Explaining Violence A four-part series on causes and consequences of violence

Part 4 / Guns

• 1 Terrorism Why they do what they do
• 2 Intimate Partner Violence Designing interventions
• 3 Resilience Overcoming victimization
• 4 Guns The long shadow

Series: Explaining Violence

Healing the Wounds of Gun Violence

BMC programs provide family counseling, education, community

Lisa Allee, Thea James, Peter Burke, and Bindu Kalesan.

In this four-part series, BU Today looks at the work of BU researchers and medical experts who study and treat the causes and consequences of violence. Considered together, the four stories depict a vicious cycle of hurt, frustration, and vengeance that reverberates through every aspect of American life.

Gun violence claims the lives of 33,000 Americans a year, disproportionately—and dramatically—taking a toll on the low-income neighborhoods like those served by Boston Medical Center (BMC), the largest around-the-clock trauma center in New England and the teaching hospital of the BU School of Medicine.

Lisa Allee has seen the people behind the numbers. She has watched as nearly all hands in a room go up when middle-schoolers in a crime-plagued Boston neighborhood are asked if they know someone who’s been shot. As director of the Community Violence Response Team (CVRT) at BMC, she sees these children as victims too.

Every year, about 200 gunshot victims arrive at BMC, one of six 24-hour, Level 1 Trauma Centers in Boston. And for every victim, fatal or not, there is a ripple effect: the survivor whose post-traumatic stress disorder prevents her from venturing outdoors, the teenage gunshot victim rendered a quadriplegic or brain-damaged and draining strained family finances, the child orphaned by a gun, the teen victim bent on revenge.

Because the efforts of people like Allee, a MED surgery instructor, and programs like CVRT, BMC has emerged as a national model for treating survivors of gunshot wounds and their families.

Gun violence is a scourge that cuts across all income levels and life circumstances. In fact, nearly all Americans are likely to have a victim of gun violence within their social networks during their lifetime. That’s the finding of a new study by BU researchers Bindu Kalesan, a MED assistant professor of medicine, a School of Public Health assistant professor of community health sciences, and director of the Evans Center for Clinical Translational Epidemiology and Comparative Effectiveness Research, Sandro Galea, SPH dean and Robert A. Knox Professor, and Janice Weinberg, an SPH professor of biostatistics, who say their findings underscore that Americans are closer to gun violence than they think. The researchers used fatal and nonfatal gun injury data from the US Centers for Disease Control and Prevention (CDC) and estimates of the number of social relationships people accrue in their lifetime to gauge the likelihood of Americans knowing a gun violence victim. Published in the December 2016 issue of the journal Preventive Medicine, the study determined that the likelihood of knowing someone who was shot within any given personal network was 99.85 percent. The chances of knowing a gun violence victim who died (rather than was injured) was 84.3 percent overall.

CVRT, created in 2010 after survivors of homicide victims told their stories at a Boston City Hall hearing, is one of the few programs of its kind in the nation. It was born out of the belief of BMC trauma service staff that their role as healers required them to study the psychological fallout of gun violence and to work closely for as long as it takes in at-risk communities to halt what has become a vicious cycle of loss and pain. BMC surgeons, resident physicians, social workers, nurses, and outreach workers are all on the front lines.

“Often trauma services put people back together and put them back out there, and that’s fine. But we have a different approach. I tell patients that we care about their emotional and mental health as well as their physical health.” —Peter Burke

The hands-on involvement of Allee and her team is part of the broad, proactive vision of Peter Burke, a MED professor of surgery and BMC chief of trauma surgery. “With each gunshot case, we take the longer view,” says Burke. “We work with patients, and if they die we work with the family. Often trauma services put people back together and put them back out there, and that’s fine. But we have a different approach. I tell patients that we care about their emotional and mental health as well as their physical health.” As Allee puts it, “one thing Peter and I say all the time is that CVRT is an integral part of the trauma service.”

At BMC, which handles half of Boston’s homicides (40 total in 2015) and 70 percent of its gunshot and stabbing victims, Allee’s team assesses the psychological state of both victim and family, offers bedside and later clinic-based or community-based counseling, and ultimately works with victims and families as long as they need their services. Working alongside them are trauma response workers, violence intervention advocates, and family support advocates with the 10-year-old Violence Intervention Advocacy Program (VIAP), who are on call day and night. Because many of the workers have grown up in the communities they serve, they gain the kind of trust other clinicians must cultivate over time.

The two programs complement each other, and for those working out in the community, no need, no detail, is too small. One counselor recalls rearranging home appliances for a client blinded by a gunshot. Advocates, social workers, or street workers might take a recovering victim for his first ID card to help him prepare for a job interview. As soon as gunshot or stabbing victims arrive at the hospital, they and their families are met by one or more members of BMC’s crisis support team, both CVRT and VIAP, who will provide bereavement counseling if the patient dies.

Thea James, VIAP director and founder, BMC’s vice president of mission and associate chief medical officer, and a MED associate professor of emergency medicine, is active in a national network of hospital-based violence intervention programs. Although accredited Level 1 Trauma Centers are required by the American College of Surgeons to have an injury prevention coordinator, not all programs have the resources to be as rigorous as BMC’s, says James, who recently received a $1 million Department of Justice grant to develop support programs for male survivors of violence, predominantly men of color. The program draws funding from sources that include the Massachusetts Department of Public Health, the Liberty Mutual Foundation, the Boston Public Health Commission, charities, and individual donors.

All of the CVRT services are free to clients and are paid for from reparations offered through the victims’ fund of the federal Victims of Crime Act (VOCA), which provides money for state and community-based organizations to offer free mental health counseling and other specialized services. Each year, more than $7 million in VOCA funds is distributed to almost 100 programs across the commonwealth.

“We work in tandem with CVRT and community organizations,” James says. She speaks highly of Allee’s team. “We love them. Most clients come from vulnerable populations, and many of our patients are stigmatized by their injuries. When they get here, they have no resources, no mentors, and no one to protect them. We try to get these young people to college and to jobs.”

VIAP’s research shows that gun violence in Boston disproportionately affects males (85 percent), the young (about 60 percent of victims are under 29), and people of color (69 percent are black and 16 percent are Latino). Treating cases from the streets of Roxbury, Dorchester, Mattapan, and beyond, BMC is at the epicenter of this grim epidemic. BMC staff and street workers estimate that less than 9 percent of gunshot injuries are gang-related. Most stem from personal violent encounters, such as domestic violence.

“Most clients come from vulnerable populations, and many of our patients are stigmatized by their injuries. When they get here, they have no resources, no mentors, and no one to protect them. We try to get these young people to college and to jobs.” —Thea James

As a rule, the identities of BMC clients are confidential. But one pair shared their story in the spring/summer 2016 issue of BMC’s Inspire. Kynndall Martin and Thomas Grant, self-described “brothers from another mother,” sustained bullet wounds—Martin one and Grant two—in a drive-by shooting as they stood in a parking lot. Brought to BMC’s emergency department, they received medical attention for their wounds, as well as bedside visits from VIAP patient advocates Kendall Bruce and David Wiley, who the victims describe as angels. Wiley helped Grant find housing and gain partial custody of his children. Bruce offered mentoring and friendship. “We’re from the neighborhood and understand personally what they’re going through, so they can relate to us,” Bruce says. Both Grant and Martin now work as cooks, and each young man shares custody of his children. What’s most rewarding, says Wiley, is “when you see a client doing well—someone who no longer needs your help and is asking how he can help others.”

Martin and Grant are 2 of the 1,085 first-time patients seen by VIAP between 2014 and 2016 who suffered 1,120 penetrating traumas (gunshot wounds accounted for 45 percent in 2015 and 42.5 percent so far in 2016). There were 33 return victims among the 1,085, and one person was treated on three separate occasions. So far this year, the team has found housing for 7 people and new jobs for 16, and provided needed services to 168.

James and Allee are working to improve data collection, following up on gun violence survivors not just at BMC, but citywide, with the same collaboration as occurred in the sharing of data after the 2013 Boston Marathon bombings. In a qualitative study published in 2014 in Academic Emergency Medicine, coauthored by James, social worker and VIAP clinical director Elizabeth Dugan, and others, the team wrote in its conclusions that after looking into the lives of 20 VIAP clients, “participants described positive, life-changing behaviors on their journey to healing through connections to caring, supportive adults.” But more research is needed to identify and fine-tune best practices, James says.

When James launched VIAP, she didn’t have a precedent. “At BMC, 80 percent of patients are vulnerable,” she says. “I focused on the things that drive the cycle—when you remove those things, you are able to stop the cycle of violence and leverage the strengths and assets of victims of violence.”

“We really want to prevent collateral damage downstream, and if, through our response and prevention people, we can get to one of their relatives or friends, maybe we can empower them to make good choices,” says Burke. “This is our particular windmill.”

This Series

Explaining Violence: Healing the Wounds of Gun Violence

Also in

Explaining Violence

• November 14, 2016

  Explaining Violence: Lessons from Terrorists

• November 13, 2016

  Explaining Violence: Intimate Partner Violence

• November 12, 2016

  Explaining Violence: Facing Adversity, Building Resilience

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