By Margaret C. Albert

Published June 1997

• React to this article in the Discussion Forum.

PND: What prompted the report?

MH: The U.S. Attorney for the Western Region of Pennsylvania put together the Youth Crime Prevention Council to look at statistical knowledge. We thought that if we all had a document that stated the problem clearly and looked at different ways to attack the problem, we might have the benefit of all starting on the same page. It was prepared by the Jewish Healthcare Foundation, the United Way of Allegheny County and Blue Cross of Western Pennsylvania for the council.

PND: Why should physicians regard violence as a medical problem, rather than a social or law enforcement one?

MH: The report points to the problem of youth injury and violence as being epidemic in the same way as a polio or HIV epidemic is a public health menace. Physicians and medical institutions too often see the evidence of violence—kids being brought in with gunshot wounds—as sporadic and incidental. But never in a systematic way have they been challenged to look at violence like any other disease. It is much harder for physicians to feel like they can make a dent in a problem that has roots that are so tough—poverty, unemployment, inadequate education, racism—all these come into play as root causes for violence. When physicians are asked to attack other diseases, the first thing they do is try to get to the root cause, and usually it’s something you can develop an antidote, an antibiotic or chemotherapeutic intervention for. There’s no quick way to turn off those root causes. This is everyone’s problem. A 15-year-old who is shot in the spine is going to eat up $300,000 in acute care costs and $100,000 in rehabilitation costs in the first five years. It’s an enormous drain on an almost bankrupt medical system.

PND: What kind of data collection can be done to study the problem?

MH: Data systems such as the ones the Centers for Disease Control runs out of Atlanta are always two or three years behind. The Pennsylvania Trauma Centers Foundation collects data of patients admitted to the trauma centers. There is no one body that looks at patients seen in ERs or other health centers. Those systems have to coalesce into a central reporting database. There is no current mandated reporting. If the patient expires, a report is generated for the coroner’s office. If the patient is involved in a crime, the police will usually be on the scene, asking for details of the victim’s status. We’ve come a long way with child abuse, domestic abuse and rape. When those are identified, many centers have a response team. We don’t have a generic violence response team. At Allegheny General, we tried to set up a local response team for violence, using a combination of hospital social work, community liaison and mental health workers and linking them up with schools. They need to start dealing in the school with conflict resolution. If nothing else, the physician should have a way to enter the patient in a data base leading to a central terminal.

PND: What impact would injury prevention have on the physician?

MH: If you spend $20,000 on a population of kids giving them information about gun safety, how to avoid problems on the street, and if even one of those kids avoids getting into a gunshot wound situation, you’ll save $300,000. The federal or state government should have a license to mandate every HMO to give something back to that community.

PND: What role could non-emergency care physicians play?

MH: I run the Child Health Committee for Allegheny County Medical Society. We sent a questionnaire to all ACMS members—pediatricians, family practitioners, obstetrician/gynecologists, pediatric surgeons and ophthalmologists—about the amount of time they can spend on injury prevention issues during a well child or well patient visit. The results were frightening. Because of time constraints, many of them HMO-related, the well child visit ranged from 10 to 20 minutes at a maximum, and out of that the doctor had less than three minutes to do any talking. The practitioners didn’t feel they were covering these issues. It’s not enough just to have passive information like brochures on gun trigger locks in your office. Many said they would like to have a patient advocate in the waiting room to talk to patients about safety issues. In the obstetric setting you could teach parenting skills to prevent child abuse and inform parents of the risks of leaving guns around the house with little ones. Very little of this goes on in the standard OB setting. I would like to push legislation that would encourage them to take five minutes for basic injury prevention sessions with all young parents and all potential parents. It would be something we could design very easily, a questionnaire that is actively administered.

PND: The report seems to emphasize intentional injury. Was unintentional injury also studied?

MH: The advisory committee dealt less with unintentional injuries because so many programs out there are dealing with those. However, I believe that until a community embraces and deals with unintentional injuries, it won’t be able to deal with intentional injury and violence. First, you have to set up the paradigm that the kid’s safety is important. If you just keep saying, "Don’t get shot!" and you’re not giving them bicycle helmets, it doesn’t mean anything. Statistics in both the city and county still show that 60 percent of the injuries are unintentional; we can’t ignore that. The two go hand in hand.

PND: Are medical schools preparing young doctors for dealing with the issues of violence?

MH: Some are and some are not. Medical school is a schizophrenic experience. During the first two years, when students aren’t doing a lot of clinical work, they have been yearning for exposure to patient issues. Medical schools responded by requiring some form of community service. This is fertile ground for recruiting manpower for violence prevention. If medical students and young residents are taught that this should be part of their day, it will become part of their practice.

PND: What is the next step for your committee?

MH: I hope we could convene a summit to see what we are going to do with the information we have collected. We need to tap that deep pocket to support the programs that are working. We could be the watchdog to be sure that projects approved by the Youth Crime Prevention Council "get a life." We have to also take a page from Fred Thieman’s book. He said youth gang members should "drop their colors" and come together to solve some of these problems of youth violence. As adults, we need to drop our colors. We’ve been too protective of our hospital and organization affiliations, and we’re not as collaborative as we ought to be. I think that we have to force that kind of collaboration to occur for the good of the community. Many programs are duplicated. Collaboration would broaden the base and effectiveness of the individual programs.