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Opinion What if we treated violent crime the way we treat Ebola?


Last month, I expressed some skepticism about a new study cited by Attorney General Jeff Sessions that blames something called the “ACLU effect” for the 2016 spike in homicides in Chicago. The theory is that an agreement between the city and the civil liberties organization resulted in fewer stops and stop-and-frisks by Chicago police, which caused an increase in violence. You can read the post to see why I don’t find that convincing.

So what did cause the increase? And why hasn’t crime dropped in Chicago the way it has in, say, New York?

One interesting difference between the two cities is that New York doesn’t have anywhere near the gang violence that Chicago does. About a decade ago, a study by the Justice Policy Institute offered a reason for that. The interventionist, public-health-based approach adopted by New York in the 1970s and 1980s was simply more effective than the heavy-handed suppression approach in cities such as Chicago and Los Angeles. “The evidence that punitive responses to youth crime do not effectively increase public safety mounts,” the authors concluded. They recommended “implementation of evidence-based practices to treat young people who are in conflict with the law” and urged that “funding for such programs should be routed through the health and human services system, where they have been proven to be more effective than in the criminal justice system.”

The good news is that funding such programs tends to be cheaper than funding anti-gang task forces and other aggressive law enforcement approaches. The bad news is that it’s often hard to convince people that such programs really are effective.

In Chicago, a group called Cure Violence has been successful in reducing violence in nearly every area of the city it has been tried. The organization takes a public-health-based approach to violence, sending trained counselors (sometimes former gang members and formerly incarcerated people) to intervene in disputes before they turn bloody. In March 2015, the state of Illinois cut funding for the organization, reducing the number of workers from 71 to 10. Until then, shootings in the communities where the organization was operating had been in steady decline. After the cuts, shootings began to soar. Moreover, the only police district in the city where the group had enough staff to continue to operate also happened to be the only district where shootings dropped between 2014 and 2017.

Gary Slutkin, the founder and chief executive of Cure Violence, agreed to an email interview.

Tell us what Cure Violence does, and what it has been doing in Chicago in particular.

Cure Violence is a global violence prevention initiative whose sole purpose is to reduce violence through the application of public health methods. I am a physician and infectious disease specialist who worked with the World Health Organization on epidemics of cholera, tuberculosis and AIDS. I became involved in violence prevention when I returned to the U.S. and saw unavoidable similarities between the spread of disease and the spread of violence in U.S. cities — in Chicago, but also in all of the cities I studied. I summarized what I found in an Institute of Medicine Report in 2013.

So the approach to managing this epidemic is the same as for other health epidemics: early detection and interruption of events and transmission (spread), identification and treatment of those at highest risk, and changing overall community norms.

Currently, Cure Violence operates through partnerships in about 50 communities across more than 20 cities in the U.S., as well as in 10 countries – including in Latin America (Mexico, El Salvador, Honduras, Colombia and elsewhere), Africa and the Middle East.

In the summer and fall of 2017, Cure Violence got a return of funding to operate at 10 sites in Chicago, and other community groups got funds from philanthropy to operate similar intervention programs in 8 sites (with overlap) for a total of 15 sites.

How are you funded? 

Cure Violence has been funded over the years by government, foundations and philanthropy. Major funders in the U.S. have been the U.S. [Department] of Justice and the Robert Wood Johnson Foundation. Major funders of our international work have been mostly the international development community such as the U.S. Agency for International Development, the World Bank, IDB (Inter-American Development Bank), and others.   

Cure Violence city and community sites in the U.S. are funded by a variety of sources – public and private.  In Chicago, Cure Violence sites have historically been largely funded by the State of Illinois and philanthropy. Today, most of the sites are funded by the State of Illinois, with several others funded by a group of foundations that are also supporting violence prevention efforts around the city.

In other cities, the funding structure varies. New York City is primarily funded by city government, with some communities supported by state or federal funds. Baltimore started as primarily federally funded, but has since received significant private funding, and just recently received state funding for new expansion. Latin America is funded by USAID, IDB, UBS Optimus, and other private foundations

Cure Violence receives a lot of requests from communities, so the demand is usually greater than what we can deliver. This is especially the case for poor cities.

You’ve claimed that empirical evidence overwhelmingly shows that your approach is working. Can you give us a summary of that evidence? 

The program has been independently evaluated several times in several different locations and has consistently shown large reductions [in] violence – as much as 70 percent

The first implementation of our approach began in Chicago in 2000 in West Garfield Park. We saw a 67 percent reduction in shootings and killings. We then replicated the approach in four other communities with an average drop of 45 percent. We’ve been continuously operating in Chicago since, but with ups and downs in our funding, usually related to state budgets. As funding has increased or decreased, we’ve seen an inverse relationship with violence every time.

There have since been three independent evaluations of our work to reduce shootings and killings in Chicago, as well as several other independent evaluations in other cities, also with strong results.

A recent evaluation of the NYC program is perhaps most convincing.  It was a very sophisticated analysis, done by experienced researchers using police data, hospital data, interviews and surveys.  It showed not only reductions in shootings by up to 63 percent, and a change in norms (towards rejecting the use of violence). It also showed that the program resulted in an increase in confidence in police. We’ve heard from several people that this study convinced them even more that the Cure Violence approach really worked. 

Here are some U.S. evaluation highlights (there [are] more — see our website):

  • New York City: 37 to 50 percent reduction in gun injuries, 63 percent reduction in shootings, increased confidence in and willingness to contact law enforcement, evidence of norm change on violence
  • Baltimore: Up to 56 percent reduction in killings, 44 percent reduction in shootings, evidence of norm change
  • Chicago: 41 to 73 percent reduction in shootings and killings, 100 percent reduction in retaliations
  • Chicago (hospital): 50 percent reduction in re-injury
  • New Orleans: 47 percent reduction in shootings victims, 44 percent reduction in shooting re-injury
  • Philadelphia: 30 percent reduction in shootings

There will be an evaluation of the Trinidad replication released soon – their local presentation showed a 67 percent drop in shootings and killings. 

Attorney General Jeff Sessions recently cited a paper that blamed the “ACLU effect” for the rise in homicides in the city in 2016. But some have pointed to a reduction in funding to groups like yours. What’s the evidence for the latter? 

The simplest answer to your question is to point out that violence in Chicago shot up immediately after a large program was shut down that was specifically designed to prevent violence and had been repeatedly shown to be highly effective. When you dig deeper into the data, the case for the increase in violence in Chicago being linked to cuts to Cure Violence becomes even stronger.  The data shows that the increase occurred at the same time and in the same places as the cut to Cure Violence, and that at the one site in which funding continued, violence continued to go down.  The increase in killings was very predicable. In fact we did predict it at the time.

The evidence is summarized here, with a longer analysis linked to in the report. The correlation isn’t just about when, it’s also about where.

Cure Violence funding was cut in March 2015, which resulted in us being shut down at all sites but one. The increase in violence also began in March 2015, not in 2016 as is commonly reported, and it grew throughout the summer in comparison to prior years. 

The one site that remained operational continued to have reductions. Also, not only did the areas that were shut down show increases, but the largest increase occurred in the district where Cure Violence had the most workers (and the longest lasting and most embedded workers).

Further, this has also happened before, and it has  reversed before with the return of funding and staffing. For example, in 2007, 18 months of interrupted funding from a budget impasse and political fight resulted in an increase of 50 killings and 400 shootings. Violence then dropped rapidly when Cure Violence was re-funded and able to get up and running again. We saw the same thing in 2011-2012. Way back in 2004, Cure Violence received an increase in funding that allowed us to go from five sites to 15, and then to 20, and from 20 workers to 80. Killings in the areas where we were working dropped 50 percent. Killings across the entire city dropped 25 percent.

The wide disparity in the crime rate between New York and Chicago has spurred a lot of speculation about what New York has done right, and what Chicago has done wrong. What’s your theory?

The difference in how New York City, Los Angeles and Chicago have addressed community violence is incredibly instructive to communities everywhere.  New York City embraced the health approach to preventing violence beginning in 2009 and Los Angeles in 2006 – and they have never stopped.  We have done all the training and support in NYC (there are now 18 sites, expanding to 22) working with the community groups, health department and mayor’s office.  We helped Los Angeles get organized in 2005 and 2006, but they’ve since adapted it to their own needs — and have done very well. Both cities have had uninterrupted funding.

New York City invests more than $25 million a year.  This has resulted in reduced levels of violence, as confirmed by two independent evaluations. At a community level, this means that among people at high risk for involvement in violence, intervention is happening much earlier, and in a way that is much more helpful, supportive, and acceptable. So in addition to the reduction in violence, the program is helping people stay out of prison, it’s preventing negative interactions with police, it’s helping with employment, and much more. Cure Violence has effectively replaced stop and frisk in New York. Practically, that means the city is primarily helping people day to day, rather than harassing or bothering them. 

For two and-a-half years in Chicago, beginning in March of 2015, no one was filling those roles. Most critically, no one was working to stop the spread of contagious violence, the kind where one act leads to retaliation, which leads to another retaliation, and so on. This is  a major reason why Chicago went from just over 400 to about 760 or so murders annually in just a matter of 2 years. It was essentially an unmanaged epidemic. This part of the problem is being remedied now that funding has returned, from both the state and from philanthropic organizations – for Cure Violence and for other critically important community partner organizations doing great work..

Let’s say every large city adopted the Cure Violence model. What would policing look in those cities? 

What we say is that we need to treat violence as a health issue, and what we advocate for is the effective prevention of violent behavior through highly specific public health methods. 

All other epidemics are managed by public health. They’re managed from the inside out, with health officials guiding and training healthcare workers, collecting and using data, and ensuring results. By managing violence as a health issue, we’re able to detect potential violence before it happens, to mediate conflicts before they turn violent. These interventions are done by credible, highly trained workers. (They get over 100 hours of training before the start, then ongoing on the job.) They know how to talk to people in these communities, and they’re known throughout the community as a resource in violence prevention. Our workers identify those most likely to be violent, then intervene to reduce the risk.  They also work to change norms in the community so that violence is discouraged. This is very similar to how health workers help people in [cases of] Ebola, cholera and other epidemics. You change behavior to prevent the disease from spreading. 

If this is done effectively, and resourced properly, violence can be prevented so that police are not needed as frequently — and are much less likely to be needed for highly traumatic and stressful violent events. Policing would be a backup, a last resort.  Policing in cities would look much more like policing in the suburbs. We’d need much less from law enforcement day to day. 

I managed a TB epidemic in San Francisco. We put about five people out of 2,500 in jail, temporarily. But only kept [them] there the minimum time necessary — until they were no longer infectious. Police were backup only. Both the police and immigration wanted to get more involved, but it was the health workers who did the detection and encouraged the changes in behavior. I also managed a cholera epidemic in Somalia where a Somali general wanted to shoot the patients to stop the epidemic. They didn’t understand the means of spread. During the last Ebola epidemic in West Africa, some of the policing efforts actually contributed to the spread of the virus. In the end, it again was health workers who changed the course of the outbreak.

For the most part, our behavioral norms are formed, maintained and changed through the expectations of others — mostly our peers. This is especially true when it comes to dangerous or violent acts. Much as we’d like to believe otherwise, the imposition of consequences has little effect on norms. Young people especially are much more concerned with what their friends think than with what consequences law enforcement may impose for their actions. That’s why local and credible health workers are so effective, and punitive approaches are less effective. Whether we do or don’t use condoms, do or don’t smoke cigarettes, and most of our behaviors are much more contingent on what our peers think than about laws, police or consequences.  

Right now, there is an enormous gap in reducing violence that the health field needs to fill. In many places where these programs are operating, the police already know to, and do leave, retaliation prevention and violence detection to interrupters and outreach workers. Yet the public is not aware of this because our work is largely behind the scenes (as with all public health), and we don’t make public announcements every time we prevent an act of violence. We’ll of course still need police and courts if someone breaks the law — that is their role. However, there will be a lot less law-breaking when public health is brought to sufficient scale.

You’ve mentioned some studies showing that public confidence in the police has actually increased in the neighborhoods where you’ve been working. Why do you think that is?

Without more study, its impossible to know for certain why confidence in policing increased. What we do know is that these communities had large reductions in violence, and they had workers who were mediating very dangerous conflicts. One hypothesis is that the police were less likely to be involved in highly traumatic and stressful situations — the kind that drive distrust in law enforcement. Another hypothesis [is that] when there’s less violence, the community feels safer, and when the community feels safer, they think the police are doing a good job.

How does the law enforcement community react to your group — in Chicago and elsewhere? Are they supportive? Antagonistic? Indifferent? Is there a difference between the attitudes of police leadership and rank and file cops?

Most police accept us and get the approach, and that’s true among both the leadership and the rank and file. Our staff and I have been thanked by many police officers for our work. Many police leaders credit our workers for the reductions in violence in their community. What these police officers realize is that Cure Violence workers can make their jobs easier by de-escalating situations, by dealing with individuals who are known to be high risk and by reducing overall violence in the community. All of this makes police officers safer themselves and more respected in a community. 

Generally, the police officers who work closely with Cure Violence are highly positive, while in areas where the program is new, they may be more reluctant. Some police officers can also be reluctant to praise our work publicly. Some have trouble accepting workers who were formerly involved in violent crimes. This attitude is a holdover of the “bad people” theory — which of course is what we used to think about people who contracted diseases. That attitude tends to change as they start to understand and work with the health approach.

I was going to ask about that. Many of your counselors and “violence interrupters” are formerly incarcerated people, or people previously involved with gangs or violent crime. Can you explain why you use them, and why you think they’re effective?

Utilizing credible workers is a standard practice of public health. I’ve used it for other epidemics for 20 years. To change the behavior of sex workers, we hire former sex workers. To change sanitary habits in refugee camps, you hire refugees. When you are trying to change behavior, it is far more effective to use credible, trusted people — people who have shared interest and experience with the people whose behavior you’re trying to change. When the workers are from the same background and same community as the clients, the program is more trusted, influential and credible. It’s easier to follow up.

What are the biggest misconceptions about violence? What else should the public know about how to prevent it?

Here are some of the things we’ve learned from our work:

  • Violence is the only contagious epidemic that isn’t primarily managed by the health sector. So what we have in most cities with a crime problem are unmanaged or undermanaged epidemics of violence. This includes mass shootings. What we have in Latin America and the Middle East are also unmanaged epidemics of violence.  There is much more that can be done to prevent these epidemics.
  • The breadth and scope of data showing both that violence is contagious and that health approaches are effective is overwhelming. There are thousands of studies showing violence to be a health problem and hundreds showing that it’s contagious. Most people think prevention is complicated, or takes a long time. The evidence that intervention works is also overwhelming. Also, the results come fast — usually in the first few months — and the results are sustained.  
  • We can also apply these approaches to mass shootings. We generally know who the people are who are at most risk for being violent, yet we are failing to do enough to prevent them from acting. The people who are at risk have health or social problems and they often give warning signs, but those who have concerns either don’t want to go to officials (they don’t want to get their friend or family member in trouble based merely on suspicion) or the officials they go to don’t have the skills or time for prevention.
  • People think that if you have a serious problem, you need police. The most serious problems need intervention — fast solutions with interrupters. 
  • Epidemics can be reversed fast.
  • In many communities, we see not only a large reduction in violence but a complete eradication of killings for months, or even years. In epidemic control, you work toward elimination of the contagion, not merely a reduction. A reduction of Ebola would not be acceptable, since the contagion can spread quickly. Similarly, we employ specific techniques aimed at eliminating violence completely. Just a few events could cause another outbreak.
  • Most importantly, public health epidemic control techniques have been highly underutilized for reducing the violence epidemics that continue to plague us and for which we keep being frustrated. Public health has the expertise to find and stop rare events before they happen, prevent spread, and change behaviors. We are greatly underutilizing this expertise, although more and more cities are now beginning to step up.