Science AMA Series: I'm Charlie Ransford, director of science and policy for Cure Violence, a program that treats violence like a disease and uses ex-gang members to help mediate disputes and prevent violence. Our program has cut violence in half in most neighborhoods we work in. AMA!

Abstract

I'm Charlie Ransford, director of science and policy for Cure Violence, a violence-interruption program that treats violence like a disease and uses ex-gang members to help mediate disputes and prevent violence.

Ranked among the top 20 NGO's by Global Journal, Cure Violence stops the spread of violence in communities by using the methods and strategies associated with disease control – detecting and interrupting conflicts, identifying and treating the highest risk individuals, and changing social norms – resulting reductions in violence in neighborhoods of 40 to 70 percent. Evaluations have shown that the program reduces violence at the community and individual level, as well as helping participants to get assistance in education, employment, parenting, and other issues, helping them to get themselves on a better path. The Cure Violence model is being used in more than 20 U.S. cities including Chicago, New York City, Philadelphia, Baltimore, and New Orleans, and in 9 countries with a focus on the United States, Middle East, Latin America, and Africa.

You may be familiar with the critically acclaimed 2011 documentary The Interrupters, which follows Cure Violence workers into Chicago neighborhoods to mediate gang-related conflict.

In Chicago, where Cure Violence is headquartered at the University of Illinois at Chicago School of Public Health, neighborhoods with Cure Violence workers where violence had been on a downward trend, immediately saw a surge in killings when violence interrupters were laid off due to lack of program funding. Cure Violence argues that the lack of funding over the past two years, more so than the splintering of gangs and their use of social media, or housing disruptions caused by the destruction public housing apartments, is a major factor contributing to some of the deadliest months Chicago has seen in more than 20 years. AMA!

I’ll be back at 2 pm EST (11 am PST, 7 pm UTC) to answer your questions, ask me anything!

Hi Charlie

Thanks for the important work you do.

I'm curious: if you had Carte Blanche to make three changes to public policy (be they local to Chicago or on a national scale), what three things would you do to try to have the maximum impact on rates of violent crime? Perhaps for simplicity and based on your expertise, we could focus on Chicago as the test case, so measuring the impact on violence there as opposed to nationwide or in a random city.

explodingbarrels

The policies I would like to see for Chicago are very similar to what I would like to see for the country as a whole, but taking Chicago as a test case is great way to simplify and explain.

  1. Funding for community health workers in all violent communities. Outreach and interruption through trained community health workers has been shown through several independent evaluations to decrease shootings where it is implemented by as much as 70%. However, it has only been implemented in about 20% of the communities that need it - and it is currently only implemented in 2 communities. These kinds of workers can stop events before they have a chance to escalate to a shooting and they can work with those at highest risk to make sure that they don't become violence (sort of like mentors).

  2. Build systems that connect community, hospitals, social service agencies, schools, police, and other sectors. The key to stopping violence - like any contagious problem - is identifying cases (violent people) and getting them treatment. To be really effective at both parts of this, you need systems that connect these sectors - so that when a school or police officer or hospital can identify someone who is potentially violent, and then know how to refer them to the appropriate resources/services. San Francisco is an example of a city that is trying to implement these types of interconnected systems to treat violence politically as a health problem.

  3. Changing the language and spokespeople who talk about violence. Violence is contagious and exposure to violence can lead to spreading of the behavior. If we could spread the understanding of the effects of exposure, people will know better how to respond to violence when they or their loved ones are exposed to violence.


This sounds like great work, thank you. What is the basic philosophy that your program uses? Feel free to point towards other resources instead of explaining it all here. I'm a kindergarten and elementary teacher and dealing with minor conflicts (usually not violent) is a normal part of my day, so I'm looking for strategies.

thefishinthetank

Although I am a parent of young children, I don't know that I have a particular expertise in dealing with minor conflicts, but I do think there are an important lessons to be learned from the basic philosophy of the Cure Violence program. Our basic philosophy is that violence is a contagious health problem that can be best treated using health approaches.

So, first - it is contagious. It is well established in the scientific literature that behaviors are contagious (see Albert Bandura 's Bobo Doll experiment for example). This is true for several reasons, most notably because people unconsciously model behaviors that they are exposed to and because norms encourage behavior to spread through a group or community. With violence, because it is traumatic, it is particularly contagious.

Second - health approaches work to change behavior. Many people may think of health approaches as something medical. However much of what health professionals do is actually behavior change. For example, heart disease - we change diet and exercise behavior. STDs, we change sexual behavior. The health and public health sector is actually very good at changing behaviors. With violent behavior, we can use the same techniques to change this unhealthy behavior. A key aspect of this is the use of credible messengers - people who are respected and trusted by those whose behavior you are trying to change.

What does this mean for you in your elementary school class? First, know that behavior is contagious and that exposure to behavior can lead to copying and spread of that behavior. So if a behavior is exhibited and others are exposed to it - you should address it with all of those exposed or else risk that it will be repeated by others. Second, to change behaviors, using credible messengers can be very effective. While persons of authority can have some effect (you as the teacher or the police in a violent community), you can be much more effective by using peers or possibly others who will be more readily accepted. Positions of authority will sometimes be viewed as outsiders and therefore not listened to or trusted as someone who is viewed as more of a peer or trusted person.


The cities you list are all very different culturally and politically. And you say that you also work in the Middle East, Africa, and Asia. How do you adapt your program to local needs and concerns? Any good public health campaign has macro goals and frameworks. But it adapts to the local in order to encourage buy-in and be relevant to local realities. Can you give some examples of how you've focused and adapted to the local communities rather than the "copy paste" approach many non-profits are criticized for?

firedrops

You are absolutely right - you need to adapt to the local context. What we implemented in Iraq is the same model, but had some important differences to the programs in Honduras or the US.

The basic model remains the same with the same 3 elements: 1) detect potentially violent events and interrupt them before they escalate to become lethal; 2) identify those most likely to be violent and work with them to address any issues they have to make them less likely to be violent; 3) Change community norms so that violence is discouraged by the community. However, we must take into account who is driving the violence and what is available in the community to play a role in stopping it.

A first step for Cure Violence before implementing in any area is to do an assessment. Out technical assistance team spends significant time in a community talking to people in violent communities - from the leaders to the residents to those actually involved in violence. The aims of this assessment are to determine the characteristics of those that are involved in violence, the resources that are available in the community to help those at risk of violence, and the potential organizations and individuals who could implement the program.

This assessment will lead to differences in the types of workers hired (looking for those most credible to those involved in violence) and the approach for how these workers interact with those who are driving the violence. In Iraq, we had to identify workers that could work within the contexts of sectarian violence and who would be respected by entire families. In Honduras, because of the way the gangs are structured, it was difficult finding credible workers who were also no longer involved in illegal activity. In each of these cases we identified people within the community who helped us to make the connections to people who were close enough to the violence to be able to address the violence.

Another example of a modification is the program at the Cookham Youth Detention facility in the UK. In this case, we had to "hire" prisoner to be the workers of the program so that they could have the credibility and be in constant contact with the other prisoners.

The big take away here is that the program cannot be "copied and pasted." You do need to go through a process of adaptation to make sure you can get to the people who are actually doing the violence.


Is violence something innate in human beings? And does the method (yours) of treating conflict differ across cultures and peoples or is it a single solution for everybody?

kc_anon

The science suggests that violence is not innate and in fact most people never or rarely exhibit overtly violent behavior. Violence, like all behaviors, are learned unconsciously through observation and further embedded through social norms.

The Cure Violence method provides a framework that has been shown to work across cultural and contexts, however, it requires that you take into account and make adaptations based on the local factors (as outlined in another answer).

The key for adapting the model is getting access to and having credibility with those committing violence. This access and credibility allows for getting timely information on who is most likely to be violent and about ongoing "beefs" in the community, as well as the ability to find those involved and be influential with them. Access and credibility is key, so you must adapt to make so you can work with all of those involved in violence.

This them has to be coupled with training for the workers and a systemic approach to addressing violence - operating as a team to cover all violence in the community.


What's your position on drug legalization?

xSialicAcidx

I'm only an expert on violence and the health approach to violence. I believe that violence can be eradicated in our society independent of the status of the drug laws as well as independent of the status of gun laws, although both may have an effect on violence currently. I have not seen any studies on the effects of recent legalization on violence in the US - but I would be very interested in reading any if there are any that show this effect.


Hey Charlie,

Are there any suburban models of cure violence or cases to read up on that take place in a suburban setting? Baltimore Safestreets is huge but the Safestreets model might not be as efficient in a suburban setting like in Baltimore County. Violence is less of an issue in suburbs, or at least different, but I think the public health model of violence prevention should be in every hospital and health department in every city, so wondering if you know about that.

Also if you want to talk about your relationship with the police departments I would be interested in that too.

Thanks!

TyranosaurusLex

First - let me echo you - I too think that violence prevention should be in every hospital and health department!!! This is not just for community violence, but should also be used to stop domestic violence, mass shootings, suicide, and other violence. We are currently leading a movement to try to make this happen. It is being led by Dr. David Satcher (former Surgeon General), Dr. Al Sommer (dean emeritus of Johns Hopkins) and Dr. Gary Slutkin (Cure Violence). We will soon be launching our public campaign to press this issue.

The model has been implemented in suburbs in Chicago (Maywood, Waukegan, Cicero) and DC (Prince George County), as well as in rural areas (Loiza, Puerto Rico). As well, the model has been adapted to schools, prisons, and will soon be used to address domestic violence specifically (all of our urban programs address domestic violence to some degree). Unfortunately, none of these program have been written up - but the data showed that the program in Maywood coincided with a 70% decrease in killings and Loiza with a 50% drop in killings. A report on the prison program will be out before the end of the year.

The basic model stays the same, you just adapt to the local context - hire workers credible with those who are violent and train them to detect and interrupt conflicts, identify and change the behavior of those involved in violence, and change the norms of the community. It can be done in any context.

With the police, in many of our communities police recognize the unique role that our workers play and often times call on our workers to intervene in situations to prevent violence from happening. There are some individual police who have had difficulty with the fact that we hire workers who have formerly been involved with gangs and illegal activity - some serving time in prison. Over time, as this method of stopping violence is better understood, we will be able to overcome these biases.


Thank you for your work. Do you do any research or direct community work involving the link between food insecurity and violence? Physiologically speaking, the link between hunger and irritablity is well documented; we are more prone to outbursts and violence when under- or malnourished. That said, my question is, is fixing food deserts part of your mission?

Janitaur

We do not work on food insecurity as an organization or as part of the model, but we our workers on the street often deal with this issue as part of their work. In trying to change the behavior of someone who is violent, we have to address whatever set of issue that they have - drug problem, unemployment, lack of education, family problems, and even food insecurities. However, this is done at the individual level. We do not address food deserts as part of our mission.

I agree that it is an important issue - however, I don't believe you would see a sizable impact on violent associated with changing this. The reason is that violence is being driven by its contagious characteristics. Malnourishment is likely a factor - much like poverty, employment, green spaces - and making changes to any of these factors can have some effect. However, you must actively stop the contagion as well as change norms and behaviors.

As an (imperfect) example - to eradicate AIDS, you can can make condoms more available and have some impact - but you really need to change behaviors and norms.


Hi Charlie,

What counts as violence in your statistics? Do violence interrupters impact domestic violence? Do you see residual drops in other types of crime (drug trafficking or robberies)?

trogdor1776

The results for our program are mostly decreases in all shootings and killing in a community - without any segmenting of motives or types of violence. This is usually based on police data, though in some instance hospital data. One study of our program in Chicago showed that about 10% of the conflicts that we mediated were classified as domestic (Nicholas Grant fro University of Illinois did this study, as yet unpublished) - so yes our interpreters do impact domestic violence. Additionally, the evaluation of the Chicago from 2009 showed that we helped our clients with family conflicts and helped them get parenting assistance. I did a survey last year of our clients in Chicago and New Orleans that showed that more than 90% reported that the program decreased violence in their home as well as their community. We are also currently working with partners in Dallas/Ft Worth to adapt the model to specifically address domestic violence.

There has not been any evidence to show impacts on other types of crimes - besides violent crimes. No studies have looked at robberies or drug crimes or anything else yet. It is not our expectation that we would impact these since we do not try to work with those involved these types of crimes (there is some overlap, but they are not the same groups).However, it is possible that we could have some impact on other crimes.


Thanks for this AMA. It's a little distressing that violence sees a resurgence back to levels similar or even higher after violence interrupters are laid off and cease fires stop. With diseases we can work towards herd immunity and eventually eradication, do you see this as a realistic goal when it comes to violence?

Super_Whack

Great question! Yes, herd immunity is not only possible, it is what keeps most communities safe. When you look at the communities where lethal violence is very low - it is not because there is better or more policing. It is not because the people there are in some way superior - morally, physically, mentally. It is because there is a herd immunity such that most of the people in the community will not act with lethal violence. This is manifested by social norms which make violence unacceptable.

Even in these communities, there are sometimes violent events. But we do not see the chain of retaliations and spread of behavior largely because of norms (also sometimes because there are systems to treat exposure and prevent retaliations)

As part of the Cure Violence model, we try to change the norms of the community such that there is this herd immunity. This is a longer process made more difficult when there are violent events occurring that normalize violence, so it is also necessary to also try to interrupt violent events and change behaviors.


Hi Charlie,

I wonder if you can comment on resistance you encounter to deploying your approach. What are the biggest political challenges to running your program, and what successes are you most proud of?

superhelical

The biggest problem we have is that violence is NOT generally understood to be a health issue. Many of our political leaders, as well as the media and general public, see violence as a moral issue (committed by "bad people") and that the appropriate response is therefore a criminal justice/police response. This is why when violence breaks out - the response is usually a call for more police.

Understanding it as a health issue means that we understand that exposure to violence lead to spread of the behavior. Labeling people as good or bad (or as a predator) are of no value and have no basis in science. On the other hand, understanding exposure and the traumatic effects that it has can lead to finding solutions that help people and get them on a better path.

This is really changing now. For example, Mayor de Blasio in New York City spent over $13 million on implementing the Cure Violence model throughout the whole city. This was made possible by some initial pilot that proved successful as well as some city commissioners and state representatives who were forward thinking in the response to violence. This is our biggest success in terms of policy.

In terms of programs, the Honduras program really stands out to me as a big success. We implemented in San Pedro Sula, the most violent city in the world with homicide rates more than 10 times Chicago's. To be honest, we were not sure whether we would be able to accomplish mush there because of the nature of gangs and violence in these areas, and we had initial difficulty finding partners that could be credible with the population involved in violence. In the end, we found a great organization and some great workers and the data has shown decreases in violence greater than 80%. http://cureviolence.org/wp-content/uploads/2016/08/Report-on-the-Cure-Violence-Adaptation-in-San-Pedro-Sul.pdf


Thanks for doing this AMA

In light of your expertise, if you could update the definition of violence to be more descriptive what would you add?

What are the biggest challenges in your quest to eradicate violence?

In your opinion are there any necessary forms of violence?

Thanks again!

oskiwiiwii

I like the WHO definition of violence: The intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation.

The important additions here to what we typically think of violence - 1) its not just the use of force, but also the use of power; 2) its not just actual, but also threatened; 3) its not just to others, but also to oneself; 4) it includes psychological harm and deprivation. These are important distinctions when considering violence as a contagion.

The biggest barrier is people thinking that those who are violent are morally "bad people" instead of understanding it as a contagion that can be treated with health approaches.

Its hard to unequivocally state that violence is never necessary. My aim is to stop the violence and the spread of violence. There may be some conceivable times when the use of violence is the only available method of doing this. Certainly situations of war present situations that do not have alternative methods of responding to halt the violence. Also, people under attack in other settings may not have an alternative method of responding. However, I do not think that there are other justifications - other than stopping further or future violence or self preservation. Also, I believe that we should work towards a society where all situations do have alternative and more effective ways of responding in all situations.


Hello! Thanks for the AMA. I'm a psychologist who just finished college and I'm thinking about starting up an instituion that deals with addiction, violence, homelessness...

Do you have any advice?

Maybe questions that could help are:

How did you start Cure Violence?

How did you create the theoretical construct that supports Cure Violence?

Gallardo175

Cure Violence was started by Dr. Gary Slutkin, an epidemiologist who had previously worked on stopping the spread of tuberculosis, AIDs, cholera and other contagious diseases in Africa and elsewhere. He created the Cure Violence model based on the exact same components of the WHO methods for addressing these other contagious problems.

My advice for addressing addiction, violence, homelessness, etc. 1) focus is important - so you may want to consider a focus on one of these issues. You will end up dealing with a host of related issues, but lacking focus often leads to a scatter shot approach that may help individuals, but cannot change a problem community-wide.

Also, use credible workers - those who have access and the ability to influence those that you seek to help. Problems like these are most efficiently treated from the inside, not from people outside coming in.


Charlie, I have been following Cure Violence on Facebook, your website, and periodic YouTube videos and love the simplicity and practicality of the model. Could you speak to the cost of implementation and its (financial) return on investment for a community? Cities / townships operating on tight budgets, often limited to funding only essential public services, may find the Cure Violence a useful but cost prohibitive model. Was that a factor with the closure of some of the Chicago CV offices?

narrowingin

There are many studies on the cost of violence, but I do not feel any of them really capture the impact. Many studies look at the costs of individual shootings, but they do not look at the benefit of fundamentally changing the situation in a city or community. What would be the financial impact if violence in Chicago was cut in half? It would shed its reputation as a violent city overnight, the schools would operate better, more people would be drawn to Chicago for travel and to live, businesses would grow, costs would shrink, etc. A profound change.

The problem in Chicago was due to a decision by the Governor to cut the state funding - as he did with many other programs. I'm not sure if he looked at our specific data when he made that decision (of note - just months prior to the cut he awarded Dr. Slutkin the highest honor in the state for his work with Cure Violence).

We have done calculations that show that for every $1 spent on our program, you get $17 in savings. http://cureviolence.org/wp-content/uploads/2015/08/Return-on-Investment-ROI.pdf

I understand that budgets are tight and spending is hotly debated. What is more essential than community safety? While police play an essential role in maintaining safety, it is not appropriate to hold them accountable for stopping a contagious health problem when you have epidemic violence. They do not have the training to interrupt violence and change behavior and norms, and because of their power to arrest and use violence, they are not the right sector to be changing behaviors.

Having health systems in place to stop violence is essential. As workers get the epidemic under control, the costs of maintaining this health system drop considerably. But right now we have to understand that we have an epidemic that is not being controlled and is resulting in the death of thousands, the injury of hundreds of thousands, and the traumatizing of millions. This is the great problem of our time and we need to step up to put an end to it. We invested millions when Ebola came to the US - and we had only a handful of cases.


Does CV talk about the program in the streets of Chicago (out in public) or always within conference quarters?

bcboncs

We have had programs in Chicago for over 16 years - as many as 20 communities at one time. Our workers are well known in their communities and are constant advocates for the program on the streets of Chicago - and in all of the cities that work in. Furthermore, our local Chicago team will go and talk to nearly any group or in any community where we are welcomed.

We are also starting a movement to advocate for understanding and treating violence as a health issue. We will be bringing this campaign to the communities affected by violence and will be especially concentrating in Chicago.


I was wondering what your thoughts are on combat sports like MMA and boxing? Do you think the glorification of violence is a good or bad thing in such sports?

fathead467

I have not looked into the effects of these sports - but I have done some reading in violence in the media and in video games. Some of the top studies in this field were done by Rowell Huesmann from the University of Michigan, who did a 40 year longitudinal study that shows that exposure to violence in the media increases aggression. So, the evidence is pretty clear that there is an effect, and in fact one of Rowell's studies is titled "Nailing the Coffin Shut on Doubts that Violent Video Games Stimulate Aggression."

Its important to keep in mind the epidemic disease framing here - because violence does act like a contagious disease. Like with contagious diseases, not everyone exposed develops the "disease." Prior immunity matters - perhaps you have a social or family norm that prevents you from being as susceptible. Age matters - young people are more likely to be effected by exposure to violence. Dose matters - how serious was the exposure to violence and how frequent? Context matter - are others present when you are exposed? Also with context, studies tend to show that violence on TV is experienced different that violence in real life.

Also, glorification of violence helps to make violence be seen as normal, which increases the risk of violence occurring. If you think violence is bad for our society, then you should seek to change this norm.


Additional Assets

License

This article and its reviews are distributed under the terms of the Creative Commons Attribution 4.0 International License, which permits unrestricted use, distribution, and redistribution in any medium, provided that the original author and source are credited.