A 360 Approach From the hospital bedside, to the schools, to the streets,
public health strategies can help stop violence
By Elizabeth Fite

When Savannah’s district attorney wanted to change the alarming trend of kids showing up to the city’s hospitals with bullets in their bodies, he started a program that treats violence like a disease that’s contagious but also curable.

Firearm-related injuries are the second-leading cause of childhood death in the United States today behind motor vehicle crashes, as opposed to a century ago, when pneumonia, tuberculosis and intestinal infections were leading causes of death.

Guns were responsible for 15 percent of the 20,360 deaths in children and adolescents ages 1 to 19 in the United States in 2016, according to a recent article in the New England Journal of Medicine. Of those firearm-related deaths, 59 percent were homicides, 35 percent were suicides and 6 percent were accidental discharge or undetermined.

Chatham County District Attorney Meg Heap talks about initiatives through her office that work to curb violence on Aug. 16, 2018, at her office in Savannah, Georgia. There are several programs that focus on prevention, intervention and suppression of violent crime. Staff photo by Erin O. Smith

“When you think about it, it is a health crisis,” said Meg Heap, the current district attorney for Chatham County, Georgia, where Savannah is located.

Just as improvements in sanitation, better monitoring, vaccines, antibiotics and education efforts help prevent and treat many of the diseases that once killed, research shows that multidisciplinary, public health programs can curtail gun violence. Research also supports that prevention costs less to taxpayers and society than the long-term effects of gun violence, which include but are not limited to costs to families, police, prisons and courts, the health care system and communities.

Youth Intercept in Savannah, the Southeast’s first hospital-based violence intervention program, was launched in 2010 by former district attorney Larry Chisolm. The program uses public health strategies to detect potential conflicts, treat high-risk individuals, and change the norms that allow violence to fester and spread.

“There was a lot of crime going on at the time, a lot of gangs,” program director Sheryl Jones said. “His idea was to stop these youth from dying.”

While hospitals and medical providers are an important part of the public health infrastructure, public health responses to health crises don’t always happen in a health care setting. They often utilize disciplines beyond medicine, such as epidemiology, sociology, psychology, criminology, education and economics. That’s because our health is influenced by many social and environmental forces outside of clinical care.

A public health approach to combating violence can work in a variety of settings — schools, hospitals, communities — but the premise is the same, said Dr. Ted Corbin, an emergency room physician in Philadelphia.

“Folks aren’t exactly right after they have been shot, stabbed or assaulted, and they need support services,” said Corbin, who co-directs a hospital-based violence intervention program called Healing Hurt People at Hahnemann University Hospital, a tertiary care center in the heart of Philadelphia and the teaching hospital of Drexel University College of Medicine.

The program provides free therapeutic services to violently injured Philadelphia residents ages 8 to 30. Those support services come from doctors, social workers and certified peer specialists who have been trained to execute the model, Corbin said.

Sheryl Jones, program director for Youth Intercept, talks about the program’s public health approach to combating violence on Aug. 15, 2018, in her office at Memorial Health University Medical Center in Savannah, Georgia. Staff photo by Erin O. Smith
Time for intervention

In Savannah in 2010, victims, families and law enforcement were grappling with high rates of gun violence, and so were the hospitals, Jones said.

The emergency department frequently went into lockdown mode to ward off revenge attacks against shooting victims, who were being treated there, and their families.

Aside from the safety concerns, victims discharged to the same violent environment often wound up re-injured and readmitted, she said. This cycle of retaliation and recurrent injury costs people their lives and the hospital money — readmission rates for subsequent assaults can be higher than 40 percent and subsequent homicide rates as high as 20 percent, studies show.

With the hospital and local law enforcement onboard, the district attorney’s office secured a grant to launch Youth Intercept.

“You want to get all of those people at the table to have a discussion, because that’s going to be vitally important for it to work,” Jones said.

The program set up shop in a small corner office at Memorial Health University Medical Center, the home of the Savannah region’s only Level 1 trauma center and children’s hospital.

Now when a Chatham County resident age 12 to 25 enters the emergency room with an intentional injury, such as a shooting, stabbing or assault, “intervention specialists” from Youth Intercept work to connect them to service providers at no cost to the patient or their family. Enrollment is voluntary, and participants have access to a variety of services, including counseling, housing assistance, substance use disorder treatment or tutoring for school. Youth Intercept also hosts its own team building and educational activities.

The idea to approach victims at the hospital bedside stems from the notion that the time when someone with an intentional injury enters the hospital is a teachable moment. It’s seen as an opportunity to connect victims to services that hopefully will prevent them from retaliating or getting re-injured, thus saving lives and costly readmissions.

The program is modeled after Caught in the Crossfire, which was established in Oakland, California, in 1994. Since then, more than 30 other similar programs have aligned to form the National Network of Hospital-based Violence Intervention Programs. The group shares evidence-based best practices, cost-benefit analysis and effective case management strategies.

Youth Intercept is housed inside the Heart and Vascular Institute at Memorial Health University Medical Center in Savannah, Georgia. From there, staff respond when victims of intentional injuries arrive at the hospital’s emergency department. Staff photo by Erin O. Smith

Hospital-based intervention staff can be employed by the hospital but often work for a trusted outside agency instead. In Savannah’s case, that’s the district attorney’s office, but it could also be another government agency or private nonprofit group.

Trauma centers like Erlanger hospital in Chattanooga are required as a condition of their trauma designation to have social workers who guide injured patients through the discharge process, but few, including Erlanger, offer the level of intensive services to shooting victims that hospital-based intervention programs provide.

Corbin said hospital-based intervention programs address the numerous physical, emotional and social needs that young victims of violence face.

“It’s not the usual practice of having someone come in, they sit down, they have a dialogue about what is happening,” Corbin said. “Our social workers and outreach workers, they do home visits. They also meet clients in neutral places, if, in fact, home or the office in the hospital is not comfortable for them. So, just really meeting them where they are, literally and figuratively.”

Youth Intercept program director Jones said “intensive services are very important,” with an emphasis on the word “intensive.”

Intervention specialists make themselves available 24-7 and check in with participants at least once a week for a year until they “graduate.” As of August, 236 individuals had completed the program.

“You have to stay in contact with these individuals, because you have to change their mindset, and they have to know that they have consistent support,” she said. “This is not a job for anyone who says that they work eight-to-five. I can tell you that. The parents are calling. The kids are calling, every day.”

Turning to data

In Chatham County, Heap continued the Youth Intercept program when she took the helm, and she joined forces with a researcher from Georgia Southern University to evaluate its success.

What began in 2010 as an intervention program for hospitalized, young victims of violence expanded its presence to local schools in 2013, Jones said.

“We were looking at the data and saying, ‘What can we do before they get here?’”

That’s when Youth Intercept began to shift toward using another program model — Cure Violence — along with the hospital-based program.

Cure Violence was created by a public health professor in Chicago, where it was first implemented in one of the area’s deadliest neighborhoods and quickly earned acclaim for reducing violence by up to 70 percent.

It employs street teams of “violence interrupters” who work to diffuse personal disputes before they turn violent. Interrupters must be “credible messengers,” meaning they are trusted and live in the community where they work. Former gang members or people with a criminal record can make great interrupters.

A condemned house sits at the corner of Hudson Street and Tuten Avenue in Savannah, Georgia, on Aug. 16, 2018. A fatal shooting happened on Tuten Avenue in June 2018. Staff photo by Erin O. Smith

Cure Violence and hospital-based programs often work in tandem, since they both use a public-health framework to address gun violence. While hospital programs treat the effects of violence using psycho-social interventions, Cure Violence works to prevent the epidemic of violence from spreading in the first place.

“We started working with the school system to identify those kids who are high-risk youth, and so we pretty much get referrals from them,” Jones said. “The trends are showing that not just our program, but other programs in the community working together, are actually decreasing the rate of crime, the rates of homicides and shootings.”

In Savannah, years of data and personal anecdotes convinced the community that it was working.

The county commission voted in 2018 to permanently fund Youth Intercept for $218,000 a year, which supports a team with a full time coordinator, three full time intervention specialists, one part time intervention specialist and several interns.

Rather than recreating services, Youth Intercept bridges the gap between existing programs and those who need them, said Kristin Fulford, public information officer for the district attorney.

“It’s done on a shoestring [budget] using existing resources. That’s why we are able to do it fairly inexpensively,” Fulford said.

While violence comes in many forms, most health programs are geared toward victims of child abuse, sexual assault and domestic violence, but there’s a void when it comes to people who are intentionally injured, said Corbin from Philadelphia.

“It turns out that those individuals happen to be largely people of color — largely boys and men of color — and there are not a lot of services available for that population,” Corbin said.

Dr. Ted Corbin, left, and Dr. John Rich talk about the hospital-based violence intervention program called Healing Hurt People in Philadelphia, Pennsylvania, at the Drexel University College of Medicine. Staff photo by Allison Shirk Collins

To get the Healing Hurt People program off the ground, Corbin and co-director Dr. John Rich secured grant money from the Pennsylvania Department of Behavioral Health.

Rich said the core mission of the program is to bring a “trauma-informed perspective” to treating victims of violence.

“What we know from a trauma-informed perspective is that just being a victim puts you at risk for being victimized through a cycle of violence because of post-traumatic stress,” Rich said. “To add to that, a punitive approach generally doesn’t work for people who have been traumatized.”

The program is currently under evaluation to gauge its effectiveness, but Corbin said preliminary results are promising.

“The trends are more toward better, decreased symptoms of trauma, depression, improved sleep quality and improved connectedness to agencies and organizations,” Corbin said.

In North Philadelphia, a separate program called Philadelphia Ceasefire is taking a Cure Violence approach in the 22nd police district, which had the highest number of Philadelphia’s shootings and homicides when the program began in 2011. The number of homicides fell from 13 to eight after the program’s first year and down to two homicides the second year.

Quinzel Tomoney, 47, grew up in North Philadelphia and has served six years in prison for selling drugs. He said he never woke up wanting to be a drug dealer, but his single mother couldn’t afford food or electricity, and selling drugs was the “norm” in his neighborhood.

“These days, this is what kids are struggling with, too, but they hide it,” said Tomoney, who now works as a violence interrupter for Philadelphia Ceasefire, a position he’s held since 2012.

He uses his personal story to relate to high-risk youth and then show them better options.

“We try and let them see the difference and that, hey, you don’t have to go this route. Once you shoot somebody and kill them, it’s different. Only thing I can do is write you a letter and come see you,” Tomoney said.

What started off as a street team of violence interrupters who canvassed neighborhoods has since moved into the hospitals and schools, as well, with headquarters at Temple University Medical Center.

Chattanooga’s approach

Dr. Harold “Bo” Lovvorn, a national expert on pediatric trauma surgery and ballistic injuries from Vanderbilt University Medical Center, spoke about his experience treating pediatric firearm injuries in Tennessee at the Erlanger Trauma Symposium in Chattanooga last August.

“I very much respect the right to own a firearm and the second amendment, but somehow we need to come together,” Lovvorn said. “This really is a public health problem, especially as it relates to children.”

“I very much respect the right to own a firearm and the second amendment, but somehow we need to come together. This really is a public health problem, especially as it relates to children.”

Based on his years of research, Lovvorn said that the Southeast has substantially higher rates of non-fatal and fatal firearm injuries than any other region listed in the U.S. census bureau. The risk of sustaining intentional injuries surges for urban residents as they enter early adolescence, he said.

“These data show there may be an opportunity to intervene at younger ages to prevent the significant morbidity and mortality of being shot later in age,” Lovvorn said. “We need to think about this evidence critically, look at what programs currently exist, where the gaps in knowledge are.”

Although Chattanooga’s leaders often refer to violence as a public health issue, none of the city’s or county’s public health initiatives specifically target gun violence.

Erlanger Health System CEO Kevin Spiegel said victims “always seem to end up on our doorstep for intervention,” but the hospitals are limited in the amount of services they can provide on their own.

Kevin Spiegel, President and CEO of Erlanger Health System, said violence prevention efforts could save health care providers money. Staff file photo by C.B. Schmelter

“Nine times out of 10, those people are uninsured, so we’re caring for them for free,” Spiegel said. “If we could use that money somehow to provide prevention and the gun violence is reduced, that would be a good dollar spent that would hopefully be more effective than just sit back and wait.”

Starting in 2014, Chattanooga’s Violence Reduction Initiative offered social services to gang members, but Chattanooga’s program was for convicted felons, not at-risk youth.

In 2018, Mayor Andy Berke’s administration tried to shift the VRI’s social services to focus on mentoring and services for vulnerable youth. Berke’s administration asked the Chattanooga City Council to support a two-year, $600,000 contract with Father to the Fatherless to provide wraparound support for troubled adolescents under age 18.

Police Chief David Roddy and Public Safety Coordinator Troy Rogers pitched the idea to council members, saying kids who end up on the streets selling drugs, joining gangs and committing violence often do so out of desperation. If someone intervened earlier, they could prevent future violence and young lives could be changed for the better, they said.

Although the plan had many supporters, the council rejected it, saying there were too many unanswered questions and limited evidence of the nonprofit organization’s success.

City Councilman Russell Gilbert said in January 2018 that the city had already spent around $500,000 over the past two years on VRI social services through Father to the Fatherless, which took over services for gang members from A Better Tomorrow.

He said the city had been given no data or evidence-backed feedback from the nonprofit organization on success or failure. Any feedback only came in the form of anecdotes, council members said.

A spokesperson for the organization questioned those claims but declined to comment for this story. Councilman Anthony Byrd echoed those sentiments to the Times Free Press, stating he means no disrespect to Father to the Fatherless and the work they continue to do in the community, even if they aren’t the VRI social services provider.

“I think we have to vet these programs and have monthly/quarterly updates for outcomes that say, ‘Hey, what is this program doing?’” he said. “The situation with Father to the Fatherless — I salute those guys and the work they were doing, but you have to have fact-checkers in the end.”

The task ahead

While Chattanooga’s violence reduction strategy is based in law enforcement, Marla Davis-Bellamy, director of Philadelphia Ceasefire and the Center for Minority Health and Health Disparities at Temple University, advocates a “360 approach.”

“We are in the street, school and hospital and community. Everybody has got to be all hands on,” Davis-Bellamy said.

Marla Davis-Bellamy, director of the Philadelphia Ceasefire program, discusses the Cure Violence method of treating gun violence as a public health crisis in North Philadelphia at Temple University Medical Center. Staff photo by Allison Shirk Collins

Although police play an important role in reducing gun violence, she said they are not the only answer.

“They are falling short because of sheer numbers,” Davis-Bellamy said. “To me, if they were smart, they would use the quote, ‘We can’t arrest our way out of the problem,’ because they can’t.”

Dr. John Rich from Drexel said the person who initially funded Healing Hurt People — Arthur Evans, former commissioner of Philadelphia’s Department of Behavioral health — had a dream of creating a trauma-informed city.

“That idea means that everybody can see that they are playing a part, even if the benefit doesn’t accrue directly to them,” Rich said.

But as it played out, turf wars got in the way. With seven Level 1 trauma centers in the city, Philadelphia’s health care industry is highly competitive.

Rich said there’s sometimes a conflict between what’s best for the city and what’s best for the hospitals. And then there’s the “elephant in the room” — a competitive health care climate rarely rewards these efforts.

“We have heard before there are some institutions that don’t want ‘those kind of people’ in their hospital,” Rich said. “We have to try and identify the opportunities for us to be totally aligned with the mission of the hospital, and the hospital certainly doesn’t want to see people be treated and come back again with another injury.”

With only one Level 1 trauma center, Savannah is more comparable to Chattanooga. But unlike Chattanooga, Chatham County didn’t ask local taxpayers for help launching its program for at-risk youth. They used grants. And the local government only started funding Youth Intercept after eight years of careful data collection and outside evaluation that convinced the county it was working.

Funding is an ongoing issue for intervention programs, so finding creative revenue streams is a must, said Fulford from the Chatham County District Attorney’s Office.

“We learned that you don’t just necessarily go just to [the Department of Justice],” she said.

In Philadelphia, Healing Hurt People was able to start billing Medicaid for its services. But Pennsylvania has expanded its Medicaid program to cover more than just poor mothers, children, seniors and disabled people — something that Georgia and Tennessee haven’t done.

For years, Savannah’s Youth Intercept was funded using federal grant money from the Office of Minority Health, until the county decided to pick up the tab.

Now, the county has a full-funded, three-pronged approach that suppresses, intervenes and prevents violence using law enforcement link to law enforcement solutions story and public health models, but it wasn’t easy, said program director Jones.

Sheryl Jones, program director for Youth Intercept, talks on the phone in her office at Memorial Health University Medical Center in Savannah, Georgia, on Aug. 15, 2018. Staff photo by Erin O. Smith

Securing buy-in and trust from law enforcement and hospital staff took time. It also helped that the hospital had a physician who championed the program from the beginning, she said.

“The lines are very hard,” Jones said, since about 75-80 percent of the kids who are shot know the person who did it.

Although staff try to convince youth to report that information to law enforcement, she said it’s more important that trust is preserved between intervention specialists and the community they’re serving.

“It is just, unfortunately, one of those difficult things with this population. They’re in it, and they’ve been in it for life … so it’s hard to talk to these individuals,” Jones said. “They’ve got to go back into their same environments. A lot of times they have been injured in their own homes, and they’re afraid.”

Youth Intercept workers keep their communication with victims confidential, so the district attorney can’t use the program to build cases against perpetrators. The only exceptions are if kids in the program commit a crime while in the program or threaten to harm themselves or others.

Still, the program could be dissolved by a change in leadership.

On one hand, being under the district attorney’s leadership is an advantage. Staff have automatic credibility and access into places — schools, hospitals, juvenile courts — they may otherwise be denied. But Jones thinks a nonprofit may be more sustainable in the long run, since the district attorney is an elected official. A new DA who may not be interested in keeping the program could take over.

Davis-Bellamy also spoke of the struggles sustaining Philadelphia Ceasefire, citing competing programs and reluctance on the part of city officials to acknowledge Philadelphia’s gun violence problem.

“I had no idea that doing the right thing was going to be so hard,” she said. “It is rewarding, it is exhausting, but it is just way too hard.”

In the Cure Violence model, often the best violence interrupters are former gang members or people who have encountered the criminal justice system, because they understand what the people they’re trying to help are going through.

Davis-Bellamy said she had a difficult time convincing Temple that this was an asset and not a negative.

“We have guys who this is all they have ever done — nine of the 10 have a record,” she said. “That was sort of a challenge with Temple as it relates to human resources and risk management … It took me about a year to get them on board.”

She said the university is now one of the program’s biggest advocates, but this has been a problem for other cities that try to replicate the model and think they can “tweak” it to work for them, leaving out parts they don’t like.

“This is a model — evidence-based model proven to be effective in terms of reduction of homicides and shootings — you’ve got to replicate the model with fidelity,” Davis-Bellamy said. “You may want to add to the model to compensate for your uniqueness of your community, but … whether we are in Chicago, Baltimore, Camden, we are all dealing with the same thing and same population.”