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5
Contagion and Interruption
in Practice
T
he previous chapters explored the contagion of violence in the con-
text of the pattern of spread, the possible mechanisms at both the
individual and social levels, and the factors that might reduce or
exacerbate exposure and transmission. Drawing from this framework,
speakers also examined potential processes of interruption or mitigation.
Speakers at the workshop also explored some real-life examples of this
contagion at work, bringing all of these concepts together, as well as inter-
ventions currently in practice that seek to reduce it.
THE CONTAGION IN ACTION
Speakers Jason Featherstone of Surviving Our Streets and Zainab Al-
Suwaij of the American-Islamic Congress both spoke of recent occurrences
in which single acts of violence sparked an epidemic in very different ways.
UK Riots
On August 4, 2011, Mark Duggan was shot and killed by police in the
Tottenham neighborhood of North East London, England. Two days later,
friends and family marched to the police station to obtain information re-
garding the shooting. After several hours of silence, patience ran out, and
a series of altercations led to the overturning and burning of several police
cars. Captured on video, the burning cars became a symbol for those who
felt frustration around relationships with law enforcement, the current
41
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42 CONTAGION OF VIOLENCE
economic climate, and various political austerity measures related to educa-
tion and public services. In addition, Mr. Featherstone noted, residents of
Tottenham had a preexisting ingrained mistrust of law enforcement, related
to perceived injustices and deaths in police custody over the previous de-
cade. Mr. Featherstone also showed several video clips and commented on
the sense of relief and anticipation expressed by participants of the violent
acts that followed the initial event. Notably, many of the organizers and
participants belonged to groups with traditional rivalries, which were set
aside in these events. Following the burning of the cars, violence spread
throughout Tottenham, London, and then other parts of the United King-
dom over the next several days. Mr. Featherstone noted that rioters were
diverse and did not fit the “traditional” image.
Calls to commit violence were sent via social media to those within
close geographical proximity as well as those in other locations outside the
United Kingdom. Footage of the rioting and looting was shown constantly
on television, and made headlines in major newspapers. Violence spread
through the country for 5 days, and then subsided as police presence in the
streets ramped up significantly, and large numbers of arrests were recorded.
Through video clips and his own reflections, Mr. Featherstone painted
a complex story of not just violence throughout the country, but a sense of
resentment, frustration, and inequality that had bubbled over. Previously
that year, large antiausterity protests had been held, with little to no relief
presented. In one map he showed, there was strong geographical correlation
between the violent incidents and areas of deprivation. While gang violence
was cited as a major factor in the violence, Mr. Featherstone argued that
only a small number of rioters were members of gangs, and even then they
behaved in ways not typical of gang rivalries. Throughout his presentation,
Mr. Featherstone echoed a number of elements that had been noted previ-
ously by other speakers, specifically the importance of the social context,
the dynamics of groups, the emotional response to witnessing violence,
and the potential for epidemics to peak and then decline, in describing the
complexities of this event.
In discussing potential interventions to reduce violence related not just
to the riots, but the preexisting social and economic conditions, Mr. Feath-
erstone noted the importance of empowering individuals to not identify
as victims or perpetrators. He also noted the importance of developing
community–law enforcement relationships to build trust. He stated, for
example, that in the case of Mark Duggan, some of the immediate incendi-
ary violence might have been prevented if police had spoken to the family
and conveyed a sense of working with the community. Speaker and plan-
ning committee member Charlotte Watts of the London School of Hygiene
and Tropical Medicine shared concerns that while interruption programs
reduced street violence, they did not address the underlying issues that
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CONTAGION AND INTERRUPTION IN PRACTICE 43
exacerbated the tense situation. Mr. Featherstone concurred, and noted that
such reforms would take years to implement, while reducing retaliatory
violence could be an easier issue to address in the short term.
The “Arab Spring” and Iraq
The “Arab Spring” is a term coined to describe events across the Mid-
dle East and North Africa (MENA) characterized by wide-scale populist
uprisings against dictatorial governments. While many of the events are
continuing, the uprisings have been likened to the “Autumn of Nations”
that occurred in Eastern Europe in 1989. The singular event that was said
to have begun the wave was the self-immolation of Tunisian Mohamed
Bouazizi on December 18, 2010, as an act of protest against police and gov-
ernment corruption. Immediately in response, protests cropped up through-
out Tunisia, and eventually led to the toppling of the government. A month
later, similar protests swept through Egypt, and spread to Bahrain, Libya,
Syria, and Yemen. Protests also occurred in Algeria, Iran, Iraq, Jordan,
Morocco, and Oman and continued to spread through the region.
Unlike the UK riots, a contained trajectory of events has not presented
itself in the MENA region. Additionally, many forms of violence have been
reported, not limited to political conflict, but also spikes in interpersonal
violence (e.g., sexual harassment). Ms. Al-Suwaij noted that as collective
violence has destabilized communities, it has normalized the use of other
types of violence, echoing comments by other speakers about different
“syndromes” of violence.
Ms. Al-Suwaij also spoke of her experience with violence in Iraq, go-
ing back to her time as a student during Saddam Hussein’s regime, and the
protests that occurred then, reminiscent of those occurring now. She noted
that much of the violence is sectarian or interethnic and she is exploring op-
portunities to reduce such violence. She established Ambassadors for Peace,
a program she has sold with varying degrees of success to community and
religious leaders in various locations in Iraq. In describing her experience,
she noted that much of the conflict that occurs is related to simmering re-
sentment, and is often set off by something innocuous, such as two children
arguing over a soccer game. Thus her approach to mediating conflict draws
heavily on the Cure Violence (formerly known as CeaseFire) model, and
aims to interrupt retaliatory or tribal violence related to preexisting griev-
ances. She noted that in one of three areas in Basrah, in which her program
has been operating for 3 years, intertribal violence has been reduced to zero.
She also discussed plans to scale up the program and move to other areas.
Ms. Al-Suwaij also noted challenges in the Ambassadors for Peace
program, notably continuing political violence, lack of trust in law enforce-
ment (an issue that is being addressed), and the inability to intervene as
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44 CONTAGION OF VIOLENCE
successfully in other forms of violence, such as domestic violence. She noted
that it is still taboo to talk about domestic violence, and much of it is vastly
underreported. When her interrupters hear about violence in families, they
attempt to address it, but the existing legal structure prevents significant
addressing of the issue. She also noted that, in peer group sessions of only
women, some conversation around gender equality, gender norms, and
violence against women is introduced.
INTERRUPTION AND APPLICATION
Panelists in the afternoon of the second day described some ap-
proaches to interruption, and challenges and opportunities to scale up.
Before the panel, participants watched the documentary film The Inter-
rupters, which chronicles the work of four violence interrupters as part
of the CeaseFire Illinois initiative (CeaseFire Illinois is a Cure Violence
program). CeaseFire Illinois, the program initially developed by speaker
and planning committee member Gary Slutkin of the University of Illinois
at Chicago, uses individuals called interrupters to halt the further spread
of violence. These interrupters are respected in the community and usually
have some history of violence themselves. They intervene when violence
occurs, usually to prevent further spread or to prevent retaliation. They
also work with high-risk individuals in the community to reduce tensions
and other conditions that might result in violence.
In introducing the film, facilitator and planning committee member
Brian Flynn of the Uniformed Services University School of Medicine ex-
plored some key concepts in the natural cycle of violence. He noted, ref-
erencing Stephen Pinker’s book The Better Angels of Our Nature, that
traditionally violence is lower in urban versus rural areas. Pinker’s premise
is that rule of law and governing systems are responsible for reducing
violence, but in areas where violence spikes, people may not feel that
rules apply to them, or systems are capable of upholding justice. Dr. Flynn
also stated that, per Pinker, as women become more empowered, violence
decreases as well. He urged the audience to consider these points as they
watched the film. Finally, he posited that as previous discussions highlighted
the observation of violence (either near or far) as a risk factor for future
perpetration or victimization, perhaps the observation of violence interrup-
tion could further the spread of prevention as well.
Community-Based Intervention
Following the film, speaker and CeaseFire Illinois program director Tio
Hardiman spoke about the experience of the interrupters, the program, and
potential for scaling up. He gave four examples of recent events, which
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CONTAGION AND INTERRUPTION IN PRACTICE 45
transpired within an hour, that required the intervention of the interrupters:
(1) an incident involving a man who stole his girlfriend’s pain medication,
prompting threats and retaliation from her sons; (2) an incident involving
two men in a territorial altercation that had expanded to involve several
others; (3) two men arguing over a woman; and (4) two men involved in an
altercation over the sale of drugs, which the interrupters did not mediate,
though they did ensure that the situation would not result in violence. Mr.
Hardiman went on to note that CeaseFire interrupters worked with 1,100
high-risk individuals and mediated 800 conflicts in 2011.
In Chicago, homicide is the leading cause of death for 15- to 24-year-
olds, and Mr. Hardiman estimated that in the past decade, potentially
5,000 homicides have occurred. He described the circumstances in which
many young individuals involved in violence and crime grow up with the
mentality of needing to shoot first, to not be victimized, and to find ways to
leave the structural poverty of family neighborhoods behind. He noted that
violence is often normalized in these situations, and has lasting effects in a
number of settings, such as schools, where children have difficulty learning
because of fear of events outside of school. He noted that businesses often
leave neighborhoods because of the destabilizing effect of violence. He
also noted the importance of addressing issues on “the front end,” that is,
intercepting rumors of potential violence, and intervening before it occurs.
The Cure Violence model, in addition to interrupting the spread of vio-
lence, also aims to address social and group norms and behaviors around
violence. Some of the work involves reaching out to individuals and assist-
ing them with employment or education. In addition to the work of the
i
nterrupters, outreach workers are constantly in communities monitoring
the pulse and providing educational opportunities. The interrupters also
liaise with local law enforcement and mediate conflicts with victims of
shootings who end up in hospitals.
School-Based Intervention
Speaker Patrick Burton of the Center for Justice and Crime Prevention
in South Africa shared his experience with working in schools in South Af-
rica to reduce violence in youth. The program, in particular, was interested
in preventing “low-level,” high-frequency violence such as bullying and
dating violence, and in improving academic outcomes. He also noted the
importance of addressing the social milieu and how students relate to one
another in terms of forming more positive relationships. Dr. Burton spoke
of data issues, particularly a lack of insightful, robust data, often due to
non-reporting because of fear of the perception that schools are not safe.
Despite this, he estimates that about 15 percent of students had experienced
violence in the previous 12 months.
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46 CONTAGION OF VIOLENCE
In describing the approach, Dr. Burton explained the “whole-school”
approach, in which the program works with all stakeholders in school-
based learning, including the teachers, students, parents, school governing
body, and policy makers. It is also embedded in communities, working
with families and homes in which students are experiencing or at risk of
experiencing violence. The program places responsibility of identifying
priorities and interventions on the schools, while providing guidance on
response and prevention. Schools are shown how to identify safe and unsafe
spaces within schools, how to manage and respond to reports of violence or
threats of violence, and how to demonstrate action on such reports.
Dr. Burton went on to explore some of the challenges faced in the pro-
gram and in scaling up. In 2005, the program was piloted in 85 schools; it
is now active in just over 2,000 schools nationally. It is also currently being
developed to other sites outside South Africa. Two formal outcome evalu-
ations have been performed, and several informal process evaluations. He
noted challenges in accountability, such as who is responsible for violence
occurring and for response or lack thereof; ownership, management, and
institutionalization. These challenges are especially difficult because effec-
tive school managers are often moved around. There are also challenges in
supporting schools, whose primary task is education, to also work toward
providing safe environments and the shared vision of what a safe school
means—not just physical security.
The social context in South Africa has played a strong role in the
exacerbation of violence, including a sizeable percentage of students (16
percent) having family members who have committed acts of violence and
are currently incarcerated. Mr. Burton noted that the success of the school
intervention program has been dependent on the integration with home-
based efforts to address family violence. In the most successful sites, where
there has been integration with parenting programs and the school’s efforts,
school-based violence has dropped significantly, some down to zero.
Family Violence Prevention and Interruption
In thinking about interrupting violence at the family level, speaker
V
alerie Maholmes of the Eunice Kennedy Shriver National Institute for
Child Health & Human Development explored a series of studies being
funded by her institute. She noted particularly how much of the research
focuses on early development, and the importance of both the research and
that age group in framing violence prevention. The first study she noted
is that of Judith Langlois, which looks at the development of appearance-
based stereotypes in children. Children naturally differentiate between more
and less attractive appearances, but it is the observation of differential be-
havior by parents that ingrains value in appearance. Throughout life, these
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CONTAGION AND INTERRUPTION IN PRACTICE 47
biases are more firmly established through repeated observation, and serve
as barriers to receptivity of counterstereotypic messaging. Dr. Maholmes
noted that the important implication here is that this work may prompt
the development of interventions that ameliorate negative judgment based
on attractiveness, and learning about these mechanisms may help inform
evidence-based practice.
Dr. Maholmes went on to describe an intervention in India designed by
Suneeta Krishnan, called DIL-MIL (Hindi: “hearts together”), which lever-
ages the role of mothers-in-law to reduce violence against daughters-in-law.
She noted that women are vulnerable to gender-based violence because they
often have to acquiesce to the marital family, and that efforts to empower
women must take into account social and family dynamics. She noted that
mothers in law are crucial entry points, but people do not often realize that
their role can be pivotal. This intervention brings these dyads together and,
using social-cognitive theory, educates and empowers the women to reduce
gender-based violence. Finally, Dr. Maholmes described a study by Amy
Marshall looking at aggression within families, disaggregating interparen-
tal aggression (IPA) and parent-to-child aggression (PCA) to see if the two
co-occur, if PCA is an outcome of IPA, if either or both have a “spillover”
effect to violence between other family members (i.e., sibling-to-sibling) or
outside the family.
In response to a question from a participant, Dr. Maholmes noted that
intergenerational transmission of violence is strongly influenced by the
normalization of violent behavior within families and the internalization
of such by girls. She posited that useful interventions in breaking this cycle
would need to include messaging around self-worth and self-esteem, as well
as the ability to show other types of relationships.
Trauma-Informed Approaches
Speaker John Rich of the Drexel University School of Public Health
spoke of the importance of the trauma-informed approach to violence
prevention, noting that trauma is at the center of violence and that “hurt
people hurt people.” He also referenced other words from Sandra Bloom
from the Drexel University School of Public Health about reframing inquiry
from asking about what is wrong with someone to asking what happened
to someone, knowing that early adversity and stress can have deleterious
effects. In thinking about how to approach the interruption of violence in
the health care setting, Dr. Rich noted the importance of examining these
roots of trauma because patients who present with physical injury often
have psychological injury as well. Failing to address those secondary inju-
ries runs the risk of retraumatizing the individual. He also pointed out that
the “injured” included not only the individual with the injury, but those
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48 CONTAGION OF VIOLENCE
who might have witnessed the violence, and potentially even those who
work with the injured and traumatized; thus, understanding trauma across
populations informs violence prevention at larger scales.
Dr. Rich also stated that violence is a recurrent disease, with high risks
of recurrence. He cited some studies that show, 5 years out, that 45 percent
of those with serious injury have experienced another serious injury, and
20 percent of them are dead. Of that 20 percent, 70 percent had substance
abuse listed as a contributory cause. In other situations he referenced,
young men who present with serious injury have high rates of posttraumatic
stress disorder (PTSD), hypervigilance, and history of childhood adversity.
Dr. Rich also pointed out that perpetrators are also at risk of PTSD symp-
toms, so it is not just victims.
Hospital-based interventions that are trauma-informed have been
known to work. Shock Trauma in Baltimore has an intervention that has
shown a reduction in involvement in the criminal justice system for its
patients. Dr. Rich explained that hospital-based interventions are about
recognizing the additional trauma faced, as a bigger picture approach to
reducing violence. The interventions screen for past trauma and provide
guidance in navigating systems, both medical and criminal justice, which
might also potentially retraumatize. It also provides an outlet for aggression
or rage, usually conversation with a case worker, as a means to reduce the
potential for retaliatory violence. Finally, he noted it is important to include
direct trauma recovery assistance as well, citing a few in use with evidence
to back effectiveness.
Most salient though, Dr. Rich noted, is system-wide transformation
into treating trauma as a cause and not just as an outcome, and to reflect on
the comorbidity of different forms of violence, in the context of trauma. In
addition, educating the community on trauma and its effects would provide
a more nuanced perspective, including structural violence and intergenera-
tional oppression. He noted especially that moving the conversation out of
just hospitals and into a number of partnering organizations as well as the
community would be the most effective approach.
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CONTAGION AND INTERRUPTION IN PRACTICE 49
Key Messages Raised by Individual Speakers
• The spread of violence has a number of complex factors, including social and
contextual undercurrents that fuel frustration, anger, and mistrust in systems
(Featherstone, Flynn, Rich).
• Finding a key leverage or entry point could optimize interventions (Hardiman,
Maholmes).
• Recognizing and addressing the fundamentals of trauma provides a holistic
approach to hospital- and community-based interventions (Hardiman, Rich).
• Scaling up requires attention to a number of factors, including accountability
and finding and working with partners (Al-Suwaij, Burton, Hardiman).
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