The workshop opened with a keynote presentation by John A. Rich, professor at the Dornsife School of Public Health, Drexel University. He noted that although mass shootings such as the one on June 12, 2016, in Orlando, Florida, get the nation's attention, acts of violence—homicides, shootings, aggravated assaults, and others—are everyday events in too many communities across the country. Asked by the planning committee to begin a conversation about racism and violence and their impacts on communities, Rich said the goal of his presentation was to create a sense of hope. “When you are talking about violence and racism, it can sometimes seem overwhelming in terms of what we need to do,” said Rich, “but I hope, at the end, that we get to the point where we recognize that by addressing violence in the context of inequality, we move toward something more than simply reducing violence. We move toward greater health equity.” Highlights of Rich's presentation are in Box 2-1.

BOX 2-1

Highlights of Keynote Presentation Made by John Rich.

To illustrate the problem, Rich cited data on the number of homicides, shootings, and aggravated assaults in Philadelphia and New York (see Figure 2-1). These figures show that while violence is often tracked in terms of homicides, murder represents just a small fraction of the violence in affected communities. Moreover, those figures do not account for assaults that are not reported to the police, nor do they measure the impact on a child who has to walk past yellow crime scene tape on the way to school or on the grandmother sitting on her porch who wonders if the gunfire she just heard had something to do with a family member. “The scope of violence and trauma goes far beyond these numbers and the specific medical or public health issues that we see, and that means trauma is really at the heart of what we are thinking about in terms of violence,” said Rich.

FIGURE 2-1

Violence in Philadelphia and New York City, 2015. SOURCE: Rich presentation, June 16, 2016.

There are a number of frameworks from which to think about violence, said Rich. For example, violence can be viewed through the lens of trauma, but it can also be seen in terms of contagion, learned behavior, or addiction. Some people consider violence a mental illness or a moral defect, or in terms of a culture of violence. Regardless of the framework, however, violence is a public health issue, said Rich, and he suggested these frameworks are not mutually exclusive. As an example, he said that violence might be seen as contagious with the agent being trauma. Not all combinations are useful, though—the view of violence as a combination of learned behavior and moral defect, he added, led to the development of ineffective programs such as Scared Straight.

Many commentators use the “war zone” metaphor to portray communities affected by violence, but Rich said the loss these communities feel may be larger than in actual war zones. Between 2001 and 2010, for example, 1,446 American soldiers lost their lives fighting in Afghanistan and 4,400 were killed serving in Iraq. Over that same period, 3,391 people were murdered in Philadelphia. “So in one U.S. city, the order of magnitude of loss is tremendous,” said Rich, who added that there are tremendous disparities in the ways in which violence affects communities. He noted, too, that over the same 10-year period, 45,416 African American males under the age of 34 were killed by gunfire in the United States.

Race, however, should not be the focus of the discussion about violence, said Rich. “We know that race is a social construction. We know that race does not bear any reality in terms of biology, that it is just a phenotypic manifestation,” said Rich. “Therefore, whenever we see this kind of disparity, it is not enough to talk about, for example, Black-on-Black violence as though that is an answer to a question.” Instead, he said, it is important to understand that race is serving as a proxy for the real cause, be that poverty, disadvantage, or disparity. He cited a study (Feldmeyer, 2010) in which the author concluded that racial and ethnic segregation contributes to the elevated rates of homicide among both Latinos and African Americans and that the effects for both groups are mediated by concentrated disadvantage.

In addition to the number of frameworks for thinking about violence, there are various frameworks for looking at racism. The framework developed by Camara Jones (Jones, 2002) defines racism as a system of structuring opportunity and assigning value based on phenotype that unfairly disadvantages some individuals and communities, unfairly advantages other individuals and communities, and saps the strength of the whole society through the waste of human resources. According to this framework, racism has more than one effect in that it does not merely disadvantage those affected by it, but gives advantage to others, which in the context of violence means there are some young people who are more likely to be victimized and others who are less likely to be victimized because of privilege and birth position, said Rich. “We must account both for what is lost and what is gained in thinking about racism,” he said.

This framework for racism also includes three levels at which racism functions (Jones, 2000). The first is institutional racism, defined as the differential access to the goods, services, and opportunities of society by race. Institutional racism, said Rich, explains the association between social class and race. The next level, personally mediated racism, is what is often thought of when discussing racism, and it is defined as the differential assumptions about the abilities, motives, and intents of others by race—prejudice—or the differential actions based on those assumptions, that is, discrimination. This framework holds that institutional racism is mediated through individuals. The third level of racism is internalized racism, which represents that acceptance by the stigmatized races of negative messages about their own abilities and intrinsic worth.

Turning to the recent attention focused on police violence and racism, Rich said police violence against young people of color has become a critical factor in how the nation thinks about the violence happening in communities. Police violence against people of color is not new, but Rich believes it has only now grabbed the public's attention because it is being captured on mobile phones and played back for all to see. As examples, he recounted Rodney King's brutal beating in 1991, Abner Louima's brutalization and torture by New York City police in 1997, the 1999 shooting of Amadou Diallo when police mistook his wallet for a gun as he was entering his home, and Sean Bell, the young groom who was shot 50 times by police on the day of his wedding in 2006. Rich said it is likely that between 2006 and 2012, when Trayvon Martin was killed by a vigilante in his Sanford, Florida, neighborhood, that there were other black male children and adults killed in the United States in a similar manner not brought to the public's attention. Since then, however, the police-involved deaths of Michael Brown, Eric Garner, Freddie Gray, Laquan McDonald, Tamir Rice, and Walter Scott have reinforced the notion that young people may not see the police as a protective force.

Applying the racism framework, Rich said police violence requires first thinking about the relationship between historical discrimination and institutional racism. He noted that in 2015, the police commissioner of New York City said, “Slavery, our country's original sin, sat on a foundation codified by laws enforced by police, by slave catchers.” Today, said Rich, institutional racism is seen in the police policies that legitimize and even incentivize aggressive action against young men of color, with “stop and frisk” policies and racial profiling as examples. Rich recounted an incident in Philadelphia that involved the police being called by a ticket agent who said a young man did not pay his fare to board a train. In a surveillance video, an African American transit police officer has his hands around the neck of the young African American man who was holding a child. This incident is illustrative of institutional racism, said Rich, because in explaining what happened, the head of the transit police said the officer believed it was his duty to act that way or he would be disciplined for violating policy. This may also be an example of the internalized racism of the African American police officer, Rich said.

What is also powerful about this example, said Rich, is that a young child was impacted by police violence. “In this day where we talk more and more about early childhood adversity and its impact later in people's lives, we know that police officers often encounter families in settings where there are children and where what they are doing will serve as a traumatizing effect on that child that may have a future impact on that child's health and the family's health,” said Rich.

Personally mediated racism can then lead to the dehumanizing treatment of young men of color driven by implicit bias, instances of which Rich said he heard in the interviews he and his colleagues have done with hundreds of young people who have been victims of violence in their communities. One young man from Boston, for example, was shot when a robber tried to take his chain and he recalled the police officer saying, “Don't do nothin' stupid like die.” Often, young people said they were verbally assaulted in an attempt to get information from them when they were injured. Rich said these young people understand that police have a role to play in apprehending the individuals responsible for the violence, but these types of encounters stick in their minds.

Internalized racism is apparent in the aggressive and violent acts by police officers of color toward young people, and these acts, said Rich, can have an impact that goes beyond what happens in the streets. One study found, for example, that participants who reported more police contact, particularly intrusive police contact, experienced more symptoms of trauma and anxiety (Geller et al., 2014). The associations were tied to how many stops the individuals reported, the intrusiveness of the encounters, and their perceptions of police fairness. Another study found that young people who have had contact with the criminal justice system are more likely to avoid interacting with that system in the future (Brayne, 2014). This latter finding is important, said Rich, because young men of color have the highest victimization rates of any group. “One might argue they need the police as much or more than any other group, so these encounters designed to keep the community safe often have a negative consequence,” he explained.

After showing a video of Dave Green,² a client of Healing Hurt People³ recounting the impact that his multiple experiences with violence have had on his health and well-being, Rich said some might listen to that story and say the young man was living in a culture of violence. However, looking at this young man's experiences through a trauma-informed lens would suggest he is experiencing the classic symptoms of posttraumatic stress disorder (PTSD) and depression that sends him into a spiral of feeling unsafe. Rich noted one study's findings that nearly three-quarters of the victims of violence have high rates of PTSD (Corbin et al., 2013), but another study at the Boston Medical Center found that 23 percent of the patients in a primary care clinic had PTSD, though that diagnosis was recorded in only 11 percent of the cases (Liebschutz et al., 2007).

Research has also shown violence to be a chronic, recurrent disease. Studies in Chicago and Baltimore found that 44 percent of the individuals who had experienced a penetrating injury were injured again over the next 5 years and 20 percent of those individuals were dead. These data, Rich said, show that “efforts that focus on health care environments or places where victims are seen have to be part of a broader solution for interrupting the cycle of violence.”

A common image among those who work in medical settings is that someone repeatedly injured is involved in activities that predispose that person to violence, said Rich. However, when Rich and his colleagues talked to young people, they found that this is not a reliable way to think about their lives. Instead, a trauma-informed approach takes the view that a young person who has been injured and has PTSD or other symptoms of trauma is rarely informed they may experience those symptoms. As a result, when that youth has nightmares and flashbacks, and feels as if he or she is going crazy and turns to whatever is available in the environment to treat his or her distress, in communities lacking access to health care, what is available is often alcohol or marijuana.

For a young person of color living in the inner city, said Rich, access to marijuana in particular often means that individual will have limited access to employment, particularly for entry-level jobs that require drug testing. It also means they are more likely to have contact with law enforcement and the criminal justice system, which places them in the world of mass incarceration that leads to other negative downstream effects, said Rich.

One consequence of young men of color's general distrust of law enforcement, Rich explained, is that they are more likely to own a firearm in order to protect themselves. Having a weapon, however, then increases the odds of experiencing further trauma and even death. “A trauma-informed framework might suggest ways of interrupting this cycle,” said Rich.

Rich and his colleagues developed Healing Hurt People, a hospital-based, trauma-informed, community-focused violence intervention program for victims of violence who are at high risk of further exposure to violence. After their discharge from the hospital, victims of violence are assigned to social work staff and outreach workers who assess the person's living arrangements and environment to determine if they are at risk or safe. An individual having symptoms of trauma is invited to enroll in a trauma-informed program that includes a deeper assessment, case management, and navigation to systems that may be otherwise inaccessible to these young people. Youth also receive mentoring, powerful group interventions in which young people have the opportunity to process their trauma, and where needed, more specific therapy.

The health system can intervene in a way that is consistent with a trauma-informed framework, said Rich. However, it cannot avoid dealing with racism given the health care system's past display of historic institutional racism, such as the Tuskegee Experiment⁴ and Jim Crow segregation in hospitals, and the fact that there are disparities in medical care and a lack of diversity among health care providers. Individuals of color also report examples of personally mediated racism such as disrespectful treatment by health care providers and the phenomenon of mistaken identity, in which health care providers are mistaken for custodial staff, experiences that some may call microaggressions. There may also be internalized racism that manifests in persons of color preferring white providers because they have come to believe that providers of color could not possibly be as good as their white counterparts.

Given that this is the context in which violence occurs, Rich explained how they can incorporate these insights into trauma-informed approaches to violence and racism. The first step is to acknowledge the historical racism in medicine and health care. To deal with institutional racism, he and his colleagues convene quarterly gatherings of the leaders of health systems in Philadelphia that serve these young people, and present a case to them so they can begin to think about structural barriers. They also collect data and engage community health workers who are more likely to be aware of institutional racism.

Rich and his team address personally mediated racism through implicit bias training for staff and residents that includes having clients reflect on their experiences of racism. To address internalized racism, one approach that Rich's team uses is engaging young victims in trauma-informed dialog about racism as a trauma in addition to training them to be community health workers. After receiving their training, the youth then share their experiences with other members of the health care team.⁵

In conclusion, Rich said, “In all of our efforts, we should be seeking to reduce violence, but it is not enough to reduce violence if we are not also addressing health equity.” Addressing health equity requires a different level of resources, he added, because these young people are for the most part not plugged into what he called the grid of opportunity. “Young people of color often need help plugging into that grid of opportunity so that they can thrive and so that their health can improve and we can begin to address the social determinants of health,” said Rich. The outcomes and benefits of devoting those extra resources, he added, will accrue to public health beyond reducing violence in affected communities.

As a final note, he stated that firearms remain a tremendous challenge. The Institute of Medicine and the National Research Council have articulated a set of priorities for firearms research (IOM and NRC, 2013b), and Rich called on those at the workshop to put forth as forcefully as possible the idea that firearm-mediated violence is a health equity issue.

Footnotes

1

This chapter is the rapporteurs' synopsis of the presentation made by John A. Rich, professor at the Drexel University Dornsife School of Public Health, and the statements have not been endorsed or verified by the National Academies of Sciences, Engineering, and Medicine.

2

Dave Green's digital story may be viewed as part of John Rich's presentation at http://www​.nationalacademies​.org/hmd/Activities​/PublicHealth​/PopulationHealthImprovementRT​/2016-JUN-16​/Videos/Welcome/2-Rich-Video.aspx (accessed September 12, 2016).

3

For more information, see http://www​.nonviolenceandsocialjustice​.org​/Healing-HurtPeople/29 (accessed August 18, 2016).

4

For more information, see http://www​.cdc.gov/tuskegee/timeline.htm (accessed September 12, 2016).

5

For more information on Healing Hurt People, see http://www​.nonviolenceandsocialjustice​.org​/Healing-Hurt-People/29 (accessed November 1, 2016).