A quarantine on killing

An epidemiologist who helped stem the spread of cholera and AIDS in Africa, Gary Slutkin has a new – and successful – strategy to stop the contagion of violence: Treat it like a disease

Twenty-three years ago, Gary Slutkin moved to Chicago to take a break. A doctor trained in infectious diseases, he had spent his career battling tuberculosis in San Francisco and cholera in refugee camps across Africa. Working with the World Health Organization, he played a key role in reversing the AIDS epidemic in Uganda. But he had also spent more than a decade surrounded by suffering and death. “I was exhausted,” he says. 

In 1995, when he was 44, Slutkin left Africa and his job with WHO and moved back to the United States to recharge. Yet the headlines kept him from winding down: Violence dominated the news. “All across the country, I saw that violence was an issue in the same way that cholera or diarrheal disease had been an issue in Bangladesh or AIDS was in Uganda,” he says. So he began to research violence the same way he had investigated the causes and patterns of disease as an epidemiologist.

Last September, Slutkin discussed his findings while speaking about “Peace in the Age of Uncertainty,” the first installment in a three-part Pathways to Peace Series sponsored by Rotary International and the University of Chicago’s Harris School of Public Policy.

 “Looking at violence,” he explained, “we can see through maps and charts and graphs that it behaves exactly like all other epidemic issues.” And like other contagions, violence tended to cluster, with one event leading to another. “How does that happen?” he asked. “It’s because of exposure. That was the insight I came to years ago. What was the greatest predictor of violence? The answer: a preceding act of violence.” What’s more, he insisted, if violence is predictable, it can be “interrupted.”

With that in mind, Slutkin began investigating new ways to treat violence. He started an initiative originally called the Chicago Project for Violence Prevention; in 2000, it implemented its first program – CeaseFire – in a violence-plagued Chicago neighborhood. Known since 2012 as Cure Violence, it’s based at the University of Illinois at Chicago, where Slutkin is a professor at the School of Public Health. 

The Cure Violence model employs three components used to reverse any epidemic: interrupt transmission; reduce risk; change community norms. Cure Violence outreach workers prevent violence by counseling people exposed to violence in their home or community. These “violence interrupters” work with high-risk individuals to discourage them from acting out violently.

Where implemented, the Cure Violence model typically reduces violence by 41 to 73 percent in the first year. In 2011, a film called The Interrupters documented the success of the program, and today its impact is felt worldwide. “We have a global effort to reduce violence through partnerships in multiple regions, in particular Latin America, the Caribbean, and the Middle East,” as well as in 25 U.S. cities, Slutkin says.

 “Public health has been responsible for some of the greatest accomplishments in human history,” he says. “It’s gotten rid of multiple diseases like plague and leprosy and smallpox. Polio is on its way out. Violence is next.”

Slutkin spoke with contributing editor Vanessa Glavinskas about his pioneering methodology, behavior change, ineffective punitive remedies, and ways Rotarians can lend a hand in the fight to cure violence.

Q: How does the Cure Violence model work?

A: All epidemics are managed from the inside out. They’re not managed by outside forces; they’re managed from the inside. The health sector guides and trains in the specific methods for how to detect, how to interrupt, how to persuade, how to change behavior, how to document work, and how to change local strategies when things aren’t working. Epidemics are managed through a partnership between community groups, health departments, and other services. It works over and over again.

Managing disease is something Rotarians are familiar with because of polio eradication. To vaccinate children, health workers go door to door in the communities and talk to parents about the importance of the vaccine. The most important thing that these health workers have is trust. 

Cholera was managed this way when I was working in Somalia. We used Vietnamese and Cambodian outreach workers to reach Vietnamese and Cambodian tuberculosis patients and their families. This is the way it really works. But the U.S. is in a punitive mode about a lot of things that are health problems. 

Q: Why doesn’t punishment work? 

A: Behavior is not formed, maintained, or changed by punishment. It’s formed by modeling and copying. It’s maintained by social norms. People care more about what their friends think than what some authority is telling them. Belonging is not just a nice thing; it’s a way to survive. This whole carrot and stick idea doesn’t even work for donkeys. It’s very primitive thinking.

Q: What are you doing to change the way the public thinks about violence?

A: The public still has an ideological and punitive lens on what is really a scientific, epidemic health problem. We’re training health workers to speak up. Right now violence is being explained by a punitive sector. We need to stop using scary words like “criminal” and “gang” – all these demonizing terms – and begin to use words from the health sector like “behavior,” “transmissible,” “interruption,” and “outreach.” I think public perception will change if the language changes.

Q: How do you get people to look at violence as a public health issue? 

A: Arguing against an existing narrative doesn’t work. Science tells us this too. The brain is wired for people to stick to their ideas. But the good news is that everyone has an understanding of health, and even if they don’t know exactly what public health does, they understand contagion. They understand that epidemics can be reversed. If we continue to talk in that way, everyone has a space in their brain for a new set of ideas. Then you have to develop the ability to look at the person – not just the person in the hospital, but the person who did the violent act as a person who’s been exposed to violence many times. The brain picks up [violent tendencies] just the way the lungs pick up flu or the intestines pick up cholera. We need to be exposed to the scientific idea that the person who’s being violent is reacting to exposure. 

Q: The “violence interrupter” is a unique type of health worker. How did this role come about? 

A: For five years, we didn’t put a single person on the ground. We were doing strategy development, trying to find out what would be acceptable and what kind of workers needed to be hired. We started with outreach workers. But they had too many things to do. They were helping to stop violence from occurring. That was emergency work that had to be done at 9 p.m., 10 p.m., midnight, 2 a.m., 4 a.m. They were doing all this emergency work, and then they were also trying to keep talking to people and help them get back in school or get their family’s life in order or get some kind of employment. As I was talking to the workers, especially two workers who became the first two interrupters, Chip and Tony, we decided that we should make two different categories of worker. One for the acute phase [the violence interrupter] and one for the longer term, so they could both be done well. 

Q: During those five years, did you have funding or were you just building on a theory?

A: I started without any funding, as I’ve done before in other things, but then I got enough funds to support one worker. Then we became about three workers, and we enticed the Robert Wood Johnson Foundation to try our new strategy. They helped strengthen the core of the work. Then one Illinois state senator, Lisa Madigan, who went on to become the Illinois attorney general, fought for it. She said, “We have to try this. This makes sense to me.” So she got us the first money. I said, “Sen. Madigan, do you want us to try this in your neighborhood?” And her response was, “You know better than I do who needs it most.” So we started in the Chicago neighborhood that needed it the most – West Garfield Park – and we had a 67 percent drop in violence in the first year. We went from 43 shootings and killings to 14. It was almost immediate. Moms were having picnics on their lawns, and the kids were playing in the street. They were using a park that no one ever used. It was amazing.

Q: Why did it work so fast?

A: It’s from the inside out. That’s what we do in public health. We hire people who have access and credibility and trust. We talk to people in their own interest. We train people very well. Behavior change is the bread and butter of public health. We do behavior change all the time: sexual behavior, smoking behavior, drug-use behavior, hand-washing behavior, sanitation behavior. It’s exactly what we do. 

Q: Who is best suited to the work of a violence interrupter? And how risky is the job?

A: It’s best suited for people who used to be involved in violence themselves and know the people in the neighborhood very well, especially the people in the neighborhood who we actually have to reach: shooters. So it’s best suited for people who know them and are trusted. There have been very few injuries. I think there have been three during the 17 years in Chicago and 12 years in Baltimore and almost 10 years in New York. Many of the workers will tell you that they feel safer than before they were a worker, because everybody knows what they’re doing and who they are. They’re respected and valued.

Q: What’s your take on the rash of mass shootings we’ve seen lately?

A: Almost every one of these shootings had warning signs that should have gone to the public health sector. There’s nothing wrong with law enforcement being called, but they frequently can’t do anything because no event has happened. If they don’t have someone to catch, there isn’t anything to do but watch. Like the shooter of the nightclub in Orlando, the FBI had been watching him. But that’s like watching someone develop a disease without intervening. One of our workers could help someone change their course. It’s very similar to the basic work we do on the street. Mom calls because her son is loading up weapons in the basement. She doesn’t want to call the police on her son. She doesn’t know what to do. She’s pulling her hair out. So what does she do in this case? She calls an interrupter who comes by, cools this guy down, and helps him see why where he was going makes no sense. He keeps working with him for months, and nothing happens. No shooting. 

Q: So should people call an interrupter or law enforcement?

A: Both could be called. But you have to have this option of letting in. When there are interrupters in the neighborhood, they pick up on information. You may not even need to call, because they hear from other people in the school that this one kid was expelled and they’re worried about how angry he is. That’s enough to try to check him out. Ask, “How are you doing?” “None of your business.” “What’s going on?” “None of your business; I don’t want to talk to you.” “Well, I’m here.” And we hang around a little bit, pay attention, maybe bring in someone else who has a better relationship with him, but it becomes a contact that we have some responsibility for. We do this all the time: make contact with people who have HIV or syphilis or TB. We’re talking to people who don’t necessarily want to talk with us, but it’s our job to make sure that nothing goes bad for the health and safety of the neighborhood. Whether the event is a mass shooting or a neighborhood shooting, or an event of plague or leprosy or bird flu or Ebola, when you have these workers, things get better instead of getting worse.

Q: Despite the success of Cure Violence, it still has critics. Why?

A: This is a relatively new theory. It has to go through a generational change until people see it properly. People didn’t want to believe that cholera was transmitted by water; they thought it was in the air. People thought that people with leprosy or plague were bad people; there was not an understanding of invisible micro-organisms. At the same time, we now have USAID, the World Bank, Inter-American Development Bank, UBS Optimus Foundation, the Robert Wood Johnson Foundation, and many city councils and mayors supporting it. There’s a push toward actually getting rid of the problem rather than living with it.   

Q: What can Rotarians do to promote the Cure Violence program?

A: They should talk to city leaders and philanthropic organizations and the business community, and they should bring in or help build Cure Violence where it’s needed. The Cure Violence method works very fast. Once it gets put into motion, once all the workers are hired and trained, the drop in violence usually happens within a couple of months, and it’s usually very dramatic. It might take a while for the government to decide to do it, but once everybody gets on the street and the right people are hired and trained, the change is very, very fast. 

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