Ending violence

Physicians take to the streets to protect Boston’s youth

It was 3 a.m., and third-year medical student Deborah Prothrow-Stith was in the emergency room of a Boston hospital, caring for a young man who had been cut in a fight. The young man promised her she’d soon be stitching up his adversary. “Stitch them up and send them out was the protocol,” she recalled.

Dr. Howard Spivak © Mark Morelli

For Howard Spivak, youth violence simply seemed to be permeating everything he did as a pediatrician. Every conference he attended, every meeting he went to brought with it accounts of bullying, of people who had lost siblings to violence or had lost a parent or a child.

The time was the early 1980s, and the two physicians, who met at Boston City Hospital, began what would be a commitment to preventing youth violence that would span decades. The two played key roles in helping Boston reduce violence among youths in efforts that still gain national attention. Now they have collaborated on a book describing the problem and outlining some solutions. Murder is No Accident, Understanding and Preventing Youth Violence in America (Wiley, 2003) is an account of what they learned as leaders of efforts that united neighborhood, religious and community leaders to work toward treating youth violence as a public health problem with prevention as the goal.

Spivak is chief of the division of general pediatrics and adolescent medicine and vice president for community health programs at Tufts-New England Medical Center. He is a professor of pediatrics and community health at Tufts School of Medicine and is the director of the Tufts University Center for Children. Prothrow-Stith is associate dean for faculty development and professor of public health practice at the Harvard School of Public Health.

Public health epidemic
“The book is about several things,” Spivak said during an interview. “It’s about the Boston experience, and it’s also an overview of youth violence written for people who are not experts in the field. It’s a personal reflection on our own experiences in Boston and around the country, and it’s an effort to engage people into taking action, particularly at the community level.”

The key lesson, Spivak said, is that youth violence is a complex problem, and there are no simple answers. The building of a critical mass that drew upon a range of programs and support were what helped alleviate the problem in Boston, he said, “not plopping in a single program.”

Violence, say Spivak and Prothrow-Stith, needs to be treated like a public health epidemic with prevention being the goal. One of the ways of reaching that goal is by helping to make cultural changes that emphasize hope over hopelessness and promoting a positive vision for young people and those who work with them.

At its height in Boston in the early 1990s, nearly one juvenile homicide occurred every month. By the end of the decade, there were no juvenile homicides, and the overall juvenile crime and violence rates had dramatically declined.

“The kinds of things that we did contributed to the building of a movement,” Spivak said. “We did basic community organizing. We brought many people to the table. We started building coalitions that had a vision of violence as being preventable, and we trained people to disseminate information.”

The book discusses the risk factors for violence: poverty, alcohol, the availability of guns, violence on TV and in the movies, witnessing and experiencing violence and adolescent vulnerability, meaning a time when children are risk-takers and are solidifying their identities, while becoming especially vulnerable to slights and criticism.

Johnny Appleseed approach
Spivak and Prothrow-Stith began their work by “pounding the pavement for a year,” he said. “We met with anyone we could identify who might be a stakeholder in the problem: schools, educators, the police, mental health practitioners. We added tenants associations, church congregations, religious leaders and street outreach workers. We did basic textbook community organizing. We didn’t define stakeholders but cast a very wide net around everyone who was concerned about kids and affected by [violence],” Spivak said.

“We used the Johnny Appleseed approach: Give people information and skills and trust they will use them in a way that adapts to specific needs and populations,” Spivak says.

“So we had preachers talking about the issue from the pulpit, physicians talking to parents and teens about risk factors. The Boys and Girls clubs did projects to get kids thinking about violence in their lives. Peer counselors began to talk about violence in their work with other kids. Police departments began to read about domestic violence and now looked at kids in those situations, knowing exposure to domestic violence creates the risk of more violence.”

Spivak said that he and Prothrow-Stith functioned as catalysts, encouraging people to think and act about the issue differently. They realized they had to empower people, to help them realize they could take action to make violence preventable.

“When you think something is inevitable, you not only don’t do anything about it, you perpetuate the idea that the people involved can’t do anything themselves,” he said. “When a minister is in the inner city, and people are dying all around you, and no one is talking about it, you are passively communicating that nothing can be done.”

Among the areas addressed were:
Healthy and safe communities: Youth centers, after-school programs and other recreational activities began stressing non-violence.

Positive behavior: The authors helped bring conflict resolution and violence prevention curricula to schools.

Domestic violence: Home visitation programs began in an effort to prevent kids from becoming witnesses to violence.

Gun buybacks: These programs helped reduce the number of firearms on the streets.

The authors’ efforts to train a broad spectrum of community agencies in violence prevention resulted in youth programs at Boys and Girls clubs; slogans and public service announcements developed by the Hill Holiday advertising agency; black clergy organizing a march against crime; the Drop a Dime Program, which encouraged local residents to report drug dealing or other crimes; a Boston City Hospital program to ensure that all children and youth admitted to the hospital with violent injuries received a prevention assessment and follow-up to try to reduce their risk for further injury. Numerous other programs were established in schools, community agencies and churches.

Survivors—and inspirers
The authors also learned that they could help parents of murdered children heal by involving them in programs aimed at preventing further violence. Those parents, in turn, were able to inspire others. “We learned that survivors of violence are the cornerstone of a prevention movement,” Spivak said. “They bring passion and immediacy to the issue that no one else can.”

Spivak said it was also important to understand what promotes resiliency in young people. Kids who have a healthy relationship with an adult, he said, are far less likely to be involved in violence, and the same holds true for religious involvement, which provides access to support and healthy role models. “So we know there are things we can incorporate into kids’ lives and communities that promote success.”

The authors also write that success depended on both large and small things. The Boston Police Department, for example, initiated community policing, in which police officers were taken out of patrol cars and put on the street and into public housing projects, allowing them to be part of the community instead of remaining faceless authority figures. But, said Spivak, “the woman who sits on the porch and talks to kids” is just as important. “Some people do big things to help, and some do little things, but it’s a combination of all this help that works.”

The two authors also recount some of their personal backgrounds as a way for readers to relate to them and also to challenge some stereotypes about peoples’ attitudes about violence. “Deborah is an African-American woman who grew up in a family that was very nurturing and taught skills to negotiate with others. I grew up in an upper-middle-class Jewish family that was violent and dysfunctional…It was not until I got involved in the issue of youth violence that I realized the enormous impact my background had on me and the kinds of things I had to deal with in becoming an adult,” Spivak said. “It was also very influential in my becoming a pediatrician. And it helped me reflect inwardly and find insights that may be helpful in my work.”

Spivak and Prothrow-Stith are currently working on a second book on violence among girls.