Community Based Intervention-Why We Haven't Solved the Gang Violence Problem:...

Well, thank you all and Rich, thank you for inviting me. And what I'm gonna focus on is, um, Community-based interventions, but I'm actually going to take somewhat of a provocative approach to this, and I'm going to suggest that the community-based interventions, particularly those that have Achieved a fair lot of media attention and I'll touch on some of them, uh, have been incremental at best, and I, I think that we need to look at a more holistic systemic approach to this. And it prompts me as I've been, uh, a serious student of this, is, is that, uh, we haven't solved the gang problem and I think that unless we change our thinking and really uh create a paradigm shift, uh, we will never solve this problem. So I wanna touch on some of the community uh uh interventions, um, and then sort of provide the audience and the listening audience here, uh, uh, at least a glimpse of what I've come to realize is the real reason why we've not really addressed this. And if anything, uh, depending on fluctuations in our economy, things get worse and actually get better with the economy. So this is a slide for the Cure Violence program. It's Gary Slutkin's program. He's an epidemiologist. He proposes that the violence is a social disease and that his approach is actually one to look at it by reversing epidemic outbreaks. And he does so by using three things, interrupting the transmission of the disease, i.e., if these, these groups of uh individuals not only from the community but also trained interventioner will say, OK, who is beefing with whom and go out onto the streets and, and help interrupt what is uh sort of proposed to be a retaliatory shooting. Uh, and they also look at reducing the risk of the highest of those at highest risk and then changing community norms, getting rid of the no snitch sort of approach. And um he feels that this is an evidence program, evidence-based program. It's actually an, an international program and when you look at the 41 to 73% drops in shootings and killings in these uh violent zones, that, that's pretty impressive, but one of the things that if you look at more closely at his experience there is, is that juxtaposed neighborhoods continue to have the violence and to my view is, is that it's not really getting to the root cause. This is the ROCA program. This is a program that was in Boston. It was introduced to me by a, a systems thinker named Peter Singer. He's also at MIT in Boston. And they are in 21 communities in 5 sites. They're impacted some 854 individuals, high-risk individuals, individuals that everybody else, every other nonprofit has given up on. Uh, and this is for fiscal year 17. And as a consequence of their approach, which is unrelentless, unrelenting transformational relationships, uh, they've had some impressive figures there, 84%. But one of the things that I would like the audience to realize is that this is dealing with the individual and what I hope they'll come away from my remarks is, is that We need to look at the neighborhood context of where these shootings are taking place. The program of Roca has actually been so successful that it's one of the largest, if not the largest paper success project to date. And for those who perhaps need a little bit of clarification for that. Roker actually gets funding from such notables such as Goldman Sachs, uh, the state, and they will not get paid unless they really achieve the success, uh, points that are, uh, sort of, uh, you know, mutually agreed upon. Uh, so that's certainly something that has attracted a lot of attention in the media. Homeboy Industries is uh part of Greg Boyle's program in uh LA. Again, this is looking at transformation. No one is rejected. And if you look at the t-shirt here, uh, one of the things that he's focusing on is jobs, not jails. And it's really identifying individuals, developing this relationship with them regardless of what they've done, reframing how they look upon themselves, uh, and then going through this transformation. Part of that ritual is getting rid of the tattoos, uh, that many of the gang members have. Another program again in Boston looks at systems, uh, a systems approach, and they engaged the community then in the development of a dynamic, dynamic model of youth violence. And what was particularly interesting about this program is, is that they actually engaged individuals who were the problem, i.e., gang, gang groups, actually. Uh, gang members. Uh, and they paid them, and they paid them to participate in the focus group sessions and they got extraordinary information as to why shooters are shooters and why, uh, there is such things as retaliatory shootings. This program was quite successful. It was part of the Boston Miracle, um, but it too was looking at the individuals, did not deal with the neighborhood context and sadly was not sustained. But there were certain learnings that came out of this approach. One, number one is he that it challenged the perception uh uh about uh that, that these are really evil, bad people, uh, and really draws, draw, draws attention to the concept of toxic stress. It's not too dissimilar to the toxic stress that military individuals returning from Afghanistan and Iraq have. And if you know anything at all about PTSD in the military, it's actually one of the more uh significant causes of life lost uh as a result of being exposed to violence. So one of the opposite and intended consequences is that there's an increased number of gangs actually now because of the breakup of the sort of the larger gangs. And then this traumatic stress is actually changing the way nonviolent youth behave, making them much more susceptible. Again, looking at the importance of the context. And gangs are an alternative social system because of the social isolation that you'll see is as a consequence of not only economic but political as well as cultural. What I found particularly interesting, uh, in this work, which is supported by other works, uh, by such notables as the fragile Family Study at Princeton. Is that employment and and and marriage were the most effective deterrents and we'll see that to be the case as we move along. There's a program that I started here in Cincinnati and again, it had uh some early successes, but again, because it didn't deal with the root causes and the system issues, it was not effective. It was based on David Kennedy and Anthony Brager's work on pulling levers. Uh, myself, uh, and the chief of police, were the co-chairs of this working, uh, at the pleasure of the mayor at the time. But it reflected then uh an understanding of, of, uh, really the importance of addressing the community issues here for these individuals uh and uh engaging the community and looking at it from the standpoint of how do we engage these individuals so that they can provide services for them. Uh, these were individuals who had a fairly lengthy arrest record, but what I want to draw your attention to is, is that because of the initial effort, we did see a drop in violence. But here's was the, so the Achilles' heel. We initially thought that we weren't gonna have that many individuals uh sort of um respond to the, uh, to the request to come in and stop the shooting and in fact, we had uh over 400. And the challenge here again is one of not looking at it from a system's perspective and that is that we were not able to accommodate these individuals with their efforts to really find employment. They wanted employment, they wanted out, but they didn't have, we didn't have the resources for that. Now Jack Shankov has, I think, captured this somewhat in a way that I would, um, uh, I, I, I, I like and that it looks at not just the, the growth and development, but it also takes into account the ecology, the social and physical environment, and also draws attention to toxic stress. Uh, what you'll see is something that is emerging now in our understanding of why there is this perpetuation, not only, uh, within a certain generation but intergenerational, multi-generational. Excuse me. So this idea of looking at it from a complex standpoint, complex adaptive systems where the players are interdependent, they are interconnected, they are adaptive so things will change, uh, and, um, they are diverse, uh, is the definition of a complex adaptive system. And Other entities such as the NIH and the National Academy of Sciences, which was chartered in 1863 by Abraham Lincoln to provide science for our governing body, uh, for public policy, I recognized that in these dynamically complex systems, you need system sciences and it needs to be a transdisciplinary approach. So let's address some of the myths or misperceptions that this is a black thing, that is just simply limited to the black community. Well, uh, the evidence would suggest that that's not the case and if you look at The degree of concentrated disadvantage in white and black communities, you'll see the violent crime is really quite proportional in both black and white communities. Well, Robert Sampson. Uh, from Harvard, uh, sociology, took a different perspective. He looked at Stockholm, Sweden, and Chicago and looked at concentrated disadvantage, which is another frame of capturing concentrated poverty, segregation, female heads of households, multiple children. And looked at the log of violence rate and you could not think of any two distinctly different cities than Stockholm and Chicago. And what you'll appreciate and what he points out is that the relationship between concentrated disadvantage and violence is quite the same. Certainly, Stockholm does not have a degree of violence, but concentrated disadvantage that neighborhood context is something that we are not addressing as we look at ways to stop gang violence, interpersonal violence. and even suicides in these impoverished segregated neighborhoods. So what the sociologists will tell you and William Wilson has really challenged us to look at this differently is is that currently, Most of the adults in inner city ghetto are not working. And today's problems in the inner city are really as a consequence of, of this disappearance of work. And I would add that one of the phenomena that we're seeing now with the opioid epidemic is disproportionately affecting the white community, uh, middle-class whites, and what Angus Deaton and Anne Case, who was the lead author in this, uh, in that work that was rejected by the New England Journal and then subsequently published elsewhere. Is that these individuals who are killing themselves or overdosing, they're not trying to kill themselves. These are deaths of despair, not too dissimilar to what we saw in the 1980s in Philadelphia when I was there as a Medical student and surgical, uh, pediatric surgical fellow. So the racial difference at the neighborhood level. It really is a consequence of availability of jobs and the effect that that has on family structure and it underlies the racial differences in crime and homicide. Homicide is the leading cause, first or second for adolescent black males in this country. Now, a little sobering news is, is that If we understand that this neighborhood context is this phenomenon that needs to be addressed. There's little change in the neighborhood inequality that exists in the United States. Again, this is Samson's work that looked at Chicago, but you'll also see a very similar consistency then as far as impoverished neighborhoods in our state. And when you look at the raw numbers as far as the the consequences of the Uh, great, uh, the Great Recession, uh, you'll see then that, uh, blacks, unfortunately and Hispanics also, and we don't have the data for that, uh, were very, very significantly affected as far as their median net worth. Concentrated disadvantage, 66% of black children in the United States are living in concentrated disadvantage. So when you understand that poverty and concentrated disadvantage is really a driving factor. For not only the violence that we see in hyper-segregated neighborhoods that are in most of the metropolitan areas but also for a host of other health inequities, uh, you have to come to the sort of the realistic conclusion that we need to do something about that. The chances of somebody living in an impoverished neighborhood in Cincinnati of getting out of that, this is work from Chetty, Hendri, and Katz is 5.1%. 5.1%. OK. Another factor that contributes to the persistence of violence and poverty in our neighborhood is the effect of mass incarceration. And that has increased, uh, though, though it has increased in, in recent decades, it's still, uh, disproportionately has affected black males. So that at this particular point in time, as Lawrence Bobo Bobo pointed out, 1 in 9 black men between 20 and 34 in jail or, are in jail or prison. Um If you have a criminal record, your chances of getting meaningful purposeful work is less than 5%. Further complicating the issues as far as neighborhoods is the racial ecology of lead poisoning. The title is taken from again another paper written by by Rob Sampson looking at lead poisoning. In Chicago, but Cincinnati is actually known for the longest longitudinal study of lead exposure. And Doctor Ken Dietrich is the one who has really led the charge on understanding that lead exposure, racially stratified neighborhoods. is associated with criminal behavior in adulthood. And um we'll come back to that. This study from the fragile families, joblessness and unemployment, again recognizing the effect of Mass incarceration. This is the major barrier to marriage and we know that single-parent households are hampered in their ability to actually raise kids. So it's abundant, if not incandescently clear. That fixing our failing neighborhoods and not these individual programs, looking at the failing neighborhoods and not these individual programs really has to be the focus of not only our public policy but also our work as healthcare providers. Uh, I'm gonna very quickly slide through these to, just to show you the complexity. This was developed for me by the 16 Systems Thinking Collaborative at the MIT, uh, and it basically shows the interrelationship between incarceration, violence, drug trading. Drug trading is the informal economy and ladies and gentlemen, we're not winning the war on drugs. And that then has associated with the violence as well. Uh, this violence then leads to incarceration or drug training leads to incarceration and then that further than accentuates then this joblessness that, uh, again, uh, compromises family structure. So this family structure is affecting the ability to nurture children, cognitive ability, readiness to work. The poverty-related stress in and of itself contributes to toxic stress. And then we have this further uh um Uh Adverse effect as far as educational outcomes. So To further add to the good news. The 20-year study of looking at place-based community change initiatives, all best practices, $11 billion. None have had any widespread change in child and well-being or reductions in neighborhood poverty. We need to think differently about how we're going to deal with this. And from a toxic stress, knowing how poverty affects and actually contributes to toxic stress. Children between 2 and 8 years of age. are diagnosed with hypertension in these neighborhoods when looked at contributes to something this phenomenon called epigenetics where there's aggression and it's gender-specific, more specifically affecting males than females. And then there's mental illness as far as maternal depression. These two, aggression and mental illness, maternal depression are major issues in dealing with the upbringing of these kids. Um The adolescent development in vulnerable neighborhoods, the wave of the well-being is something that further accentuates this effort, this phenomenon as far as toxic stress. Um Bob Blum, uh, was one of the participants in this Baltimore was the one city from the United States. Reflecting back on the PTSD phenomena that we, that I mentioned, 80% of children living in these neighborhood in this neighborhood um are affected by PTSD because of witnessing. So, we have clear evidence then that neighborhood poverty, concentrated disadvantage. is something that is probably the key driver of not only the violence that we see because of the family breakdown, but also affects life chances of the next generation. Um, and that interventions need to be holistic, systemic, and enduring. Uh, and the neighborhoods of black families play a central role in the reproduction of racial inequality. Point in time investments are not going to Create the transformation that we need. And so the implications are clear that we need to look at improving as healthcare. Individuals, the social and economic conditions, something outside of our Our, our wheelhouse, but yet something that we need to Uh, pay attention to. And so our approach is really Looking at how do we catalyze market-based business development. So if I were to ask, be asked how do I deal with violence in the inner-city neighborhood? Nothing stops a bullet like a job. And I took the advice of Michael Porter, uh, and the only true solution for revitalizing these underperforming neighborhoods is reversing the tide of rising income inequality. Our current situation is not upstream enough. It's not addressing the disparities in individual and community wealth. It's not intentional enough. And it's not targeting the most at risk, i.e., those who are in prison that are going to be released. 93% of the people who are in prison get released. And meeting them where they are, not too dissimilar from what the other programs that uh have been quite effective like uh Father Greg Boyle's program. So the innovation is a market-based strategy that's located situ situ that's situated locally intentionally targeting the truly disadvantaged. And doing it in a way that it actually democratizes wealth and ownership of the individuals in those neighborhoods where we have the high violence. Uh, taking place. And it's not just income, but it's wealth building and helping them, meeting them where they are. And doing this in a way that it actually engages the anchor institutions, the multi-billion-dollar academic hospitals that are neighbors that call home to these to these neighborhoods. And that prompted me to start a nonprofit which inspired the development of a business called Water Fields. It basically is uh take money from the rich and give it to the poor by looking at a high high margin specialty product locally situated and then engaging a large unskilled, low-skilled labor pool. All the major boutique restaurants here in Cincinnati uh purchase Waterfield's Microgreens. Uh, it is now, um, with revenue of about $800,000. Uh, so, as I come to the conclusion about how do we need to look at this differently, I would ask us to not be judgmental but recognize that the living conditions that we are in every day, uh, these are the things that really determine our choices. Um, And are largely outside of the immediate control of the individual systems approach. And John Sturman, who's the John J. Forrester, Professor of uh Systems Thinking at MIT, when we attribute behavior to people rather than the system structure. The focus of management and the focus of our policy. is to blame and scapegoat rather than design in the neighborhood. In which ordinary people can achieve extraordinary results. So I take, I took this from Jack Shenkov's uh talk. When he started his residency, uh, the survival rate for acute lymphocytic leukemia for children was a dismal, dismal 20%. Fast forward to today. It's an 80 over 80% survival rate. Um, there's no question in my mind that if we look at it from an interdisciplinary, transdisciplinary standpoint, Uh, we can achieve what we've achieved with not only motor vehicle passenger safety, but also with survival rates with acute lymphocytic leukemia. And with that, I thank you for your attention. That was great, Vic, as, as expected. Um, but I'd like to ask both of you kind of, where's, where's the hope? You kind of left us with a little bit of, a lot of disappointment and, uh, a little bit of, a little bit of hope. I like the, uh, that your work getting, getting folks back to jobs, um, and, and the impact that's already having and, and certainly advocacy is a, is a big piece of this. Um, but clearly as you both pointed out, we haven't seen a lot of change yet. Um, in, in moving the dial, um, so where, where should we have hope, uh, in this situation? Well, I, um, I mean, I think from my perspective, uh, there's a great deal of reason for hope. Um, it's just having the political will to do it and it's not going to be just in the neighborhood. Um, you know, the economic issues, the, the, the, uh, things like redlining, things like, uh, why do we have hyper-segregated neighborhoods. Uh, this is going to require not just local governments, but state governments. And um, I don't know that our federal government is in a position right now to look favorably at this kind of work, but I'm hopeful, looking at what Uh, folks have done not only here in Cincinnati, that if we could scale this, that we could really create, um, that tipping point, uh, to borrowed a term from Malcolm Gladwell, of getting individuals uh engaged in meaningful, purposeful work and then they themselves then can make the decisions as far as their, uh, their, their, their futures, not only for themselves but for their children. I, I guess I would say we, um, we've barely scratched the surface of, of, you know, consistent efforts to fight this battle. So I think, um, as we continue efforts and have sustained efforts, I think we can, we can make some inroads. Um, I think, you know, one of the things that we do well is, is care for patients, and I think we should have some hope and some satisfaction that we've done a much better job over the years. And so. While the ideal would be prevention so that they never see us, um, and I think we also, at the same time as we work on prevention, we also work on improving ways to care for the patients that we do see. I figured I was hopeful that you guys would both have some hope and that we're all, we're all still fighting and trying to figure out how to do this so I was, I was hoping that didn't stump you, but, um, and I'm glad it didn't, um, the, the other thing that's interesting, I'm, I'm actually, uh, at the Institute for Healthcare Improvement meeting where there's lots of talk about quality improvement in, in healthcare and, and systems thinking. So, so Vic, I was glad that you mentioned kind of thinking about the system being broken, um, not the individuals and how do we approach that, and I think. Uh, this sounds like there's probably some opportunity for us to not only be in these communities and understand the problem as opposed to being, you know, uh, we're, we're probably the three of us live and we don't need to worry about having a gun for our own protection every night, uh, when we go to sleep to understanding what's happening in those systems. So other final thoughts on that? Well, I, you know, one of the things about systems thinking is I've dabbled in it it's, it's, it's way beyond my, uh, my, my bandwidth. Uh, and what the systems thinkers that we're working with will tell us is, uh, when you're dealing with very, very complex models, um, the human brain is incapable of really harnessing all the various, you know, uh, reinforcing loops and balancing loops. And one of the tools that systems thinkers have is um agent-based modeling. You can do simulations and the NIH has done that quite well with uh looking at diabetes, for example. Um, but there is, uh, there are resources that, that need to be brought to the table, not to tell the community what to do, but to help the community to see the system itself. And that's one of the essential parts of this work, this community work, is you don't come into the community and say this is what's good for your community. You actually want to develop a relationship with them and then actually help them co-create that system, that systems uh map. So they can see the interrelationships between, for example, harsh parenting. Harsh parenting is one of the, one of the drivers for uh children misbehaving and it begins very, very early in the fetal stage. Thanks. Like any final comments from you? I think, I think if you have interest in this issue, you just need to um To, to focus or to let others around you know, uh, the kind of problem that it, that it is, and work with others and, and, uh, you know, continue. We'll win. I like to despite the challenges, I, uh, I appreciate all of what you both, uh, both taking time, number one, and I think there is hope. I think, uh, this, the difference in the lectures and difference in the approach of thinking about this is what I think we need. There's not one, there's certainly not going to be one solution to this complex, uh, problem. So I'm I'm hopeful that that folks like you are both of you are out there thinking about this. Uh, and helping us move the, move the dial. So thank you for your time. The audience has, uh, has commented with thanks, uh, for the information and, uh, and, and appreciate the diversity. Uh, we have, uh, I haven't got, I asked if anyone owns a gun, either no one's, no one's willing to admit it. Doctor, uh, Ponsky said he owns a squirt gun, but that's, uh, that's about it. Um. But um I, I think it's not a matter, I think as, as we've said here, it's not necessarily a matter of getting rid of guns, it's kind of changing the culture and, and making things safer all around in a better uh getting rid of some of the disparities that we see in the, the challenges that lead to the problem. So I'd like to thank everybody on the line. I'd like to again thank Children's Institute for, for helping to support this, this conversation, um, and Cincinnati Children's where, where Vic and I are at for helping to support this work. So thank you everybody and have a good night. Thank you.