It is not uncommon to read or hear about serious problems that affect people on a large scale described as “epidemic”. For example, last year US Transportation Secretary Ray LaHood called cell phone use or distracted driving “an epidemic on America’s roadways.” We normally recognize these statements as metaphors and don’t interpret them literally.

However, Gary Slutkin, a Chicago epidemiologist, appears to be getting increasing discussion and traction, for his idea that violence is a contagious disease and that it should be taken more literally in thinking about the causes and treatment of violence. “It has been said for a long time that violence begets violence, but it is just as tuberculosis begets tuberculosis, or flu begets flu, that violence begets violence,” wrote Slutkin in a paper presented to an Institute of Medicine workshop last year entitled “Contagion of Violence”.

Workshop Goals

 The workshop was organized to explore the contagious nature of violence, according to the organizers, and especially “the epidemiology of the contagion, describing possible processes and mechanisms by which violence is transmitted, examining how contextual factors mitigate or exacerbate the issue, and illuminating ways in which the contagion of violence might be interrupted. The report on the workshop pointed out that not all speakers approached the issue of contagion literally.

Slutkin’s paper at this workshop entitled “Violence Is A Contagious Disease” appears to have been instrumental in framing the discussion at the workshop. According to Slutkin, violence is a contagious disease because it meets the definition for a contagious condition, namely it is spread from one person to another.

Wired Magazine Article

In a Wired magazine article earlier this month, Brandon Keim wrote, “the idea that violence is contagious doesn’t appear in the Obama Administration’s gun control plan, nor in the National Rifle Association’s arguments. But some scientists believe that understanding the literally infectious nature of violence is essential to preventing it.” He goes on to write, “To say violence is a sickness that threatens public health isn’t just a figure of speech they argue. It spreads from
person to person, a germ of an idea that causes changes in the brain, thriving in certain social conditions.”

Slutkin told Wired  “It’s extremely important to understand this differently than the way we’ve been understanding it. We need to understand this as a biological health matter and an epidemiologic process.”

Origin of the Idea

Slutkin worked on infectious diseases internationally and was struck by the similarity between maps of disease in those populations and maps of violence in the US. This type of spot map is what has triggered his approach in the US.  As he told Wired, “the epidemiology of this is very clear when you look at the math. The density maps of shootings in Kansas city or New York or Detroit look like cholera case maps from Bangladesh.”

Mechanism of Action

What is believed to be the mechanism of action? Keim explains the underlying theory by saying that acts of violence are the germs, which instead of lodging in the intestines or lungs, lodge in the brain. When people, especially the young, repeatedly witness or experience violence their neurological function is altered such that in the future they perceive threats as enhanced and violence as normal. They are more likely to behave violently.

According to other experts quoted in the article, the underlying theme to Slutkin’s approach is learned behavior that gets transferred from one person to another. It’s a generalization of the contagion of behavior concept by means of observation and imitation.

Limitations

Harvard’s David Hemenway, director of the university’s Injury Control Research Center, told Keim that the idea of violence as contagion is more useful as metaphor than literal description. “It helps you understand things better.  What it means is that sometimes, if you get the infection early, you can have a big effect. But if you wait and wait, it’s hard to impose a policy that will have a big effect.”

Direct Interventions

Interpreting the metaphor more literally has led Slutkin and colleagues to act more directly on the violence problem, not by implementing policies, but by hiring field workers who are familiar with urban violence. This work actually started years ago in a program started by Slutkin in Chicago called Cease Fire  which has now been renamed Cure Violence.

The Cure Violence approach hires ex-convicts as public health workers to intervene in potentially violent situations and has reportedly reduced gun violence in Chicago and Baltimore where it has been tried and evaluated. As Slutkin told Wired, “You do interruption and detection. You look for potential cases. You hire a new type of worker, a violence interrupter, trained to identify who is thinking a certain way. They have to be like health workers looking for the first cases of bird flu. In a violence epidemic, behavior change is the treatment.”

Gaining Ground

According to Slutkin, the idea of violence as a contagious or infectious disease is rapidly catching hold. For example, he noted in a recent posting on his Cure Violence website that President Obama called violence a public health issue in his recent talks to the nation and called for expanding the role of the CDC to do more research.

Slutkin noted that last year CDC and Johns Hopkins studied an approach called Safe Streets which uses the approach first employed in Chicago of gathering data about the clusters involved and the transmission dynamics to identify those most likely to be involved in a shooting. They combine this analysis with street level outreach to prevent or interrupt problems before they get out of hand. According to Slutkin, the CDC found that Safe Streets Baltimore cut homicides by more than half in one neighborhood where violence had reached epidemic proportions, and positively changed the attitudes of young persons there on the acceptability of using violence to solve a dispute.

Concluding Statement

Slutkin concluded his paper to the IOM last year with a strong statement about the more epidemiologic or scientific approach he advocates. He stated “The science and the public understanding that follows this science are bringing us into a new era. This new era is an era of discovery—but more importantly of transition. We can now leave the days of a vocabulary of “bad people” and “enemies” and apply a scientific understanding and a scientific approach to this problem.

“Violence is a contagious disease. This is good news as this knowledge offers new strategies for control. There are massive implications for how to better treat urban violence, as well as for international conflicts. As we have done before----for plague, typhus, leprosy, and so many other diseases---we can now apply science-based strategies and, as we did for the great infectious diseases, similarly move violence into the past”,  he added. 

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