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