Archive for the ‘Violence Prevention’ Category

Violence is a critical public health issue and one that contributes to an astounding number of years of life lost, with homicide and suicide among the top 5 causes of death for those aged 1-44.

Yet our response to violence as a society is not to treat and prevent but rather to criminalize and punish, which doesn’t seem to have helped prevent crime, much less have addressed the root causes of crime, as I have noted before.

The issue of criminal justice in the U.S. and the desperate need for a shift in the justice paradigm, from a system focused primarily on punishment to one emphasizing restorative practices, is one that has once again been on the forefront of my mind in the face of extensive coverage of the trial of Dharun Ravi last month.

Ravi and Clementi

Quick background: Dharun Ravi was charged on all 15 charges he faced for using a webcam to spy on his roommate, Tyler Clementi – Clementi killed himself soon after the spying incidents, though as this board member of the American Foundation for Suicide Prevention eloquently captures, blaming Ravi for Clementi’s suicide is utterly inaccurate and unfair. Suicide is an incredibly complex phenomenon, which always has multiple risk factors at play, including diagnosable mental health conditions which are present in over 90% of cases of completed suicide. You cannot draw a causal link between any one specific incident and suicide and you certainly cannot blame another individual for one’s suicide. Although Ravi was not charged for Clementi’s death, I find it highly unlikely he would be facing 10 years in prison as he currently is if it were not for the fact that Clementi killed himself.

Though Ravi’s actions – and any homophobic motivations behind them – were wrong, I am sure they have been, are, and will be repeated across dorm rooms everywhere – college kids can be foolish and immature, and I fail to see how putting Ravi behind bars for 10 years does anything to address the root issues here. We as a society need to be more tolerant of differences, more respectful of each other, and more communicative with those around us. We need to stop discriminating against others based on race, sexual orientation, religion, and any other such category. But instead of revisiting what we as a society are doing wrong that leads to incidents such as this one, we are instead throwing the blame at the feet of one college student, punishing him in a way that will neither help him, nor prevent cases like this in the future. It seems we perpetually take the easy way out – revisiting what we do as a society and as university, school, and other communities, would be much too difficult; blaming one individual and punishing them – far easier.

Moving beyond this one incident to the array of crimes that land people in prison, the true solution lies in prevention. At the individual level, depending on the nature of the issue, this means things like drug treatment, interventions with at-risk families, and school completion programs (among other things), all of which research has demonstrated to be “more cost-effective than expanded incarceration as crime control measures” according to this Sentencing Project report. At the population level, this means instilling values of respect and equality, tolerance and diversity, beginning at very young ages, at home, in our schools, and in our communities – through education, prevention programs, policies, laws, and more.

Yet, this does not seem to be the direction in which we are moving. I recently attended a symposium during which a prominent political figure, speaking on internet crimes (particularly child sex trafficking and sexual abuse), said “I really think the most meaningful solution is to put these people behind bars for as long as possible – as far as I’m concerned, that’s what prisons are for.”

I felt sick to my stomach – not a word about prevention or restorative practices in his talk, do people really not see how we are not only failing to treat and prevent and improve society, but also resigning ourselves to perpetually be throwing people in jail?

But there is hope, and there are ways out of this mess. A more recent publication of The Sentencing Project compiles the essays of 25 leading scholars and practitioners on their strategic vision for the next 25 years of criminal justice reform.

A truly incredible compilation of perspectives that is worth a read, but for now I will highlight some points from the essay capturing the public health perspective, written by leading violence prevention public health scholar and practitioner, Deborah Prothrow-Stith.

She writes, “We can’t address the many challenges in the criminal justice system without reducing the number of people entering the criminal justice system in the first place. This means prevention must be on par with law enforcement and punishment. As a nation, we already promise to respond to violence with expensive and sometimes harsh solutions. We need a companion promise, the promise of prevention.”

And, as she points out, this is an area in which we do have firm science as to what works and what doesn’t. Public health-based programs such as CeaseFire Chicago and the Urban Networks to Increase Thriving Youth (UNITY), school-based violence prevention efforts that have proven effective, programs like Boys and Girls Clubs and the Big Brothers Big Sisters of America initiatives, and the Nurse Family Partnership home visiting program have all proven to reduce crime and violence in meaningful ways.

Instead of focusing on punishment within a flawed and discriminatory system, instead of cutting prevention funds (as of last week, the Prevention and Public Health fund is yet again on the chopping block, much to my – and many other’s – dismay), let’s focus our attention on programs like the ones mentioned above – programs that prevent violence, promote health, and foster a more vibrant and productive society.

This post is cross-posted at http://occupyhealthcare.net


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Note: This post is cross-posted at Occupy Healthcare – be sure to check out the other posts there, and check out #occupyhealthcare on twitter too, the movement is growing! 

In my last post, I wrote about the importance of occupying an array of fields that impact our country’s health. Lest this task seem too daunting to be accomplished, I thought I’d take a moment to highlight some success stories on this front.

Access to healthy foods is an important determinant of health and an important factor in health inequities. The Food Trust, a non-profit based out of Pennsylvania, is tackling this problem, aiming to make healthy food available to all. Among their many innovative projects is the Pennsylvania Fresh Food Financing Initiative, a grant and loan program to encourage supermarket development in underserved neighborhoods throughout the state, an idea that is now being replicated nationally. Some other creative developments in the field of nutrition and healthy food access: taking a page out of the junk and fast food industry’s book, with their billions spent on marketing, and branding baby carrots in a way that’s fun and exciting; and tapping into behavioral economics to redesign cafeteria lunch lines in a way that increases purchase of healthy foods and decreases purchase of unhealthy foods (an inexpensive and effective approach!).

Given that homicide and suicide are among the leading causes of death among those age 1 to 34, violence prevention is another key aspect of attaining the health our society deserves. Chicago-based CeaseFire combines research and street outreach to track violence, interrupt and intervene (with well-trained professionals from the communities they represent with a background on the streets), and engage in longer term risk reduction and behavior and norm change. Even more exciting – it’s working.

Neither access to healthy foods nor neighborhood safety – not to mention walkability, pollution-free environments, and a host of other things – is possible without intelligent and innovative urban planning. Thankfully, we have the likes of The Congress for the New Urbanism working to promote walkable, mixed-used neighborhood development, sustainable communities and healthier living conditions.

And while our national political discussion is so bogged down by discussions of whether to help low-income individuals and families that we haven’t had a conversation about how best to help them, organizations like the Family Independence Initiative, which was featured in the New York Times this past summer, are taking an approach radically different from our typical social service model, tapping into the strengths and support systems of low-income families, allowing them to determine their own paths and advance together. This too, has been shown to work.

Across all of these health-related issues, the media plays a role in shaping behaviors and norms, and Hollywood, Health, and Society is bridging two drastically separate sectors with its work to provide entertainment industry professionals with accurate, timely, and engaging information and case examples for health storylines, as well as study the content and impact of these storylines.

Of course, just because it’s not all about healthcare doesn’t mean healthcare isn’t at the table – healthcare providers can play just as important role in prevention and promotion as they do in treatment, and places like the Codman Square Health Center make that crystal clear. A community health center in one of the most impoverished areas of Boston, the Center provides a range of public health and community services (ranging from computer classes and financial help to fitness opportunities and hands-on cooking classes, not to mention youth services, civic engagement initiatives, and a close linkage with the Codman Square Academy charter school).

So, as daunting as the task of occupying for health seems, there are many people in many places doing amazing things. To quote the founder of the Codman Square Health Center: “We need to create integrated systems that promote community and health values. Like all change such cultural shift will take a generation or more to accomplish. But I am reminded of the story President John F. Kennedy told of the French leader who asked his gardener to plant a rare tree on his estate. ‘But the tree won’t bloom for 100 years’ the gardener said. The response: ‘In that case, plant it this afternoon.’”

So here’s to starting planting – and occupying. Cheers.


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A couple weeks ago, President Obama proposed $3.5 billion in cuts to the federal Prevention and Public Health Fund as part of the President’s Plan for Economic Growth and Deficit Reduction.

And as the Prevention Institute alerted me to via e-mail, the Senate Appropriations Committee approved a bill on September 21st that “zeroed out funding for the CDC’s Youth Violence Prevention activities – suddenly and without input”.

The e-mail I received pointed out that elimination of this $19.7 million in funding would have a devastating impact on violence prevention efforts across the country and compromises decades of work.

I agree wholeheartedly. Even more frustrating though, is the fact that not only do these cuts to prevention and public health funding affect critical work, they go against the very purpose of these funding cuts, i.e. “economic growth and deficit reduction.”

Cutting prevention funding does NOT help the economy or the deficit. Whether it’s the Prevention and Public Health Fund, CDC’s Youth Violence Prevention efforts, or other funding streams, public health takes a systems level, upstream approach to preventing population-level health problems – this means a lot of public health efforts are targeted at things like helping people find jobs or gain a better education, and making neighborhoods safer and revitalizing communities. These things make our economic situation better, not worse.

As the Prevention Institute points out:

“Cutting prevention may seem to save a few dollars in the short run, but it will cost an enormous number of lives and money in the long run…Prevention shows a 5-to-1 return on investment. Cutting 3.5 billion in prevention would shut the door to as much as $20 billion in potential savings in health care costs in the future.”

And there are a lot of other cost savings too – keeping youth out of the criminal justice system, keeping community members gainfully employed, and more.

I understand that cuts need to be made, but let’s stay away from cutting things that are actually saving us money, shall we?

Pick up the phone, call your senators and representatives (I just did!), and try to make it to clear to politicians and the general public that prevention funding is not merely an expendable cost, but an investment – and one that is far more likely to pay off than pretty much any other.

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The United States spends $60 billion each year on incarceration and has the highest incarceration rate in the world (due more to the length of sentences than the number of individuals incarcerated each year), as this New York Times article details. The only other major industrialized nation that even comes close to the U.S.’s rate is Russia, with others having much lower rates (1/5 the U.S.’s rate or lower). The U.S. has less than 5% of the world’s population but almost 25% of its prisoners, with 2.3 million criminals behind bars, more than any other nation. China is a distant second with 1.6 million people in prison.

And as this NAACP report points out, there’s a lot more to worry about:

–  The majority of the 2.3 million people incarcerated in U.S. prisons and jails are people of color, people with mental health issues and drug addiction, people with low levels of educational attainment, and people with a history of unemployment or underemployment. (According to a 2008 study, 1 in 100 U.S. adults of any age and 1 in 9 black men ages 20-34 are in prison).

–  The nation’s reliance on incarceration to respond to social and behavioral health issues is evidenced by the large numbers of people who are incarcerated for drug offences – nearly a quarter of all those incarcerated.  (And as mentioned here, in 1980, we had 41,000 drug offenders in prison; today we have more than 500,000, an increase of 1200%.)

– During the last two decades, state spending on prisons grew at six times the rate of state spending on higher education.  (And according to a Pew report, total state spending on corrections, the bulk of which is spent on prisons, quadrupled during the past 20 years, making it the second fastest growing area of state budgets, trailing only Medicaid.)

Even worse – much of what we do in terms of incarceration does not seem to be preventing crime, much less helping people escape the various vicious cycles that can lead to things like poverty, crime, substance abuse, poor education, poor health, etc. This can be seen not only in the recidivism rates mentioned above (with about 1 out of 4 American offenders ending up right back in prison within three years of release), but also limited drug offender effects,  negative impacts on family and community, and other issues detailed in this Sentencing Project report. Moreover, as the report goes on to say, “a variety of research demonstrates that investments in drug treatment, interventions with at-risk families, and school completion programs are more cost-effective than expanded incarceration as crime control measures.”

The call is echoed in editorials such as this one, written to describe a consensus reached in a Pennsylvania conference among prosecutors and defenders, victim advocates, prison reformers, and parole officers and judges. The consensus: the need for a change in the justice paradigm, from a system focused primarily on punishment to one emphasizing restorative practices. The editorial goes on to highlight a number of public health strategies as promising alternatives including therapies that address addictive behaviors and mental and emotional disorders.

And there have also been repeated calls to take some of the billions of dollars we spend on incarceration and put it toward education, one of the more recent calls coming from Gaye Tuchman, a University of Connecticut sociology professor, in one of this week’s New York Times Room for Debate articles about Rick Perry’s “plan” for a $10,000 B.A. degree – “New money for education has to come from somewhere,” Tuchman writes. “Why not a new kind of retrenchment: Cut back on imprisonment for some victimless crimes — like marijuana possession — and use the money for higher education. As The New York Times reported in February, arrests for marijuana use have been skyrocketing in New York City alone. Better to educate people than lock them up.”

And indeed better to educate and support high risk youth than lock them up. Let’s target youth in high risk communities (a la “hot spotters”) for intensive tutoring and mentoring support, provision of safe spaces, and more, providing them with role models and people and places to turn to when in distress or in need of help accessing various resources.

John F. Kennedy once said “children are the world’s most valuable resource and its best hope for the future” – let’s invest in this resource and nurture this hope, preventing our children from entering the criminal justice system in the first place.

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At a conference on gang awareness and prevention that I attended last week, I heard folks from a local community service board speak about their work supporting youth in the community through in-school and after school programs. They showed video testimonials from some of the youth they worked with, and it was just amazing to hear these teens’ heartfelt words about the CSB personnel and the impact they had on these young people’s lives as tutors, mentors, role models, and trusted sources of support and advice. These were for the most part high-risk youth, growing up with a number of factors against them – poverty, unsafe neighborhoods, unstable family lives, constant exposure to drugs and alcohol, and more – making the impact of the CSB’s work even more valuable. One girl, breaking into tears, said that this group saved her life.

And it got me thinking…

In Atul Gawande’s New Yorker article “The Hot Spotters”, he talks about how medicine’s primary mechanisms of service, the doctor visit and the E.R. visit, are vastly inadequate for people with complex problems, comparing them to “arriving at a major construction project with nothing but a screwdriver and a crane.”

In some ways, I feel like the way we handle young people in this country is like that too. On one end, you have the regular public education system, which is fine for those of us lucky enough to have grown up in a stable family and neighborhood environment, with all our basic needs and much besides that met. On the other end, you have the highly punitive criminal justice system, which some would argue is necessary to keep dangerous youth off the streets.

I have many qualms about the latter point, but that notwithstanding, there’s still a major problem here: both systems are vastly inadequate for the vast majority of high risk youth in this country, who need one-on-one mentoring and support, consistent role models and safe spaces, etc. that organizations like the CSB I mentioned above provide. This could result in a much healthier, happier, better-educated population of youth that are far more likely to break through the cycles of poverty, substance abuse, etc. that often contribute to their behavior. Neither the traditional education system nor a punitive approach is going to the trick for these youth.

In addition to being punitive, the criminal justice system makes it incredibly hard for young people to get back to living happy, healthy lives – their criminal records make it hard to become gainfully employed and the system does very little to help address the root causes of criminal behavior, and provides little in the way of education or job skills. And as this recent Pew Report details, more than four out of 10 adult American offenders return to prison within three years of their release, suggesting that “the system designed to deter them from continued criminal behavior clearly is falling short”.

Gawande points out in “The Hot Spotters” that if we recruited staffs of primary-care doctors and nurses and social workers, based right in the neighborhoods where the costliest patients lived, staff expenses would be more than covered with the tens of millions of dollars in hospital bills that could be saved.

Similarly, if we recruited staffs of mentors, tutors, social workers, educators, and prevention specialists, based right in the neighborhoods where the highest risk youth lived, expenses would likely be more than covered by the money saved in criminal justice expenses.

Seems like an investment worth making, doesn’t it? If I haven’t convinced you yet, more on U.S. criminal justice statistics and ways to support youth coming in Part II!

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In addition to entertainment media (covered in Part I), the news media can have immense impact on the public’s perceptions and behaviors as well as policymakers’ perceptions and the policy agenda – for better or for worse. News media’s critical role in my (current) area of focus within public health, violence prevention, is something I’ve been thinking about a lot lately.

A quick quiz (take a guess before you read on): How many homicides are there in the U.S. each year? Suicides?

In the most recent year for which data is available from the CDC (2007), there were 18,361 homicides and 34,598 suicides in the United States. Twice as many people died by suicide as died by homicide. Yet, almost everyone responds that there are more homicides than suicides. Why? At least partially because the news media report on homicides far more than suicides, contributing to the perception that homicides are much more common. I’m not 100% sure what impact this misperception has, but it’s worth considering.

Moving on to things where the impact is clear – I listened in on a Prevent Connect webinar last week in which Larry Cohen of the Prevention Institute and Lori Dorfman of the Berkeley Media Studies Group spoke about violence against women and the role media plays. They highlighted a number of problematic issues when it comes to news coverage of violent incidents:

–          perpetuation of key norms that contribute to gender based violence (power/control, limited role of women, limited definition of masculinity, violence, and silence/privacy when it comes to talking about the issue);

–        language that humanizes the perpetrator (details that help audience relate to the perpetrator as a person)     and dehumanizes the victim;

–          a focus on criminal justice as opposed to prevention;

–          and a focus on individuals as opposed to institutions and policies.

Cohen and Dorfman talked about the need to reframe news media coverage, moving from a personal responsibility frame to one of institutional accountability. When a news story is framed around personal responsibility, people blame the victim. In order to advance prevention, it is critical that we focus more on the environment in which we live, including policies and institutions and how they can contribute to promoting health. (As a side note, another interesting case study in news media framing is obesity – when framed around personal responsibility, it is easy to blame those who are overweight and keep moving; when framed around the environment in which we live, then we get into prevention discussions – better access to healthy foods, more opportunities to exercise, etc.)

There were a lot of practical suggestions arising from the webinar, including working with survivors of violent incidents to speak to the media in a way that advances prevention – so that they not only explain what happened, but also express their anger that the incident could have been prevented and focus on parts of their story that they can link to what could happen next to prevent future incidents. We in public health definitely need to do more to work with advocates and media personnel to encourage safe and responsible reporting.

News media reporting can also contribute to more violence on the suicide front. Over 60 research articles have examined the issue of media reporting of suicide and found that certain types of coverage can lead to imitative behavior – examples of dangerous coverage, as well as coverage that can actually aid prevention efforts, can be seen in the diagram below.


The diagram is taken from recommendations on reporting on suicide published jointly by a number of suicide prevention organization based on the aforementioned research on the subject.

On a related note, in the last year or so, bullying has captured the attention of the nation, and stories linking bullying and suicide abound. Most of the news media coverage linking specific suicides to bullying in a direct, causal way are inaccurate, and even more concerning, this kind of coverage is dangerous: vulnerable people (particularly those already contemplating suicide) who see such coverage relate to the victim’s experiences being bullied and may be more likely to attempt suicide as a result.

Indeed, as covered during yesterday’s Suicide Prevention Resource Center webinar, there are a number of prevailing suicide narratives in the media, and they can play a dangerous role in suicide contagion. One such narrative is that of bullying leading directly and inevitably to suicide. One example they talked about in the webinar: headlines proclaiming Phoebe Prince “bullied to death”. The big picture: Prince had moved to a new country, her parents had divorced, she was struggling with poor grades, recently broke up with her boyfriend, had a history of depression and had previously attempted suicide.

This is not to say that bullying does not have terrible impacts – it often does. But in simplifying the story, and making it sound like Phoebe Prince’s death by suicide was a direct result of bullying she experienced at school, and nothing else, the news media risks leading other vulnerable youth who are experiencing bullying to see suicide as an answer. Alternatively, media could touch on the complexities of these issues and focus on resources for prevention (for bullying and suicide), sources of support (particularly mental health services), counter-narratives of hope and recovery, etc., all of which could help prevent suicides instead of risking perpetuating them.

Public health professionals have a responsibility to work with media to ensure recommendations regarding safe and responsible reporting are followed and to ensure prevention efforts are getting attention. And media personnel have a responsibility to seek out and follow such recommendations, realizing that the stakes are as high as they get – their reporting can be the difference between life and death.

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