Violence, Interrupted: Breaking Cycles in the Hospital and on the Street

SHANOOR SEERVAI: We’ve all woken up to headlines about mass shootings and violent attacks. Guns kill almost 40,000 Americans each year. Millions more arrive at the hospital with violent injuries. And even though they may recover physically, the issues that caused violence often go unchecked. On today’s episode of The Dose, we’re going to talk about how hospital-based interventions can help break cycles of violence in the communities worst impacted by it. My guest is Fatimah Loren Dreier. Fatimah is the executive director of the Health Alliance for Violence Intervention and a Pozen-Commonwealth Fund Fellow in Health Equity Leadership.

Fatimah, welcome to the show.

FATIMAH LOREN DREIER: Thank you so much for having me.

SHANOOR SEERVAI: So let’s get started by talking a little more about you. Tell me about your life and your experiences. What made you want to work towards addressing violence in communities?

FATIMAH LOREN DREIER: Sure. So I was born in New Jersey. I was born in a one-bedroom apartment that included both my parents, my younger brother, and myself. And unfortunately, since the age of 16, my father has been in and out of prison. And actually one of my earliest memories, I’m four years old, and the police come storming through the door of our apartment to arrest my father. And a cigarette falls out of his mouth and he’s handcuffed, but he asks me to come and pick up the cigarette and put it in his mouth. Maybe an act of defiance, who knows. But the officer comes, gets between us and he holds out his hand for me to give the cigarette to the officer. And I see his gun. And I think to myself, four years old, that this officer, if I don’t do what he says, he’s going to kill me and he’s going to kill my family.

And so I give him the cigarette, he takes my father away. And I share the story because in my neighborhood, this was normal, right? This is typical. This is not atypical. The experience of violence and all the different layers in which that arrives at our doorsteps is so part of the experience of growing up in these neighborhoods, that it becomes compounded over time, the trauma becomes compounded over time.

SHANOOR SEERVAI: What makes a community particularly susceptible to violence?

FATIMAH LOREN DREIER: That’s a great question. So I think it’s important to first start with history. That there are communities that have experienced systematic divestment, economic exclusion. So they are poor, but it’s often a poverty that has persisted due to these much larger social factors. These are related to policies around redlining and housing, access to capital. There are a whole host of reasons that create communities that have a level of economic exclusion that sets, I think, a context in which violence can arise at the concentrated levels that we see. It is not economic exclusion or poverty alone that causes high rates of violence. One of the strongest predictors we’ve seen is exposure to trauma and violence. That once these intergenerational realities get set up, then generation after generation, they can get perpetuated. So it’s just important to name that incidents of state-sponsored violence, incidents of violence at a larger structural level impact interpersonal violence.

And what we’re finding, what the research is beginning to help us understand is that our proximity to those who have experienced, either as a victim of violence or perpetrator of harm, impacts our risk factors for being a victim ourselves of violence and potential harm in the future. And so it creates this kind of network effect. Some researchers have called this a contagion in the same way that we think about a virus like COVID. Our exposure impacts us in some ways. There’s far more we could be learning about violence. We need Congress to act, to continue to invest in the kind of research we need to understand violence at this level and the ways that people on the ground experience it.

SHANOOR SEERVAI: When we hear the word violence, I think most people, their mind immediately goes, crime. But the research that you describe is coming from experts who say we should address violence differently. We need to think about violence as a public health issue. So tell me more about this idea.

FATIMAH LOREN DREIER: Sure. So we’ve been talking about violence as a public health issue for a long time. And often people say, “Well, what is public health?” I think that given that we are in the middle of a global pandemic, people have a much deeper appreciation for the tools and the strategies of public health. That it’s important to understand at a population level where violence is. So there’s a data component. How do we find where there’s greatest risk and then bring resources to that? So public health approach takes a step back and say, “We can actually do something further upstream to address violence and ensure that people have an opportunity to live lives that are filled with their own goals and hopes and dreams, and not kind of go down this road based on their own exposures.” And there are actually ways of doing this effectively.

SHANOOR SEERVAI: So based on the work that you do, can you walk me through an example of what it would look like to address violence upstream in this way?

FATIMAH LOREN DREIER: Sure. I’ll share our first example, what really helped launch this work. So this happened in the early nineties, there was a young man named Sherman Spears. Sherman had been shot in Oakland, California, where he’s from. And was in the hospital, was taken to the hospital through the ambulance. And was given treatment for his wounds. Unfortunately, he became paralyzed from the waist down and was confined to a wheelchair. He had spent weeks in the hospital and doctors had come to attend to him and they had really no idea what Sherman’s reality was outside the hospital doors. That people were coming to his bedside asking him, “Do you need us to take a hit out? We think we know who might’ve done it.” Mothers coming and crying at his bedside. People in the hospital really had no idea what he was experiencing.

And he had a lot of time to think about his own life and rethink his own goals. And following his time in the hospital, when he left, he decided — he made a choice himself, that he wanted to change his life in new ways. And he wanted to come back to the hospital and talk to other young men from his neighborhood who’d also been shot about the sort of decisions they’re making. And so he did, he happened to be part of a program run by Youth Alive called, Caught in the Crossfire.

They helped him gain access to the hospital to be a part of what ultimately launched a new movement. In which people who are directly impacted by violence or people who have credibility within their neighborhoods are able to sit at the bedside with those who’ve been shot and talk them through some of the trauma and concerns they have about what lies outside their doors. And not only while they’re in the bed, excuse me in the hospital, but following their discharge. That these are deep relationships that get launched that really help patients who’ve experienced violence and are again, addressing that trauma, navigate their world.

SHANOOR SEERVAI: I think it’s important to pause for a moment, so our listeners can get a sense of the scope of this work. So Fatimah, your organization, the Health Alliance for Violence Intervention, works with people who are victims of violent injury in the hospital, but also connects them to resources outside in their communities that will help to prevent violence in the future. So how many cities do you have programs in? Where do you work?

FATIMAH LOREN DREIER: So we are a membership based-organization. So we have 40 members, 40 individual cities that have programs and an additional 45 cities that are either starting programs or are beginning to put together teams to start a program. So in total 85 cities, we’re working at 85 cities. Mainly in the U.S., but we also have members in Europe, particularly in the U.K., and in Latin America.

SHANOOR SEERVAI: There are two aspects of the care I want to talk about. The one in the hospital, you talked about somebody sitting at the bedside of somebody who’s suffered violence and talking to them, just trying to figure out what’s going on. Which is very different from what we think of somebody going to the hospital with a gun wound, and having the bullet removed and stitched up. That’s a very important reframing: that the violence isn’t only the physical gun wound. But then, what happens when that person goes back into their community and perhaps the environmental factors that caused the violence in the first place are still moving around?

FATIMAH LOREN DREIER: It is the case that our programs are really supporting individuals, but we also act as advocates, looking at the entire ecosystem. So first of all, where are the programs? Where are the resources that exist in society to support those who are most marginalized, who are economically disenfranchised? Where does that exist in society? That’s a big question. But even when those scant small resources exist, are they connected to the young men and young girls that we see who have been impacted by violence? And overwhelmingly, we say it doesn’t exist, right? Those connections don’t exist. So it’s about finding housing. It could be as simple as helping a young person get an ID so that they qualify for other programs. Sometimes, it’s something really significant like tattoo removal. Maybe there’ve been tattoos that are associated with a gang or a group that are out in the streets and as they rethink their life, getting rid of that tattoo is a really big component of their own healing and support.

So it really ranges, what those supports are. So that’s one piece of it, but then we’ve got to actually advocate and reimagine the ecosystem. So we have programs in which the hospital itself, as part of that ecosystem, pushes to ensure that there are grocery stores and actually provide some of the financing for those stores. That’s big-level thinking. That’s thinking about how do we address the ecology itself?

SHANOOR SEERVAI: Homicide is the number one cause of death for black men under the age of 44, and the number two cause of death for Hispanic men below 44. So, stating the obvious, any efforts to prevent violence are really important work. Could you tell me more about the violence intervention specialists and what they do in their communities?

FATIMAH LOREN DREIER: Sure. So our violence intervention specialists, they are credible messengers. They are from the community. They understand. Sometimes they’re formerly incarcerated. Sometimes they’re mothers who’ve lost their sons to gun violence. Sometimes they’re people who have themselves have been victims of violence. However they arrive at this, they have a deep passion and deep experience building relationships within their community and are able to marshal and leverage their experience, building those relationships with their capacity to help patients navigate again, identifying and navigating those resources. Sometimes it’s a community-based organization and it’s hospital-linked or it’s hospital-based, where the hospital itself hires people from the community within the hospital and they provide care directly to patients and then follow them postdischarge for months, even years, if necessary.

SHANOOR SEERVAI: Let’s move now to the scene in the community. Could you describe to me if there’s a moment of tension perhaps, a fear that there is going to be a shooting, people are having an argument, it’s escalating. To what extent can your programs support people in those situations?

FATIMAH LOREN DREIER: Our partners, again, there are many different kinds of interventions. I would say street outreach is a different violence prevention, intervention strategy that helps in the mediation of disputes out in communities. And so our street outreach partners, and some of our members have both a street outreach component as well as a hospital-based component. But the street outreach component hires credible messengers who are violence interrupters. So they do this work of mediating disputes and actually starting to kind of collect information and understanding of what the word is on the street. So before someone goes to another person’s side of town to kind of work through a beef or a conflict, if relationships have been built, the violence interrupters might learn of this and go to the person’s home, let them know that they’re able to help navigate. They quite literally, if you think about an expert crisis negotiator who comes to a scene, they are very deftly able to negotiate peace agreements. They’re able to help people think about other ways of managing the conflict and set up these really tightly spun agreements to ensure that peace is maintained.

SHANOOR SEERVAI: So you’re describing a situation in which peace is maintained by violence interrupters and by the community itself. But when there’s violence, the police are going to show up. And what we know is that there’s a history of racial bias in policing, and in communities of color there’s a lot of mistrust toward the police. How does our system of policing impact your work with communities?

FATIMAH LOREN DREIER: For our part, police exist, and part of our responsibility is to protect our patients as much as possible from the overreach of the criminal justice system. So if you imagine, if there is a person who’s a victim of a crime, the police are involved and they want to collect information. They want to know who did it. There are a whole host of, unfortunately for our patients, there’s this idea that as victims, they’re implicated in their own crime, which actually colors the criminal justice system’s view of our patients and therefore, what services they are able to receive.

So for example, we’ve got things like victims of crime compensation, they’re resources for those who’ve been victimized by crime. And a lot of our patients don’t qualify because police might say, “You were uncooperative in helping us with the investigation.” And by checking that box, they don’t qualify for the financial resources that they need as victims of a crime. There are some police departments in which they’ve seen these interventions work and actually have impact in a way that they as police don’t that have actually begun to kind of take a step back and allow our people to do their work.

SHANOOR SEERVAI: We’re having this conversation after the summer of 2020, when we had huge national protests around racism and police violence. Many of us saw on TV, read in the news, scenes in which the police were tear-gassing innocent protestors, they were beating them. And I wonder about how the approaches that your programs take can fit into this infrastructure, this reality on the ground, where we have a very violent criminal justice system?

FATIMAH LOREN DREIER: Our programs make different choices about their kind of orientation or whether they even open up relationships with police. And those relationships are always, I think, in the context of how do we make sure that we shield, again, shield our patients from the criminal justice system. It’s about advocacy to make sure, for example, police don’t check off the uncooperative box. To ensure that we can get financial resources and compensation for our patients and their families. We see places like the City of Newark that has reallocated millions of dollars from the police department to an office of violence prevention. We’re seeing that happen in Austin, Texas. We’re seeing what’s going on in Minneapolis. What’s powerful about this is there are places like Newark, where the police chief is supportive because they’ve seen the power of these interventions. And essentially saying, “We as police shouldn’t be called for these sorts of concerns.” I think that’s powerful.

SHANOOR SEERVAI: What could communities and cities do with resources that are spent on the police, if they were to reallocate them to different approaches to violence prevention?

FATIMAH LOREN DREIER: These programs do not work unless there is financial investment and people on the ground willing to do the work. We’re part of a movement of those peacekeepers. We have to hear and learn from their experiences. And when you listen to the needs of those who are on the front lines, our peacekeepers will say, “Look, we care very deeply about reimagining the criminal justice system. The criminal legal system needs absolute transformation. It needs reform. We need to see police reimagine its role.” I am not hearing folks say that they advocate completely getting rid of the police. They are advocates of seeing a different way in which renegotiating the relationship and reimagining what police do. But in order for peacekeepers, who do not have weapons and don’t have the authority, that there is a need for some sort of authority. I’m really proud to be on the invest side. I absolutely want to see these strategies and interventions expand significantly. And I look forward to developing the infrastructure it requires to build, to bring these to scale in a way that really honors those on the ground.

SHANOOR SEERVAI: The Dose is hosted by me, Shanoor Seervai. I produce this show for the Commonwealth Fund along with Andrea Muraskin, Naomi Leibowitz, and Joshua Tallman. Special thanks to Barry Scholl for editorial support, Jen Wilson and Rose Wong for our art and design, and Paul Frame for web support. Our theme music is “Arizona Moon” by Blue Dot Sessions, with additional music from Podington Bear. Our website is thedose.show. There you’ll find show notes and other resources. That’s it for The Dose. Thanks for listening.