By Isabela Dias and Megan Messana
Dr. Robert Gore, 41, anticipated a “cool and calm” shift when he entered Kings County Hospital’s pediatric emergency room at 3 p.m. on a sunny Monday in early September. For the next eight hours, the emergency physician would check on a 5-year-old girl showing initial signs of pinkeye, a teenager whose stomach-ache got worse after a hazardous combination of bread and pickles and a young boy who appeared fully recovered from a mild fever by the time the doctor went in.
But the calm ended abruptly as Dr. Gore passed by the trauma center on his way out of the building for a quick break. He saw a familiar face, a patient and ex-gang member who had been shot multiple times. The patient, who had a history of depression and substance abuse, was sobbing as he lay handcuffed on a stretcher. Dr. Gore asked police officers to secure the patient to the stretcher by his feet instead because he had track marks on his arms.
“They aren’t trying to figure out how to fix that situation because that’s not their job,” he said. “But if you take your job at face value and just check boxes, nothing is going to change. We’re doing a lot of defensive work, a lot of repairing instead of building and that’s why a lot of these situations will continue to exist.”
As an emergency room physician in an urban hospital, Dr. Gore juggles the ordinary illnesses of some of his patients and the extraordinary violence inflicted on many young men of color who end up in his care.
Eventually, he felt he had to do more than just treat wounds. So in 2011, he founded the Kings Against Violence Initiative, or KAVI, a hospital and school-based violence intervention program supported by donors like The Pinkerton Foundation, Trinity Wall Street and The Wellmet Group. Relying mostly on volunteer work, the organization has an operating budget of roughly $400,000.
KAVI is one of about 30 similar initiatives across the country that are modeled on the Caught in the Crossfire program in Oakland, Calif., started in 1994.
The common thread is the approach to violence as a disease. At the core of prevention is identifying populations at risk and tackling factors contributing to its dissemination, such as “socioeconomics, education and environment,” according to a 2016 study conducted by Dr. Rochelle Dicker, Associate Professor of Surgery and Anesthesia at the University of California San Francisco and founding director of the San Francisco Wraparound Project.
For Linnea Ashley, managing director of the National Network of Hospital-Based Violence Intervention Programs, the success of these programs depends on their ability to meet patients on spot right after an incident takes place or in the emergency room. “We recognize that as the golden moment,” she said, “when the person is more open to receiving help and thinking what could be useful to them beyond physical recovery.”
According to a 2016 report from the Center for Disease Control and Prevention (CDC), 4,733 people aged 15-24 were victims of homicide in the United States in 2015. Another 2016 report by CDC’s Division of Violence Prevention shows that in 2014, 501,581 people between the ages of 10 and 24 were treated in emergency departments for injuries resulting from physical assaults.
Dr. Gore still remembers the first patient treated by KAVI. He was a young skateboarder who had been badly beaten up after family members engaged in a fight with a rival group. He had fractured bones all over his face, including in his eye socket, and several busted teeth. In that case, the most important thing was to move the family to a safer environment.
Providing continuous follow-up support after discharge is also crucial. In some instances, after going through an assessment, patients can be referred to the hospital’s behavioral health department or to counseling services offered by community-based partner organizations such as Good Shepherd or Safe Horizons.
“I don’t want my patients to just be alive and exist,” Dr. Gore said. “I want them to thrive … and when you understand what wellness looks like for communities that are marginalized, your approach to care delivery shifts. You start looking at the cause of the cause: economics, education, location.”
In recent years, hospital-based violence intervention programs have been implementing trauma informed care approaches. But one of the biggest challenges is to keep track of the patients who are complying with referrals to external services and those who aren’t. “We can’t have a hospital program if we are attending the physical needs but not the emotional ones,” said Jacquel Clemons, the chief operating officer at KAVI. “We need to be more vigilant.” That’s why she thinks initiatives like KAVI are so promising. “There is some real strength in models like this, where community and industry work together to solve a social problem,” she said.
Besides the hospital initiative, KAVI also runs a school and a community program. With a team of one full-time and four part-time paid employees and a group of between 20 and 30 volunteers, the organization provides after-school activities and workshops focused on conflict resolution and life skills development to an estimate of 200 to 300 kids and teens annually.
To become a full-time member of the National Network, hospital-based programs have to meet eligibility criteria requirements – being in operation for at least one full year and having had encounters with at least 20 violently injured patients, for example – and have their application evaluated by a committee.
Ashley emphasizes the importance of making sure that new initiatives are sustainable and safe for both patients and staff.
“People who have been shot or stabbed are a vulnerable population,” she said. “They’re much more likely to be injured again in part because of symptoms from their original trauma … The last thing we want to do is further traumatize someone who’s been through a lot.”
Lawrence Brown, 46, who works with the Bedford-Stuyvesant chapter of Save Our Streets (S.O.S.), a pioneer anti-violence program in New York, is one of the people dispatched to the hospital when a victim of a violent crime lands in the ER.
“I introduce myself and offer assistance, I’d say it’s 80/20 for those who respond well,” Brown said. “Eighty percent of the people I approach want help; 20 percent tell me they’re not interested.”
Outreach workers are credible messengers because they are members of the community who are familiar with the neighborhood and have often been affected by violence on a personal level. “For a lot of young people of color, there’s just a distrust of medical institutions,” said Clemons, “so the hospital responders legitimize the hospital.”
The goal of Askia Askari, 42, is to make sure that the patient doesn’t come back the next time with a fatal injury. As one of the two intervention specialists from KAVI, he is now part of that chain of public health professionals, community leaders and social workers who are trying to break the deadly cycle of violence.
Askari is no stranger to trauma. By the time he was released from Queensboro Correctional Facility in 2008 after serving 16 years for first-degree manslaughter, most of his childhood friends from Brooklyn were dead as a result of community violence.
Askari attended counseling sections and anti-violence workshops while in prison. When he heard about S.O.S through a friend who worked for the organization, he decided to join it. Then, in 2015, he started working with KAVI.
Askari addresses issues that can go from the need to call a family member and get food to post-traumatic stress disorder in that “teachable moment” at the hospital bedside when the person is more likely to respond to an intervention. After that conversation, he introduces risk reduction resources like school programs and a referral to mental health services.
“Violence is already a reality and you want to stop it from maturing into something more complicated,” Askari said. “We don’t want to have a band-aid approach. Success is a long-term goal, not an immediate response. This is a long fight.”