Violence as a Disease: Innovative Program Aims To Stop the Spread of Gun Injuries

What is a disease? Most people would be hard-pressed to define it precisely, but they have a firm idea about what does — and what does not — fit the description. Health problems like transmissible infections, cancer and genetic conditions are diseases. Gunshot wounds are not.

But according to David Milia, MD, trauma surgeon, Medical College of Wisconsin faculty member and medical director of the Froedtert & MCW adult Level I Trauma Center at Froedtert Hospital, trauma experts view violent injury through a different lens.

“Historically, few people have seen trauma, let alone violence, as a disease in itself,” Dr. Milia said. “People perceive violence as the result of a character flaw, a lapse in judgment or simply someone else’s fault.”

However, in recent years, epidemiology research has shown that violence behaves the same way as infectious diseases like cholera and AIDS.

“Violence spreads from one person or one group of people to another. Another characteristic violence shares with spreadable disease is the clustering of cases and patterns of outbreaks,” Dr. Milia said. “As with infectious diseases, exposure to violence increases the risk of future violent injury. Nearly half of patients who arrive in our Trauma Center as victims of violence experience further victimization within five years.”

Framing violence as a disease is a practical strategy for improving patient outcomes. “If you consider violence as a disease process, it becomes something you can study and subsequently treat using a public health model,” Dr. Milia said. “It is incumbent upon us to do this: Violence in any community affects all communities.”

In 2019, the Trauma Center launched a new effort to bring a public health approach to violent injury — the Hospital-Based Violence Interruption Program. It was developed in collaboration with the City of Milwaukee’s 414LIFE initiative, a team of “violence interrupters” who work at the neighborhood level to reduce the impact of violence.

“The Hospital-Based Violence Interruption Program arose from our recognition that treating a victim of violence cannot end with ‘plugging the holes’ and sending the patient on their way,” Dr. Milia said. “Treatment is an opportunity for us to intervene and prevent further acts of violence or victimization.”

How the Program Works

When the Trauma Center receives a patient with a gun injury, staff page Tonia Liddell, the in-hospital coordinator of the program. Liddell meets with the patient, usually within a matter of hours. She also connects with the victim’s family members and friends.

“In my initial assessment, I look for the risk of retaliatory violence,” Liddell said. “Those cases are high priority because violence can have a domino effect and spread like wildfire.”

If a risk of retaliation is present, Liddell counsels victims to take a step back. “My goal is to get the patient or family members to think before they respond,” she said. “I ask them to think about the lives that will be affected by retaliation, including their own.”

If needed, Liddell alerts members of the 414LIFE “street team” to identify other individuals at risk and defuse tensions. “Our boots-on-the-ground team canvasses neighborhoods, letting community members know what’s going on and offering support,” she said. “Sometimes, they can identify key people in an incident and get them to agree to mediation.”

The ultimate aim is to avert the recurrence of violence. “The goal of this program,” Liddell said, “is to prevent patients from returning with additional injuries stemming from the first incident.”

Liddell has changed the course of several potentially dangerous situations. “Tonia and her team are stopping the cycle of violence in real time,” Dr. Milia said. “Before we had access to a violence interruption team and a program, we could not influence this kind of change.”

Liddell also helps patients access social support resources that are critical to avoiding future violence. Another goal is to keep injured victims connected to the health care system.

“In the demographic I work with, for a variety of reasons, there is a huge level of mistrust for health care providers,” she said. “It results in disengagement from treatment. That’s why people don’t want to return for follow-up visits.”

Liddell strives to create understanding. “I try to bridge gaps between patients and families and my health care colleagues.”

Liddell’s credibility as a member of the community is critical to keeping victims of violence engaged with the trauma care team. “Her intervention is key to preventing further issues with our patients’ postoperative course and achieving optimal health outcomes,” Dr. Milia said.

Measuring Success

Liddell is a strong advocate for mental health. “It is something we shy away from culturally, but I strongly encourage patients to take advantage of the trauma psychology resources offered at the Trauma Center.”

Terri deRoon-Cassini, MS, PhD, trauma psychologist, MCW faculty member and director of the Medical College of Wisconsin Comprehensive Injury Center, leads the trauma psychology program at Froedtert Hospital. She and her colleagues help violence victims and other trauma patients cope with the after effects of injury, including depression and post-traumatic stress disorder. She is also leading efforts to study the Hospital-Based Violence Interruption Program and rigorously evaluate its outcomes.

“The first phase of our study looked at implementation. Our initial data show that roughly 81% of people referred to the program fit the target demographic — young men of color ages 15 to 35,” she said. “We know we are getting to the highest-risk group the majority of the time. We also know we are getting to all highest-risk neighborhoods.”

Going forward, the research team will also assess the effect of the program on individuals and the community. For these studies, trauma registry data will be linked with data from the Milwaukee Police Department and Wisconsin Department of Corrections.

“In the second phase of research, we’ll discover if patients in our Hospital-Based Violence Interruption Program are reinjured less compared to others who were not in the program,” Dr. deRoon-Cassini said. “The third phase will look at community impact — does this program translate into less violence in our city? That’s what we’re all hoping for, but answers are a number of years down the road.”

Dr. deRoon-Cassini believes the Hospital-Based Violence Interruption Program is having a positive impact. “The program is helping put the focus on understanding the root causes of violence,” she said. “It is moving health care away from assigning blame and moving everyone toward learning how to uplift patients and provide better care.”

Now More Than Ever

Liddell believes the disease model is key to understanding and stopping the spread of gun injury. “Gun violence is a significant public health problem, and the traditional approach is not meeting the needs of those affected by violence,” she said.

So far, none of the patients Liddell has worked with have returned to the hospital because of retaliatory violence: “I want to say it is because we identify and address problems patients face after they leave the hospital.”

According to Dr. Milia, these efforts are critical. “With the pandemic, we saw a horrendous rise in violence in the City of Milwaukee,” he said. “Milwaukee suffered the greatest percentage increase in violence of any major urban center in the country. Now, more than ever, we need to go at this on all eight cylinders.”