A Decades-Old Approach To Prevent Gunshot Wounds Is Catching On In Hospitals Around The U.S.
While working as an orthopedic surgeon in Hawaii, Dr. Diane Payne had treated one person with a gunshot wound in three years. But when she moved to Atlanta in 2013, Payne said it was like treating gunshot victims was suddenly all she was doing.
“I was shocked by the number of gun-related injuries that we’re seeing and taking care of here,” said Payne, who works at Atlanta’s busy downtown trauma center, Grady Memorial Hospital.
In 2013, Grady treated more than 600 gunshot victims.
“And I started asking ‘What is going on?’ And the answer I was getting routinely from my colleagues was ‘Welcome to Grady. That’s just how it is here,'” Payne recalled.
She said it was like everyone had just gone numb.
So she did some research, and found a model that’s well established in other parts of the country, called hospital-based violence intervention. Payne successfully applied for a grant through the federal Bureau of Justice Assistance.
The approach is designed to offer a menu of resources and support to gunshot victims, like educational support, job training and mental health services. It’s all in the hopes that they won’t end up back in the Emergency Room — or worse.
Grady’s hospital intervention program is called PIVOT, and it’s about six months old.
Arik Johnson is a licensed social worker at Grady, and he’s the guy implementing PIVOT on the ground.
“So I got somebody that I’m working with. He got into a situation with a guy and the guy shot him,” Johnson said. “Come to find out, he’s a kid. He’s not even 20. And he doesn’t have a high school diploma or GED, no job. Only thing he knows is the hustle.”
His task is to get that 19-year-old his GED, find him job training and maybe mental health care. Basically, to keep him alive.
That’s because injury researchers have found that if you survive a gunshot wound, your likelihood of dying within the next few years increases significantly. That’s what hospital violence intervention tries to fight.
For now, the PIVOT outreach is reserved for people shot in a select set of zip-codes, based on data from the Atlanta Police Department. They are all predominantly black neighborhoods with median incomes significantly lower than average for metro Atlanta. PIVOT is looking to follow a well-trodden path.
A product of the ’90s
Hospital intervention programs have been around for almost 25 years. So why is the approach just catching on in Atlanta?
“In 1995, as a children’s hospital, we had an alarming number of firearm injured children,” said Dr. Marlene Melzer-Lange, a pediatric emergency doctor in Milwaukee, Wisconsin. The violence intervention program she helped start at Children’s Hospital of Wisconsin was one of the first in the country.
“In looking at some of the records of the children that came [to the emergency room with gunshot injuries], we noticed something startling,” said Melzer-Lange. “It wasn’t the first time they had come for an injury that was provoked through violence.”
Children were returning to the emergency room after having shown up the before because of fights or stabbings.
The Milwaukee program, called Project Ujima, adopted an approach used to help abused children and applied it to victims of violence.
“When you identify an abused child, there are a lot of services that come around,” said Melzer-Lange.”Social services, child protective services, parenting programs in the community are all surrounding that child and family to help them out.”
On the other side of the country in Oakland, California, doctors formed a parallel model in 1994 at Highland Hospital. Over the years, similar hospital-based programs took root across the country. And in 2009, a handful formed the National Network of Hospital Based Violence Intervention Programs (NNHVIP).
The network is working with the American College of Surgeons on issuing an official recommendation for trauma centers that treat a high rate of violent injury to create violence intervention programs.
Word of mouth is the main way the model has spread according to Melzer-Lange.
“I think people train in one place where there’s been such a program, and then they move to another place for their next job and they either start it up, or encourage other people in the new hospital to start up a program,” she said, adding that the number of applications to join NNHVIP is growing.
Wide open spaces
If you look at a map of where these programs are, there are clusters: California, the Northeast and the Great Lakes region. In other areas, they’re spread thin. The South is one. The Mountain West is another.
In Kansas City, the Aim4Peace program operating under the city’s health department isn’t technically hospital-based, but it does offer violence intervention services to victims at two local hospitals: Truman Medical Center and Research Medical Center.
Five workers coordinate with other Aim4Peace workers who focus on some of the city’s neighborhoods, said Rashid Junaid, who manages the program.
“If something happens on a particular block, they go... and see why it happened and how we can reduce or not have that happen again,” he said. And while the city’s overall homicide rate has increased in recent years, Junaid said neighborhoods where Aim4Peace operates have generally held steady or seen reduced violence.
In Denver, Colorado, the AIM (At-Risk Intervention and Mentoring) program began 10 years ago, and remains the lone violence intervention program in the Mountain West region.
“There was somebody from the city who came and wanted to do an assessment on youth who came to our facility with injuries, and their idea was to put out a survey in the waiting room for youth to answer if they were gang involved,” said Katie Bakes, an emergency physician at Denver Health and AIM’s director.
Bakes wasn’t a fan of that original plan.
“I suspected that that was not a really good approach,” Bakes said. “That maybe youth who were involved in something they thought could bias providers were not going to be honest about their involvement.”
But it got her looking for an alternative, which led her to the hospital-based violence intervention model.
Last year, AIM did more than 200 bedside interventions. In the early days, Bakes said it was a balancing act.
“One of the problems that programs like ours face is that funding is always an issue and so you end up working to get the funding as opposed to working on the program,” Bakes said.
She thinks funding challenges may be what slows down geographic expansion as well.
The AIM program is city-funded now, but she had no doubts there’s a need in nearby communities outside Denver.
“My hope is that we’ll be part of what will create a snowball effect in our region,” said Bakes, “but it’s hard to promote what you’re doing when you’re trying to raise funds and you’re trying to function in the program.”
Culture also plays a role in why these programs have yet to sprout in some parts of the country, said Bakes.
“There’s a lot on the East and the West Coast,” she said. “In Denver, at least, we’re a pocket in the [Mountain West] that tends to be more socially minded and maybe more action-oriented in terms of reaching out to our communities.”
Who’s in the room?
Like the AIM program in Denver, the Kings Against Violence Initiative in Brooklyn, New York, has also been around for 10 years.
Dr. Rob Gore, who runs the program out of Kings County Hospital, says his dedication to violence intervention is personal. Earlier in his career, he worked in Chicago’s Cook County.
“I looked around the [emergency] room and the only two people of color in that entire room was me and the clerk,” said Gore, who’s black.
In Chicago, he found himself treating members of his own family, which was different from what his colleagues in the ER were experiencing.
He thinks the growing national attention on mass shootings may have something to do with a the increasing interest in really understanding where violence comes from.
That interest is positive, said Gore, but “it does make me upset, because we’ve been dealing with issues of violence and conflict in the black and Latino and even in poor white communities in the United States for a long period of time.”
In New York, Gore has been able to be vocal about the disproportionate impact of gun violence on young black and brown men.
But depending on where you are in the country, hospital-based violence intervention programs may have to steer very clear of any message that can sound like political activism.
How to survive in Atlanta
In Atlanta, Diane Payne says PIVOT is about tackling a public health issue, full stop.
“This is not about gun control,” said Payne. “I think a lot of people, when they hear about or listen to stories about gun violence, it’s such a politically charged topic that it tends to be very divisive.”
Social worker Arik Johnson said the work has been slow going, so far. Out of 80 patients who have qualified, just a handful have agreed to work with him. For Johnson, that’s understandable.
“Poverty is trauma,” said Johnson. “Even understanding that and helping break that down to some of these families is really astonishing. They’re looking at me like a deer in the headlights like, ‘I thought that was normal. My cousin got shot. My uncle got shot, with six of us in the house.'”
The normalization of violence is just one of the many challenges Johnson’s up against. A lack of health insurance and a learned distrust of institutions are also major hurdles.
“I’m a black guy. I’m cool, whatever,” said Johnson. “But I’m just another guy representing another system who said they were gonna do something.”
He’s hopeful more support will come with time. Ideally, that will look like enough sustained funding to hire another social worker and allow the program to reach people in their neighborhoods. That has been a crucial part of making violence intervention work in other cities.
The program is still in its infancy in Atlanta, which makes it vulnerable. Payne’s goal now for the program is a lot like what she wants for her patients: for it to survive and grow.
Guns & America is a public media reporting project on the role of guns in American life.