Violence and Crime as Urban Public Health Issues...high-crime communities) • Health effects...

Violence and Crime as Urban

Public Health Issues Dr. Judy Lubin

Why is violence a public health issue?

"The violence is something we deal with daily and it's a real struggle... You get scared and youth here are angry when their friends are shot. The violence really does something to a person…

“It's sometimes bigger than the crime itself," Morris said…It affects you more, maybe even more than the person injured, because it lingers.”

Veronica Morris, community organizer and resident of Chicago's Englewood neighborhood

Source: CNN.com, March 27, 2014

Why is violence a public health issue?

• Leading cause of injury, disability, and premature death

• Violence affects other determinants of health

▫ Physical activity ▫ Healthy eating (food deserts-business may choose not locate in

high-crime communities)

• Health effects include post traumatic stress disorder (PTSD), depression, anxiety, substance abuse ▫ Studies have found:

75% of urban elementary school children living in high-violence neighborhoods had been exposed to community violence

35% of urban youth exposed to community violence develop PTSD

Effects on Mental Health and Cognitive Functioning

• Indirect and direct violence are often concentrated in poor, urban environments ▫ Cognitive and emotional stress

Reduces working memory, limits academic achievement, lower verbal and impulse control scores among children, acute psychological distress among caregivers

Source: Sharkey et al. 2012; CNN.com, March 27, 2014

Effects on Mental Health and Cognitive Functioning

• Indirect and direct violence are often concentrated in poor, urban environments

▫ Overall, about 8 percent of Americans suffer from PTSD at some point in their

lives (Propublica 2014). Compare this to: Chicago’s Cook County Hospital (2011)

43 percent of patients examined – and more than half of gunshot-wound victims – had signs of PTSD

Atlanta's Grady Memorial Hospital Study (Ressler et al.)

8,000 inner-city non-psychiatric patients interviewed ▫ at least half knew someone who had been murdered ▫ two-thirds said they had been victims of a violent assault ▫ one-third sexually assaulted ▫ one-third suffered PTSD symptoms (hyper-vigilance, social separation and avoidance)

Source: Propublica 2014; CNN.com, March 27, 2014

http://www.ncbi.nlm.nih.gov/pubmed/22846957

When Violence Became a Public Health Issue

• By middle of the 20th century ▫ The incidence and mortality from infectious diseases (e.g., TB, yellow

fever, poliomyelitis, diphtheria, and pertussis) that were once major killers of Americans were dramatically reduced

• Since 1965 ▫ Homicide and suicide have consistently been among the top 15 leading

causes of death

• 1979 ▫ Surgeon General’s report, Healthy People identifies control of stress and

violent behavior as one of 15 priorities for the next decade

Source: Dahlberg and Mercy 2009


• 1980s ▫ Risk of homicide and suicide reached epidemic proportions

▫ First measurable objectives for violence are established for the nation by

the Department of Health and Human Services – Promoting Health/Preventing Disease

▫ CDC establishes the Violence Epidemiology Branch to focus its public health efforts in violence prevention (1983)

▫ Report of the Secretary’s Task Force on Black and Minority Health identified homicide as a major cause of the disparity in death rate and illness experienced by African Americans and other minorities relative to non-Hispanic white (1985)

▫ Surgeon General’s Workshop on Violence and Public Health (1985)



• 1990s

▫ CDC establishes The Youth Risk Behavior Surveillance System to monitor priority health risk behaviors among adolescents, including violence-related behavior

▫ Several violence prevention programs being implemented in schools and communities across the country

▫ Congress passed the Violence Against Women Act (Title IV of the Violent Crime Control and Law Enforcement Act (1994)


48 Hours on Crack Street- The Streets

https://www.youtube.com/watch?v=GMGYwAnuEXI

Source: Centers for Disease Control and Prevention. Homicides among 15-19-year-olds Males—United States, 1963-1991.

MMWR 1994;43(40):725-727.

• Editorial Note: The increase in the annual homicide rate for 15- 19-year-old males during 1985-1991 was a dramatic change from the pattern during 1963-1984. Although the immediate and specific causes of this problem are unclear, the increase in the occurrence of homicide may be the result of the recruitment of juveniles into drug markets, the use of guns in these markets, and the consequent diffusion of guns to other young persons in the community, resulting, in turn, in more frequent use of the guns for settling disputes.

Disparities in Violence among Youth

Violence disproportionately affects young people and people of color • Among 10 to 24 year-olds, homicide is the leading cause of death for

African Americans; the second leading cause of death for Hispanics; and the third leading cause of death for American Indians and Alaska Natives.

• Homicide rates in 2010 among non-Hispanic, African-American males 10-24 years of age (51.5 per 100,000) exceeded those of Hispanic males (13.5 per 100,000) and non-Hispanic, White males in the same age group (2.9 per 100,000).

Source: CDC Youth Violence Fact Sheet, http://www.cdc.gov/violenceprevention/pdf/YV-DataSheet-a.pdf

2014 Most Violent Cities

Violent Crime Rate*

Murder Rate*

Pop. Officer to Pop. Ratio

Median Hhold Income

Pop. Below Poverty Line

1. Detroit 2,072 45 699,889 1:297

$26,955 38.1%

2. Oakland 1,977 22 403,887 1:632

$51,683 20.3%

3. Memphis 1,656 19 657,691 1:284

$36,817 26.2%

4. St. Louis 1,594 38 318,563 1:248

$34,384 27.0%

5. Cleveland 1,478 14 389,181 1:264

$26,556 34.2%

*per 100,000 Source: Law Street Media – data derived from FBI: Violent crime, population, murder, and officer statistics, measured January – December 2013; U.S. Census Bureau: Median household income, measured 2007-2011. U.S. Census Bureau: Poverty, measured 2008-2012.

http://www.fbi.gov/about-us/cjis/ucr/crime-in-the-u.s/2013/crime-in-the-u.s.-2013

http://quickfacts.census.gov/qfd/index.html

http://quickfacts.census.gov/qfd/index.html

Is violence preventable?

Source: Dahlberg LL, Krug EG. Violence-a global public health problem. In: Krug E, Dahlberg LL, Mercy JA, Zwi AB, Lozano R, eds. World Report on Violence and Health. Geneva, Switzerland: World Health Organization; 2002:1-56.

Public health approach to preventing violence

Step 1: Define and Monitor the Problem

• Understand the "who",

"what", "when", "where" and "how" associated with violence.

▫ Data sources: police reports, medical examiner files, vital records, hospital charts, registries, population-based surveys,


Step 2: Identify Risk and Protective Factors

• Understand what factors protect people or put them at risk for experiencing or perpetrating violence. ▫ Risk Factor - Characteristic that

increases the likelihood of illness, death or disability

▫ Protective Factor - Characteristic that decreases the likelihood of illness, death or disability (i.e., likelihood of a person becoming a victim or perpetrator of violence)


Step 3: Develop and Test Prevention Strategies

• Take an evidence-based approach to program planning and evaluation. ▫ Program Planning - Research data

and findings from needs assessments, community surveys, stakeholder interviews, and focus groups are useful for designing prevention programs.

▫ Program Evaluation - Once programs are implemented, they are evaluated rigorously to determine their effectiveness.


Step 4: Assure Widespread Adoption

• Disseminate findings and encourage adoption of successful programs.

▫ Dissemination techniques to promote widespread adoption include training, networking, technical assistance, and evaluation.



• primary prevention orientation: efforts designed to prevent violence before it occurs;

• data-driven: approaches based on data that describes the nature

of the problem as well as contributing risk and resilience factors; • collaborative: multiple partners from public health, law

enforcement, education, recreation, economic development, mental health, substance abuse, business, and others working together to produce change; and

• population-based: seeking community wide or “environmental”

solutions.

Source: Prevention Institute, A Public Health Approach to Preventing Violence:


• Most effective and sustainable strategies for preventing violence: ▫ Are community- or population-based

▫ Address the complex interplay of social, behavioral,

and environmental contributors to violence: poverty, homelessness, school failure, lack of activities, oppression, mental health problems, substance abuse, victimization history

▫ Focus on changing environments and norms within communities.


• Cure Violence founded in 1995 by Dr. Gary Slutkin ▫ CeaseFire Program

uses prevention, intervention and community-mobilization strategies Sends former gang members into targeted

neighborhoods to intervene in gang violence to prevent revenge shootings and curb fights.

Provides services such as GED programs, anger-management counseling, drug or alcohol treatment, and help finding child care or looking for a job

Public health approach to preventing

violence • The CeaseFire Chicago model has been replicated 16

times and has been validated by a 3-year US Department of Justice study conducted by four universities, showing 41 to 73% drops in shootings and killings, and 100% drops in retaliation murders.

• The first year of impact regularly shows 25 to 45% drops in shootings and killings.

• The return of businesses have been seen in these neighborhoods.

Source: Prevention Institute, A Public Health Approach to Preventing Violence

Suicide and Fatalistic Behavior

Suicide Rates* Among Persons Ages 10 Years and Older, by Race/Ethnicity and Sex, United States, 2005–2009

Source: CDC, National Suicide Statistics at a Glance, http://www.cdc.gov/violenceprevention/suicide/statistics/rates02.html

• Suicide is the third leading cause of death among blacks ages 15-24. It is the 16th cause of deaths for blacks of all ages

• The average age of black suicide decedents is 32, and that of white decedents is 44.

• Black youth were substantially less likely than white youth to have used a mental health service in the

year during which they seriously thought about or attempted suicide. • Since the black community in the U.S. is disproportionately young, the number of deaths among

youth may have a particularly strong impact on the black community.

Source: Suicide Prevention Resource Center. (2013). Suicide among racial/ethnic populations in the U.S.: Blacks. Waltham, MA: Education Development Center, Inc.

(2010 data from the CDC)

General Population

Blacks

• Effective mental health care

• Connectedness to individuals, family, community, and social institutions

• Problem-solving skills

• Contacts with caregivers

In addition to the factors identified for the general population, research has shown the following to be among the most significant protective factors for black populations:

• Religion

• Emotional and social support

(e.g. family and peer support, community connectedness)

• Strong sense of heritage/black identity (especially among black women)

Protective Factors


General Population

Blacks

• Prior suicide attempt(s)

• Alcohol and drug abuse

• Mood and anxiety disorders

• Access to a means to lethal means

In addition to the factors identified for the general population, research has shown the following to be among the most significant risk factors for black populations:

• Marital status

• Family conflict

• Acculturation into white society

• Hopelessness, racial discrimination

• Mental health services access and use

Risk Factors


Suicide and Mental Health Services Access and Use

Percentages of adults who did not seek or receive any psychiatric services in the year prior to having suicidal thoughts or attempts


Is fatalistic behavior masking suicidal behavior?

Blacks and Victim-Precipitated Homicide

Poussaint and Alexander (2000)

• What is suicide by cop?

• What are some other examples of fatalistic behavior, especially among black men in high-crime urban environments?

▫ How might these behaviors reflect a response to stress and mental health issues?

• Why might physical confrontation be the preferred option over verbal negotiation in inner cities?

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