How hospitals need to help fight gun violence: 3 experts weigh in on Chicago's pressing public health problem

Two Chicago-based trauma physicians and a violence preventionist discuss gun violence as a public health issue and how hospitals fit into the picture.

Since 1985, only six cities have held the undesirable honor of "murder capital" of the U.S. for the highest number of homicides per 100,000 residents. Those cities are New Orleans, Washington, D.C., Detroit, Flint, Mich., Richmond, Va., and Birmingham, Ala., according to a Pew Research analysis of the FBI's Uniform Crime Reporting Statistics.

Not on that list once is Chicago, where 2,987 people were shot in 2015 and where most residents, at least in some parts of the city, would agree — the staccato of gunshots is all too frequent.

This year, between Jan. 1 and Jan. 31 alone, 289 people were victims of a shooting. That's more than nine people every day. It's also nearly double the number of shootings compared to January last year, according to The Chicago Tribune, which tracks all shootings — not just homicides — and updates the count several times per week.

Chicago may not be murder capital of the U.S., but it undeniably has a gun problem. This is important because each shooting, fatal or nonfatal, has a profound ripple effect on the physical and mental health of the communities where it occurs. It also adds significant strain on health systems within those communities. The average emergency room visit for an individual gunshot victim cost hospitals $1,126 in 2010, according to data from the Urban Institute. The average inpatient stay for a gun shot victim was $23,497 in 2010.

As the number of shootings grows, the cost to Chicago's residents and hospitals grows too. But the WindyCity is not alone. Based on the "murder capital" rankings, Chicago comes in 21st among sizeable U.S. cities. Clearly, cities and towns across the nation face gun violence as a mounting public health issue, and law enforcement and government regulation alone have not proven a solution.

So, the question is what can and should healthcare professionals across the country be doing about it? We asked those on the forefront of Chicago's trauma response:

  • Faran Bokhari, MD, chairman of the Cook County Trauma & Burn Unit at John H. Stroger Jr., Hospital, one of the first comprehensive trauma units in the U.S., and now one of the country's largest,
  • Catherine Humikowski, MD, medical director of the University of Chicago Medicine's pediatric intensive care unit, who recently penned an article in The Chicago Tribune about what it's like to care for children who have been victims of gun violence, and
  • Shannon Cosgrove, MHA, director of health policy for Cure Violence, an organization that applies disease prevention models to violence, and was started at University of Illinois at Chicago by Gary Slutkin, MD, under the name CeaseFire.

Editor's note: Responses have been edited lightly for length and clarity.

Question: Do you think gun violence is viewed through a health lens in Chicago, or is it viewed as more of a law enforcement issue?

faran bokhariDr. Faran Bokhari: It depends on who we are talking to and who is viewing it. Public health officials will look at it through a public health lens and law enforcement will look at it as a law enforcement issue. I think the answer is somewhere in the middle.

catherinehumikowski2Dr. Catherine Humikowski: In Chicago, it is viewed largely has a law enforcement issue. I suspect a lot of places think of it in this way. But here, in particular, gun violence is largely linked to criminality, and that's not true all over.

For example, suicide is a big piece of gun deaths in the U.S. However, in our population, certainly where I work on the South Side, it really is linked mentally to gang activity and criminal behavior. A lot of people say, "This is a law enforcement issue. This is related to community-police relations. We need tougher sentences for gun criminals."

All of that is very well true, but my perspective is that it's one piece of a bigger issue. While we do tend to view it through the law enforcement and criminality lens in Chicago, we have to shift that debate to be more encompassing. This public health angle is another part, but it's not going to capture the entirety of the problem. It's not isolated to the "bad guys" on the South Side. It really is everybody's problem.

Ms. Shannon Cosgrove: Chicago was the first city to implement the health approach as Cure Violence knows it and sees it. That was in 2000. In that aspect, Chicago was very much ahead of the curve.

shannoncosgroveQuite a few efforts are underway in Chicago that look at violence as a health issue, but it hasn't elevated to a place where healthcare professionals are seen as leaders in response to the epidemic. We really feel the health sector is underutilized and has a lot to bring to the table.

When you think about the Ebola response, if there was even a threat of a case coming into the U.S., everyone was ready and had their policy programs and protocols in place to respond accordingly. Similarly, we want the same response for violence.


Q: There's no medical cure for violence. What makes it a public health issue?

Dr. Humikowski: The modern era of medicine really isn't about cure; it's about predictive analytics and prevention. There is no medical cure for violence, but violence is a pervasive problem in our culture that leads to disease states. In that sense, we have to understand what factors contribute to it and limit those factors so fewer people are injured by violence in the population of patients we care for.

Gun injuries and gun-related deaths are instantaneous. You go from being a healthy kid — my perspective on this is as a pediatric intensivist — to a neurologically devastated person in a vegetative state. There is no transition state. You are either protected or you are really, really badly hurt. To me, it makes this a crisis beyond typical health proportions.

Dr. Bokhari: It is important to put this in perspective. Look at how much violence you see in the U.S. It's not just Chicago; it's not just major cities; it's also small cities. It's everywhere.

There are 10,000 deaths in the U.S. from homicide gun violence annually, but on top of that, there are 20,000 suicides per year, which is a lot for an industrialized nation. Our death rates from gun violence are 10-fold compared to countries similar to us. So something is not right here.

Gun violence has become a public health issue because it affects more than the people who are dying. For each person killed, there are 10 times as many people disabled by it, and somebody has to bear the cost for that. Somebody has to bear the cost for dying people as well.

Ms. Cosgrove: When we think about public health issues as a whole, we often think of disease — diabetes or cancer — as a leading cause of death. Violence is too. We have 60,000 violence-related deaths per year. Violence is the leading cause of death among African American males. It has huge implications for the public health system as a whole and for an entire community. People exposed to violence regularly are 30 times more likely to be involved in violence in their lifetimes.

The more we see, the more it does to our mental health and our physical health. Stress related to violence causes our blood pressure, heart and even cancer risks to increase. We really believe if we don't stop this epidemic, it will be difficult to establish health in our nation.

Q: What preventive measures can be taken? How do you successfully pinpoint and reach those most likely to pull the trigger?

Dr. Bokhari: Before you take any preventive measures, you need to know where gun violence is occurring, who is doing it and why. You need to make sure you are not biased through your own lens. So if you are a public health official, you don't want to define everything else through the public health lens of where, who and why, and the same thing for the police officers. You have to be balanced, yet come to a solution kind of fast.

Dr. Humikowski: No. 1 is don't keep guns at home with children — and I know that's an extreme view and a lot of people won't hear that. At the end of the day, guns are deadly weapons and really should not be around children. There are actually data to show preventive educational strategies directed at kids don't work. In real time, when kids are faced with a violent weapon, all the things they have learned in simulations and classes don't apply. Kids are impulsive by nature.

It's responsible and imperative pediatricians speak to families about gun safety, because it really is like any other safety issue. Any responsible pediatrician would talk to family members about how to keep their kid safely strapped into a car, bathtub safety, pool safety, how to store household cleaners. The sad reality in our country is that guns are no different.

No. 2 is if you have a gun at home with a child, it should be stored and locked separately from the ammunition. Even if you find your patient doesn't have a gun in their home, they may send their children to a home that does have a gun. Pediatricians can still counsel parents who are not gun owners about how to keep their children safe in homes that may have guns.

No. 3, and I think this is really where physicians can get involved, is lobbying for common sense, safe gun manufacturing. That's trigger safety. Not an easy lock a kid can undo, but fingerprint identification. That's something pediatricians and physicians can lobby for in the name of safety for children.

Ms. Cosgrove: One of the key pieces is really having trusted community members involved with violence prevention. When Dr. Slutkin worked with the World Health Organization in Africa, he lived there for 10 years and worked with six other physicians to help control the spread of cholera, tuberculosis and HIV. They trained individuals to deliver messages through the community about food handling, sanitation, etc. From there, he was able to get ahead of the trend of these incredibly contagious diseases.

When he came back to the U.S., he saw violence clustering and transmission very similar to the infectious diseases he was working with in Africa. And, what he learned in Africa about treating diseases was true here in the U.S. for violence.

Having someone intervene who has respect, is trusted and understands what those individuals are going through is critical. Our interrupters and our outreach providers are the key to stopping the spread of violence. They are significantly trained in conflict mediation and de-escalation strategies, so they know the full needs of individuals at highest risk.

[Editor's note: Interrupters are carefully selected individuals who were formerly engaged in violent behavior. They are still credible members within potentially violent communities and are trained to help mitigate gang violence before it occurs.]

Q: What is not working in Chicago?

Dr. Humikowski: Frankly, there are just too many guns in the city of Chicago. The statistics about how many are recovered from the streets of our city is mind-boggling. In all cities — big and small across America — people have guns, but there are more guns in this city, particularly unregulated gun sales coming across the border from northwest Indiana.

We are not the only city with gangs. We are not the only city with poverty. We're not the only city with racial tension, but we happen to have a lot more guns on our streets than other cities and part of it is how guns get trafficked here. I'm certainly not saying I have all the specific statistics on this, but when I talk to families in my ICU, everybody has a gun.

Ms. Cosgrove: I worked closely with law enforcement for multiple years and they say, "We cannot arrest our way out of this." There are significant mental health issues and health issues in the fold that healthcare professionals are capable of responding to, and we need them to step into that space. Chicago, like many other communities, can really benefit from implementing a full health system approach to violence.

In communities with CeaseFire programs, we were able to reduce retaliation-related shootings by 100 percent. Overall reductions in homicides and shootings were anywhere from 40 to 70 percent in those communities. Illinois, like many other places across country, is looking for ways to reduce its budget, but the amount of money a gunshot victim costs is substantial. We're talking anywhere from upwards of $250,000 just to stay in the hospital for four or five days, and then you have transportation costs, which if a person has to go via helicopter is likely $20,000. The amount of money each conflict mediation saves is substantial and, we believe, worthy of investment.

Dr. Bokhari: We've had some high-profile things happen with the community police being brought to the forefront. They have to be more intimate within communities, yet carry out their charge of enforcement. That's one part of the dialogue.

There's also the question of how some of the population became disenfranchised. If people won't call law enforcement because they don't trust them, there's a big problem there. You see this across the board actually, where law enforcement is really weak or not trusted. In our country, the disenfranchised people have to be brought to the forefront.

Q: How does gun violence impact hospitals, particularly in terms of finances, staff and reputation?

Dr. Humikowski: In general, it depends on whose lens you are looking through. Imagine you are a well-insured average American with a problem and you want the very best medical center. If all other things are equal, you have a choice, and one hospital is in the hub of a neighborhood known to be afflicted by gun violence and one isn't, you are not going to pick the hospital that is. That's just common sense.

From my perspective on South Side, I certainly get the sense that impacts us compared to some of our otherwise equivalent peers. We at the University of Chicago have a great tradition of research, investigation and scholarship, and we are fortunate we continue to attract a lot of folks who want to get that care. But at the end of the day, it's a different thing to drive to South Side of Chicago than the Gold Coast.

The other side of that is trauma care is very expensive. It is notoriously one of the most expensive, if not the most expensive, branch for a hospital to run. It's talented, multidisciplinary professionals, systems-based care, and you have to do very high-acuity things very quickly and effectively. That's what all hospitals strive to do. It's the top of the line. If you can do trauma care well, you can do anything well. From that perspective, as a physician of the University of Chicago, I'm excited we will be able to offer that service for our community, because as I said, it represents the best of the best.

[Editor's note: The University of Chicago plans to open a Level I trauma center on its Hyde Park campus in early 2018, in addition to expanding emergency room services and inpatient beds. South Side residents have pressed for better access to trauma care since UChicago closed its adult trauma center in 1988 for financial reasons. Protests reignited in 2010 after a young man died from a shooting three blocks from the University of Chicago Medical Center.]

Ms. Cosgrove: Violence overall is estimated to cost about $450 billion dollars per year. Gunshot victims could even be in excess of even $1 million for some of the most critical patients. You also need to think beyond the visible wounds to the trauma that exists within that person and the community.

This manifests in hospitals in multiple ways. Gunshot victims are disproportionately poor, underserved and underinsured. They are often single men who aren't eligible under the old form of Medicaid. Men, in general, are less likely to sign up even if they are qualified under the Affordable Care Act. Hospitals will likely be unable to bill for the cost of treating gunshot victims, so they have to take on those costs.

For staff, it's incredibly stressful. You can imagine having someone's life in your hands on a regular basis and having to see the impact of gun violence on your community. There's also the surrounding issues. You have police who are trying to investigate the case, upset family and friends who may want to retaliate, assailants who might be coming in to try to finish the job, which unfortunately has happened and is a significant stress to the hospital and staff. We call it vicarious trauma. They may not have the gunshot wound themselves, but the trauma for the staff serving these individuals is significant.

Dr. Bokhari: It depends on what population you are getting. In general, you might get people that are insured or uninsured, so it is hard for me to say how it impacts finances. Most hospitals are a charity, and you are not supposed to be making a lot of money.

It can be a drain on finances if somebody comes in who was trying to commit suicide, which is statistically more likely than a homicide. It uses resources and it is completely unnecessary. We have not been able to prevent that unnecessary spend.

As far as staff goes, it is very psychologically taxing because it's so sudden. It's not like cancer where it is expected. It's emotionally taxing for the staff.

Q: What is a hospital or health system's responsibility in addressing gun violence? What about individual physicians?

Ms. Cosgrove: We've studied the benefits of hospital-based violence intervention programs and seen significant cost reduction and life-saving measures. Upon presentation of a gunshot victim in hospital, within five years there is a 45 percent chance of reinjury.

When we think about this contagious process, we need to get to heal that infected point so that person doesn't become a perpetrator later on. When someone comes in, if they are talking about retaliating, or even if family members or friends are talking about retaliating, the hospital system has the ability to treat those individuals. There are communities doing it in Chicago and many other cities. We really recommend having a social worker or crisis response team available to respond to these victims. Ideally this is a person with personal experience, credibility and knowledge, who is able to establish trust.

Dr. Bokhari: Forhealth systems, gun violence usually comes through the ER or trauma systems. Some systems have a responsibility for prevention at a regional and local level, and we do a lot of that. We have teams of social workers and programs — for example, we are part of CeaseFire.

[Editor's Note: In addition to John H. Stroger, Jr. Hospital of Cook County, other Chicago hospitals with Cure Violence/CeaseFire programs include Advocate Christ Medical Center, Northwestern Memorial Hospital and Mount Sinai Hospital. Current neighborhood sites of the programs include Little Village, South Shore, Roseland and Woodlawn.]

We've got a team funded by grants and supported by people's personal efforts to intervene with victims of gun violence and their families. When they come in with a gunshot wound, they might be amenable to changing their lifestyle or environment, if they were actively involved in violence. That team is led by prevention chief Kimberly Joseph, MD, who is also a trauma doctor, and Rev. Carol Reese, who leads implementation of those programs and is also a prevention counselor.

They deal with what happens to a patient's psyche. Maybe they become anxious and develop behaviors that make them more amenable to being shot again or committing violence, or they are edgy and [inaccurately] interpret innocent movements of people in their environment and might shoot them. So that self-awareness is what we hope to instill in these patients through these teams. We also do a lot of PTSD work.

But this debate has to be elevated beyond a local level to more regional and national level. Everybody has an opinion on this, but there are certain people who are actually responsible for solving this issue. We have to look at their performance and see if have they solved the problem or not. Remember that during election season.

Dr. Humikowski: It's really challenging when you apply top-quality medical care to victims of gun violence and then send them back into the community where they got hurt. It doesn't feel like you've done anything for them. We as physicians, as health systems, have to have a voice on the state and national scale when it comes to impacting these problems.

As a physician, to imagine that you could have an impact on a problem this big with your individual patient is short-sighted. We need to think bigger and more globally. How do we get guns off the streets? How do we keep them out of the hands of criminals? How do we as physicians, lobby for that on a national level to recognize that this really is a public health problem? If we start to frame the conversation around what this costs in terms of health and dollars, rather than the way the conversations have been framed so far — which is, "Look at how bad this is, look at the drama, look at the lives lost," — let's look at the numbers. If we look at the numbers in terms of victims, it's staggering.

If we look at the numbers in terms of cost to society, both in terms of life-years lost and dollars, which is how we look at other healthcare problems, those numbers might help people in the hospital administration community start to realize this really is everybody's problem. I would encourage anybody to understand their state and national legislation that impacts this problem in their personal community, write to their representatives and fight for things that make sense, like resuming dedicated funding for research into the problem.

Editor's Note: This article was updated Feb. 24, at 11:45 a.m. CT to reflect that Ms. Cosgrove and Cure Violence are affiliated with the University of Illinois at Chicago, her current title is director of health policy and she has a Master of Healthcare Administration. We apologize for this error. 

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