In an emergency, get the playbook off the shelf … and use it

In Hartford and New Haven hospital-based violence intervention programs (HVIPs), physicians and frontline intervenors treat violence proactively – as a public health emergency.

Until February, shootings had been our communities’ most dire public health emergency. Since then, COVID-19 has taken hold. The grave lesson now reinforced 125,000-plus times is this: What is known about prevention cannot be ignored.

If we look the other way when facts forewarn – and we know how to forestall – a public health emergency, lives are saved or lost by action … or inaction. As uncertain as the future is under COVID-19, it signals how vital it is to intervene with urgency when a life-or-death situation is at hand.

At the very same time the pandemic was exacting a vise grip on our nation, a new, multidisciplinary Connecticut alliance had formed in early 2020 to systematically confront the public health crisis more common all across our country: the epidemic of gun, knife, and blunt force violence.

Pre-covid, our CT HVIP (Hospital-Based Violence Intervention Program) Collaborative had just convened stakeholders statewide, examining data on how coordinated efforts abate gun violence fatalities.  Focusing on the young men of color disproportionately among the victims, we were scrutinizing how HVIP efforts work to prevent both the first incidents of violence and the all-too-frequent subsequent acts of vengeful retaliation.

Since January, these Collaborative partners with sometimes competing interests have joined forces to prevent gun violence through hospital- and community-linked action:

• The 16-year-old Trinity-Saint Francis and Hartford Communities That Care (HCTC) connection (which in 2018 became the first Connecticut HVIP to join the premier national training and technical assistance network coordinated by the Health Alliance for Violence Intervention [The HAVI]);

• The Yale-New Haven Hospital partnership with the front-line CT Violence Intervention Program (also committed to the HVIP model and receiving support from The HAVI);

• An emerging HVIP, focused on research and evaluation, launched by Hartford Hospital in conjunction with the CT Children’s Medical Center; and

• A widening network of HVIP colleagues among key congressional and state legislative leaders, the Connecticut Hospital Association, and state agency officials, plus issues advocates ranging from CT Against Gun Violence to key professional and philanthropic organizations, all committed to address particular systemic inequalities and barriers related to public health.

Deliberating at first in person as a full collaborative, and more recently in policy, research and evaluation, and training and technical assistance work groups via teleconference, we have studied the most promising federal and state laws, governors’ executive orders, and community-based partnerships for preventing and reducing gun violence, advised by policy-analyst partners from The HAVI and the Giffords Law Center.

We have reviewed how the HVIP playbook, rather than gathering dust on a shelf, gets active use in the prevention and reduction of gun violence in many locales, including Hartford and New Haven.

From July 1, 2019 to May 28, 2020, for example, the Hartford Care Response Team of Trinity-Saint Francis and HCTC served 72 clients – including 28 survivors of homicides and 40 assault victims –- offering a total of 286 services to clients and connecting 62 families to services.

Similarly, the record of HVIP service from the Yale-New Haven Hospital-CT Violence Intervention Program partnership in New Haven shows approximately 250 cases of victims of violence from January through May of 2020 alone, of which more than 40 have been engaged by the Connecticut Violence Intervention Program and the YNH HVIP.  Almost all had been shot.

Under the HVIP care umbrella, the best case scenario on the street is prevention of harm to at-risk individuals.  But even in the worst cases, wraparound coverage works to reduce future harms by aligning physicians, follow-up wound care nurses conducting home visits, trauma therapists, and “bureaucracy navigators.”  Collectively, over lifetimes, they bring a significant return on society’s public health and public safety investments.

Follow-up case reports confirm that HVIP coordination connects victims to the housing, job, education, and health opportunities that permit them to change lanes from antisocial dead ends to pro-social avenues.  We see every day that victims and families accompanied through the stages of grief and recovery by trained prevention professionals can overcome significant mistrust barriers and festering PTSD, conditions that return nearly half of gunshot victims to the ER within five years.  Later, some 20 percent of those repeat victims die.

The alternative?  By understanding and coordinating efforts across all agencies engaged in Medicaid reimbursements and Victims of Crime Act (VOCA) services for families struck by violent crime, HVIP partners can break out prevention and intervention techniques before the outbreak of violence.

As we work to recover from COVID-19, can we profit from its reminder against the common human tendency to procrastinate until catastrophe strikes?  The good news, if we heed it, is that this pandemic could not more clearly demonstrate what is at stake in any emergency.  Think George Floyd, Ahmaud Arbery, Breonna Taylor, Rayshard Brooks.

In any crisis response, it is not enough to go through the motions or pretend theatrics will help.  Leaders must immediately communicate strategies without equivocation, so they can be popularly understood.  For the CT HVIP Collaborative, a driving lesson from COVID-19 is clear.  In a public health emergency, there is no time to lose.  Get the playbook off the shelf and use it.

Dr. James Dodington is a Yale Medicine emergency medicine doctor based in the Pediatric Emergency Department at Yale New Haven Children’s Hospital and at Greenwich Hospital’s Emergency Department and is an assistant professor of Pediatrics (Emergency Medicine) at Yale School of Medicine.  Leonard Jahad is Executive Director of CT Violence Intervention Program.  Andrew Woods, MSW, is Executive Director of Hartford Communities That Care.  Dr. C. Steven Wolf is the Chairman for the Department of Emergency Medicine at Saint Francis Hospital and Medical Center and Assistant Professor for the Department of Traumatology and Emergency Medicine at the University of Connecticut School of Medicine. 

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