Background America is in the midst of a gun epidemic that can be examined from two very different lenses. Through one lens, we see a general and systemic decline in urban violence across key American cities that were once viewed as unsustainable epicenters of violence and trauma. Such declines are a testament to coordinated public support, police reforms, community collaboratives, and highly deliberate public policy to re-allocate taxpayer resources in support of the aforementioned. However, the second lens tells the bleak story of a country that still has the highest number of gun-related homicides per-capita of any other developed economy. While mass-shootings and calls for gun reform dominate the debate, there remains significant and causal factors that continue to perpetuate this national challenge.
For matters of primary prevention:
We have too many people with too great of access to too many high-powered weapons.
Wholesale divestment and abdication of vulnerable communities have eroded the economic potential of residents, giving way to shadow economies and extra-judicial systems for dispute resolution.
We have failed to instill any measure of confidence in such communities that other communities understand the seriousness of their plight.
Addressing primary prevention opportunities is critical to addressing the fundamental core of the issue. But there is a certain political fortitude and private sector collaboration required to make such overtures and cities are in a constant state of flux and fluidity regarding serious, sober reforms.
Frustratingly, the recourse to addressing primary prevention defects is through the political process. Systemic solutions rely on a cross-section of federal, state, and civic policy with the necessary inclusion of community leaders. Primary prevention reforms are highly difficult to achieve and sustain, though strong success cases have emerged in cities like Boston, New York, and Los Angeles in recent decades.
However, secondary prevention opportunities introduce a new group of players further downstream with some (selectively) economic incentives to take action. The ultimate ideal of any public policy action is in the reduction of secondary prevention needs. However, in the face of political intransigence, secondary prevention can be a means of organizing an infrastructure to treat and re-direct victims, perpetrators, and families to resources that can remediate and lessen violence.
What is Secondary Prevention In public health parlance, a secondary prevention intervention represents a point in the continuum where primary prevention infrastructure has failed to impede some kind of target event. In the case of gun violence, such failure has a multitude of different end points. These end points can be punitive (law enforcement, judicial, incarceration), custodial (safe zones, housing, environments), emergent (hospitals), clinical (mental health), and community (further violence escalation, community support, etc.).
Many of these, particularly when siloed, suffer from the same limitations as primary prevention in that they are conditional on public support and funding. But other limitations are decidedly more artificial and vexing, namely a fundamental discontinuity that exists between the various demarcation points. These demarcations fan out like a river, with seemingly disconnected terminus points that do not have a deliberate pathway for a victim or perpetrator to some form of stable and consistent rehabilitation.
Because of the failure of primary prevention, we assume a trauma has occurred which places an increased onus on secondary prevention for facilitating treatment and remediation as well as laying the groundwork for future prevention.
Systemic Initiation Points for Secondary Prevention As previously indicated, there are a litany of different points in the spectrum for some kind of secondary prevention. However, many of these are disconnected from core systems that are capable of organizing resources and supporting a trauma victim through recovery, treatment, and stability.
There are two unique domains that create the physical safety conditions that would portend a potentially higher likelihood of successful secondary prevention efforts. The first is with law enforcement, which may be physically safe but often lacks the confidence or trust of victims, perpetrators, and families.
A second key area of initiation is located within an emergent clinical setting (i.e. emergency department, intensive care unit, in-patient setting, etc.). In this setting, trauma victims and their families enjoy a greater degree of physical safety within an environment that fosters connectedness and at least some marginal improvement in trust and confidence over a criminal justice setting.
Victims who enter these secondary prevention points can generally be classified along one of three primary categories:
Non-Offending Victim – A victim who was in the wrong place at the wrong time and was unwittingly harmed during an altercation between other parties. The victim and their friends or family will be susceptible to the significant mental effects of trauma, requiring some sustained treatment and support to prevent the onset of other physical or mental defects.
Offending and Unrepentant Victim – A victim who was an active participant in the violent event. This person may have been the offender or defender but was not necessarily an innocent bystander. If unrepentant, the victim intends to continue engaging in activities that lead to violence and may seek some form of retribution for the current circumstance. A prevailing thesis is that this is the majority of offending victims.
Offending and Repentant Victim – This victim may have been an active participant in the event, but they have an expressed desire to make some shift in their life consistent with recovery and treatment. There is wide conjecture about how prevalent this victim is.
Through all secondary prevention points, there are moments were a complicit victim or perpetrator may experience a moment of moral clarity about the behaviors they are engaging in with some attendant desire for remediation. These moments are fleeting and absolutely require some intersection with a system that is adequately structured to meet their needs at those precious moments.
Through all secondary prevention points, both non-offending and offending, repentant victims should be met with a well-functioning trauma informed treatment structure. Further, offending, non-repentant victims should be made aware of the existence of and access points to such systems so that if and when a moment of clarity arises, they are able to engage a system that can support a fundamental transition.
Trauma Informed Medical Home Model We are proposing the creation of a Chicago-specific trauma informed medical home model. We believe this model can have the following features:
A no wrong door approach that provides a pathway for victims to the medical home structure from any place in the secondary prevention system regardless of their complicity in the violent event.
A means of engaging victims in clinical settings to de-escalate, educate, and potentially support a transition to a medical home.
A highly secured, private, trauma-informed registry that logs violent events and the recovery-based actions undertaken by a patient.
A community-referral system that links to the registry and supports the victim in accessing social, mental, or physical health resources. The referral system essentially comprises a network of services specific to the victim’s needs.
A centrally managed peer-recovery coach who functions at the community level and engages the victim regularly through their recovery journey.
Fully integrated and coordinated network of biopsychosocial supports that can be managed through a trauma informed registry, community referral platform, and supported by a peer-recovery coach who similarly functions as a recovery/care coordinator.
Central physical space that houses key staff, technology, and community supports.
Central entity that assumes a payment for organizing and executing the trauma informed medical home model.
We believe that this model can serve as a point of integration and coordination in support of trauma victims who are navigating recovery or fundamental life changes. This would include a physical space that would house recovery coaches, staff, and technology. The physical space would also include common areas for recovering victims and may also include specialized social supports that can directly engage the patient in the setting.
The central medical home would seek payment from managed care companies that acknowledge the long-term impact to a victim’s recovery, health, ongoing stability, and increased likelihood of avoiding another event that might catalyze deeper expenses and outlays.
Proposal We propose the establishment of a facility, a community engagement team, the development of a trauma-informed registry, the integration of a community health platform, the creation of a biopsychosocial network, and the direct integration of other organizations that can address the key capabilities required to support secondary prevention efforts.
To be successful, the following elements will be required:
Level I trauma centers facilitating connectivity with violence interrupters.
Other secondary prevention platforms capable of supporting a transition to the medical home.
Partnering managed care organizations willing to remunerate the medical home with a fixed payment for providing the core programs for a patient.
Identification of an organization that can create a trauma informed registry system.
Identification of an organization that can support an integrated community-referral platform.
Forward Health Group
McDermott Will & Emery LLP
Michael Reese Trust