The cost of murder

Jason was 8 years old the first time he came to the emergency department at 236-bed Children's Hospital of Wisconsin in Milwaukee with alarming injuries, the results of being severely beaten on the playground.

Four years later, he returned to the ER with multiple stab wounds from scissors reportedly plunged into him by a classmate. The same nurse who cared for Jason the first time took care of him again, now concerned for his safety but powerless to do anything.

The last time Jason came to Children's, he bypassed the emergency room and went directly to trauma, where surgeons tried to repair the damage of a gunshot wound to the chest. He was 16 years old, and he never left the hospital. For the third time in eight years, the same nurse was at his side and trying to reconcile her conscience as she tended to him on his deathbed.

“The nurse was saying, we have to do something for these kids. We're just treating their wounds and not figuring out what is causing them and having them come back to us,” said Toni Rivera, recounting the story of the nurse, Jennifer Wincek, and the young patient, whose name was changed to protect his family's identity. Rivera is today the manager of Project Ujima, one of the longest-running hospital-based violence prevention programs in the country.

Through education and community-outreach activities, Rivera said the program has decreased emergency-room recidivism—repeat trips to the ER within a year's time—from the 18% seen in 1995 to 1% today among the 300 kids who take part in the program annually.

In 2009, 14 years after Project Ujima formed, it remains the only such program in Wisconsin. Officials with the Chicago-based organization CeaseFire, which partners with hospitals to help break the cycle of retaliatory street violence, estimates that 80 metropolitan areas are ripe for such programs judging by their per-capita rates of intentional violent injury.

“The hospital is absolutely a key partner in preventing violence,” said Sheila Regan, hospital response program specialist for CeaseFire. “On a daily basis, the hospital is a central partner.”

Proponents of the programs say many administrators whose trauma centers record high rates of violent intentional injuries are missing a crucial chance to save more lives and prevent costly admissions and readmissions. Although such programs can be expensive and operationally complex, all are based on the idea that the most efficient way to locate people most likely to be involved in the next violent incident is to meet them at the hospital in the aftermath of the latest trauma.

Supporters often compare the state of such programs to domestic-violence prevention programs in the 1970s. Just as it would be virtually unthinkable today to discharge a battered wife into an abusive home without offering help, proponents of community-violence prevention programs are hoping for the same kind of widespread acceptance of their ideas in hospitals someday. Although some evidence shows that community-violence programs save lives and cut healthcare and government costs, many of the existing projects are at risk of losing funding while money remains a major hurdle for prospective initiatives.

All such programs are founded on the belief that hospitals ought to be doing more for community violence victims than sewing up their wounds and handing them the phone number of some community agency. This new approach is known as the public health response, and employs epidemiological principals in the prevention of community violence.

“It's very frustrating to you as a surgeon to see someone who you've spent three, four, five hours in their abdomen putting together their bowels … and then a year later, you see them come back to the hospital, this time for a gunshot wound to the head,” said Carnell Cooper, associate professor of surgery at 666-bed University of Maryland Medical Center in Baltimore, and executive director of the Violence Intervention Program in the hospital's R. Adams Crowley Shock Trauma Center.

Anti-violence programs have been executed widely in large and small communities alike for decades, but the more recent idea of involving hospitals in the formula is based on three concepts. The first is that the most accurate predictor of a violent injury is if one person has already been violently injured, so that hospitals are seen as collection points for people who know where the next incident is going to happen, including not just victims but their families and friends.

The second is that experiences in trauma rooms often trigger moments of clarity in which the victim may finally listen to entreaties for life changes that he would otherwise ignore, especially around his friends. “It's really this golden window of opportunity, when they're open to change,” said Marla Becker, associate director of Oakland, Calif.-based Youth Alive, which runs another of the country's longest-running hospital-based programs, Caught in the Crossfire, started in 1994. “For so many people, it's kind of this (realization) that, ‘Maybe I need to change so I don't end up back here or end up dead.' ”

Finally, nearly all such programs employ specially selected case workers—known as “violence interrupters” in some programs—who are drawn from the local community. Unlike hospital-based social workers, whose roles usually end when a patient leaves the hospital, these case workers visit patients in their homes and communities and can use their “street cred” to form a rapport that might not be possible with an overworked, office-bound social worker.

The programs in Baltimore, Chicago, Milwaukee and Oakland were among a group of programs that banded together earlier this year to form the National Network of Hospital-based Violence Intervention Programs with the intention of spreading the model across the country.

For their first and only meeting so far last March, organizers of nine programs that involve hospital components gathered in Oakland. Since then Philadelphia's Pennsylvania Injury Reporting and Intervention System, or PIRIS, lost its state funding and no longer operates, decreasing the number of active programs in the national network to eight from nine.

Why so few? If urban street violence is at so-called epidemic levels in 80 different cities, and if hospital-based programs can save money by preventing $40,000 traumas for patients who rarely pay their bills or carry insurance, why do only eight active programs constitute a national network?

“If healthcare could work together in partnership with our communities, I think we could have a significant impact on violence in our society. I just don't think we've thought about that as another way to leverage our skills and competencies,” said Colleen Scanlon, senior vice president of advocacy for the country's second-largest not-for-profit healthcare system, Denver-based Catholic Health Initiatives. The system this summer began what it called a first-of-its-kind program to award $500,000 in grants to 14 of its hospitals, some of which are pursing community-violence prevention.

On the surface, organizers say funding has historically posed a huge barrier.

A bare-bones version of these labor-intensive programs can cost $200,000 per year, while more extravagant programs can top $1 million—costs that are proving tough to fund during a long recession creating financial headaches for community hospitals. Experts say nearly every existing program relies on grants and community fundraising drives, which often prove unreliable in the long run as government administrations change and donor sympathies shift.

“To some degree, some people feel that these kids are hopeless, to be honest. I don't personally. But they feel that if we're going to spend our money, we should spend it earlier,” said Tina Cheng, a division chief and associate professor of pediatrics at the Johns Hopkins Children's Center and co-author of several journal articles on hospital-based violence prevention programs. “That general feeling that you can't prevent injury is pervasive out there.”

Academic studies of patients readmitted for violent injuries within a year of initial hospitalization have found widely disparate rates of hospital recidivism. CeaseFire estimates that between 30% and 50% of people who go to the hospital for a nonfatal violent intentional injury will return, while a 2007 study in the Journal of the American College of Surgeons found a wide lack of agreement in previous studies: “Although violence-related recidivism varies widely (6% to 44%), penetrating trauma from gunshots, stab wounds and assaults remains a robust predictor of future violent injury,” according to the journal.

Program supporters like to say their activities produce declines in trauma visits and overall costs by reducing recidivism and retaliation, but the reality is that the data are not that clear. Several studies have shown decreases in the costs to the criminal justice system, but the search to quantify declines in hospital costs has proven elusive.

Data-gathering is a top priority for the new network, though advocates say it could take a decade for a startup program to demonstrate evidence-based results. A major part of the difficulty is the ephemeral nature of what is being measured: How does a researcher prove that a trauma visit was prevented by a specific program, and how much the averted violence would have cost had it occurred?

The figure most commonly cited by violence prevention groups is that trauma visits from violent injuries cost an average of $40,000 each, with spinal injuries representing a far more costly outlier. The last time researchers attempted to estimate the cost of traumatic violence was in 1999, when an article in the Journal of the American Medical Association found that the cost of acute-care treatment for nonfatal gunshot wounds in 1994 was roughly $15,000 per injury, measured in 1994 dollars.

Meanwhile, specific programs cite widely varying declines in hospital recidivism as results of their activities. One of the goals of the PIRIS program was to evaluate which specific services within anti-violence programs worked better than others, based on recidivism rates.

“There is some evidence, and I think there needs to be more evidence,” Cheng said. “I don't think there's tons of evidence out there, but it's only recently that people have thought about violence as a public health problem that is preventable. So it doesn't surprise me that it's taken awhile to get the evidence that we all want to have.”

The PIRIS program was also working to quantify other cost-savings, starting with the acute care already provided. Usually the interventionists' first job is to get eligible violence victims enrolled in whatever subsidized insurance programs they can, lowering hospitals' upfront charity-care costs.

More ambiguously, program organizers hoped to chip away at the chronic healthcare costs associated with exposure to violence, based on research that has shown that adverse childhood experiences can cause lifelong chronic health problems like high blood pressure, cardiac impacts and poor insulin regulation by keeping the body in a constant state of hypersensitivity.

“In the short term, this requires money that you don't see necessarily immediate returns on. In terms of investment, this is more of a mid- to long-term investment,” said Rose Cheney, executive director of the Firearm and Injury Center at the University of Pennsylvania, which formerly housed PIRIS in collaboration with two other trauma centers in the city.

Bottom lines could benefit from such programs in other ways, particularly at not-for-profit systems that tend to own the urban hospitals that see the highest numbers of trauma cases. In the current political environment, such hospitals have a keen financial incentive to find ways to prove their worth to the federal government.

Lawmakers and regulators have recently been increasing the pressure on tax-exempt hospitals to prove, in specific dollars through specific programs, that they do enough to support their local communities to deserve the billions of dollars in tax breaks the not-for-profit hospital industry receives. The implicit threat is that their tax-exempt status may eventually fall into jeopardy.

Although many of the leaders in the anti-violence programs may be unaware of it, not-for-profit hospitals all across the country are writing their first community-needs assessment reports, in which they intend to show that programs like blood-pressure screening clinics, health fairs and obesity education programs constitute enough “community benefit” activity to justify special tax status. Yet for every CPR class put on by a hospital, there's a nurse or administrator who has to lock their doors as they drive to work through some of the most violent urban centers in the country.

“It's one thing to prevent obesity or offer CPR classes. It's another to figure out where to step in and try to stop this epidemic of violence in our communities,” said Jane Lowe, team director with the Robert Wood Johnson Foundation's Vulnerable Populations Portfolio, which has awarded grants to many of the programs that exist today, and is funding a seven-city extension of the CeaseFire program.

And whether the hospital administrators know it, the American College of Surgeons in 2006 began requiring all Level I and Level II trauma centers to have on staff a dedicated, salaried injury-prevention coordinator in order to receive the ACS' voluntary endorsement sought by many leading hospitals. Some hospitals have begun making this position responsible for community-violence prevention.

But if hospitals with high levels of trauma have direct and indirect financial incentives to start programs to prevent violence in their communities, and several successful models already exist for such projects, why are they still relatively rare and subject to spotty funding?

Perhaps hospital administrators don't want to hear that they may be exhibiting the exact same biases held by society as a whole and separating patients into groups of good people and bad people. Observers say that attitude has in many ways allowed the problem of pervasive urban violence to develop and remain at the alarming levels seen for the past several decades.The instinct to judge is particularly strong when the people involved come from different racial, economic and educational backgrounds than hospital staff. Program directors say most such patients are young black males and Latinos from impoverished neighborhoods.

“When you're dealing with kids that are coming in with these injuries, a lot of people in the hospital stigmatize them because of the injury. They feel if you got shot or stabbed you must be in a gang. First of all, a lot of these kids are not in a gang,” said Thea James, assistant professor of emergency medicine and director of the Violence Intervention Advocacy Program at 520-bed Boston Medical Center, a safety net hospital that sees about two-thirds of the city's gunshots and stab wounds.

The stereotypes are not all false, however. A study of patients at Baltimore's Shock Trauma Center, one of the nation's busiest trauma centers, found that 75% or more of the participants in the violence-prevention program there had prior criminal records.

“That opened our eyes,” said Cooper, the surgeon who founded Shock Trauma's violence intervention program. “These are not poster children for United Way. These are tough folks. That gave us pause. Seventy-five or 80% was a bit daunting.

“But we said, ‘They're our patients, let's move on.' ”

Here are the grim facts, as reported by the Centers of Disease Control and Prevention: Homicide is one of the leading causes of death for blacks as well as among Hispanics, the most recent data show.

Among all demographic groups, the second-leading cause of death for Americans ages 15 to 24 is homicide. In some specific cities like Oakland, homicide is the No. 1 cause of death in that age group.

And despite what has been reported in the news media about falling crime rates, the federal data show that the per-capita rate of death by homicide for adolescents and young adults in 2006—the most recent year for which CDC death data are available—was at its highest rate in at least eight years.

In 2006, at least 5,958 people ages 10 to 24 were murdered. That's one young person killed by intentional community violence roughly every 88 minutes for the whole year.

The violence among youth has proven so pernicious that a growing number of advocates are calling for a full-scale epidemiological response. Among the advocates is Gary Slutkin, executive director of CeaseFire and one of the leading national voices demanding an integrated public health response to the problem of urban street violence.

The criminal justice system only teaches criminals how to avoid getting caught, but the public-health approach—with hospitals at its core—can affect individual decisions that perpetuate a retaliatory cycle of violence, Slutkin said. Over time, he believes this type of approach can change community and societal norms, which have a far greater impact on individual behaviors than laws do.

Slutkin is a physician by training, and spent the first half of his career fighting disease epidemics, first in Africa and later in San Francisco, which explains his epidemiological approach to urban violence. He compares efforts like CeaseFire to tuberculosis clinics, which try to control outbreaks by focusing on the people who are spreading TB with their infected sputum.

“But instead of changing the sputum, we're changing the thinking,” Slutkin said during a Sept. 25 presentation in Chicago addressing violence and the ethics of urban healthcare at Northwestern University's Feinberg School of Medicine.

Under the CeaseFire approach, the program dispatches street-savvy violence interrupters to the ER, where they can directly contact and confront anyone present—including the victims and their peers or families—and attempt to stop a retaliatory incident before more victims are sent to the trauma unit with gunshot wounds. Many times all it takes to prevent another shooting is convincing everyone to hold off on any action for 24 hours.

“These guys go to the interrupters months later and say, ‘Thank you so much for not letting me make a mistake. I was off the hook,' ” Slutkin said. “Sometimes money needs to be returned. … Sometimes there are occasions where someone needs to get beat up a little bit, but not killed. We don't talk about that much.”

In addition to CeaseFire, which is a community-based not-for-profit run out of the University of Illinois at Chicago School of Public Health, several programs originating entirely within hospitals have sprouted up. Some run intervention and life-skills programs, while others serve as active contact points to existing community services.

The exact details vary as widely as the cities they serve, but nearly all hospital-based programs use or employ the violence interventionist who comes from the local community and often has been to prison and back. These are paid employees, not volunteers, and in addition to talking about violence-avoidance with victims and their peers, the workers help victims with getting GEDs or vocational training, advocating in court, getting mental health or substance abuse counseling, removing tattoos, preparing resumes and serving as job references.

The emphasis on holistic life changes is a defining element of all such programs. Philip Leaf, director of the Center for the Prevention of Youth Violence at the Johns Hopkins Bloomberg School of Public Health in Baltimore, put it this way: “When any of us go to the hospital, when we get out we go back to our job. If drug dealing is your job, you're going to sell drugs when you get out, unless there's an intervention.”

Melvin Juette knows what it's like.

He grew up in a Chicago neighborhood permeated with gang influence, and joined one himself in the eighth grade, taking comfort in the belief that even if he were gunned down as part of his dangerous lifestyle, his brothers in arms would always be there to avenge him.

That day came on April 16, 1986, when he found himself in the hospital with a gunshot wound to the back at age 16. At the time, he was looking forward to the revenge that would be doled out by his fellow gang members. “They were going to go out and spray bullets at anyone from the rival gang,” Juette said. “I was, for lack of a better word, excited about it.”

However, a church choir director reached out to him in the hospital, and as he recounts in the book he co-wrote, Wheelchair Warrior: Gangs, Disability, and Basketball, Juette ultimately was convinced of the downward spiral of violence. But once he changed his mind, he had to figure out how to convince his friends of the same thing. He decided to tell them to hold off on revenge until he got out of the hospital, saying he wanted to be there for it, though he wound up spending so much time in the hospital that the vengeance eventually went uncommitted.

“It was the first time I ever thought about involvement in gangs and how destructive it was,” said Juette, who today works as the community service coordinator in the deferred prosecution unit of the Dane County district attorney's office in Madison, Wis.

What's surprising to many outside observers is the pettiness of the squabbles that lead to shootings and trauma visits. Popular conception would have it that hardened street warriors are shooting each other over gang turf or drug-dealing territory. While that does happen, researchers and former gang members say, many times the shots are fired in emotional disputes over girls or paranoid perceptions of disrespect. Frequently, not only the attackers but also the victims are intoxicated on alcohol and drugs.

On the street, disrespect can be a capital crime, and the offense can be as slight as making a comment perceived to be disparaging toward one's neighborhood. A stabbing will beget a revenge shooting, and then a counter-retaliatory strike will follow, and soon the cycle of violence has begun and several people from separate legs of the same incident will find their way to the same Level I trauma center for treatment.

But Aretha Franklin would not recognize the brand of respect that gang members talk about. “For me, being in a gang, respect wasn't something you earned. You took it,” Juette said. Retaliatory violence “ends up happening all too often because of pressure from his peers. For a lot of these young men, they are so worried about their reputation that they end up doing something they regret for the rest of their lives.”

That's why the programs use case workers who often have past histories with gangs and the criminal justice system. Some of them may even be graduates of the anti-violence programs. As opposed to social workers, whose duties don't begin until the patient returns after another violent injury, violence-intervention specialists represent not only a friendly face but a community role model.

“It's so hard to change your life,” said Caught in the Crossfire's Becker. “They are living proof that, yes, you can change your life, and they'll support you. It's not just handing (victims) a phone number.”

What do you think?

Write us with your comments. Via e-mail, it's [email protected]; by fax, 312-280-3183.