Strategies for Trauma Centers to Address the Root Causes of Violence: Recommendations from the Improving Social Determinants to Attenuate Violence (ISAVE) Workgroup of the American College of Surgeons Committee on Trauma

Abbreviations and Acronyms ACS: American College of Surgeons; COT: Committee on Trauma; HVIP: hospital-based violence intervention program; ISAVE: Improving the Social Determinants of Health to Attenuate Violence; SAMHSA: Substance Abuse and Mental Health Services Administration; SDH: social determinants of health; TIC: trauma-informed care.

In 1985, Surgeon General C Everett Koop held the “Workshop on Violence and Public Health.”¹ His initial remarks to the attendants included the following: “Our focus will be squarely on how the health professions might provide better care for victims of violence and also how they might contribute to the prevention of violence.” He went on to say, “It is clear that medicine, nursing, psychology, and social service professions have been slow in developing a response to violence that is integral to their daily professional life.”¹ Dr Koop speculated that health professions can make a big impact, but it will require a multidisciplinary approach and the recognition that violence is a public health issue. Applying a public health framework to the issue provides a foundation to explore root causes, risk factors, and protective factors in pursuit of solutions. The American College of Surgeons (ACS) Committee on Trauma (COT) is working to prevent firearm-related injury, death, and disability by working together to address the root causes of violence and simultaneously making firearm ownership as safe as possible. A multidisciplinary working group, Improving the Social Determinants of Health to Attenuate Violence, or ISAVE, was established in 2019 by the ACS COT. Perhaps the efforts of this working group are what Dr Koop envisioned 36 years ago.

In the ensuing decades since Dr Koop's workshop, community violence still plagues our nation. Firearm-related injuries and deaths continue to represent a national public health crisis. Between 2010 and 2018, more than 300,000 people died from firearm-related injuries in the US.² In 2019, interpersonal violence of all mechanisms was responsible for 19,141 deaths and more than 1,400,000 injuries.² Nonfatal injury data have been elusive, so this number is likely an underestimate.^2,3 This problem affects both the young and old, but is the leading cause of death in adolescents. Among 14- to 18-year-olds, firearm-related injury was the leading cause of death in 2018, 25% higher than motor-vehicle crashes. More than 42% of people who died from firearm-related injuries in 2018 were younger than 35 years. In fact, firearm-related injuries account for 7.1% of premature deaths or years of potential life lost before age 65 years in the US.³

There are substantial direct and indirect costs associated with violent injury. Thomas Abt characterized the cost in his book Bleeding Out: “No statistic can capture a child's lost potential or a mother's grief, but when the collective costs of murder are estimated, they are staggering: Anywhere from $173 billion to $332 billion in criminal justice and medical costs, lost wages and earnings, damaged and devalued property, and diminished quality of life. That's between $531 and $1,020 per American, paid out in higher taxes, higher insurance premiums, and lower property values….”⁴ It is difficult to imagine another public health crisis with such a profound human and financial toll over decades.

The US is an outlier in firearm-related injuries, having more than 5 times the number of injuries than 23 other high-income countries combined, and has a firearm homicide rate more than 25 times higher than other high-income countries.^5–7 Although these injuries have a national effect, the impact is not distributed equally. The burden of interpersonal or community firearm-related injuries and deaths falls disproportionately on Black, Brown, and marginalized populations. Black men are 14 times more likely than White men to die from firearm-related homicide.⁸ Firearm-related homicide was the leading cause of death for Black adolescents and young men aged 15 through 34 years.⁹ Among 20- to 29-year-olds, the firearm homicide rate among Black men was at least 5 times higher than for Latino men and 20 times higher than for White men.⁹ Men are almost 25 times as likely to die from legal intervention compared with women, and Black men are 2.5 times more likely to die from legal intervention compared with White men.¹⁰

Public health and many in the healthcare fields are making concerted efforts to address community violence with a comprehensive approach. In 2019, the ACS convened an historic Medical Summit on Firearm Injury Prevention, bringing together 45 major medical, public health, and injury prevention organizations and the American Bar Association.¹¹ Discussions focused on working together to address firearm violence in the US using a public health approach. A central theme throughout the Summit was the notion of looking upstream and encouraging organizations to address the root causes by creating strategies that impact the social determinants of health (SDH).

This article outlines and describes structural racism and SDH, and how the ISAVE Workgroup leveraged its wide-ranging expertise to develop 4 strategies to represent our initiatives. Built on the structure of our strategies, we outline our vision of the future care of victims of violence, in our trauma centers and beyond those walls, and to the communities plagued by this epidemic.

STRUCTURAL RACISM AND THE SOCIAL DETERMINANTS OF HEALTH

Despite the toll of firearm violence in the US, virtually no investment has been made toward prevention strategies. To understand and address firearm violence, we must review the SDH, define structural racism and detail its history, and describe the impetus for the formation of ISAVE.

We look at social determinants through a broad lens: Without addressing the underlying cause of disease and ill health, the risk of perpetuating a cycle of inequity, disparity, and inequality will remain for generations to come. The association between low socioeconomic status and poor health has been recognized for centuries, but not until 1996 was the term social determinants of health used regularly and methodically. The WHO has a unit dedicated specifically to SDH and defines social determinants as “the conditions in which people are born, grow, work, live and age, and the wider set of forces and systems shaping the conditions of daily life.”¹² During the past 20 to 30 years, a new discourse on the impact of social factors on health has emerged in the US. It is now commonly recognized that healthcare contributes to only 20% of a person's overall health and wellness, and socioeconomic factors contribute >40%.¹³ In the last 10 years, the causality of health disparities in the US have been highlighted across all medical disciplines, underscored in 2020 by the disproportionate toll COVID-19 has taken on Black and Brown populations. The health disparities we face cannot be addressed solely and successfully by medical care alone. This is perhaps much more acute in firearm-related injury compared with other health conditions because of the lethality of the mechanism. Social responsibility and social accountability within the broader context of healthcare are essential.

Understanding the underpinnings of disparities requires us to examine our history. Structural racism can be defined as “the macrolevel systems, social forces, institutions, ideologies, and processes that interact to generate and reinforce inequities among racial and ethnic groups.”¹⁴ Only a few generations before us, European settlers forcibly removed indigenous people from their ancestral land and waged unrelenting wars against them. Racial, civil, and cultural injustices also reached the African people during the colonization of the US, with the practice of slavery and its systematic, organized, and sanctioned violence persisting approximately 250 years. Approximately 3.5 million enslaved people were decreed to be free on September 22, 1862. This was followed by more than a century of racially biased practices that affected how these newly freed people were treated in society and by the law. The most salient of these practices include de jure segregation through Jim Crow Laws, residential segregation that was compounded into redlining during the New Deal era, and the creation of laws that disproportionately criminalize minority populations.

These explicitly discriminatory historical practices, along with implicit discrimination related to education and other vital services, created intergenerational socioeconomic disparities that we see today and contribute to the epidemic of violence evident in affected communities. In addition to the lived experience, intergenerational historical trauma continues to plague Black and Brown populations.

Low neighborhood life expectancy and endemic inequity lead to a sense of hopelessness. Harm or risk of harm to oneself seems much more rational to the hopeless person compared with the hopeful person. This is not the result of maladaptive or pathologic thought. When death seems imminent and unavoidable, high-risk behavior and short-term thinking are not irrational or pathologic. Social determinants of mental health, including sociodemographic and economic characteristics, which have long been tied to risk of suicide, underscore the similarities in the underpinnings of suicide and interpersonal violence; a sense of hopelessness is pervasive.

Although this story might seem bleak, there have been considerable gains in reframing the discussion to a solutions-based narrative. This strategy of engaging communities at risk as a part of the solution is a key principle of the ACS COT's firearm injury prevention strategy.¹⁵

EXPLORING SOLUTIONS

ISAVE represents a collective effort to work together as professionals, hospitals, and communities to implement effective strategies to improve health and healthcare for marginalized communities that are disproportionately impacted by violence. The intersection of community development and health improvement is a focus of ISAVE's work. The group believes that health promotion and violence prevention strategies should not only reach individual patients but also communities at risk, to influence daily living and working conditions. This work requires vital external partnerships with healthcare networks, business, philanthropy, and social services, such as workforce development. The challenge is defining the critical elements of social care and financing this integration of social care within healthcare. The US consistently ranks at or near the bottom on key measures of health among affluent nations, and spends far more on healthcare than any other nation.¹⁶ Investing resources into social care and social services is feasible and would likely result in a decrease in spending on healthcare and would improve health outcomes.¹⁶

In concert with the development of strategies to address the root cause of violence, research addressing the feasibility, implementation, and value of these programs needs to be conducted. For that, funding at the federal and local levels should be commensurate with the burden of disease. The importance of funding, conducting, and translating research to evaluate the effectiveness of social care practices was also highlighted by the National Academies of Sciences, Engineering, and Medicine in a 2019 consensus report.¹³

THE COMPOSITION OF IMPROVING SOCIAL DETERMINANTS TO ATTENUATE VIOLENCE

The ISAVE Workgroup is a diverse, multidisciplinary group representing healthcare (ie surgery, emergency medicine, internal medicine, psychiatry, and pediatrics), hospital and community-based violence intervention programs, community-based organizations, and law enforcement. The ISAVE Workgroup has a common purpose: To develop strategies that can help trauma centers better address the root causes of violence. The group has broad experience at the intersection between physical and psychological trauma. Addressing root causes of violence requires recognizing that acute physical or psychological trauma can have a life-long impact, and there are modifiable factors that can attenuate this impact.

THE 4 STRATEGIES OF IMPROVING SOCIAL DETERMINANTS TO ATTENUATE VIOLENCE

Based on discussions and consensus gained during the inaugural workgroup meetings, the ISAVE Workgroup recommends 4 strategic areas of focus to improve health, reduce inequities, and break the cycle of violence in marginalized and disinvested communities. What follows is a brief description of each thematic area with pragmatic recommendations.

Development and implementation of trauma-informed care in all trauma centers

Depending on one's healthcare discipline, the term trauma can take on different meanings. From the mental health perspective, trauma is often defined as a deeply distressing and disturbing experience. From the perspective of trauma surgery and emergency medical services, trauma is perceived as an acute physical injury. From the patient perspective, the 2 separate definitions are artificial and lead to a fragmentation of care. For many people injured violently, trauma is all of the above. The Substance Abuse and Mental Health Services Administration (SAMHSA) provides an integrated definition: “Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being.”¹⁷ For families and communities negatively affected by SDH (ie structural racism, poverty, inequity in access to education, housing, or nutrition), trauma can be acute but is also chronic and often repetitive.

In many of our trauma centers that see a high rate of violence, trauma can become expected, normalized, or even inevitable in the eye of our practitioners. Trauma care practitioners use of cynical, sarcastic, and negative psychological coping mechanisms is unfortunately common. These coping mechanisms place barriers between the patient and the care team and can lead to patient-blaming and negative interactions between patient and practitioner, which lead to or exacerbate compassion fatigue and burnout.¹⁸ Some examples of this type of language are: “I am sure he was on his way to church when he was shot” or “that guy is a frequent flyer” or “that patient is combative and doesn't want help.” This approach leads to antagonistic interactions with patients and can be responsible for retraumatizing our patients. Couple that with a deep-seated history of mistrust in our healthcare system in communities of color, and we almost certainly add another layer of psychological distress and injury. From the healthcare professional vantage, 3 factors highly associated with burnout are work overload, negative patient interactions, and emotional demands at work.¹⁸

Trauma informed care (TIC) is an organized approach that leads to patient-physician partnership and improved trust, and creates psychological safety for patients and more positive patient interactions for the care team. Implementation of TIC holds the promise of improving patient care from the vantage of both the patient and the healthcare professional. The vision of our TIC curriculum is to make this approach a standard practice in trauma centers to foster a sense of empowerment, autonomy, and partnership in the injured person to help patients thrive, not just survive.

TIC is a strengths-based framework that is grounded in an understanding of, and responsiveness to, the impact of trauma that emphasizes physical, psychological, and emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a sense of control and empowerment.¹⁹ SAMHSA emphasizes the “four R's.”²⁰ In the context of the violently injured population, the trauma center and providers realize the widespread impact of trauma and understand potential paths for recovery; recognize the signs and symptoms of trauma in victims, staff, families, and others involved with the system; and respond by fully integrating knowledge about (repetitive and chronic) trauma into policies, procedures, and practices; and seek to actively resist retraumatization.²⁰ SAMHSA also promotes 6 key principles when developing and implementing a trauma-informed approach. The 6 principles are safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment, voice, and choice; and addressing the history and culture of racial and gender inequity.²⁰

ISAVE has partnered with the Institutes for Nonviolence staff in Chicago, IL and Providence, RI, to build a TIC curriculum that is designed to be implemented in trauma centers. In building this curriculum, ISAVE focused on ensuring the fidelity of the SAMHSA principles, and creating an approach that is most relevant for our trauma center personnel. The curriculum teaches the principles of TIC, and also allows for practice in mock situations and for debriefing. We know that providers experience vicarious trauma, so part of our efforts are geared toward exploring healthy ways to cope with the frequent trauma we see as practitioners. The curriculum is designed to be pertinent to any provider who is in contact with injured patients. Finally, the curriculum will have an element of adaptability so that local sites can both recruit members of the community to participate in teaching and tailor content to the relevant history and culture of their communities.

Integrating social care into trauma care

The National Academies of Sciences, Engineering, and Medicine report, Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health,¹³ introduced a set of goals that would result in better integration of social care into healthcare. Although these goals are widely applicable, the ISAVE Workgroup worked to identify trauma center-specific strategies. This led to a discussion of the following pragmatic question: Why is it important that trauma practitioners have some understanding of the social care system?

Patients enter a trauma center with a history; this can include pre-existing physical or mental health conditions or physical and/or emotional traumatic experiences. Particularly when these experiences occur early in life, they are collectively referred to as adverse childhood experiences. Even those who have not been personally affected by earlier trauma can be impacted by exposure to physical and psychological trauma in their families and communities. Familial and community trauma can be just as impactful as if the patient had experienced it themselves. Survivors of physical and psychological trauma can have toxic stress, and unmet basic social needs related to housing, employment, nutrition, and education. These factors represent the lived experience and affect the individual patient's response to acute treatment and will almost certainly have an impact on their long-term recovery and functioning.

Social workers and mental healthcare professionals are usually available in trauma centers to provide social and mental healthcare support. The ISAVE Workgroup believes it is important that trauma practitioners have some basic competence in social care, just as these practitioners must have basic competence in pharmacology and interpretation of radiographs even though pharmacists and radiologists are available in trauma centers. A better understanding of the social services system and how it functions is needed. By improving our level of awareness in this regard, we can work better with our other team members to provide optimal care and support to the patients, families, and communities we serve.

Social service systems vary by county and localities within counties. There is a common misconception that social services are designed only for “the poor,” and there is often a stigma associated with receiving such services. Government, not-for-profit, and faith-based organizations provide social care and support to a wide variety of people—veterans, farmers, low-income workers, unemployed people, homeless people, people with congenital or acquired disabilities, and the elderly. These functions are part of the social care system, often with the aim of reducing the need for acute care by improving health. Private- and public-sector social care can also supplement early childhood education. Social care often involves nutrition support to vulnerable or isolated populations and, in ideal settings, provides mental health support and access to rehabilitative services for those recovering from injury or violence.

Multiple studies, as well as the National Academies of Sciences, Engineering, and Medicine report,¹³ have provided data that document that addressing social needs leads to improved health outcomes. A 2016 study by Bradley and colleagues²¹ suggested that investment in social services and public health can affect individual health outcomes. A pilot study conducted in Boston looked at families who experienced both medically complex issues and housing instability and found that a population-specific model incorporating health, housing, legal, and social services was able to improve health-related outcomes at the household level.²² Providing robust acute healthcare with robust social care is the concept behind integrated care. Integrated care refers to care that uses a maximal degree of collaboration among the acute healthcare team and the social care team. It requires sharing of information among team members related to patient care and the development of a comprehensive plan to address the biologic, psychologic, emotional, spiritual, and social needs of the patient. Optimum integrated care requires collaboration with the patient, family, and people from the community with similar lived experiences as the patient.

Hospital-based violence intervention programs (HVIPs) represent an important example of how trauma centers are incorporating social care into trauma care. HVIPs have the following 3 essential tenants:

1. Identification of high-risk individuals in the hospital after a violent injury.
2. Engagement of these patients, at the bedside, by culturally appropriate violence prevention professionals. Many HVIP frontline workers have lived experience from a similar background and are immediately seen as credible messengers and potential mentors to victims of violence. Violence prevention professionals are the most skilled member of the trauma team to identify high-risk individuals.
3. Development of an individual needs assessment by the violence prevention professional and the HVIP client. The violence prevention professional connects the client with mental healthcare and risk reduction resources in the community to address their SDH. This portion of care might focus on employment; education; navigating government and legal systems; housing and relocation; and a number of important ancillary services, such as tattoo removal, mapping out safe transportation, and other needs. This occurs in concert with mental healthcare and substance abuse services as needed. The relationship of the client and the violence prevention professional typically lasts for months, but unofficially often extends beyond any official timeline. HVIPs represent a model of equity care. Instead of providing “one size fits all” services, the type and intensity of services are based on individual need.

The COT has a partnership with the Health Alliance for Violence Intervention, an umbrella organization that promotes scaling up, evaluation, advocacy, and sustainability of HVIPs nationally. A roadmap for development and sustainability of HVIPs, along with best practices, was produced by the ACS COT as a result of this partnership.²³ Evaluation of efficacy of HVIPs should include a qualitative component to include the most essential voice—that of the client.²⁴

The trauma center's role in investing in at-risk communities

The most known form of segregation occurs at the geographic level. Racial residential segregation occurred with the great migration during reconstruction after the Civil War with movement of Black Americans into cities where there was a pervasive practice to deny, or to only provide high-interest loans, to these individuals who were categorized as financially hazardous to lenders.²⁵ These efforts predated and informed the practice that we now recognize as redlining, which was developed in the 1930s to determine which areas were worthy of government investment and economic development by taking into account a number of indices that included Black, immigrant, and Jewish populations.²⁶

Health and wealth are inextricably tied to one another. There is thought to be a 10-year gap in life expectancy in the US between the most and least advantaged populations. Impoverished communities experience acute illness, chronic disease, food deserts, environmental exposures, and violence disproportionately. As we described, Black and Brown communities experience a racial wealth gap relative to White communities, although rural White Americans are also deeply impacted by this gap and share a common lack of access to mechanisms to build financial security. Development of the racial wealth gap can be traced back even further than redlining and continues to plague communities. Creating opportunities for financial and educational inclusion might not be seen on the surface as a health-related matter but, in fact, it is at its core.

Trauma centers, as with other institutions and businesses, have investment choices. Using the Community Health Needs Assessment,²⁷ which is mandatory for tax-exempt hospitals under the Affordable Care Act, can provide a clear impetus to invest in at-risk communities. Trauma centers can use simple strategies, such as committing to using local vendors for their cafeteria food or engaging in the Health Care Anchor Network to consider integrated strategies with their local communities. Most critically, investment in community requires partnership with the community to understand the perspective of the people we serve in our trauma centers as a first step to understanding where we can be most supportive.

There are some landmark examples of healthcare investment in community. In 2017, Boston Medical Center pledged to invest $6.5 million in affordable housing initiatives during a 5-year period. The pledge was based on their Community Health Needs Assessment in which stable, affordable housing was characterized as the priority. The initiative is being closely studied and Boston Medical Center is now joined in their pledge for housing investment by Boston Children's Hospital and Brigham and Women's Hospital.²⁸

Boston Medical Center's initiative includes plans to track how community health improves in the long term. Housing, like other upstream SDH, is part of a long and complex pathway with multiple intervening and interacting factors that eventually leads to improved health and reduced health disparities. However, there are often prolonged lags when looking for these subsequent health effects. In trauma, there are recent data that show that violent deaths are higher in economically distressed areas and that housing vacancy rates are a predictor of violent youth firearm events.²⁹ An investment in housing works to reverse the socioeconomic disinvestment and decline in at-risk communities and therefore alter the life course of trauma victims and optimize a path of independence and freedom from harm.

Advocacy

The fourth strategy of ISAVE is advocacy and is considered an overarching theme across the other areas of focus. Our vision is that trauma center personnel, as part of their intrinsic duties, address the SDH that lead to violence using advocacy and in partnership with their community. Trauma centers, in their commitment to prevention, have a key role to play in advocacy. Considerable opportunity exists from our vantage point as trauma practitioners and trauma centers to partner with affected communities in cohesive and comprehensive advocacy efforts. Advocacy is necessary to support each of the 3 other ISAVE strategies and it comes in many forms. For example, developing an advocacy strategy by which we can engage hospital and healthcare system administrators might include leveraging the Affordable Care Act's Community Health Needs Assessment²⁷ to encourage hospitals to engage in addressing poverty and unemployment, as well as being versed in the Community Benefits Program. Finally, gaining an understanding of how equity care and value-based care are tightly related is another important approach in conversations with administrations.

Stakeholders do not include only hospital administrators. Being engaged in the political process by working with our local and federal representatives is also very important in addressing root causes of violence. For example, many members of the ISAVE Workgroup have been involved in crafting and supporting the H.R. 5855 Bipartisan Solutions to Cyclical Violence Act³⁰ and the Biden Administration's efforts in funding community violence prevention initiatives, along with funding for firearm injury prevention research.

Forms of advocacy can range from aiding in crafting bills, to constructing “elevator pitches,” to testifying and letter writing. Working in tandem with our affected communities aids the notion of strength in solidarity. We can be a powerful voice to support our patients and highlight the consequences of the cycle of violence. Civic engagement is a powerful instrument in the US that can lead to tangible realization of the initiatives outlined in our ISAVE strategies.

CONCLUSIONS

For trauma center care in the future, we envision that all victims of violence will have not only the optimal care for their physical injuries, but also receive patient-centered care using a trauma-informed approach leading to a restored sense of empowerment. We see an integrated team of medical, social, and mental healthcare professionals working together to provide all of the services that facilitate an optimal and full recovery. Broader efforts, driven by individual trauma centers’ and healthcare systems’ investments in the communities they serve, hold the promise of systematically breaking the cycle of violence by reducing economic poverty and disrupting the structural barriers that feed the cycle of violence.

Pragmatically, the ISAVE Workgroup understands there is no perfect or simple solution for an issue as complex as violence in America, and we understand there is much more to be done; however, implementing these recommendations is a strong step toward addressing the root causes of violence. This basic approach is supported by the leading professional organizations across the US. The foundation of this approach rests on the best available science on the neurocognitive and psychosocial impact of trauma. The economic investment ISAVE recommends is feasible and focused on the communities our trauma centers serve.

Physical trauma leads to psychological trauma and psychological trauma predisposes to physical trauma.³¹ Optimally addressing one requires addressing the other. Although complex, effective interventions for violence are not as complicated as those required to combat a novel coronavirus pandemic, and as the COVID-19 pandemic has plainly demonstrated, we are all in this together. What affects one of us, affects all of us. Vulnerable populations are at much greater risk of poor outcomes and deaths, but all are impacted, and all are susceptible.^32,33 We all bear responsibility for the epidemic of violence impacting our children, families, friends, and neighborhoods. Responsibility requires creation of a culture of hope, resilience, and safety so that we, our patients, and their families can see a clear path forward to a better future. Proceeding down this path will save tens of thousands of American lives every year, and simultaneously support the development of safe, thriving communities to the benefit of all. We know this can be done, and we are optimistic and hopeful that the same public health approach that has saved hundreds of thousands of lives from infectious disease and unintentional injury can do the same for intentional injury.

AUTHOR CONTRIBUTIONS

Study conception and design: Dicker, Thomas, Bulger, Stewart, Bonne, Dechert, Smith, Love-Craighead, Dreier, Kotagal, Kozyckyj, Michaels

Acquisition of data: Dicker, Thomas, Bulger, Stewart, Bonne, Dechert, Smith, Love-Craighead, Dreier, Kotagal, Kozyckyj, Michaels

Analysis and interpretation of data: Dicker, Thomas, Bulger, Stewart, Bonne, Dechert, Smith, Love-Craighead, Dreier, Kotagal, Kozyckyj, Michaels

Drafting of manuscript: Dicker, Thomas, Bulger, Stewart, Bonne, Dechert, Smith, Love-Craighead, Dreier, Kotagal, Kozyckyj, Michaels

Critical revision: Dicker, Bulger, Stewart, Kozyckyj, Michaels