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5 Contagion and Interruption in Practice T he previous chapters explored the contagion of violence in the con- text of the pattern of spread, the possible mechanisms at both the individual and social levels, and the factors that might reduce or exacerbate exposure and transmission. Drawing from this framework, speakers also examined potential processes of interruption or mitigation. Speakers at the workshop also explored some real-life examples of this contagion at work, bringing all of these concepts together, as well as inter- ventions currently in practice that seek to reduce it. THE CONTAGION IN ACTION Speakers Jason Featherstone of Surviving Our Streets and Zainab Al- Suwaij of the American-Islamic Congress both spoke of recent occurrences in which single acts of violence sparked an epidemic in very different ways. UK Riots On August 4, 2011, Mark Duggan was shot and killed by police in the Tottenham neighborhood of North East London, England. Two days later, friends and family marched to the police station to obtain information re- garding the shooting. After several hours of silence, patience ran out, and a series of altercations led to the overturning and burning of several police cars. Captured on video, the burning cars became a symbol for those who felt frustration around relationships with law enforcement, the current 41

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42 CONTAGION OF VIOLENCE economic climate, and various political austerity measures related to educa- tion and public services. In addition, Mr. Featherstone noted, residents of Tottenham had a preexisting ingrained mistrust of law enforcement, related to perceived injustices and deaths in police custody over the previous de- cade. Mr. Featherstone also showed several video clips and commented on the sense of relief and anticipation expressed by participants of the violent acts that followed the initial event. Notably, many of the organizers and participants belonged to groups with traditional rivalries, which were set aside in these events. Following the burning of the cars, violence spread throughout Tottenham, London, and then other parts of the United King- dom over the next several days. Mr. Featherstone noted that rioters were diverse and did not fit the “traditional” image. Calls to commit violence were sent via social media to those within close geographical proximity as well as those in other locations outside the United Kingdom. Footage of the rioting and looting was shown constantly on television, and made headlines in major newspapers. Violence spread through the country for 5 days, and then subsided as police presence in the streets ramped up significantly, and large numbers of arrests were recorded. Through video clips and his own reflections, Mr. Featherstone painted a complex story of not just violence throughout the country, but a sense of resentment, frustration, and inequality that had bubbled over. Previously that year, large antiausterity protests had been held, with little to no relief presented. In one map he showed, there was strong geographical correlation between the violent incidents and areas of deprivation. While gang violence was cited as a major factor in the violence, Mr. Featherstone argued that only a small number of rioters were members of gangs, and even then they behaved in ways not typical of gang rivalries. Throughout his presentation, Mr. Featherstone echoed a number of elements that had been noted previ- ously by other speakers, specifically the importance of the social context, the dynamics of groups, the emotional response to witnessing violence, and the potential for epidemics to peak and then decline, in describing the complexities of this event. In discussing potential interventions to reduce violence related not just to the riots, but the preexisting social and economic conditions, Mr. Feath- erstone noted the importance of empowering individuals to not identify as victims or perpetrators. He also noted the importance of developing community–law enforcement relationships to build trust. He stated, for example, that in the case of Mark Duggan, some of the immediate incendi- ary violence might have been prevented if police had spoken to the family and conveyed a sense of working with the community. Speaker and plan- ning committee member Charlotte Watts of the London School of Hygiene and Tropical Medicine shared concerns that while interruption programs reduced street violence, they did not address the underlying issues that

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CONTAGION AND INTERRUPTION IN PRACTICE 43 exacerbated the tense situation. Mr. Featherstone concurred, and noted that such reforms would take years to implement, while reducing retaliatory violence could be an easier issue to address in the short term. The “Arab Spring” and Iraq The “Arab Spring” is a term coined to describe events across the Mid- dle East and North Africa (MENA) characterized by wide-scale populist uprisings against dictatorial governments. While many of the events are continuing, the uprisings have been likened to the “Autumn of Nations” that occurred in Eastern Europe in 1989. The singular event that was said to have begun the wave was the self-immolation of Tunisian Mohamed ­ Bouazizi on December 18, 2010, as an act of protest against police and gov- ernment corruption. Immediately in response, protests cropped up through- out Tunisia, and eventually led to the toppling of the government. A month later, similar protests swept through Egypt, and spread to Bahrain, Libya, Syria, and Yemen. Protests also occurred in Algeria, Iran, Iraq, Jordan, Morocco, and Oman and continued to spread through the region. Unlike the UK riots, a contained trajectory of events has not presented itself in the MENA region. Additionally, many forms of violence have been reported, not limited to political conflict, but also spikes in interpersonal violence (e.g., sexual harassment). Ms. Al-Suwaij noted that as collective violence has destabilized communities, it has normalized the use of other types of violence, echoing comments by other speakers about different “syndromes” of violence. Ms. Al-Suwaij also spoke of her experience with violence in Iraq, go- ing back to her time as a student during Saddam Hussein’s regime, and the protests that occurred then, reminiscent of those occurring now. She noted that much of the violence is sectarian or interethnic and she is exploring op- portunities to reduce such violence. She established Ambassadors for Peace, a program she has sold with varying degrees of success to community and religious leaders in various locations in Iraq. In describing her experience, she noted that much of the conflict that occurs is related to simmering re- sentment, and is often set off by something innocuous, such as two children arguing over a soccer game. Thus her approach to mediating conflict draws heavily on the Cure Violence (formerly known as CeaseFire) model, and aims to interrupt retaliatory or tribal violence related to preexisting griev- ances. She noted that in one of three areas in Basrah, in which her program has been operating for 3 years, intertribal violence has been reduced to zero. She also discussed plans to scale up the program and move to other areas. Ms. Al-Suwaij also noted challenges in the Ambassadors for Peace program, notably continuing political violence, lack of trust in law enforce- ment (an issue that is being addressed), and the inability to intervene as

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44 CONTAGION OF VIOLENCE successfully in other forms of violence, such as domestic violence. She noted that it is still taboo to talk about domestic violence, and much of it is vastly underreported. When her interrupters hear about violence in families, they attempt to address it, but the existing legal structure prevents significant addressing of the issue. She also noted that, in peer group sessions of only women, some conversation around gender equality, gender norms, and violence against women is introduced. INTERRUPTION AND APPLICATION Panelists in the afternoon of the second day described some ap- proaches to interruption, and challenges and opportunities to scale up. Before the panel, participants watched the documentary film The Inter- rupters, which chronicles the work of four violence interrupters as part of the CeaseFire Illinois initiative (CeaseFire Illinois is a Cure Violence program). CeaseFire Illinois, the program initially developed by speaker and planning committee member Gary Slutkin of the University of Illinois at Chicago, uses individuals called interrupters to halt the further spread of violence. These interrupters are respected in the community and usually have some history of violence themselves. They intervene when violence occurs, usually to prevent further spread or to prevent retaliation. They also work with high-risk individuals in the community to reduce tensions and other conditions that might result in violence. In introducing the film, facilitator and planning committee member Brian Flynn of the Uniformed Services University School of Medicine ex- plored some key concepts in the natural cycle of violence. He noted, ref- erencing Stephen Pinker’s book The Better Angels of Our Nature, that traditionally violence is lower in urban versus rural areas. Pinker’s premise is that rule of law and governing systems are responsible for reducing violence, but in areas where violence spikes, people may not feel that rules apply to them, or systems are capable of upholding justice. Dr. Flynn also stated that, per Pinker, as women become more empowered, violence decreases as well. He urged the audience to consider these points as they watched the film. Finally, he posited that as previous discussions highlighted the observation of violence (either near or far) as a risk factor for future perpetration or victimization, perhaps the observation of violence interrup- tion could further the spread of prevention as well. Community-Based Intervention Following the film, speaker and CeaseFire Illinois program director Tio Hardiman spoke about the experience of the interrupters, the program, and potential for scaling up. He gave four examples of recent events, which

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CONTAGION AND INTERRUPTION IN PRACTICE 45 transpired within an hour, that required the intervention of the interrupters: (1) an incident involving a man who stole his girlfriend’s pain medication, prompting threats and retaliation from her sons; (2) an incident involving two men in a territorial altercation that had expanded to involve several others; (3) two men arguing over a woman; and (4) two men involved in an altercation over the sale of drugs, which the interrupters did not mediate, though they did ensure that the situation would not result in violence. Mr. Hardiman went on to note that CeaseFire interrupters worked with 1,100 high-risk individuals and mediated 800 conflicts in 2011. In Chicago, homicide is the leading cause of death for 15- to 24-year- olds, and Mr. Hardiman estimated that in the past decade, potentially 5,000 homicides have occurred. He described the circumstances in which many young individuals involved in violence and crime grow up with the mentality of needing to shoot first, to not be victimized, and to find ways to leave the structural poverty of family neighborhoods behind. He noted that violence is often normalized in these situations, and has lasting effects in a number of settings, such as schools, where children have difficulty learning because of fear of events outside of school. He noted that businesses often leave neighborhoods because of the destabilizing effect of violence. He also noted the importance of addressing issues on “the front end,” that is, intercepting rumors of potential violence, and intervening before it occurs. The Cure Violence model, in addition to interrupting the spread of vio- lence, also aims to address social and group norms and behaviors around violence. Some of the work involves reaching out to individuals and assist- ing them with employment or education. In addition to the work of the i ­nterrupters, outreach workers are constantly in communities monitoring the pulse and providing educational opportunities. The interrupters also liaise with local law enforcement and mediate conflicts with victims of shootings who end up in hospitals. School-Based Intervention Speaker Patrick Burton of the Center for Justice and Crime Prevention in South Africa shared his experience with working in schools in South Af- rica to reduce violence in youth. The program, in particular, was interested in preventing “low-level,” high-frequency violence such as bullying and dating violence, and in improving academic outcomes. He also noted the importance of addressing the social milieu and how students relate to one another in terms of forming more positive relationships. Dr. Burton spoke of data issues, particularly a lack of insightful, robust data, often due to non-reporting because of fear of the perception that schools are not safe. Despite this, he estimates that about 15 percent of students had experienced violence in the previous 12 months.

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46 CONTAGION OF VIOLENCE In describing the approach, Dr. Burton explained the “whole-school” approach, in which the program works with all stakeholders in school- based learning, including the teachers, students, parents, school governing body, and policy makers. It is also embedded in communities, working with families and homes in which students are experiencing or at risk of experiencing violence. The program places responsibility of identifying priorities and interventions on the schools, while providing guidance on response and prevention. Schools are shown how to identify safe and unsafe spaces within schools, how to manage and respond to reports of violence or threats of violence, and how to demonstrate action on such reports. Dr. Burton went on to explore some of the challenges faced in the pro- gram and in scaling up. In 2005, the program was piloted in 85 schools; it is now active in just over 2,000 schools nationally. It is also currently being developed to other sites outside South Africa. Two formal outcome evalu- ations have been performed, and several informal process evaluations. He noted challenges in accountability, such as who is responsible for violence occurring and for response or lack thereof; ownership, management, and institutionalization. These challenges are especially difficult because effec- tive school managers are often moved around. There are also challenges in supporting schools, whose primary task is education, to also work toward providing safe environments and the shared vision of what a safe school means—not just physical security. The social context in South Africa has played a strong role in the exacerbation of violence, including a sizeable percentage of students (16 percent) having family members who have committed acts of violence and are currently incarcerated. Mr. Burton noted that the success of the school intervention program has been dependent on the integration with home- based efforts to address family violence. In the most successful sites, where there has been integration with parenting programs and the school’s efforts, school-based violence has dropped significantly, some down to zero. Family Violence Prevention and Interruption In thinking about interrupting violence at the family level, speaker V ­ alerie Maholmes of the Eunice Kennedy Shriver National Institute for Child Health & Human Development explored a series of studies being funded by her institute. She noted particularly how much of the research focuses on early development, and the importance of both the research and that age group in framing violence prevention. The first study she noted is that of Judith Langlois, which looks at the development of appearance- based stereotypes in children. Children naturally differentiate between more and less attractive appearances, but it is the observation of differential be- havior by parents that ingrains value in appearance. Throughout life, these

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CONTAGION AND INTERRUPTION IN PRACTICE 47 biases are more firmly established through repeated observation, and serve as barriers to receptivity of counterstereotypic messaging. Dr. Maholmes noted that the important implication here is that this work may prompt the development of interventions that ameliorate negative judgment based on attractiveness, and learning about these mechanisms may help inform evidence-based practice. Dr. Maholmes went on to describe an intervention in India designed by Suneeta Krishnan, called DIL-MIL (Hindi: “hearts together”), which lever- ages the role of mothers-in-law to reduce violence against daughters-in-law. She noted that women are vulnerable to gender-based violence because they often have to acquiesce to the marital family, and that efforts to empower women must take into account social and family dynamics. She noted that mothers in law are crucial entry points, but people do not often realize that their role can be pivotal. This intervention brings these dyads together and, using social-cognitive theory, educates and empowers the women to reduce gender-based violence. Finally, Dr. Maholmes described a study by Amy Marshall looking at aggression within families, disaggregating interparen- tal aggression (IPA) and parent-to-child aggression (PCA) to see if the two co-occur, if PCA is an outcome of IPA, if either or both have a “spillover” effect to violence between other family members (i.e., sibling-to-sibling) or outside the family. In response to a question from a participant, Dr. Maholmes noted that intergenerational transmission of violence is strongly influenced by the normalization of violent behavior within families and the internalization of such by girls. She posited that useful interventions in breaking this cycle would need to include messaging around self-worth and self-esteem, as well as the ability to show other types of relationships. Trauma-Informed Approaches Speaker John Rich of the Drexel University School of Public Health spoke of the importance of the trauma-informed approach to violence prevention, noting that trauma is at the center of violence and that “hurt people hurt people.” He also referenced other words from Sandra Bloom from the Drexel University School of Public Health about reframing inquiry from asking about what is wrong with someone to asking what happened to someone, knowing that early adversity and stress can have deleterious effects. In thinking about how to approach the interruption of violence in the health care setting, Dr. Rich noted the importance of examining these roots of trauma because patients who present with physical injury often have psychological injury as well. Failing to address those secondary inju- ries runs the risk of retraumatizing the individual. He also pointed out that the “injured” included not only the individual with the injury, but those

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48 CONTAGION OF VIOLENCE who might have witnessed the violence, and potentially even those who work with the injured and traumatized; thus, understanding trauma across populations informs violence prevention at larger scales. Dr. Rich also stated that violence is a recurrent disease, with high risks of recurrence. He cited some studies that show, 5 years out, that 45 percent of those with serious injury have experienced another serious injury, and 20 percent of them are dead. Of that 20 percent, 70 percent had substance abuse listed as a contributory cause. In other situations he referenced, young men who present with serious injury have high rates of posttraumatic stress disorder (PTSD), hypervigilance, and history of childhood adversity. Dr. Rich also pointed out that perpetrators are also at risk of PTSD symp- toms, so it is not just victims. Hospital-based interventions that are trauma-informed have been known to work. Shock Trauma in Baltimore has an intervention that has shown a reduction in involvement in the criminal justice system for its patients. Dr. Rich explained that hospital-based interventions are about recognizing the additional trauma faced, as a bigger picture approach to reducing violence. The interventions screen for past trauma and provide guidance in navigating systems, both medical and criminal justice, which might also potentially retraumatize. It also provides an outlet for aggression or rage, usually conversation with a case worker, as a means to reduce the potential for retaliatory violence. Finally, he noted it is important to include direct trauma recovery assistance as well, citing a few in use with evidence to back effectiveness. Most salient though, Dr. Rich noted, is system-wide transformation into treating trauma as a cause and not just as an outcome, and to reflect on the comorbidity of different forms of violence, in the context of trauma. In addition, educating the community on trauma and its effects would provide a more nuanced perspective, including structural violence and intergenera- tional oppression. He noted especially that moving the conversation out of just hospitals and into a number of partnering organizations as well as the community would be the most effective approach.

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CONTAGION AND INTERRUPTION IN PRACTICE 49 Key Messages Raised by Individual Speakers • The spread of violence has a number of complex factors, including social and contextual undercurrents that fuel frustration, anger, and mistrust in systems (Featherstone, Flynn, Rich). • Finding a key leverage or entry point could optimize interventions (Hardiman, Maholmes). • Recognizing and addressing the fundamentals of trauma provides a holistic approach to hospital- and community-based interventions (Hardiman, Rich). • Scaling up requires attention to a number of factors, including accountability and finding and working with partners (Al-Suwaij, Burton, Hardiman).

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