Let's treat violence like a contagious disease
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0:00 - 0:06I'm a physician trained in infectious diseases,
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0:06 - 0:08and following my training,
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0:08 - 0:11I moved to Somalia
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0:11 - 0:13from San Francisco.
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0:13 - 0:15And my goodbye greeting
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0:15 - 0:16from the chief of infectious diseases
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0:16 - 0:18at San Francisco General was,
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0:18 - 0:22"Gary, this is the biggest mistake you'll ever make."
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0:22 - 0:26But I landed in a refugee situation
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0:26 - 0:30that had a million refugees in 40 camps,
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0:30 - 0:33and there were six of us doctors.
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0:33 - 0:35There were many epidemics there.
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0:35 - 0:38My responsibilities were largely related to
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0:38 - 0:39tuberculosis,
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0:39 - 0:43and then we got struck by an epidemic of cholera.
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0:43 - 0:45So it was the spread of tuberculosis
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0:45 - 0:47and the spread of cholera
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0:47 - 0:53that I was responsible for inhibiting.
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0:53 - 0:55And in order to do this work, we, of course,
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0:55 - 0:58because of the limitation in health workers,
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0:58 - 1:02had to recruit refugees to be a specialized
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1:02 - 1:05new category of health worker.
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1:05 - 1:08Following three years of work in Somalia,
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1:08 - 1:10I got picked up by the World Health Organization,
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1:10 - 1:13and got assigned to the epidemics of AIDS.
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1:13 - 1:16My primary responsibility was Uganda,
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1:16 - 1:19but also I worked in Rwanda and Burundi
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1:19 - 1:22and Zaire, now Congo,
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1:22 - 1:26Tanzania, Malawi, and several other countries.
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1:26 - 1:28And my last assignment there was to run a unit
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1:28 - 1:30called intervention development,
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1:30 - 1:34which was responsible for designing interventions.
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1:34 - 1:37After 10 years of working overseas,
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1:37 - 1:39I was exhausted.
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1:39 - 1:41I really had very little left.
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1:41 - 1:45I had been traveling to one country after another.
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1:45 - 1:49I was emotionally feeling very isolated.
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1:49 - 1:51I wanted to come home.
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1:51 - 1:53I'd seen a lot of death,
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1:53 - 1:56in particular epidemic death,
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1:56 - 1:59and epidemic death has a different feel to it.
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1:59 - 2:02It's full of panic and fear,
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2:02 - 2:06and I'd heard the women wailing and crying
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2:06 - 2:09in the desert.
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2:09 - 2:11And I wanted to come home and take a break
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2:11 - 2:14and maybe start over.
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2:14 - 2:17I was not aware of any epidemic problems
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2:17 - 2:18in America.
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2:18 - 2:22In fact, I wasn't aware of any problems in America.
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2:22 - 2:24In fact -- seriously.
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2:24 - 2:27And in fact I would visit friends of mine,
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2:27 - 2:30and I noticed that they had water
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2:30 - 2:32that came right into their homes.
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2:32 - 2:34How many of you have such a situation?
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2:34 - 2:35(Laughter)
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2:35 - 2:37And some of them, many of them actually,
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2:37 - 2:40had water that came into more than one room.
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2:40 - 2:43And I noticed that they would move
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2:43 - 2:45this little thermoregulatory device
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2:45 - 2:47to change the temperature in their home
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2:47 - 2:50by one degree or two degrees.
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2:50 - 2:52And now I do that.
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2:52 - 2:56And I really didn't know what I would do,
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2:56 - 2:58but friends of mine began telling me
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2:58 - 3:02about children shooting other children with guns.
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3:02 - 3:04And I asked the question,
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3:04 - 3:06what are you doing about it?
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3:06 - 3:08What are you in America doing about it?
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3:08 - 3:11And there were two essential explanations
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3:11 - 3:13or ideas that were prevalent.
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3:13 - 3:15And one was punishment.
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3:15 - 3:17And this I had heard about before.
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3:17 - 3:20We who had worked in behavior
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3:20 - 3:23knew that punishment was something that was discussed
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3:23 - 3:26but also that it was highly overvalued.
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3:26 - 3:28It was not a main driver of behavior,
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3:28 - 3:32nor was it a main driver of behavior change.
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3:32 - 3:34And besides that, it reminded me
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3:34 - 3:37of ancient epidemics
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3:37 - 3:40that were previously completely misunderstood
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3:40 - 3:42because the science hadn't been there before,
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3:42 - 3:45epidemics of plague
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3:45 - 3:48or typhus or leprosy,
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3:48 - 3:50where the prevalent ideas were that there were
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3:50 - 3:54bad people or bad humors or bad air,
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3:54 - 3:57and widows were dragged around the moat,
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3:57 - 4:00and dungeons were part of the solution.
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4:00 - 4:02The other explanation or, in a way,
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4:02 - 4:04the solution suggested,
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4:04 - 4:07is please fix all of these things:
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4:07 - 4:10the schools, the community, the homes, the families,
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4:10 - 4:12everything.
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4:12 - 4:14And I'd heard this before as well.
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4:14 - 4:17I'd called this the "everything" theory,
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4:17 - 4:19or EOE: Everything On Earth.
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4:19 - 4:21But we'd also realized
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4:21 - 4:24in treating other processes and problems
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4:24 - 4:27that sometimes you don't need to treat everything.
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4:27 - 4:30And so the sense that I had
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4:30 - 4:32was there was a giant gap here.
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4:32 - 4:35The problem of violence was stuck,
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4:35 - 4:37and this has historically been the case
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4:37 - 4:38in many other issues.
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4:38 - 4:40Diarrheal diseases had been stuck.
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4:40 - 4:41Malaria had been stuck.
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4:41 - 4:44Frequently, a strategy has to be rethought.
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4:44 - 4:47It's not as if I had any idea what it would look like,
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4:47 - 4:50but there was a sense that we would have to do
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4:50 - 4:53something with new categories of workers
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4:53 - 4:55and something having to do with behavior change
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4:55 - 4:59and something having to do with public education.
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4:59 - 5:01But I began to ask questions
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5:01 - 5:04and search out the usual things
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5:04 - 5:06that I had been exploring before,
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5:06 - 5:07like, what do the maps look like?
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5:07 - 5:09What do the graphs look like?
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5:09 - 5:11What does the data look like?
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5:11 - 5:13And the maps of violence
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5:13 - 5:15in most U.S. cities
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5:15 - 5:17looked like this.
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5:17 - 5:19There was clustering.
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5:19 - 5:22This reminded me of clustering that we'd seen also
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5:22 - 5:24in infectious epidemics,
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5:24 - 5:26for example cholera.
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5:26 - 5:28And then we looked at the maps,
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5:28 - 5:31and the maps showed this typical wave
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5:31 - 5:33upon wave upon wave,
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5:33 - 5:34because all epidemics
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5:34 - 5:37are combinations of many epidemics.
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5:37 - 5:40And it also looked like infectious epidemics.
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5:40 - 5:41And then we asked the question,
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5:41 - 5:45well what really predicts a case of violence?
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5:45 - 5:47And it turns out that the greatest predictor
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5:47 - 5:50of a case of violence is a preceding case of violence.
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5:50 - 5:54Which also sounds like, if there is a case of flu,
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5:54 - 5:56someone gave someone a case of flu, or a cold,
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5:56 - 5:59or the greatest risk factor of tuberculosis
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5:59 - 6:02is having been exposed to tuberculosis.
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6:02 - 6:05And so we see that violence is, in a way,
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6:05 - 6:08behaving like a contagious disease.
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6:08 - 6:09We're aware of this anyway
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6:09 - 6:11even in our common experiences
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6:11 - 6:13or our newspaper stories
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6:13 - 6:16of the spread of violence from fights
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6:16 - 6:20or in gang wars or in civil wars
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6:20 - 6:22or even in genocides.
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6:22 - 6:25And so there's good news about this, though,
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6:25 - 6:27because there's a way to reverse epidemics,
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6:27 - 6:29and there's really only three things that are done
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6:29 - 6:31to reverse epidemics,
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6:31 - 6:34and the first of it is interrupting transmission.
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6:34 - 6:36In order to interrupt transmission,
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6:36 - 6:39you need to detect and find first cases.
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6:39 - 6:42In other words, for T.B. you have to find somebody
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6:42 - 6:46who has active T.B. who is infecting other people.
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6:46 - 6:47Make sense?
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6:47 - 6:49And there's special workers for doing that.
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6:49 - 6:51For this particular problem,
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6:51 - 6:53we designed a new category of worker
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6:53 - 6:55who, like a SARS worker
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6:55 - 6:57or someone looking for bird flu,
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6:57 - 6:58might find first cases.
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6:58 - 7:01In this case, it's someone who's very angry
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7:01 - 7:02because someone looked at his girlfriend
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7:02 - 7:04or owes him money,
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7:04 - 7:07and you can find workers and train them
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7:07 - 7:10into these specialized categories.
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7:10 - 7:11And the second thing to do, of course,
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7:11 - 7:13is to prevent further spread,
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7:13 - 7:16that means to find who else has been exposed,
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7:16 - 7:19but may not be spreading so much right now
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7:19 - 7:21like someone with a smaller case of T.B.,
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7:21 - 7:24or someone who is just hanging out in the neighborhoods,
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7:24 - 7:26but in the same group,
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7:26 - 7:28and then they need to be, in a way,
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7:28 - 7:30managed as well,
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7:30 - 7:33particular to the specific disease process.
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7:33 - 7:36And then the third part, the shifting the norms,
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7:36 - 7:39and that means a whole bunch of community activities,
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7:39 - 7:42remodeling, public education,
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7:42 - 7:44and then you've got what you might call
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7:44 - 7:45group immunity.
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7:45 - 7:47And that combination of factors
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7:47 - 7:49is how the AIDS epidemic in Uganda
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7:49 - 7:52was very successfully reversed.
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7:52 - 7:54And so what we decided to do in the year 2000
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7:54 - 7:56is kind of put this together in a way
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7:56 - 7:59by hiring in new categories of workers,
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7:59 - 8:01the first being violence interruptors.
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8:01 - 8:04And then we would put all of this into place
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8:04 - 8:06in one neighborhood
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8:06 - 8:08in what was the worst police district
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8:08 - 8:10in the United States at the time.
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8:10 - 8:13So violence interruptors hired from the same group,
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8:13 - 8:16credibility, trust, access,
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8:16 - 8:18just like the health workers in Somalia,
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8:18 - 8:20but designed for a different category,
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8:20 - 8:22and trained in persuasion,
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8:22 - 8:26cooling people down, buying time, reframing.
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8:26 - 8:28And then another category of worker,
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8:28 - 8:31the outreach workers, to keep people
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8:31 - 8:34in a way on therapy for six to 24 months.
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8:34 - 8:38Just like T.B., but the object is behavior change.
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8:38 - 8:40And then a bunch of community activities
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8:40 - 8:41for changing norms.
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8:41 - 8:44Now our first experiment of this
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8:44 - 8:46resulted in a 67-percent drop
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8:46 - 8:48in shootings and killings
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8:48 - 8:50in the West Garfield neighborhood of Chicago.
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8:50 - 8:52(Applause)
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8:52 - 8:54And this was a beautiful thing
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8:54 - 8:55for the neighborhood itself,
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8:55 - 8:58first 50 or 60 days, then 90 days,
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8:58 - 9:00and then there was unfortunately another shooting
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9:00 - 9:02in another 90 days,
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9:02 - 9:04and the moms were hanging out in the afternoon.
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9:04 - 9:06They were using parks they weren't using before.
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9:06 - 9:08The sun was out. Everybody was happy.
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9:08 - 9:12But of course, the funders said, "Wait a second,
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9:12 - 9:13do it again."
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9:13 - 9:16And so we had to then, fortunately,
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9:16 - 9:19get the funds to repeat this experience,
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9:19 - 9:21and this is one of the next four neighborhoods
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9:21 - 9:24that had a 45-percent drop in shootings and killings.
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9:24 - 9:27And since that time, this has been replicated
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9:27 - 9:2920 times.
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9:29 - 9:31There have been independent evaluations
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9:31 - 9:33supported by the Justice Department
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9:33 - 9:35and by the CDC and performed by Johns Hopkins
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9:35 - 9:39that have shown 30-to-50-percent and 40-to-70-percent
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9:39 - 9:41reductions in shootings and killings
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9:41 - 9:43using this new method.
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9:43 - 9:45In fact, there have been three independent
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9:45 - 9:47evaluations of this now.
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9:47 - 9:49Now we've gotten a lot of attention as a result of this,
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9:49 - 9:51including being featured on
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9:51 - 9:55The New York Times' Sunday magazine cover story.
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9:55 - 9:58The Economist in 2009
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9:58 - 10:00said this is "the approach that will come to prominence."
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10:00 - 10:02And even a movie was made around our work.
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10:02 - 10:04[The Interrupters]
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10:04 - 10:06However, not so fast,
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10:06 - 10:08because a lot of people did not agree
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10:08 - 10:10with this way of going about it.
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10:10 - 10:12We got a lot of criticism,
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10:12 - 10:14a lot of opposition,
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10:14 - 10:15and a lot of opponents.
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10:15 - 10:18In other words, what do you mean, health problem?
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10:18 - 10:21What do you mean, epidemic?
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10:21 - 10:24What do you mean, no bad guys?
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10:24 - 10:26And there's whole industries designed
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10:26 - 10:29for managing bad people.
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10:29 - 10:32What do you mean, hiring people
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10:32 - 10:34who have backgrounds?
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10:34 - 10:38My business friends said,
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10:38 - 10:42"Gary, you're being criticized tremendously.
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10:42 - 10:44You must be doing something right."
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10:44 - 10:46(Laughter)
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10:46 - 10:49My musician friends added the word "dude."
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10:49 - 10:53So anyway, additionally,
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10:53 - 10:54there was still this problem,
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10:54 - 10:57and we were getting highly criticized as well
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10:57 - 11:01for not dealing with all of these other problems.
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11:01 - 11:04Yet we were able to manage malaria
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11:04 - 11:07and reduce HIV and reduce diarrheal diseases
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11:07 - 11:08in places with awful economies
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11:08 - 11:10without healing the economy.
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11:10 - 11:13So what's actually happened is,
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11:13 - 11:15although there is still some opposition,
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11:15 - 11:17the movement is clearly growing.
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11:17 - 11:19Many of the major cities in the U.S.,
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11:19 - 11:21including New York City and Baltimore
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11:21 - 11:23and Kansas City,
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11:23 - 11:25their health departments are running this now.
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11:25 - 11:27Chicago and New Orleans, the health departments
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11:27 - 11:30are having a very large role in this.
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11:30 - 11:33This is being embraced more by law enforcement
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11:33 - 11:35than it had been years ago.
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11:35 - 11:37Trauma centers and hospitals
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11:37 - 11:39are doing their part in stepping up.
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11:39 - 11:41And the U.S. Conference of Mayors
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11:41 - 11:43has endorsed not only the approach
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11:43 - 11:46but the specific model.
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11:46 - 11:49Where there's really been uptake even faster
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11:49 - 11:51is in the international environment,
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11:51 - 11:53where there's a 55-percent drop
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11:53 - 11:55in the first neighborhood in Puerto Rico,
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11:55 - 11:58where interruptions are just beginning in Honduras,
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11:58 - 12:01where the strategy has been applied in Kenya
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12:01 - 12:04for the recent elections,
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12:04 - 12:07and where there have been 500 interruptions in Iraq.
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12:07 - 12:10So violence is responding as a disease
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12:10 - 12:12even as it behaves as a disease.
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12:12 - 12:14So the theory, in a way,
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12:14 - 12:19is kind of being validated by the treatment.
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12:19 - 12:22And recently, the Institute of Medicine
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12:22 - 12:24came out with a workshop report
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12:24 - 12:26which went through some of the data,
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12:26 - 12:27including the neuroscience,
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12:27 - 12:31on how this problem is really transmitted.
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12:31 - 12:34So I think this is good news,
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12:34 - 12:36because it allows us an opportunity
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12:36 - 12:38to come out of the Middle Ages,
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12:38 - 12:41which is where I feel this field has been.
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12:41 - 12:44It gives us an opportunity to consider the possibility
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12:44 - 12:47of replacing some of these prisons
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12:47 - 12:50with playgrounds or parks,
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12:50 - 12:53and to consider the possibility
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12:53 - 12:56of converting our neighborhoods into neighborhoods,
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12:56 - 13:00and to allow there to be a new strategy,
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13:00 - 13:04a new set of methods, a new set of workers:
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13:04 - 13:07science, in a way, replacing morality.
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13:07 - 13:09And moving away from emotions
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13:09 - 13:13is the most important part of the solution
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13:13 - 13:17to science as a more important part of the solution.
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13:17 - 13:22So I didn't mean to come up with this at all.
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13:22 - 13:24It was a matter of,
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13:24 - 13:26I wanted actually a break,
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13:26 - 13:30and we looked at maps, we looked at graphs,
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13:30 - 13:32we asked some questions
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13:32 - 13:35and tried some tools
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13:35 - 13:37that actually have been used many times before
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13:37 - 13:39for other things.
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13:39 - 13:43For myself, I tried to get away from
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13:43 - 13:44infectious diseases,
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13:44 - 13:46and I didn't.
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13:46 - 13:48Thank you.
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13:48 - 13:51(Applause)
- Title:
- Let's treat violence like a contagious disease
- Speaker:
- Gary Slutkin
- Description:
-
Physician Gary Slutkin spent a decade fighting tuberculosis, cholera and AIDS epidemics in Africa. When he returned to the United States, he thought he'd escape brutal epidemic deaths. But then he began to look more carefully at gun violence, noting that its spread followed the patterns of infectious diseases. A mind-flipping look at a problem that too many communities have accepted as a given. We've reversed the impact of so many diseases, says Slutkin, and we can do the same with violence. (Filmed at TEDMED.)
- Video Language:
- English
- Team:
- closed TED
- Project:
- TEDTalks
- Duration:
- 14:08
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