Health officials are trying to curtail violence by treating trauma, but the people who need help most are not seeking it

David Ross walks the halls of the University of Maryland's Shock Trauma Center dressed in scrubs. He waits for victims of stabbings, shootings, and assaults to recover from their injuries—and then makes his move.

As those patients are stabilized and begin to feel better, Ross approaches. He begins somewhat informally, speaking to them like a friend, a guy the victim might bump into on the street.

"When they are the most vulnerable, it's the best time to get them into service," said Ross, a Baltimore native and specialist with Shock Trauma's Violence Intervention Program.

More than a dozen times each week, hundreds of times a year, Ross approaches victims of violence who stream through Shock Trauma. The scrubs are perfect cover.

"At one point I would go into the room in professional clothes and they would ask, 'Are you a cop?'" Ross said, explaining that many of the victims have had previous brushes with the law.

For the people who come through Shock Trauma, Ross offers a friendly ear and help untangling portions of their complicated lives. If they ask for it, or give permission, he makes calls to patients' probation officers. He calls their parents. In the frenzied rush to find entry wounds on gunshot victims, emergency room staffers often cut off their clothes and Ross offers them clothes to wear home.

Just before each patient is discharged, he approaches them one more time. He tries to close the deal. He attempts to convince someone who has been shot, stabbed, or assaulted—specifically those who fit a profile of victims who are most likely to retaliate or land back in the emergency room—to spend some time with Shock Trauma's Violence Intervention Program. For nearly two decades, the program has sought to reduce violence by treating the trauma that many of the victims of violence have been suffering from since childhood.

As a violence intervention specialist, Ross tries to convince them to spend the next few months revisiting some of the most painful episodes of their lives, incidents which have led to problems with managing anger, drug abuse, and frequent run-ins with the law. In many cases, these things are a contributing factor in the incident that landed the victim in the emergency room in the first place. Treat the trauma and most likely the victim won't return to the emergency room; fail to do so and it's likely they will be back with another injury, or worse, they will be killed, Ross explained.

More times than not, Ross fails. And for those who return to ER, holding on to them is difficult.

"If they haven't begun to take the necessary steps to change their lives, it's hard to change their environment," he said. "They will eventually come back at one point or another and sometimes it's fatal."

Homicides dominate the headlines in Baltimore. The city's 344 murders in 2015 marked the highest tally since 1993, when the city had roughly 100,000 more residents. Law enforcement, criminal justice experts, and policymakers spent much of last year floating theories about the spike. The "Ferguson Effect," the theory that cops under intense scrutiny couldn't effectively police anymore, was the first thing attributed to the spike. During a CompStat meeting in June 2015, former police Commissioner Anthony Batts said looting during the uprising left the drug market awash in excess prescription opioids. As a result, the market was disrupted, fueling violence among drug dealers. It's unclear to what degree these factors impacted the rash of homicides, but those closest to the victims blamed the same constellation they say has always fueled violence in Baltimore: drug addiction, poverty, unemployment, and repeated exposure to violence and trauma.

"It's a cocktail of adversities that eventually boil over," Ross said.

For decades the answer to the violence was to flood the affected areas with cops and arrest and incarcerate. Decades of violent crime led Baltimore to adopt the zero tolerance policing policies that were lauded for reducing crime in New York. By 2005, Baltimore was arresting around 100,000 people, or one-sixth of the city's population each year. A federal lawsuit filed by the NAACP and the ACLU in 2006 put a stop to the pattern of mass arrest—and the attendant disproportionately non-white confinement—as a crime strategy. But questions have lingered about whether the strategy, which buttressed former Mayor Martin O'Malley's political career, worked as effectively as proponents claimed.

Baltimore's homicide rate declined, but the rate also dropped nationwide. And nearly 700 people who had been stabbed or shot here were streaming through Shock Trauma each year, according to officials in the unit.

Decades of treating violence as a criminal justice matter are slowly being replaced by a new paradigm focused on treatment. Like the opioid addiction crisis, health care officials insist that stemming violent crime in Baltimore can't be accomplished by mass incarceration. The strategy being pursued in Baltimore now is shifting and broadening to treat the trauma that often drives the violence.

"The victims of violence are suffering trauma," said Leana Wen, Baltimore City Public Health Commissioner. "We know the perpetrators of violence are experiencing trauma."

The plan to reduce violence is to target the city's younger population. Residents under the age of 25 account for 51 percent of Baltimore arrests for violent crimes and 49 percent of the weapons-related arrests in 2015, according to the city's 2015 Youth Wellness working group report.

These are the youth who Ross said "have pretty much thrown their lives away."

And they land in Shock Trauma. As homicides rose in 2015, so did the number of youth coming to the unit stabbed or injured by gunshots, which rose 5 percent last year.

Wen, who took her post as the city's public health commissioner in January 2015, hopes to halt the rising tide.

Her public health strategy is a product of the social media and information ages. Now 33, Wen was in high school when zero tolerance policing was being credited for the steady two-decade nationwide reduction of violent crime. The millennial-aged doctor (she is a regular on the podcast circuit, has given a TED Talk, and holds bi-monthly health town halls) has seen the limitations of punishment as a crime deterrent. And she has insisted the city can't arrest its way out of its public health crises.

In December, Wen testified before the U.S. Senate, garnering bipartisan support for treating opioid addiction as a public health crisis instead of just a matter to be dealt with by courts and cops.

But it's the timing of her appointment that is perhaps most responsible for shaping her view on public health in Baltimore. She took the reins of the city's health department in the year when Freddie Gray's death ignited an uprising and when homicides here spiked so high.

"The unrest highlighted undiagnosed untreated trauma that had been brewing for decades," Wen said.

Since her appointment, Wen has doubled down on her strategy to treat trauma to reduce violence. The city's 2015 Youth and Wellness report placed a heavy emphasis on reducing violence among the city's youth, specifically young people of color.

Wen is a staunch supporter of Operation Safe Streets and B'More for Healthy Babies. Both programs were launched before her appointment and both seek to intervene early in the lives of the city's children—before compounded trauma leads to street violence.

Wen's efforts to "interrupt violence further upstream" dovetail with the nearly 20 years of trauma treatment that has been at the core of Shock Trauma's Violence Prevention Program.

Like many urban emergency rooms, the staff at Shock Trauma operates mechanically: assess the damage, diagnose the problem, patch the wound, and send the patient back into the world.

"[As medical professionals] we don't think about the nitty-gritty," said Ruth Adeola, violence and injury prevention coordinator for the Shock Trauma unit. "We don't think about, When the patient is discharged, are they going to a stable environment?"

But that began to change in the late 1990s.

Dr. Carnell Cooper, who worked in Shock Trauma in the 1990s, noticed this turnstile-like operation. In 1998, Cooper launched the Violence Intervention Program. He began assembling demographic data to create a profile of those most likely to be repeat victims of violence. He published those results in 2000.

According to his research, the typical victim is a young, black male, unemployed or earning near-poverty wages. He has a history of either drug use, drug selling, or both, is on probation or parole, and has a tendency to use violence to deal with conflict.

"For a young guy, it's rite of passage into manhood to be able to pull a trigger and not feel anything, and fighting over the gun with guys in your crew to see who can kill that guy," Ross said.

In close to 20 years of operation, the Violence Intervention Program has a mixed track record. Those who stay in the program are 70 percent less likely to engage in or be a victim of violence. But getting them to stay is difficult. Fewer than one in 10 of the victims who would benefit from treatment seek help in the Violence Intervention Program.

"Coming back in and seeking help is the exception," said Erin Walton, a clinical supervisor with the program.

And of those who initially seek help, fewer than one in four patients will stay engaged in the program long enough to effectively treat their trauma.

"Being young and feeling invisible [creates challenges], and some of them are just not finished with the streets," said Ross. "You got a stranger coming in your room and telling you to change everything you know, including who you love."

On the surface, the arrival of a gunshot victim at Shock Trauma looks a lot like it does in the rest of the country. The staff would have been alerted through a phone system that gives them up-to-the-minute information on the victim's condition from the field.

If the patient isn't critical, the Violence Intervention team is also alerted. Once the patient is stabilized and conscious, they meet with the patient for an assessment, collecting housing information, medical and mental health history, and details on whether they are using or have used illegal drugs. If this isn't the person's first brush with violence, Shock Trauma would have collected data on the person in the past.

The staff begins to work up a recovery plan to address the patient's needs. Addiction counseling, peer support, social and emotional support counseling, housing assistance, health care, and connecting patients with job training can all be part of the mix.

Despite being armed with reams of patient data and analytics, the backbone of the Violence Intervention Program is Ross. He's one of two caseworkers, meeting with as many as 40 patients each week, and carrying a caseload of 20 or more patients at a time. Ross is constantly on the phone tracking down his current cases and trying to convince freshly released victims of violence to accept treatment.

The program hinges on how well Ross connects with patients. Ross' own story, growing up in East Baltimore surrounded by violence, occasionally gives him credibility.

"I just start talking with them, not just about the injury, but about life," he said. "I am the only male in my family who hasn't had trouble in the law or been injured by violence. I had three cousins come in to Shock Trauma and had to go to their bedside."

The Violence Intervention Program's most critical mission is treating trauma, admittedly a complicated task. Trauma can be tossed into two basic buckets. There is the single traumatic experience like being the victim of or a witness to violence. A single traumatic event can lead to post-traumatic stress disorder, which if untreated can lead to severe anxiety, substance abuse, severe depression, and trouble with anger management. A Johns Hopkins Bloomberg School of Public Health study from 2014 showed Baltimore teens suffered from PTSD at rates comparable to cities in Nigeria, India, and South Africa. The study also showed that Baltimore teens had a poorer perception of their community than teens in New Delhi.

The Violence Intervention Program screens for PTSD, but the test itself doesn't suffice in Baltimore and among the population the program is designed to serve. Too many of the victims of violence have been repeatedly exposed to trauma, much of which dates back to their early childhood.

The Adverse Childhood Experiences or ACE score measures the types and frequency of traumatic experiences in child. In the ACE rubric, exposure to poverty, physical abuse, repeated emotional abuse, living in a high crime or violent neighborhood, and having a parent who routinely used or abused drugs are considered traumatic experiences. The score ranges from zero to 10. Patients who score a four or higher are considered having lived a traumatic childhood.

But even ACE can obscure how much trauma a patient is suffering. How do you measure the impact of poverty when it's so rampant? Thirty percent of the city's children live in poverty, and according to the Brookings Institute, Baltimore is among the most unequal places in terms of income inequality.

Drug and alcohol use and poverty can be so pervasive in swaths of Baltimore that a patient might not report that their parent abused drugs or that they were frequently exposed to violence because both conditions have become normalized.

"Interestingly enough I would hypothesize the [ACE] scores would be worse, but because violence is so normal the patients don't see their environment as any less safe," said Walton, the clinical supervisor. "So many people have the same experience so they don't perceive it as abnormal."

Cynicism can set in after more than a decade working in an emergency room and watching patients repeatedly cycle through as victims of violence. Though the rate of homicides thus far in 2016 is well below the rapid clip of the previous year, Baltimore remains on pace for one of the bloodiest years in the last 10.

In its position on the front line of this violence, the Violence Intervention Program operates with a relatively spartan budget, roughly $400,000 per year, most of the money coming through philanthropy, the University of Maryland Medical Center, and grants.

Scaling up would be possible through more funding, but Walton isn't sure doing so would make a bigger dent in reducing violence in the city.

"The volume is there and the capacity will never meet the level of street violence in Baltimore," Walton said.

And the city's own financial support for using intervention strategies and treating trauma to reduce violence—$2.9 million has been allocated to youth violence prevention in the coming fiscal year—is still dwarfed by what the Baltimore Police Department spends on targeted suppression of violence, which is north of $40 million.

The move toward extending the city's trauma-informed care model is slow and incremental. It's training cops, first responders, and social workers in trauma-informed care in hopes that interactions with people in crises will have less of a compounding effect.

In April, Baltimore announced a partnership with hospitals across the city to place violence interrupters from its Safe Streets Program in emergency rooms. The program is modeled on the CeaseFire initiative in Chicago, which uses violence interrupters, often former gang members, to intervene when hostilities flare or someone is shot and is likely to retaliate. Baltimore's version launched in 2007 and has been a presence in five neighborhoods with some reduction in violence in the areas where the program is active.

The partnership is aligned with the OneBaltimore strategy announced by Mayor Stephanie Rawlings-Blake in 2015. OneBaltimore is a broad public-private partnership to revitalize the city and improve the health and well-being of its citizens.

The fixes being pushed by Shock Trauma and by the city won't likely bear fruit for some time. Wen is asking for patience in the interim.

"The trajectory of public health is long," she said.

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