The face of the young man before me is split open, in a line that extends from his chin to upper lip. Blood drips from the bottom corner of once-white, now-saturated gauze, which I hold in place with blue-gloved hands. Here in the emergency room at Harlem Hospital, surgeons bustle around me and the young man. They suture shut other wounds where the assailant’s knife found its mark.
“Hold still,” I mutter as I reach for the pile of clean gauze nearby. “Try not to speak.” The man nods, but after I pack the wound his mouth opens anyway. “I’m going to kill that son-of-a-b****,” he murmurs, his voice muffled beneath packed gauze. “He’s going to pay for this.” He states this mission as fact, addressed to no one although I’m standing beside him. Behind me, the two emergency medical responders who brought the young man into the hospital stand in a corner. They chuckle when they hear the young man’s threat. “Yeah, you’ll get him good!” one goads. The young man stares at the ceiling.
In my mind, I picture a revolving door. People enter, assaulted and bloody. When they leave, they always send someone to take their place. A classic quote comes to mind: “An eye for an eye leaves the whole world blind.” During my surgery rotation, I met patients whose stories were almost identical to that of the aforementioned individual. Each of them was young and otherwise healthy. Each of them was fortunate to survive. Each of them plotted his ultimate revenge.
The phenomenon has a formal name: the cycle of violence. Defined as a repetitive pattern of violence caused by affected individuals seeking retribution, the cycle of violence represents an enormous burden to society; in the United States, roughly 16,000 lives are lost every year to homicide1, at a direct cost of $26.4 billion annually2. Of those lives lost, 10,000 are between the ages of 15-343.
Gary Slutkin, a Chicago Professor of Epidemiology and Global Health, recognized that the growth of violence resembles an epidemic disease. Studies show that exposure to real-life violence increases an individual’s risk for future violent behavior4. Violence also clusters and spreads in a manner that mimics infectious disease. Based on these observations, in 2000 Dr. Slutkin founded Cure Violence (originally named CeaseFire), a Chicago-based organization that aims to reduce violence by treating it as a public health crisis.
Cure Violence deploys teams of outreach workers, who have often been involved in or victims of community violence, to identify points of tension in communities and prevent the escalation to violence. The workers address environmental factors that may make a community more susceptible to violence, as well as the personal factors that may make an individual more likely to perpetuate violence. These interactions may last months, and can involve putting individuals in touch with social services such as mental health resources, job training, or drug treatment.
Many cities have their own programs that follow the Cure Violence model. NYC Health + Hospitals runs one such program, called Guns Down, Life Up. There are multiple components to the program, but one division involves a hospital-based intervention program in which community volunteers enter hospitals to speak with victims of violent crimes and redirect them from plans to seek revenge.
Often absent from these conversations are the health professionals who treat the wounds of those who are assaulted. A typical surgery note at Harlem Hospital would detail that a patient needed their chest tube removed or labs collected but, except for extreme cases, there would be no mention of the mental state of the patient. We were not trained or expected to screen for the after-effects of violence. Perhaps it is unfair to expect such training, considering the immense workload that surgeons bear. An average surgeon does not have time to sit with patients after trauma; but community members, who know what it is like to experience such trauma, do.
To understand the role of medical professionals in the Guns Down, Life Up, I spoke with Erik Cliette, the Senior Director of the program. He emphasized that violence prevention, not response, is the principal mission of the Guns Down, Life Up program. Guns Down, Life up runs a youth development and mentoring program aimed at supporting the transition to adulthood for young men. “Our kids don’t go to the trauma ward,” Mr. Cliette noted, “We don’t want things to get that far.” Members receive both formal lessons in public speaking, financial planning, and how to handle encounters with law enforcement, as well as more relaxed lessons in music, photography, technology, and physical activity.
Mr. Cliette argued that physicians do play various roles in Guns Down, Life Up. During the summer, physicians speak as part of the Health Ambassador program to promote healthy lifestyles. Some health professionals are active members of the community discussion component of the program, in which members of the community come together to identify strategies to target specific trends in local violence.
Still, a surgery team spends many intimate hours with patients as they recover from an assault. Despite these interactions, many health professionals may not be familiar with the cycle of violence or trained to recognize the way trauma ripples to affect families and communities. I recall a fellow medical student during a talk about police shootings aggressively pressing the speaker, “What does this have to do with medicine?” I also think on the two emergency medical responders who pushed an assaulted man to seek revenge.
Identifying the unique relationship between provider and patient, several hospital systems have started training health professionals to recognize and react to trauma in a model called “Trauma-Informed Care.” Together with the Cure Violence and preventative Guns Down, Life Up model, such systems are working to reduce the damage violence causes to individuals like the patients I met at Harlem Hospital, as well as their families and communities.
2. Cost of Injuries and Violence. (2016, July 29). Retrieved October 08, 2017, from https://www.cdc.gov/injury/wisqars/overview/cost_of_injury.html
3. Ten Leading Causes of Death and Injury. (2017, May 02). Retrieved October 08, 2017, from https://www.cdc.gov/injury/wisqars/LeadingCauses.html
4. Gaylord-Harden NK, So S, Bai GJ, Henry DB, and Tolan PH. Examining the Pathologic Adaptation Model of Community Violence Exposure in Male Adolescents of Color. 2016; 46(1): 125-135.