Rubbing Out Violence: Critical to U.S. Health

November-December 2011


Few institutions feel the consequences of violence with as much immediate impact as the local hospital, where the grim toll of gunshots, stabbings and beatings is tallied each day in the emergency department. In recent years, recognizing that violence is a serious public health issue, many hospital leaders have adopted a more proactive, preventive approach, deploying vital resources outside the walls of their facilities in an effort to reduce — or eliminate — violence in their communities.

In fact, some hospitals — including Catholic health care facilities — are moving to the front lines of this long-term struggle, reinforcing and expanding their fundamental medical mission with collaborative initiatives to tackle violence and nurture healthier, safer communities. That means reaching out to the community and adopting a concerted, public-health approach similar to successful past efforts to deal with issues such as lead poisoning in children and immunizations. It means putting money and manpower into the effort and building effective coalitions with local schools, police, prosecutors, policymakers and community groups to deal with the myriad societal problems that so often result in violence.

Few need to be reminded that the toll of violent crime in this country is staggering — just as persistent and pervasive as any infectious disease. Each year, more than 50,000 men, women and children in the U.S. die from violence-related injuries. Homicide is the second-leading cause of death for persons aged 15-24 years, the third-leading cause for persons aged 10-14 and 25-34 years, and the fourth-leading cause for persons aged 1-9 years, according to the Centers for Disease Control and Prevention. And while the overall number of violent crimes has decreased in recent years, rising unemployment and an economy still struggling through the vestiges of a long recession may combine to reverse that positive trend.

Many of the headlines and much of the media attention focus on large, urban areas such as New York, New Orleans and Chicago, among others. Over a single weekend last year in Chicago, to cite one notable example, 52 people across the city were shot — and seven killed. The frenzy of shooting prompted two state lawmakers to demand the deployment of the National Guard on Chicago street corners. While heartbreaking stories of crime dominates mainstream media across the country, significant progress has been made in recent years on violence prevention, according to Delbert Elliott, director of the Center for the Study and Prevention of Violence at the University of Colorado at Boulder.

A number of longitudinal studies launched in the 1980s provided experts with improved indicators of risk and resilience factors, helping to increase knowledge around the causes of violence and to advance methods that can more effectively evaluate a particular program's effectiveness. But standards for judging effectiveness need to be raised — and programs must be given the time needed to succeed, Elliott said.

"If you want sustained effects," said Elliott, a distinguished professor emeritus of sociology at the university, "most programs will require multiple years. The programs that are effective are not short-term programs. There are no inoculations."

Recognizing that violence remains an intractable, troubling daily fact of life across the country, Catholic Health Initiatives (CHI) in mid-2009 established "United Against Violence," a comprehensive national program expected to eventually pave the way for violence-prevention campaigns in each of the more than 70 communities served by the health care ministry.

For CHI, based in Englewood, Colo., the national campaign represents a natural connection to its mission of building and sustaining healthy communities.

"When you look at violence prevention from a health care standpoint, it's not a traditional means of delivering health care to the community," said Kevin Lofton, CHI's president and chief executive officer. "But it makes perfect sense that health care providers should be at the forefront of this effort to reduce violence in our communities — we see the toll of violence every day in our emergency departments."

Supported thus far by almost $3 million in grants from CHI's Mission and Ministry Fund, violence-prevention initiatives at varying stages of development are in place at 20 communities where CHI operates hospitals, including such demographically diverse locales as Reading, Pa., Omaha, Neb. and tiny Baudette, Minn. (population 902). The focus is broad, encompassing problems as diverse as youth dating violence to elder abuse.

Annie Lyles, a program manager at Oakland, Calif.-based Prevention Institute, which works with CHI and other organizations and government entities on violence-prevention initiatives, said the toll of violence in many communities has prompted hospital leaders to recognize the need to move far beyond traditional services. It's no longer a matter of just patching up trauma victims or dealing with disease, she said.

"There have been providers who have been sewing up kids' wounds and saving kids' lives for a long, long time," said Lyles. "But many of these providers are saying, ‘I don't want to wait until this kid comes into the emergency department bleeding to death before we act on this problem. They're thinking about how they can make the health of the community better— and prevent that from happening in the first place.

"As these clinicians focus on this approach, there's a big push nationally for collaboration across sectors — a public-health approach that really focuses on the many factors that help make communities safe."

Those so-called "resiliency" factors — strong community networks and social service systems; positive family relationships; financial resources; and educational opportunities, among others — form the basis of a broad, community-oriented, public-health approach that answers this key question: "How can communities work effectively to prevent violence from occurring?"

And that, Lyles added, is why the involvement of hospitals is so crucial: "You have the intersection of violence, health and the community at the local hospital," she says. "Hospitals and health organizations are tremendous advocates — and trusted influences — in their communities. They need to be at the center of this work."

In fact, violence has been characterized as an "infectious disease" — something akin to tuberculosis or AIDs — that must be treated with a multi-dimensional approach that includes the pivotal participation of health care providers. This public-health methodology emphasizes "prevention in the first place — community-wide solutions rather than one individual or family at a time," according to the Prevention Institute's "Preventing Violence: A Primer." In other words, effective primary prevention strategies focus not on individuals but on populations. Examples of this successful approach include everything from reducing lead poisoning in children to a steep decline in cigarette use.

For Lofton and other leaders at CHI, the focus on violence is inextricably linked to the ministry's mission to work as effectively outside the walls of its hospitals as within them, serving the greater good of the community by confronting a chronic public-health issue as complex and unyielding as almost any medical condition.

Leaders are confident that the ambitious program will serve as a model not only for other Catholic health care ministries but also for secular organizations, school districts and violence-prevention proponents across the nation. Of course, the initiative emphasizes a commitment to sustainability — that is, continued support and cultivation of these programs so that they remain effective for many years to come.

Colleen Scanlon, the ministry's senior vice president for advocacy and the executive sponsor of the violence-prevention campaign, said, "From the beginning, we recognized this is a long-term commitment. There's no easy fix here. It's obviously a very significant problem that will take time and resources.

"In the last three years, we've seen significant movement within our ministries of the awareness and education around the reality of violence and efforts toward a multidimensional response to the elimination of violence."

"Building a culture of nonviolence — a culture of peacemaking — is an essential part of our responsibility," said Sr. Peggy Martin, OP, senior vice president for sponsorship and governance at CHI, which awarded violence-prevention grants in July to one of its participating congregations, the Dominican Sisters of Peace. "It is very much a part of the charisms of the original sponsoring congregations and predecessor health systems that make up CHI."

Although Catholic Health Initiatives may be the only health system in the U.S. to create a system-wide violence-prevention program that can be replicated in scores of communities, other Catholic health providers are involved in anti-violence work. These include Mercy San Juan Medical Center in Sacramento, Calif., a ministry of Catholic Healthcare West. The center sponsors a drug- and alcohol-treatment program for pregnant and parenting women that includes domestic-violence counseling. The program earned the 2009 Achievement Citation award from the Catholic Health Association, the organization's most prestigious annual accolade.

Lourdes Health System, Camden N.J., sponsors The Bridge, a support and enrichment program for youth ages 13 to 19 that is meant to address the challenges of adolescence with a wide array of community programs and counseling services, including violence prevention and bullying, a severe and persistent problem for teenagers.

And St. Francis Hospital in Evanston, Ill., has a long-standing relationship with Between Friends, a non-profit, community-based program that sponsors a crisis hot line, provides counseling and acts as an advocate for victims of domestic violence. In addition, the group has worked closely with hospital employees to ensure that they are asking the right questions and providing the right guidance for patients who might have been victimized by a spouse or a parent — an increasingly common occurrence, given St. Francis's location just blocks from the city of Chicago's far north side boundary.

"We see a lot of the [urban] patients they [Between Friends] serve because we're right on the border," said Judith Kosmatka, a nurse manager at St. Francis, an affiliate of Resurrection Health Care.

While the hospital screens every patient on domestic abuse, staffers focus on labor and delivery and the emergency departments, asking questions such as "Are you in a safe situation at home?" and "Do you feel like you've been threatened?" The education through Between Friends "certainly has made my staff more comfortable — they know the questions to ask, how to react and how to proceed to help [victims] get the help they need," said Kosmatka.

Like others who have identified violence as a public health issue that transcends traditional boundaries, she added, "We seek out ways to meet the needs of the population we serve."

In another effort, several violence-prevention initiatives with ties to local hospitals established the National Network of Hospital-Based Violence Intervention Programs three years ago. Those programs, much like the acute-care facilities they represent, are designed for the most part to treat and combat the results of violence rather than the root causes of a problem that plagues so many communities across the country. Unfortunately, partly as a result of costs, the network has not expanded significantly past its initial core of about a half-dozen facilities in urban areas such as Chicago, Boston and Oakland.

Among the founding members of the network is CeaseFire, an initiative of the Chicago Project for Violence Prevention that has helped reduce gang violence in some of the city's roughest neighborhoods through a mixture of conflict mediation, outreach workers and "violence interrupters" — trained staffers who often visit and counsel injured victims at hospitals as a way to reduce the cycle of endless retaliation. CeaseFire, whose work is the subject of a highly regarded new documentary film titled "The Interrupters," works with several hospitals and health systems in greater Chicago, including Advocate Health Care and Loyola University Medical Center, which is now part of Novi, Mich.-based Trinity Health.

CeaseFire's executive director, Gary Slutkin, MD, is an epidemiologist who worked on cholera and tuberculosis epidemics in Somalia in the mid-1980s and then spent a decade crisscrossing sub-Saharan Africa, measuring and documenting the spread of AIDS in countries such as Malawi and Zaire. He compares violence to an infectious disease like TB because each represents "pathological conditions causing morbidity and mortality."

"In fact, violence is the No. 1 or the No. 2 cause of death among young people," said Slutkin. "It's kind of like heart disease and cancer for the young. That's what kids are dying from — and it's what kids are seeing their friends die from."

To Slutkin it's clear that hospitals are becoming more sensitive to their crucial role in reducing or eliminating violence in their communities. In his work, he said, hospitals not only are instrumental in "patching up the person" but also must be involved in "preventing additional risk [to the patient] and additional risk to the community."

"Hospitals are aware of this," Slutkin said. "More and more, they're getting on board. Surgeons do not enjoy taking bullets out of kids' heads and chests and having to talk to their moms."

CHI's concerted anti-violence efforts extend across its far-flung ministry, encompassing facilities in 19 states. They include St. Joseph Regional Health Network, in Reading, Pa., a mid-sized city about an hour's drive northwest of Philadelphia along Interstate 76. The city itself has a population of about 90,000, but the metropolitan area of Berks County, for which Reading serves as the county seat, has about 400,000 residents.

Located in Pennsylvania Dutch country, Reading is not usually viewed by outsiders as a particularly dangerous or violence-plagued city. But in one national ranking about a year ago, Reading was listed as the sixth-most dangerous city of its size in the nation, just down the list from Compton, Calif., and Camden, N.J. Another national ranking, using FBI crime reports and including cities of all sizes, lists Reading as the 41st-most dangerous city in the nation. Gangs have become an insidious problem in the city, whose troubles — a 12 percent unemployment rate and a 34 percent poverty level, the highest in the state — were chronicled in a 2011 NBC-TV "America at the Crossroads" segment hosted by Tom Brokaw.

In 2009, CHI awarded the first in a series of annual grants to St. Joseph to help jump-start a coordinated, county-wide effort to address youth violence. Leaders at St. Joseph, an affiliate of CHI, have joined with the Mayor's Youth Violence Coalition and a roster of almost 100 other organizations to develop a blueprint for action that includes plans for mentoring, tutoring, community engagement and increased communication with youth to reduce the level of violence in the Reading School District and across Berks County. More than 1,200 incidents of violence were recorded in the Reading School District during the 2009-2010 school year. The goal of the Reading Youth Violence Project, led by St. Joseph, is to reduce that by at least 5 percent by 2014.

"From the start, we recognized that if we really want to focus on primary prevention, we have to focus on youth," said Kelly Altland, St. Joseph's vice president for development and a key member of the project's steering committee.

The comprehensive coalition — it includes social service agencies, city and county officials, the school district, law enforcement, churches, charities, local universities and community groups, among many other stakeholders — considered a number of possible areas of focus before identifying a reduction in youth violence as its principle objective. In 2011, St. Joseph received about $150,000 from CHI's Mission and Ministry Fund to help build the coalition and establish the kinds of programs necessary to cultivate dramatic changes in behavior and a reduction in youth and gang violence

"We couldn't possibly begin work on the entire scope of violence in the community — it's just too large," said Altland. "We all felt this was the right way to start. We are trying to reduce youth-on-youth violence at the same time we are trying to keep these kids in school through graduation."

St. Joseph's plans include everything from training sessions for parents to the establishment of new mentoring and extracurricular programs in the local school district, where students are far behind their peers from other parts of the state — another risk factor for bad behavior and violence. In the 2009-10 school year, only about 25 percent of 11th graders in Reading who took the Pennsylvania System of School Assessments were proficient in math — far below the 60 percent rate among 11th graders statewide.

"The ultimate goal," Altland said, "is to stop violence before it starts. To do that, we need to empower families and provide safe and positive schools and healthy neighborhoods."

In Omaha, Neb., Alegent Health, a CHI ministry, received nearly $60,000 from the system's mission and ministry fund for its work in creating education programs to raise awareness on local college campuses of intimate-partner violence, sexual assault and stalking.

In close collaboration with the Women's Center for Advancement, officials at Alegent expanded the coalition to about 15 members, setting the stage for a comprehensive mix of both primary prevention and intervention. Along with providing advocacy and assistance to those affected by sexual assault, intimate partner violence or stalking, the coalition is working to heighten awareness and increase "active bystander skills" on the university campuses. The goal of the broad coalition: Reduce sexual assaults, intimate-partner violence and stalking by 10 percent by the year 2020.

"One key to success," said CHI's Scanlon, "is building the kinds of coalitions and networking partnerships that will be sustainable over the long term."

Meantime, in Denville, N.J., just 20 miles west of Newark, St. Clare's Health System, another CHI ministry, leads a local coalition that includes law enforcement, social service agencies, school systems and other organizations involved in a program to expand support and education to new parents as a way to reduce the threat of violence. With the goal of reducing maltreatment of children and creating a more nurturing environment, the coalition is planning to unveil a comprehensive education and support network for new parents in 2012.

"By supporting parents in creating safe, stable and happy environments for their children from the start, we can foster healthy socio-emotional development for children throughout their lives," said Jamie McFarland, St. Clare's violence-prevention coordinator.

CHI identified non-violence as one of its top advocacy priorities as early as 2000, establishing a close link to the legacy of the congregations that came together four years earlier to create what was then the largest Catholic health system in the nation. In 2008, CHI formally identified violence prevention as a systemwide strategic priority, creating a separate category for the annual Mission and Ministry Fund grants. The ministry also established a long-term goal that called for all hospital facilities to work with their local communities to identify a priority area of violence prevention, with the expectation of a measurable reduction in violence in that specific category by the year 2020.

"As we looked back over the years to review Mission and Ministry Fund grants, we saw that a significant percentage focused on violence — gun violence, gang violence, bullying, elder abuse," said CHI's Lofton. "That's not at all surprising, considering the devastating impact that violence has on lives, on families and on entire communities. And so we felt the need to heighten that awareness and increase the focus on the prevention of violence."

At the heart of CHI's effort is the well-established concept of primary prevention — that is, an approach that confronts violence and its effects "upstream," where the problem starts, rather than reacting after the fact.

This focus on primary prevention in a broad effort to reduce violence dovetails with the public health approach that includes a focus on the environmental factors contributing to the problem. For instance, child abuse results in a higher risk for future health problems that include alcoholism, drug use, liver disease, smoking and depression, according to a report from the National Center for Chronic Disease Prevention and Health Promotion. "The analogy that is often used is the story about onlookers finding a person drowning in a river," said Diane Jones, CHI's vice president for health communities. "When they go to save the person, there's another one in the river. And then another. And then another. One of the rescuers begins to walk upstream and says, ‘I'm going to find out why there are so many people falling into the river in the first place.' And he finds a hole in the bridge, where the people are falling into the river."

CHI has worked closely with the Prevention Institute, a national advocate of primary prevention as the key to a collaborative, communitywide approach to the reduction of violence. An integral part of its work is based on the "Spectrum of Prevention," which includes six increasingly complex levels of work — strengthening individual skills; promoting community education; educating providers; fostering coalitions; changing organizational practices; and, finally, influencing policy and legislation. This systematic approach has been effective in areas such as anti-smoking initiatives and efforts to promote routine immunizations and motorcycle helmet laws, to cite a few high-profile successes.

"Violence is in fact preventable, but its prevention requires an investment of resources, people, leadership and commitment," reads the introduction to a summary of a Prevention Institute document titled, "Creating Safe Environments: Violence Prevention Strategies and Programs."

In addition to employing the Spectrum of Prevention's six levels of work to help propel the national initiative, CHI's violence prevention model — like many other similar programs — includes a number of sequential steps. Among those steps is perhaps the most important of all: Establishing a community partnership with other groups that share common goals.

"Our premise for all of our work in healthy communities — but certainly for violence prevention — is that this work has the greatest potential of success when it's rooted in community partnerships," said CHI's Scanlon. "We can't do this alone."

Indeed, it is the community partnership — myriad stakeholders, from the local hospital to the town mayor — that assess need and determine the focus, selecting from the myriad manifestations of violence: elder abuse, gangs, bullying, guns, rape or domestic violence, among others. Once a priority need has been determined, the coalition must gather specific baseline data, establish a timeline and define overall goals and objectives. At the same time, it is expected that the coalition will continue to expand and improve its effectiveness in helping to reduce or eliminate violence in the community.

While progress is being made slowly and steadily, measurable success will take time, said Jones.

"We have come a long way in learning what effective prevention strategies entail," she said. "To be successful, these efforts will take time. We know that. We know this will not happen overnight. But we know we are making good progress.

"And we know it's important that our communities are involved in this long-term effort."

MICHAEL ROMANO is director, media relations, Catholic Health Initiatives in Englewood, Colo.


Copyright © 2011 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.

Rubbing Out Violence - Critical to U.S. Health

Copyright © 2011 by the Catholic Health Association of the United States

For reprint permission, contact Betty Crosby or call (314) 253-3490.