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TEDMED 2013

Gary Slutkin: Let's treat violence like a contagious disease

April 17, 2013

Physician Gary Slutkin spent a decade fighting tuberculosis, cholera and AIDS epidemics in Africa. When he returned to the United States, he thought he'd escape brutal epidemic deaths. But then he began to look more carefully at gun violence, noting that its spread followed the patterns of infectious diseases. A mind-flipping look at a problem that too many communities have accepted as a given. We've reversed the impact of so many diseases, says Slutkin, and we can do the same with violence. (Filmed at TEDMED.)

Gary Slutkin - Epidemiologist
Could our culture have misdiagnosed violence? As the director of the initiative Cure Violence, Gary Slutkin approaches gunfire on neighborhood streets as a contagious disease, looking to science and public health for strategies to stop it. Full bio

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Double-click the English subtitles below to play the video.
I'm a physician trained in infectious diseases,
00:12
and following my training,
00:17
I moved to Somalia
00:19
from San Francisco.
00:22
And my goodbye greeting
00:24
from the chief of infectious diseases
00:26
at San Francisco General was,
00:28
"Gary, this is the biggest mistake you'll ever make."
00:30
But I landed in a refugee situation
00:33
that had a million refugees in 40 camps,
00:38
and there were six of us doctors.
00:42
There were many epidemics there.
00:44
My responsibilities were largely related to
00:46
tuberculosis,
00:49
and then we got struck by an epidemic of cholera.
00:51
So it was the spread of tuberculosis
00:55
and the spread of cholera
00:57
that I was responsible for inhibiting.
00:59
And in order to do this work, we, of course,
01:04
because of the limitation in health workers,
01:07
had to recruit refugees to be a specialized
01:09
new category of health worker.
01:13
Following three years of work in Somalia,
01:16
I got picked up by the World Health Organization,
01:19
and got assigned to the epidemics of AIDS.
01:22
My primary responsibility was Uganda,
01:25
but also I worked in Rwanda and Burundi
01:28
and Zaire, now Congo,
01:31
Tanzania, Malawi, and several other countries.
01:34
And my last assignment there was to run a unit
01:37
called intervention development,
01:40
which was responsible for designing interventions.
01:42
After 10 years of working overseas,
01:45
I was exhausted.
01:48
I really had very little left.
01:50
I had been traveling to one country after another.
01:52
I was emotionally feeling very isolated.
01:57
I wanted to come home.
02:00
I'd seen a lot of death,
02:02
in particular epidemic death,
02:04
and epidemic death has a different feel to it.
02:07
It's full of panic and fear,
02:10
and I'd heard the women wailing and crying
02:14
in the desert.
02:18
And I wanted to come home and take a break
02:20
and maybe start over.
02:22
I was not aware of any epidemic problems
02:25
in America.
02:28
In fact, I wasn't aware of any problems in America.
02:30
In fact -- seriously.
02:33
And in fact I would visit friends of mine,
02:35
and I noticed that they had water
02:38
that came right into their homes.
02:41
How many of you have such a situation?
02:43
(Laughter)
02:45
And some of them, many of them actually,
02:46
had water that came into more than one room.
02:49
And I noticed that they would move
02:51
this little thermoregulatory device
02:54
to change the temperature in their home
02:56
by one degree or two degrees.
02:58
And now I do that.
03:01
And I really didn't know what I would do,
03:03
but friends of mine began telling me
03:07
about children shooting other children with guns.
03:10
And I asked the question,
03:14
what are you doing about it?
03:16
What are you in America doing about it?
03:17
And there were two essential explanations
03:20
or ideas that were prevalent.
03:22
And one was punishment.
03:24
And this I had heard about before.
03:26
We who had worked in behavior
03:28
knew that punishment was something that was discussed
03:31
but also that it was highly overvalued.
03:34
It was not a main driver of behavior,
03:37
nor was it a main driver of behavior change.
03:40
And besides that, it reminded me
03:44
of ancient epidemics
03:46
that were previously completely misunderstood
03:48
because the science hadn't been there before,
03:51
epidemics of plague
03:54
or typhus or leprosy,
03:56
where the prevalent ideas were that there were
03:59
bad people or bad humors or bad air,
04:02
and widows were dragged around the moat,
04:05
and dungeons were part of the solution.
04:08
The other explanation or, in a way,
04:11
the solution suggested,
04:14
is please fix all of these things:
04:15
the schools, the community, the homes, the families,
04:18
everything.
04:22
And I'd heard this before as well.
04:23
I'd called this the "everything" theory,
04:25
or EOE: Everything On Earth.
04:28
But we'd also realized
04:30
in treating other processes and problems
04:32
that sometimes you don't need to treat everything.
04:36
And so the sense that I had
04:39
was there was a giant gap here.
04:41
The problem of violence was stuck,
04:43
and this has historically been the case
04:46
in many other issues.
04:48
Diarrheal diseases had been stuck.
04:50
Malaria had been stuck.
04:51
Frequently, a strategy has to be rethought.
04:53
It's not as if I had any idea what it would look like,
04:55
but there was a sense that we would have to do
04:58
something with new categories of workers
05:02
and something having to do with behavior change
05:04
and something having to do with public education.
05:06
But I began to ask questions
05:10
and search out the usual things
05:12
that I had been exploring before,
05:15
like, what do the maps look like?
05:17
What do the graphs look like?
05:18
What does the data look like?
05:20
And the maps of violence
05:22
in most U.S. cities
05:24
looked like this.
05:26
There was clustering.
05:28
This reminded me of clustering that we'd seen also
05:30
in infectious epidemics,
05:33
for example cholera.
05:35
And then we looked at the maps,
05:37
and the maps showed this typical wave
05:39
upon wave upon wave,
05:42
because all epidemics
05:44
are combinations of many epidemics.
05:45
And it also looked like infectious epidemics.
05:48
And then we asked the question,
05:51
well what really predicts a case of violence?
05:53
And it turns out that the greatest predictor
05:56
of a case of violence is a preceding case of violence.
05:58
Which also sounds like, if there is a case of flu,
06:02
someone gave someone a case of flu, or a cold,
06:05
or the greatest risk factor of tuberculosis
06:08
is having been exposed to tuberculosis.
06:10
And so we see that violence is, in a way,
06:13
behaving like a contagious disease.
06:16
We're aware of this anyway
06:19
even in our common experiences
06:21
or our newspaper stories
06:23
of the spread of violence from fights
06:24
or in gang wars or in civil wars
06:28
or even in genocides.
06:31
And so there's good news about this, though,
06:33
because there's a way to reverse epidemics,
06:36
and there's really only three things that are done
06:39
to reverse epidemics,
06:41
and the first of it is interrupting transmission.
06:43
In order to interrupt transmission,
06:45
you need to detect and find first cases.
06:47
In other words, for T.B. you have to find somebody
06:51
who has active T.B. who is infecting other people.
06:54
Make sense?
06:57
And there's special workers for doing that.
06:58
For this particular problem,
07:01
we designed a new category of worker
07:02
who, like a SARS worker
07:05
or someone looking for bird flu,
07:06
might find first cases.
07:08
In this case, it's someone who's very angry
07:10
because someone looked at his girlfriend
07:12
or owes him money,
07:14
and you can find workers and train them
07:15
into these specialized categories.
07:18
And the second thing to do, of course,
07:21
is to prevent further spread,
07:23
that means to find who else has been exposed,
07:24
but may not be spreading so much right now
07:28
like someone with a smaller case of T.B.,
07:30
or someone who is just hanging out in the neighborhoods,
07:33
but in the same group,
07:36
and then they need to be, in a way,
07:37
managed as well,
07:39
particular to the specific disease process.
07:41
And then the third part, the shifting the norms,
07:44
and that means a whole bunch of community activities,
07:47
remodeling, public education,
07:51
and then you've got what you might call
07:53
group immunity.
07:55
And that combination of factors
07:56
is how the AIDS epidemic in Uganda
07:58
was very successfully reversed.
08:01
And so what we decided to do in the year 2000
08:03
is kind of put this together in a way
08:06
by hiring in new categories of workers,
08:08
the first being violence interruptors.
08:10
And then we would put all of this into place
08:13
in one neighborhood
08:15
in what was the worst police district
08:17
in the United States at the time.
08:19
So violence interruptors hired from the same group,
08:21
credibility, trust, access,
08:24
just like the health workers in Somalia,
08:27
but designed for a different category,
08:30
and trained in persuasion,
08:32
cooling people down, buying time, reframing.
08:34
And then another category of worker,
08:38
the outreach workers, to keep people
08:40
in a way on therapy for six to 24 months.
08:42
Just like T.B., but the object is behavior change.
08:45
And then a bunch of community activities
08:49
for changing norms.
08:51
Now our first experiment of this
08:53
resulted in a 67-percent drop
08:55
in shootings and killings
08:58
in the West Garfield neighborhood of Chicago.
08:59
(Applause)
09:02
And this was a beautiful thing
09:04
for the neighborhood itself,
09:05
first 50 or 60 days, then 90 days,
09:07
and then there was unfortunately another shooting
09:10
in another 90 days,
09:11
and the moms were hanging out in the afternoon.
09:13
They were using parks they weren't using before.
09:15
The sun was out. Everybody was happy.
09:18
But of course, the funders said, "Wait a second,
09:20
do it again."
09:23
And so we had to then, fortunately,
09:24
get the funds to repeat this experience,
09:28
and this is one of the next four neighborhoods
09:30
that had a 45-percent drop in shootings and killings.
09:32
And since that time, this has been replicated
09:35
20 times.
09:38
There have been independent evaluations
09:40
supported by the Justice Department
09:42
and by the CDC and performed by Johns Hopkins
09:44
that have shown 30-to-50-percent and 40-to-70-percent
09:47
reductions in shootings and killings
09:50
using this new method.
09:53
In fact, there have been three independent
09:54
evaluations of this now.
09:56
Now we've gotten a lot of attention as a result of this,
09:58
including being featured on
10:00
The New York Times' Sunday magazine cover story.
10:02
The Economist in 2009
10:06
said this is "the approach that will come to prominence."
10:09
And even a movie was made around our work.
10:11
[The Interrupters]
10:14
However, not so fast,
10:15
because a lot of people did not agree
10:17
with this way of going about it.
10:19
We got a lot of criticism,
10:21
a lot of opposition,
10:23
and a lot of opponents.
10:25
In other words, what do you mean, health problem?
10:27
What do you mean, epidemic?
10:30
What do you mean, no bad guys?
10:32
And there's whole industries designed
10:35
for managing bad people.
10:37
What do you mean, hiring people
10:40
who have backgrounds?
10:43
My business friends said,
10:45
"Gary, you're being criticized tremendously.
10:50
You must be doing something right."
10:53
(Laughter)
10:55
My musician friends added the word "dude."
10:57
So anyway, additionally,
11:00
there was still this problem,
11:04
and we were getting highly criticized as well
11:06
for not dealing with all of these other problems.
11:09
Yet we were able to manage malaria
11:12
and reduce HIV and reduce diarrheal diseases
11:15
in places with awful economies
11:18
without healing the economy.
11:20
So what's actually happened is,
11:22
although there is still some opposition,
11:24
the movement is clearly growing.
11:27
Many of the major cities in the U.S.,
11:28
including New York City and Baltimore
11:30
and Kansas City,
11:33
their health departments are running this now.
11:34
Chicago and New Orleans, the health departments
11:36
are having a very large role in this.
11:39
This is being embraced more by law enforcement
11:41
than it had been years ago.
11:44
Trauma centers and hospitals
11:46
are doing their part in stepping up.
11:48
And the U.S. Conference of Mayors
11:50
has endorsed not only the approach
11:52
but the specific model.
11:55
Where there's really been uptake even faster
11:57
is in the international environment,
12:00
where there's a 55-percent drop
12:02
in the first neighborhood in Puerto Rico,
12:04
where interruptions are just beginning in Honduras,
12:06
where the strategy has been applied in Kenya
12:09
for the recent elections,
12:12
and where there have been 500 interruptions in Iraq.
12:15
So violence is responding as a disease
12:18
even as it behaves as a disease.
12:21
So the theory, in a way,
12:24
is kind of being validated by the treatment.
12:26
And recently, the Institute of Medicine
12:30
came out with a workshop report
12:33
which went through some of the data,
12:35
including the neuroscience,
12:37
on how this problem is really transmitted.
12:38
So I think this is good news,
12:43
because it allows us an opportunity
12:46
to come out of the Middle Ages,
12:47
which is where I feel this field has been.
12:49
It gives us an opportunity to consider the possibility
12:52
of replacing some of these prisons
12:55
with playgrounds or parks,
12:58
and to consider the possibility
13:01
of converting our neighborhoods into neighborhoods,
13:04
and to allow there to be a new strategy,
13:08
a new set of methods, a new set of workers:
13:11
science, in a way, replacing morality.
13:15
And moving away from emotions
13:18
is the most important part of the solution
13:21
to science as a more important part of the solution.
13:24
So I didn't mean to come up with this at all.
13:28
It was a matter of,
13:33
I wanted actually a break,
13:35
and we looked at maps, we looked at graphs,
13:37
we asked some questions
13:41
and tried some tools
13:43
that actually have been used many times before
13:46
for other things.
13:49
For myself, I tried to get away from
13:51
infectious diseases,
13:54
and I didn't.
13:56
Thank you.
13:58
(Applause)
13:59

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Gary Slutkin - Epidemiologist
Could our culture have misdiagnosed violence? As the director of the initiative Cure Violence, Gary Slutkin approaches gunfire on neighborhood streets as a contagious disease, looking to science and public health for strategies to stop it.

Why you should listen

Gary Slutkin is an epidemiologist, an innovator in violence reduction, and the Founder/Executive Director of Cure Violence, formerly known as CeaseFire. As a physician, he began his career working in Somalian refugee camps, where tuberculosis and cholera epidemics flared up regularly. He went on to work for the World Health Organization on reversing epidemics, supporting Uganda’s AIDS program which helped the country reversed the course of the disease. Upon returning to the United States, it occurred to him: could gun violence function like an epidemic? And could it be fought, and even stopped, using the principles of public health?

Slutkin has applied the lessons learned over a decade of fighting epidemics to the creation of Cure Violence, a public health approach that has been statistically validated by two independent evaluations by the Department of Justice and Centers for Disease Control. Cure Violence has been called a "pioneering violence reduction model" and its methods have received nods from the Institute of Medicine and the U.S. Conference of Mayors. The program is being replicated at more than 50 sites in 15 U.S. cities, as well as in many countries abroad.

Dr. Sultkin is an Ashoka Fellow, a Professor of Epidemiology and International Health at the University of Illinois at Chicago, and a senior advisor to the World Health Organization.

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