The United States is in the midst of not one but two pandemics: COVID-19 and gun violence. Our nation has seen the largest per-capita increase in homicides in modern history since the start of the COVID-19 pandemic. (Federal Bureau of Investigation; https://bit.ly/3EE0jbM.) That translates to 21,570 people who fell victim to homicide in 2020, a 30 percent increase over the previous year. We are collectively conditioned to assume Congress will sit back idly, but that assumption could prove false this time.
Congress may be on the brink of making the largest investment in violence prevention in our nation’s history. President Biden’s $1.7 trillion jobs and social safety net bill—called the Build Back Better Act—includes a $5 billion investment in community violence prevention and intervention, which would be distributed equally through the Centers for Disease Control and Prevention and the Department of Justice. This new funding, if passed by Congress, would allow dozens of cities with the highest levels of violence to deploy evidence-based strategies to break the cycle of violence.
The ability to disburse funds broadly across the United States is critical. Most people think of big cities as driving the bulk of violence, but the distribution of violence in this country is much more nuanced, and no region is spared. (CBS News. April 19, 2021; https://cbsn.ws/3ow0X5D.) It’s no surprise to see Baltimore near the top of a list of the 20 cities in America with the highest homicide rates, but that list also includes such diverse cities as San Bernardino, CA; Birmingham, AL; and Dayton, OH. Clearly, a national solution is warranted.
What would such a solution look like? It would maintain a laser-like focus on preventing violence among those at greatest risk of becoming victims or perpetrators. We know that violence tends to cluster not just in particular cities but in certain neighborhoods. Just one percent of individuals living in those high-risk areas are at the greatest risk for engaging in serious violence at any given time, and public health approaches can be deployed by identifying those individuals.
The public health approach is found in many violence intervention models. A few key examples identified in President Biden’s plan are hospital-based violence intervention programs, targeted trauma-informed care using cognitive-behavioral therapy, and street outreach and violence interruption. (Biden-Harris Community Violence Intervention Fact Sheet. April 7, 2021; https://bit.ly/3oAtl6T.)
Research has demonstrated that not only are these interventions effective (John Jay Research and Evaluation Center. Nov.9, 2021; https://bit.ly/3IwldMx), but their community-driven, health-oriented approach allows them to avoid the traditional partisan gridlock that surrounds Second Amendment issues.
EPs’ Critical Role
These models have differences, but they share core elements. They focus on the highest risk individuals and deploy crisis intervention when violence is imminently possible; they provide intensive, long-term community-based care that addresses physical and psychological wounds; they incorporate comprehensive case management by culturally-competent workers who provide links to community-based services, mentoring, and medical care; and they work upstream to address the social determinants of health.
This proposed investment may be news to many, but emergency physicians have played a critical role in developing and advancing many of these solutions. One example is the Health Alliance for Violence Intervention (HAVI), the national organization representing hospital-based violence intervention programs. Four of HAVI’s seven founding member programs were led by emergency physicians when it launched in 2009. The model has spread nationwide since then, and it now has 50 members and another 40 new and developing programs. (The Health Alliance for Violence Intervention. www.thehavi.org.)
Our specialty societies have also supported these approaches. The American College of Emergency Physicians Council adopted a resolution in 2013 about establishing hospital-based violence intervention programs and more recently supported the Bipartisan Solution to Cyclical Violence Act of 2021 introduced by Reps. Dutch Ruppersberger (D-MD), and Adam Kinzinger (R-IL). (https://bit.ly/3oBZLOm.) It is much smaller in scale than the investment included in the Build Back Better Act, but this legislation is supported by organizations as diverse as the National District Attorneys Association, the Fraternal Order of Police, the National Association for the Advancement of Colored People, and a variety of health organizations.
The $5 billion investment has passed the House of Representatives and awaits a vote by the U.S. Senate, as of this writing in December. Its final passage is not certain, but the proposal represents the power of public health in violence prevention. Physicians, public health professionals, and communities have built up these programs, researched their effectiveness, and advocated for them as solutions to violence for many years. Now, it’s up to Congress to take this historic opportunity to save lives by funding them.
Dr. Fischeris a clinical assistant professor at the University of Maryland School of Medicine, where he is the fellowship director in the Health Policy and Leadership Fellowship program. He also serves as the policy director for the Health Alliance for Violence Intervention.