GARY SLUTKIN: Oh, good afternoon. Hello? And welcome to Hamburger University . So, I am very grateful to be invited here to speak with you. It’s not the usual topic for you I imagine, but maybe sometimes it is. How many of you are working in communities that are too violent? So that’s what we’re working on. I’m going to try to do two or three things in the time that we have. I want to give you my perspective on the problem and how we came about it this way, and I want to go through a little bit of what the intervention consists of and the theory that drives it. You have a handout, which pretty much shows the kinds of results and reductions in shootings that we've achieved. And we’ll spend a little bit of time on that.
My perspective on this problem was really very much affected by having been working overseas for 10 years straight. And my perspective on the U.S. was very much influenced by that as well. And from the point of view of the rest of the world, the U. S. has a particular problem with its violence, both internally and externally. It’s very famous, it’s very well known, it’s very infamous. There’s what’s it all about, and from the international perspective you, having been away for a long time and spending so much time with people from other cultures, as Arden was saying I was working with the World Health Organization.
We are a multi-cultural UN Institution. Americans stand out, even those who are not shooting guns for a certain amount of aggressiveness and individualism and some listening difficulties you might say. And this is one problem set, this individualism, competitiveness, aggressiveness, and violence, that really stands out among even, for example, an American academic coming over to World Health Organization Headquarters, interacting with us in our daily work, were blown away by the usual mode of this individual. Likewise, that same individual comes out to play basketball with us on the European court and we can’t understand why he’s throwing elbows and trying to hurt us. And it also translates into the, in a way, agreeableness of an American consultant, which we might send to other countries.
At the same time as that exists, as many of you know, the U.S. cities have rates of killings that are five to 20 times higher than other industrialized countries, in fact all other countries that aren’t at war. And so there’s something particular happening in the culture here that really kind of hits you. I mean, when you back to this country and you’re sitting around rooms and watching the way the discussion goes, you suddenly realize that you don’t have two or three Americans in a group of 30 as we might have at World Health, but you have 30 Americans at that, and so the whole conversation is even about, for example, how to deal with violence. You’re already starting in the quicksand. Those who you’re working with already have a certain competitiveness and psychological matters.
The other problem that you see in the U.S. as viewed from abroad, in fact, you might say there’s only two problems, is the inequity, the way that resources are distributed. And so this really shows up to a visitor and it shows up in the statistics and this is the number one social variable that predicts violence. The number one individual variable is having violence done to you and in that context, violence is very much, behaves almost exactly like any other infectious disease. And I’m just going to spend a minute on that.
But if you look at curves of any kind of violence whether you’re talking about World War II or community violence in a U.S. city, which, you know, where the curve just start to slope up in the 60’s, or a soccer riot that goes up and down, you basically see epicenters and curved dynamics that are very similar to any infectious disease.
Now, so what, you know, struggling personally with what could I possibly work on in the U.S. because the U.S. doesn’t really have problems except for these two, I landed on this issue. And no, that’s, I didn’t mean to say that in that way exactly, because that’s the other part of the way the U.S. is viewed, and I took it too, is that the U.S. has no problems because I mean, for example, I bet the majority of you have water that actually comes all the way into your house.
How many of you have water that comes all the way into your house? How many of you have water that even comes into more than one room. And I would visit people in the U.S. and be in their home and they would change the thermostat, you call it, one degree or two degrees up or down, and so it’s really a comfort station, the U.S. and excellent land, unlike a lot of the world, so these two other things exist in a place that really otherwise has no problems.
Now, when, so I spent, I will tell you, it’s over two years, and you’re pushing three years trying to figure out what I could possible work on in the U.S. because my return here was a personal decision based on wanting to live in an English speaking country again. And in that context I began to learn about that children were killing other children with guns and when asking the question what is the strategy for dealing with this and I asked this question really broad and wide, there were not answers that made a lot of sense.
As, and it may not make any sense to you, because you’re used to trying to develop a strategy that works on a problem that has something to do with underlining variables, and a violent behavior is only a behavior, you see. And so I purely saw this as a health matter. And let me spend a minute on that, because this is an enormous reframing.
Many of you, probably everyone would raise their hand if I said how many of you have heard that violence is a public health matter? Go ahead. Raise your hands. All right. So, but what does that actually mean? How many of you don’t really completely believe it or haven’t really connected with it totally. But let me tell you what this really means to me and to us.
It’s a health problem quite obviously because it involves doctors and nurses and intensive units and emergency rooms and anesthesiologists and chest tubes and CAT scans and what not, right? Okay. But it’s a public health problem because it is of population importance. In other words, we look at cancer and heart disease because they’re number one and two or two and one causes of death in persons over 40 or so.
But this, the matter of people killing other people, violence is actually the number one cause of death of one to 35 year olds as a large group among most U.S. cities. Number one. And nationally it’s number two. And among African Americans nationally it’s number one. So obviously it qualifies as public health problem. But more to the point is the fact that it’s a behavior, and of course, it’s a behavior, a violent behavior is a behavior.
But what I’m really saying is it’s just a behavior. It’s only a behavior. It’s nothing more than a behavior. In other words, it should therefore be subject to the same types of dynamics and roles and preexisting variables and maintenance factors and conditions for change that most behaviors are driven by, because are any of them really substantially different from each other except in their final manifestation.
So the theory that’s driving this is that this is driven by the same types of things that drive--fill in the blank, sexual behavior, breast feeding behavior, seat belt using behavior, drunk driving behavior. I mean, smoking possibly has another component in that it has an addiction quality. But otherwise most of things exercise behavior, eating behavior, most of things that we deal with are in health, are related to changing behaviors.
Of course, not just the person, the individual’s behavior but group behavior, because group behavior is what drives most of individual behavior as well as all kinds of provider behaviors, right? Because we drove our child mortality down by changing mother’s behaviors into using ORT and not withholding hydration but in fact giving oral re-hydration as well as health worker behavior, you follow me? I ran a TB program for, I ran the TB program for the city of San Francisco . It’s all about behavior, drug-taking behavior, on the part of those who were infected.
So that’s really the turning point for us in the understanding of this. Likewise, we would have to say in the conversation with the general public or with the conversation of lets say a mayor or a police chief or anyone else, when we’d ask you what is your strategy for reducing violence, they would likely say, well, this is how many police officers. This is how, you know, these are what our laws are. This is how we imprison, is how many people are in prison and so on and which would leave one to believe that most of behavior is driven by punishment, which of course is not the case. Most behavior is driven by what?
It’s driven by learning and it’s driven by social expectations. And the thing that blew me away the most when I was working principally in AIDS was this research finding, which some of you may know what I’m beginning to get to, that the principle determinant of whether someone uses a condom or not was whether they think their friends use it. I mean, what a way to make a decision about your life? Think about that.
And so what other people expect of you, I mean, what you learn behavior is based on what you observe. We know that. I’m speaking with the health people now, right? So you watch what your mom is doing, you watch what your dad is doing, you watch what the people in the neighborhood are doing, and you watch very, very closely and that’s pretty much what you learn to do.
You know, you don’t suddenly start speaking Swahili if you’re growing up in an English speaking home. And if your father is reacting this way, you learn to react this way. If other people around you put their seatbelt on, and then social expectation continues to drive it. And I use this analogy of--when I’m talking with law enforcement, is that, you we have a room like this here today and, you know, what if one of you lit up a cigarette right now.
I mean, the reason you’re not doing it, maybe you don’t smoke but one, if you did, if 30 percent of you did, the reason you didn’t is principally social disapproval. It’s not because the police are here watching you. It’s social disapproval. And when I was in medical school we watch angiograms. Thirty percent of the doctors were smoking while we watched angiograms. And so this has changed.
So this is, the theory that drives this, which is on your handout, which drives what we do, is we basically programmed in behavior change theory and that’s this little diagram here, and we’ve, and this, what we do will make total sense to you and we hire outreach workers who are from the target audience, from the group themselves, to interact with those who are in the community who are doing this.
In other words, principally we’re hiring ex-offenders or people who we hire people for their Rolodex but they’re on this side of the line. They can inter react with the people who are doing it. Just like we hired sex workers to interact with sex workers in West Africa for AIDS or we hired Vietnamese refugees to reach Vietnamese refugees. You know that sometimes you hire moms to do some outreach.
So it’s the credible messenger and we have a whole program for recruitment and training and supervision and support. Then we have a massive public education program. Stop killing. If you think a killing might be happening or if you think a shooting might occur, call here, the massive public education effort. We train clergy and we mobilize the community to do a response to every shooting. So there’s another piece of the social disapproval.
And so we have multiple messengers, the community themselves, the outreach workers, the materials and the clergy and the place, also additional presence in response to shooting, same thing as the cigarette literature, if you’re doctor tells you and your mom tells you and your friends tell you, and more of your friends tell you, and you see it on television, more likely to change.
And so the idea is to transition the norm from, we usually shoot in this circumstance to we no longer shoot, until shooting isn’t expected of us. And then, you know, we, last year we intervened in 154 of these events. We average a 50 percent drop in killing the zones that we work in. Over a course of four years, we’ve taken the worst police district in the country from 72 killings a year down to 26, with this strategy.
And I heard a story from one of my staff members a few months ago, of someone who pulled the gun in a club at 2:00 in the morning on the west side and the staff member said, I finally got what you were talking about Gary about changing the norms, because what usually would have happened is, other guns would have come out and there would have been shooting happening right then. But what happened, which surprised me completely was that everyone looked at the guy like he was the biggest jerk. So that isn’t happening all over the city. That isn’t happening all of the time, but that’s kind of what, you know, the endpoint is.
Now, you know, just to spend a little more time on the theory and then I’ll take you through the components by way of the visuals. Behavior change has to facilitate an alternative, right? So it’s kind of like lets say this were our meeting room every week or something, and all the time we come into this room through that door and go out, we never think there’s another way. And so what’s involved here to change that behavior in part would have to do with this door being open and available and then that door being a little more closed and with time, no one even remembers that we used to go through that door. Do you follow me?
And so, but what’s critical is that there has to be the alternative and I’m hoping that some of you are kind of--I don’t have to hope, I would imagine some of you are taking in this kind of thinking for other things you do. And maybe, and likely you do already. But we developed this concept at World Health of an alternative, which has to do with a slightly different thinking about the usual use of the word. It has to do with the idea of on the spot alternative. You need an on the spot alternative.
So usually when we talk about alternative in reducing violence, people are thinking we’re talking about GED or school or a job, which is highly relevant as an alternative to the lifestyle. But as an alternative to the single objective we have, which is the reduction of shooting and killing, there has to be something on the spot. Like a seatbelt on the spot, you follow me? Like a condom has to be on the spot, not at Walgreen’s when you need it. And so the on the spot alternative in this is the outreach worker or the accessibility to an outreach worker through his cell phone or through a hotline.
And so what happens is we get called by, you know, here’s someone who’s about to do a car jacking and there’s a friend of his who has an awareness that this is going on. There’s no way on the planet friend is going to call the police on his friend. You follow? But he will call us because he can imagine, because he’s now getting it, he’s been around our staff enough that he knows that this is something that’s going to make things worse for him. And so, we get to the spot and we see what you might expect, maybe not, girlfriend riling him up, encouraging him.
So what is his thinking? His thinking is if I don’t do it, you know, I’m a woos, you know, I’m not really a man, so he is being driven by this thinking and he needs the help on the spot of what the heck are you listening to her for? And additional support, you know, what the heck are you talking to him about? So this shifts the thinking because the thinking is what drives this behavior. You’re totally familiar with this.
This is true of everything, but critically true of violence. And for those of you who aren’t really connected with this, you should get Aaron Beck’s book "Prisoners of Hate" an awful title. But he ran, he was one of the founders of cognitive therapy and so this is what, of course, you know, some of you maybe additionally interested or maybe even more interested in the whole field of domestic violence, of course.
So this is largely driven by men’s thinking that it’s acceptable to hit her. You know, of course, you know--I hear this in the neighbors--"Of course, I smashed her, you know, she came home at midnight ." You know, "Of course, I smashed her, she went out and spent this money." And then the next thing he goes to the barbershop or whatever, and he tells the story, and his friend goes, "I hope you hit her, didn’t you?" Now instead if the men are saying to this guy, "You did what?" You see, and so it’s all about what your thinking is, what you think is acceptable. You want one more of those?
This maybe even, you know, women always prefer peace to a piece of the action or piece of the turf. And so, your thinking may not be as distorted as ours--men, as we’ve learned. But you still may identify with this--maybe not. How many of you have in the last month been cutoff by someone, you know, when in traffic, just really cutoff? How many of you have gotten angry? Okay, can you at all get in touch with what your thought was before you were angry? Huh? Okay, I won’t spend a lot of time on that, but a lot of people have the thought, something like, he can’t do that to me. Or she can’t do that to me.
So you have a thought, he can’t do that to me, and then you have an emotion, anger. And then you have a behavior--thought, emotion, behavior--that’s the way it works. And it’s nearly spiritual and it’s like lightening/thunder, the storm. And that’s what’s going on in your mind all day long, all day long, all day long. Thought, emotion, behavior. Thought, emotion, behavior, thought going on. Sometimes just thought, emotion, thought emotion. Whenever you have an emotion you’ll ask what’s the thought? Be surprised. So, now then the behavior will be what?
Well, depending on what your own, next thought about what’s acceptable, what’s ever been programmed in, you might show a finger of your hand or you might honk, or you might chase for a while, or you might scream, some people would shoot a gun. Okay? But now replace that thought with that had nothing to do with me. Someone cuts you off, they had nothing to do, but undoubtedly is the case, because someone was daydreaming or on a cell phone or is a lousy driver anyway, or even if they looked at you and it was your appearance, racial or other, no matter what, it still had nothing to do with you. It had to do with them--their thinking.
So if you just, every time you’re cutoff, go that had nothing to do with me, you’re home free. You don’t have the emotion. You don’t have the behavior.
Our program, the Chicago project was established to do two things, to reduce violence in Chicago as fast as possible with community and mother partners and to better define what is a full violence prevention program, because obviously something is missing. It can’t all be punishment. Obviously something is missing on the community side, on the public education side, on the intervention side. And this is 2003 we’re down to 450 now. We were at 700 a couple of years before this. Chicago is, you know, one of the epicenters, like Los Angeles , the highest rate of killing of all cities over a million up until last year. And this is the way we work.
We work with communities. We develop a management--we have a management infrastructure, which consists of a community organization in each neighborhood. We develop a written agreement with them. They do a certain number of things, we do a certain number of things. They interact with the police. They distribute materials. They may hire the outreach workers, or we may, or a third party may and they mobilize the response to every shooting in the neighborhood. And so we’re operating now in 15 communities throughout the state. We kicked off a program in Newark , New Jersey . Is any one here from Newark or from New Jersey . We kicked the Newark program last week and we’re probably going to be doing something with Baltimore as well.
So here are the components. I’ll just show you what they look like. Here’s outreach workers; this is the West Garfield team. Some of these were in the original team in 2000, which is the first year that we put this into place. We chose the second worst police beat and worst police district in Chicago and got a 67 percent drop in shootings in the first year, which surprised us. We put everything we had, all the resource we had into one spot and this is the outreach teams. They work nights, you know, they work ‘til two in the morning. They have 24-hour beepers. About two-thirds of the outreach staff, are ex-offenders.
The woman in the middle had lost her son. He was a gang member and so she, you know, decided this was her way of trying to help and save others. Marilyn, who is all the way on the left, had lost her brother and she’s still with us. She’s one of the, she and Rick are two of the, our most--now in this neighborhood it’s now normative to have Cease Fire Outreach workers. They’ve been there for pushing six years. So if you’re a 10 year old, you’ve had outreach workers in your neighborhood since you were four and so on. And we’re trying to normalize and institutionalize this as new cadre of worker, like an Aids educator or an EMT person or.
This is not here really for the headline. It’s really more for the interaction. The Cease Fire workers on the left, we use these materials as helping to interface with people, to start the conversation. So for every shooting in these neighborhoods, there’s a big deal made out of it. That changes the thinking from nothing ever happens and no one--it changes the thinking from nothing ever happens to these people make a big deal of it; from nobody cares to somebody cares to we can’t do anything about it, to we’re doing something about it. So there’s changing in thinking happening in all these other ways as well.
And the group who is involved with this, people call them gang members or whatever. They frequently are hanging around and they’re frequently watching. Sometimes the person who did the shooting is even around and we, it gives us a chance to interact also with them. They’re sometimes blown away by this, but it’s an enormous educational opportunity and they expect that they can’t do business for a little while, too. This is in Rockford . And, you know, the clergy are involved in this, and so there’s usually something having to do with prayer. And then the public education effort, I mean, this is our lead material.
This is, people say really in your face--it’s the very direct message I would think. I mean, it’s like, you know, breast feed your baby, you know, immunize your child, drink coke, and it’s not a lot of all kinds of other things going on here. And those involved when we came out with this, an ad agency came up with this, those on the street said it’s about time someone said this to us. As well, don’t tell us about the drugs, but it’s about time someone told us about this. And then, you know, out of a photocopy machine we’re making all kinds of variations.
This is a new thought that you could be the one to stop it, and people even get awards for being the one to stop it. We have a hotline, and some of the other numbers, our outreach worker numbers. So we passed these out. Last year we passed out a half of million. We distributed about a half a million pieces of material, flyers leaflets, so on, about a million and a half in the last three years.
Those of you who don’t know, Bob *Hornex work public health communication strategies for change, and the relationship between intensity of public education messaging and behavior change, for those to say that public education is just about awareness, it’s not the case. Behavior change can be facilitated by a large enough intensity. And for those of you who have worked in the international realm, you would probably agree with me that we under do it in this country, the health education messaging.
This is a new idea that you might be feeling pressure to shoot. You see we have this little, this subscript in here to change your thinking, which shows up on a lot of our stuff. And then we put this out, you know, going back to the behavior change theory, there’s risk as well. You know, like it’s harder to go out that door, you always go out this door because those doors are harder to push or because every time you walk through those doors someone insults you or there’s social disapproval out that door.
And this, and you know, talking about these sentences--ordinarily sentences appear on page six of section three of our newspaper. So it’s not really in people’s face that you could get this. And they all use this as face saving too. They say, "Oh I didn’t know that or I didn’t know that," and we wrote new laws even though there are already like seven-year old laws. And then we have, we spend a lot of time with the clergy. So, some are listening to the clergy, some are not.
So that’s basically the long and short of the components. And the numbers are there. I don’t know, I think I’m preferring to spend a little time with questions than to go through the numbers because you have them in front of you.
ARDEN : You walk through them a little bit.
GARY SLUTKIN: Go through them a little bit? All right. So probably the best thing is to, because it won’t show up so well here, as well as you have it in your.
This, by the way, is our first Cease Fire Zone. It was pre-selected that we would work in beat 11/15, 11/12 was the worst. But 11/15 was where our neighborhood group located where their organization office is. So they said, "No, we want to do this in 11/15." And then we put in the outreach workers and the public education messaging and the clergy and the responses, and we end up having a 60 day and a 90 day period that year with no shootings at all, which was virtually unheard of in the neighborhood. And a 67 percent drop, went from 43 shootings to 14. And the very, very interesting is that the surrounding area, those of you who know this part of the public health, diffusion of innovation, the concentric circle, the neighboring beats had an intermediate effect.
And this is extraordinarily interesting to the criminal justice people who are used to seeing what’s called displacement from criminal justice interventions you push it from here to here like what they call Balloon Effect. And it goes over there. When in Chicago they put up street, these lights, these blinking blue lights, cameras, the activity moved to the next street. Standard displacement. But if you put in public health behavior change, innovation, it diffuses. I mean, we do, if you do immunization program in this part of the city, the moms over here get it, too. They get some effect of it. Some of them will go to the service. Some of them will understand that it’s available. Right?
And so, better for you to look at your own paper than to look at this, but we’ve, you can see the first year reductions in shooting--and better also to look at the larger page because it shows also the comparisons. And what we do for comparison is we look at the reduction in neighboring beats. A neighboring beat is every single beat is a part of a police district. And every--and so, the neighboring beat is every single contiguous area to the intervention area, and we look for its change compared to the intervention area.
We also compare to what we call comparison beats. Comparison beats are beats that have the same rate of shootings, plus or minus 10 percent taken from anywhere in the city, and then the city as a whole. And for the first, from ’99 to 2003, the city had no change in its number or rate at all. And so these first year reductions of 68, 22, 34, 31, were compare to zero in the city as a whole. And you see, it shows up statistically as a, at the point of one level as a group compared to neighboring beats and comparison beats and city as a whole, and then some but not every one.
We’ve also have been playing around with dose response curves, which I don’t have here. And originally I thought that we were getting a, a very clean, actually the curve goes this way, because we do staging of these interventions. And the more, it looked like we were doing the more we put in the more of an effect. But now it looked more like a, we don’t get an effect 'until' a certain amount and then it kind of falls off the cliff. The most powerful part of the intervention is probably the outreach workers that we’re--I’m saying that is from the, if you will, in sight to experiments that we’ve had where neighborhoods have really wanted to do Cease Fire but there’s been no money.
And there’ve been quite, there’ve been a few of those that have worked with us for a few years and so they’re, in fact, doing the things that don’t take much money, like the responses and then we give them the public education materials. But when we then add the outreach, we then see the precipitous drop and that’s really what happened in southwest. If you look at southwest Chicago , which is Gage Park , Marquette Park , they were really doing something in 2000 and 2001 and 2002, but they got the support from the outreach workers in ’03. And Logan Square is pretty much the same. The outreach was the most powerful.
Last year we expanded from working in five neighborhoods to 15 as a result of funds from our Governor, Governor Blagojevich, and that allowed us to work in more communities. Some stayed in a startup phase and some went out into, all the way to Outreach, and we averaged a 50 percent drop in killings among those zones and that data is also here.
So I think I will stop there and take any questions.