to start to solve some problems within our communities plagued by violence? We know adult mentorship, interpersonal skills, commitment to school, access to resources, even if that resource is food, as I mentioned. And then way back in 97, there was a study that was done right here in Chicago that demonstrated that social cohesion and a willingness to intervene for the common good reduced violence. What that really says is that it takes a village and that village isn't just the community where the violence is happening. That village is us. It's the healthcare system. It's the university. It's our politicians. So it's really critical to bring in the masses to be able to solve this issue. We have, and this grant actually was written up by a medical student at UCSF who applied through a foundation to get an opportunity for our young people to work at a place called Friends of the Urban Forest. So Friends of the Urban Forest teaches victims to be arborists. And so once they're physically well enough, they are taught how to maintain and how to plant trees. Now, as you're probably already thinking, that has two values, right? They can go back in their community then and plant trees, and that has absolutely occurred to green their own neighborhoods. Then you can start to build that social capital and taking pride in what your neighborhood looks like. And that's a really healthy sort of a real health issue, as I mentioned earlier. So these presented great opportunities for our young people. And the best story I have with that is there were two graduates from this internship program that were hired on by the city of San Francisco. And the city of San Francisco ran a program for middle schoolers from a wealthy part of San Francisco. And so we have these two guys from Bayview Hunters Point, which is the most socioeconomically deprived area of San Francisco, teaching a bunch of upper middle class white kids from the Presidio about how to garden. And these photos were amazing. And it was absolutely incredible. The relationships that were formed between the middle schoolers and these two guys in their 20s, it goes to this day. It was really an amazing experience. So we've now been running this program for about eight years, and that's just one example of some of the work that we do. And then we have an advocacy center that AT&T actually sponsored. We partner with school districts and a job readiness program. We have what's called Project Rebound at San Francisco State that allows people to get tutoring, to ready them for four-year degrees. We have several people in that. So it has provided us with an opportunity to have really our own center where people feel quite comfortable. Particularly now, as San Francisco is a sanctuary city, we are having people just showing up in our advocacy center for safety reasons. They feel unsafe at some of the community-based organizations. They're afraid that ICE is going to come. So they come into our advocacy center. And evaluation, we've been talking a little bit about that, and I'll just show you a couple of examples of what we've been able to do. Now, it's really important that this juncture, as programs are getting up and going, to not only do the quantitative evaluation, and I'll tell you why. In terms of recidivism, that's what everyone was thinking at the get-go, success equals a reduction in recidivism. But there is an ecologic factor that we need to take into consideration. We can't solve the whole issue all at once. We're still looking at an individual level. And the best example I have of this, which made us realize that we need to do some really serious qualitative work, was a young guy last year who was 22 years old, and he was at Friends of the Urban Forest. He had been going regularly for six months and was doing quite well. He had been injured and healed and was doing quite well. We were getting reports about how he was stepping up, taking on a leadership role. He was driving the truck. He came home to his housing project, and we considered him having housing, and he was walking into his house and he was shot a second time. So he's a recidivist. Is that a failure of the program? So that's what was really striking to us. He's back at the Arborist Program. He's doing really well. In fact, they hired him full-time to be part of Friends of the Urban Forest. But he goes on to now speak to our medical students about his experience, but we need to understand that sometimes it's not all about that endpoint of recidivism. We still need to demonstrate in other ways value of these programs. So our evaluation started just with quantitative measures. What we looked at in particular was what were the needs that people thought that they had and did a needs assessment with the case manager. These were some of the things. Definitely court advocacy was a very important one. There are days that our case managers spend in court for several hours, and judges will release our clients to us as part of their program so that they don't go to prison. So that's been an exciting relationship, too, with the court system. So we were looking specifically at whether needs are met. Now, we've become a little bit more sophisticated than this. And what I mean by that is just because we found employment for somebody doesn't mean that in three months they still have that same job. The stressors that people are under, including just being able to take a particular bus to their job, is beyond what I personally recognized up front as far as the hardship. The siblings that they may have to take care of, the three jobs that their mother is working, these are things that need to be considered. So we track things further out. In other words, just because they got a job we don't just check the box anymore. We see if that job sticks, and if not why, and if not, then we need to work harder and get another job for the person. So, and again, it's about readying them for the interview process and their resume. So there are different components to program evaluation. There's formative process, impact, and outcome. And then we wanted to look at independent predictors of success. Why is that important? Because not all cities are like San Francisco. San Francisco has a lot of resources, but just across the bay in Oakland they don't. So if you want to start a program, what do you need at a minimum to potentially be able to provide for your clients appropriately? And so what we found was that in particular, mental health and employment led to success about 86% of the time. In other words, people did not, at this time we were just measuring recidivism, and this was a five-year study, people did not come back re-injured if we were able to provide appropriate mental health for them and we were able to provide employment. That's different, of course, with a younger set of people. So with the younger set of people, it's finding safe educational opportunities for them. Mental health, I'll say, has been very difficult, but the reason that there is success in these programs with mental health is because peers tend to really augment the mental health experience for clients. People have been reluctant to seek out mental health care, but it is so prevalent to have complex post-traumatic stress and anxiety and depression in populations that are in areas that are violent that it's absolutely essential. And you really can't expect a kid to sit in a classroom when they've been up all night hearing gunshots. You can't expect somebody to focus on a job, on cutting trees if they're not able to sleep at night because of gunshots. So these issues are very real and need to be addressed before some of these other risk factors are started. And the partnership between our case managers and our mental health services has been great. And typically our case managers will sit in the first sessions. Now, this is the part that I wanted to show you earlier about how important the case managers are. One of my case managers started calling this a dose. So case manager exposure level was the dose. And my most senior case manager, Mike Texata, says, yeah, I gave him a really good dose today. And that meant that he spent an intensive amount of time with the client. So we demonstrated that in the first three months, if there's intensive case management, that the chance of success for clients was higher. We had our 10-year reunion, and this is just another plug for you to see that it takes a village. So I'll point out a few people. This woman is the heart and soul of one of the community-based organizations. Her daughter, when her daughter was five, she was shot in a drive-by. So she has been an advocate. I've known her for about 20 years now. Here is a guy who runs the San Francisco state project rebound. This is somebody from the court system. This is a hospital administrator. And this is a guy who runs the Arborist program. And I think he just came for free food, I'm not sure. And here's one of our clients. There are a couple of clients in the background there. And this is one of our clients, too, right here. So it really is a village. And this is our advocacy center. It's a weird amphitheater shape. But we've got murals up and all sorts of things that can be worked on. So then what did we do? We looked at our decade and looked at not only our success rates, but what were we doing wrong? And as I mentioned, housing, we were really concerned, was a risk factor because of that issue that I brought up. And there are times that the case managers will turn to me and just say, no, you don't understand. He needs to leave San Francisco because I'm just focused. Well, we've got to keep people in the city. The city's expensive. It keeps pushing out populations. Like, no, he needs to go to his uncles in Vallejo for a while. You know, just for safety reasons, it sometimes is baby steps. So as I mentioned earlier, for the younger population, meeting education needs was associated with success. But we really did, in a statistical way, demonstrate that housing may actually, housing may be a, safe housing may be a risk factor. So it's really important to understand shortcomings. Just because they have a roof doesn't mean that they're safe. So money is always a big question right now in particular. We were making some progress federally before this current administration came in. The way we were making progress was we got taxonomy in healthcare. The intervention specialists are now part of the healthcare system. We don't have a way to pay them through CMS yet, but it's a first step. It's kind of stalled at this point at a federal level, but some states are looking into it. So right now we know that the cost of violence is about $282 billion per year. There are all sorts of costs to it, obviously, such as the psychosocial costs of it. But as far as dollars and $282 billion each year. Now, this is an important statistic not necessarily for you sitting in the audience, but you have to know who your stakeholders are. When you're talking to certain people, they want to know about the bottom line. And so you have to tailor your discussions to what you think your stakeholders need to hear for you to be successful. And to that end, what we did is we looked and did a cost-effectiveness analysis using a Markov theory. This is an economic way of looking at different nodes. So in other words, if you have an injured patient, they either have go to an intervention program or no intervention program, and you look to see what happened to them. Were they re-injured or were they rehabilitated in each of the nodes? So it's a theoretical way of understanding based on the typical annual budget and the cost of taking care of violently injured people, whether or not it's cost-effective. And what we found was that hospital-centered violence intervention programs cost money but cost less than caring for patients after re-injury. And in fact, we found through this health economist that did this study that it was as cost-effective as other prevention type measures such as mammography. So he was quite shaken by this as well. It helped us to get the attention of the Committee on Trauma when they saw that this type of a program was cost-effective. So who funds it? And as I mentioned, what do they want to see? So far in several cities, mayors and supervisors are absolutely essential. Some mayors and supervisors want to be able to know what the cost-effectiveness is. Some want to know just about the stuff that we want to know. Is it saving lives? And some really want to meet a client. So we have several clients that want to speak to the mayor and the supervisors and they come with us and talk about wraparound. We partner with the Department of Public Health and in Los Angeles. Part of the reason I came down there was I have a joint appointment with the Department of Public Health, Department of Health Services in LA County to start up on a county-wide level hospital-based violence intervention. And they just passed a measure that went towards injury prevention funds to be able to do that. Foundations are often interested. California Wellness is one of them. Kellogg Foundation is another one. There are a couple in the Midwest just looking at focus of vulnerable populations before this talk that would be interested in funding a program, I think, in this region. And then federal government is a bit on hold right now. But the state governments really are starting to look at creating bills so that CMS may be paying for a fee-for-service for the case manager's work. And that's probably the most sustainable way to go about this, right? They do something and they get paid just like I take out someone's appendix and I get paid for it. And then private donors is also another potential. So advocacy and policy, the white coat is a really powerful thing, but we underutilize it. And we don't always recognize exactly how much we have to give to the cause of populations through our position in medicine. The National Network of Hospital-Based Violence Intervention Programs, it's a mouthful and we're considering changing our name, does advocacy. We're a group that also is developing a curriculum for the case manager's intervention specialist so that we can have some semblance of fidelity across the board as to what the expectation of the case manager's would be as far as training. There is a group that's focused on mental health. There's a group, a working group that is just front-line workers that discuss difficult situations on a monthly basis. So these calls happen monthly. There's a steering committee call. It's a very productive group and we right now have three multi-institutional studies going on. One is just simply a database surveillance to understand who's entering these programs. Are we more successful or less successful in Philadelphia as we are in the Bay Area, as we are in Boston, and what are the different components that make it better or worse? So these are all things that are being looked at right now. This was a couple years ago, the map. The most striking thing to me here is that there just aren't that many programs in the South. There's one now that's starting in Atlanta and there's a program that's starting at Louisville, but in general the South demonstrates a lack of programs. So we're trying. The best practices curriculum now has been taken up by the Committee on Trauma, and I'll mention that in just a moment. We have an annual conference with Cure Violence. Now, this is the opportunity to mention, as I was talking about community-based organizations, partnerships, you're going to hear from Gary Slutkin later in this series. It is really important to acknowledge that nobody has the perfect pill for this. And to be able to work in partnership with strong groups is a blessing. Everybody should be riding this ship in the same direction. We each have something to offer. So Cure Violence is a great partner of NNHVIP. We have unique skills and we can learn from each other. So it's important to take the opportunity to work towards a really difficult problem together instead of separating us apart. As I mentioned, the American College of Surgeons Committee on Trauma has an Injury Prevention and Control Committee run by Deborah Kuhls, and we've had the opportunity to have a subcommittee on hospital-based violence intervention. Over the course of the year, we've developed a best practices guideline and we're creating a research agenda so that we can continue to evolve because, as I mentioned, it's not a perfect science. And to potentially change the criteria for trauma centers. Now, you know intimately as you're starting your trauma center what's necessary and what's called for by the Committee on Trauma. And right now, prevention is part of that criteria. If you don't have a prevention program, it's a criteria deficiency. But specifics about that particular program, prevention work, is not really well laid out. And we hope our pie in the sky would be that if you have a trauma center that has a huge burden and whatever that burden is of violence in your community that comes to seek your care, that you should be mandated to have a violence prevention program that's best practices. This is this month's bulletin. So the Committee on Trauma came up with a consensus-based approach to firearm injury. And if you read it, you'll see that it's somewhat careful because still a huge swath of the American College of Surgeons membership is also part of the NRA. I don't know exactly how big that is. So this has been a tricky thing to write. It's mostly been written by Ronnie Stewart, who's the head of the Committee on Trauma. And we also had this opportunity to write this primer for developing a comprehensive program for trauma centers and violence intervention. And the primer has opportunities to figure out, well, where should you be six months to a year? What is the realistic timeline of forming a program like this? And it also guides different fledgling programs to, if you just want something that's bare bones, what does that look like? If you want a pie in the sky best program that's out there, what are the components to it? It also is really honest about some of the pitfalls, some of the struggles that we've had. As I mentioned earlier today, I met a CEO who said, why would I want a program like that? Trauma is a cash cow. So you encounter things that you never thought you would by doing this work. And you take a really lot of lumps because it's not perfect. So the primer also comes with a more expanded one that's on the website of the Committee on Trauma. And on the Committee on Trauma website, there is also a PowerPoint presentation. It looks a little bit like this, but it's specifically a template for stakeholders if you need to talk to a CEO or your mayor or a community-based organization. It gives you some guide. It's broad because we wanted to make it so that communities across the board could use it, but just so you don't have to reinvent the wheel. Right now we are creating a memorandum of understanding between the COT and the NNH VIP so that if people who are interested in this work want the help, it's absolutely available through NNH VIP. We have a mentorship program for new programs. So the help is out there and you don't have to then go through all the hard knocks that many of us have, but we tend to learn from the new programs as much as they learn from us oftentimes. We're still developing screening criteria right now. That's oftentimes a question that's asked, well, how do the case managers know that somebody is high risk? And that's a tough thing to capture because sometimes it's these Wednesday meetings or just, no, I know he's high risk. So we're trying to capture it simply because we are asked that question all the time. And so a Yale medical student came and worked with us last summer and tried to develop a risk assessment via qualitative analysis with the help of one of our case managers. So the gold standard was the case manager and he broke down components that looked critical in that algorithm of who's high risk and we're still validating this, but it's a start. So why should healthcare providers be a part of this work? I have hope I've convinced you a little bit, but it really does feel like you're standing at the bottom of a waterfall. It really does. So you take the spleen out, but you send somebody out to the same social determinants. So what have we done? And if it's not you, then who is it? The crux of this program is the case manager, but it's really important to have a champion within the hospital and that could be a clinician. It can be a social worker. It can be a public health professional, but it needs to be someone who is dug in and knows the culture of the hospital, but absolutely goes out into the community and doesn't stay in the ivory tower. So Malik knows that I use his picture all the time. So this is Malik. He was 109 units into this. He had a resuscitative thoracotomy that we were talking about earlier. And Malik is in San Francisco State because he wants to be a social worker. So that's really at the end of the day, that's why we do it. And I couldn't think of a better way to stay positive and hopeful than to understand that Malik is me. Malik is us. And if we're to save our population and really try to create more equity in our country, we need to look at violence and dig in and be a part of the solution. That's all I have for you. Thank you very much. Is it working? Do any of the current trauma programs, anything resembling the wraparound program? So right now, not up and running, healing hurt people in Philadelphia at Drexel is one of these veteran programs. It's wonderful. Ted Corbin, an emergency medicine physician, it's like a brother. He runs it. And he right now is engaged in conversations with Parkland. I don't know exactly today where that stands, but strangely, like, Chicago has not. And I think it's because of somehow, and that's why I brought up the cure violence thing. It's not mutually exclusive, but I think cure violence has had such a position here that maybe some hospital-based programs haven't felt that they would be up and running because of that. I'm not sure. Healing hurt people is at University of Chicago. Rad Stolbach is going to be this in January. Healing hurt people is at both the University of Chicago and at Stroger. And Ted was here two summers ago and we actively implement his protocols. We were struggling with funding for Rad Stolbach out of major SAMHSA grant. And we partner on several levels. So again, information is fragmented, but I just wanted to let people know. Wonderful. Thank you for that. One of the things you talked about is community engagement. And one of the things that has struck me in Chicago is how we partner with schools because schools are like laboratories of both engagement as well as the numerous problems that are out there. And what suggestions would you have not to come in with, you know, let's do scared straighter, let's tell them, you know, guns are bad or never join a gang. All the kind of Hail Marys that are band-aids. But what would you seriously try to do? I think the most important thing is to have the case managers go into health classes. Keeping violence in the context of health has really worked well. We haven't studied it in San Francisco but our case managers go to high-risk middle schools and high schools. And they don't talk about the blood and guts. They talk about what they do. They talk about their careers. And they give a talk like this just that they are a part of this system to build social capital. So they don't bring it down on an individual level. They stay broad and they talk about how they're basically the life force of programs like this. And so it doesn't have that negative context and they don't talk about, oh, you don't need to be in that life. It's just like, look, this is what I do for a living and it's really cool. And that's been our approach. I think there are a couple other programs that do that. And to answer your question also, sir, tomorrow the University of Chicago Trauma Department is partnering with POP, which is Project Outreach and Prevention on campus. And we're hosting a huge pep rally. And we've invited, I think, five or six high schools to come. There'll be DJs from around Chicago. Dr. Ken Wilson will be there. But this is a way to engage the community and show the high school students who we are and interact with them and get things going that way as well. They're also doing it in Northwestern Indiana at Gary. They did it today actually. So tomorrow I think is the, or today and tomorrow is like the first time it's being done. So hopefully something will continue to do. Our trauma department, but Dr. Ken Wilson is going to be the liaison tomorrow. And where will it be? Ken, where is it going to be? I was stuck in the building. I was at another meeting. I apologize. It's going to be at the University Church. I'm new to the institution. I have to give you the street address. I'll have it here for you in a second. 57th and University, thank you. And it'll be at 11 a.m. and it's a two-hour involvement. As Dr. Suha mentioned, has taken champions from the various high schools who are tired of violence in their communities and are looking to partner with the University of Chicago when residents such as Dr. Suha and herself in the trauma service have extended an invitation to anyone who wants to come. Because I think that's what is missing, is that this is a little bit about me, but I was in Michigan, Flint, Michigan before the water crisis became the issue. It was all about trauma. And we had kids who had never seen University of Michigan, and that's only 30 miles away. So it's kind of hard to navigate your way to college when you don't even know the college that is storied as in your own city. So we're hopefully going to show them, not only the University of Chicago in your own backyard, but we're welcoming you to come. So you're all invited. We do a similar thing, taking people to UC Berkeley. It's really an eye-opening experience for them. My name is Pringle Miller, and I want to just thank you for the work that you're doing. It's really tremendous. And also the statement that you made about Malik being you, because I think a lot of what concerns me is just the demographic of the population that's being afflicted and how it's not part of the greater community in our country. My question is, with respect to the statistics and I know you mentioned that the quantitative data is in everything, but when you look at recidivism rates in the areas with which there are wraparound programs, what are you seeing in terms of the trends? So right now, wraparound, that 10-year analysis that we did, we're showing that our recidivism rate has almost fallen in half. And we have, Carnell Cooper is really the only one who's been able to do a randomized controlled trial in Baltimore. He did it several years ago and demonstrated that efficacy of his program, that recidivism was statistically significantly reduced. We couldn't get IRB approval to do it, and I started talking to communities and there wasn't equipoise. Everybody thought, we have to do something, it's better than nothing. So we haven't been able to randomize. Our control is our historical control, but we've almost cut our recidivism rate in San Francisco in half. I used to, thank you. I used to say it really upfront and it just sort of fell out of my vernacular of this talk because I've learned so much about the other values to it. So thanks for asking. One other question, and I'm sorry for asking a second one. We have no mental health or public health, mental health system in Illinois, aside from the Cook County Jail. The Cook County Jail is the largest provider of mental health services in the country and they do not do a very good job at it. How do you address mental health in this era where both the funding and the capacity and the cultural sensitivity are far from equipoise? That's an excellent question and it keeps me up at night. We have in San Francisco, only because this trauma surgeon who didn't only indirectly learned about mental health because that's not the focus of trauma residency, but I think the residents are growing up much healthier and with a better background now. But has anyone heard of the Trauma Recovery Center? It's an incredible... I was wondering because it's starting to bleed into the Midwest. It's something that started on the West Coast but if you look it up, I actually think it may be in Indiana now but it's a program in Indianapolis called Prescription for Hope and I think they're taking advantage of this Trauma Recovery Center. It is an organization that is focused specifically on trauma, on psychological trauma. It manages a lot of people who have been involved in domestic violence. Some of them manage child abuse. One thing that I didn't talk about is these different violent things are sort of siloed but there are so many cross-cutting things and the vulnerability of populations is across these cross-cutting things. So the TRC is spreading and they're oftentimes funded by cities and states. In California, they're funded by the state and they're in different cities in California. I would look to see where that is right now and it's as a result of the lack of mental health care in this country that's just so extraordinarily vital. Finding private practitioners and trying to write private practitioners that are culturally appropriate into funding like SAMHSA funding is also another approach that some programs have taken. Yes, hi and I want to echo that woman's comments about thanking you for the work you're doing. I have so many questions for you. I would like to know if you want to go out and have a drink afterwards, I'm kidding. But everything from the Affordable Care Act and the Accountable Care Organizations and how that's driving some of this conversation within a hospital-based institution to some of the very particular aspects of Chicago violence and concentrations of disparity, the proliferation of guns but also what comes back to your point and I'm really glad that you mentioned it about housing and there's a real challenge when you have an opportunity to intervene in an individual's life and forget about all those other social determinants of health. They live on a hot block that there's a three-block radius that that young person can barely be safe walking out of his house like almost witness relocation programs are needed and that's very true in Chicago. So one of the things I'm curious about you talking about especially because the public health model is really helpful in some ways and in some ways it's not. You don't take someone recovering from tuberculosis and put them back in a household filled with people with tuberculosis. So I'm wondering that with the program that you do it's not a cohort model but you have these partners. Is there some impact that you're studying or seeing by creating a new community for the individuals who are recovering so that they have new positive peer or positive social outlets to continue to make progress in those other areas outside their immediate one? Yeah, that's an excellent question. We have been tracking two programs. There's one, it's called Weapons and Minors Possession. It was actually started by a judge in juvenile justice in San Francisco and it's basically like a mentorship program for first offenders kids who are about 12 years old who are caught minor offenses carrying a knife to school up to that and the judge, this one particular judge just happens to be Jerry Brown's niece. She didn't want to send him to jail. But of course still sort of criminal justice mindset well let's take him to the hospital and show him the trauma bay like no, no, but let's think of something else. And so we partner them with clients, a pay it forward kind of a thing and we're starting to look at outcomes of those 12 year olds and now we have about seven or eight years. That's one. And then the other program is our men's groups that we run. They have become, it was just organic and we're like oh we should actually look at that. They've forged new friendships as a result so their social circle, their peer group has changed as a result of some of these longer term men's groups so we're looking at that as well. And just also real quick follow up the David Lynch Foundation and their transcendental meditation that's had great biometric evidence results about young children in high violent or high trauma schools. Have you worked or do any of the programs, hospital based programs work to provide tools like that for the individuals so they can help mitigate their trauma and stress? We just sent Terrell Henderson one of our case managers volitionally, it was his idea. We paid for him to go through mindfulness training and now he's taking a course as to how to be an instructor. We actually tried to get funding for it through Robert Wood Johnson and we didn't get it. But this has been a model that's been used in the prison system and so we're hoping to bring some mindfulness training to try to build in resiliency. So yeah, thank you. Yeah so it's people who end up after they're injured they're incarcerated and do we stay engaged and reach out to them particularly in the transitional period? The answer is definitely yes. We partner sometimes not successfully with probation and parole officers some of them are really defensive and it's hard to partner with them. Most of the time it's not. But we keep track of where people are if they do go to prison through their mothers, brothers, sisters, grandparents, so forth. So to catch them on the other side when they get out to be there for them and try to work with their officers as best we can. But yeah, we have them on our database like don't forget about these 12 people. So what we have noticed a lot of times is that it's like my young man who was an arborist. So they're still in that unsafe housing situation and that's why seeing that that was a potential risk factor was quite striking. So that's a component of it. Others we lose touch and they're more thought of as a little more hardcore and it wasn't their teachable moment. So it's a mixture. We lose some people to follow up and certainly our follow up isn't perfect San Francisco only has one level in trauma center so it was a perfect area really for us to be able to study and we have a close relationship with the trauma center in Oakland which is the next likely place that people will go. But we don't know all the outcomes but we suspect a part of it is ecologic and then part of it is we just failed for that time. Thank you very much.