Lessons Learned from 50 Years of Violence Prevention Activities in the African American Community

Abstract

Purpose: This article covers violence prevention (homicide and suicide) activities in the African American community for nearly 50 years. Method: Drawing on lived experience the works of early and recent efforts by African American physicians, the author illustrates we know a great deal about violence prevention in the African American community. Results: There remains challenges of implementation and political will. Further, most physicians, like the public, are confused about the realities of homicide and suicide because of the two different presentations both are given in the media and scientific literature. Conclusions: Responses to homicide and suicides should be based on science not distorted media reports. There are violence prevention principles that, if widely implemented, could stem the tide of violence.

Full text

SPECIAL SECTION: VIOLENCE
Lessons Learned from 50 Years of Violence
Prevention Activities in the African American
Community
Carl C. Bell, M.D.
Abstract: Purpose: This article covers violence prevention (homicide and
suicide) activities in the African American community for nearly 50 years.
Method: Drawing on lived experience the works of early and recent efforts by
African American physicians, the author illustrates we know a great deal about
violence prevention in the African American community.
Results: There remains challenges of implementation and political will. Further,
most physicians, like the public, are confused about the realities of homicide
and suicide because of the two different presentations both are given in the
media and scientific literature.
Conclusions: Responses to homicide and suicides should be based on science
not distorted media reports. There are violence prevention principles that, if
widely implemented, could stem the tide of violence.
Keywords: Homicide-Suicide-Prevention-Historical perspectives
Author affiliations: Carl C. Bell, Jackson Park Hospital Family Medicine Center, USA;
University of Illinois at Chicago (Ret.), USA; Community Mental Health Council, Inc. (Ret.),
USA
Correspondence: Carl C. Bell, M.D., Jackson Park Hospital, Family Medicine Center, 1625 E.
75th Street, MOB e1st floor, Chicago, IL 60647, USA., email: bell-carl@att.net
ª2017 by the National Medical Association. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jnma.2017.04.006
INTRODUCTION
Physicians are confused about the realities of homi-
cide and suicide in the African American commu-
nity. On one side, there is the media touting the
extreme rates of homicide in the African American com-
munity with such truisms that homicide has been the
leading cause of death in African American males 15-44.
On the other side is the scientific fact that African Amer-
ican rates of homicide have always run much less than
100/100,000 per year or less than 0.1% of the population
making it a very rare event. Overall suicide rates have
always been higher than overall homicide rates. They have
always run below 15/100,000 making suicides less than
0.015% of the general population, and African American
suicides have always been half that of European American
suicides making suicides rare events. However, the media
appropriately highlights suicide as the second leading
cause of death in 15-34 year old people. Thus, physicians
are presented with two opposite perspectives eone that
these causes of death are epidemic and the other that these
events are rare occurrences. This article seeks to clarify
these perspectives and provide a thoughtful approach to
preventing the problems of homicide and suicide in the
African American community.
After nearly half a century of treating Black psychiatric
patients for a variety of disorders, one single fact has
repeatedly proven to be true e“risk factors are not pre-
dictive factors because of protective factors.”The protec-
tive factors operating in people’s lives work to mitigate
negative outcomes such as an adolescent’s participation in
violent behavior, drug use, dropping out of school, early
sexual debut, and other risky behaviors. The Community
Mental Health Council, Inc. first learned this lesson in
1982 when the research team at the Community Mental
Health Council, Inc. began to call the nation’s attention to
the inordinate number of Black children at risk for nega-
tive outcomes such as perpetration of violence, because of
exposure to violence. However, the protective factors in
these children’s lives nullified the risk of other problematic
behaviors.
After years of research, the Aban Aya project ran in
Chicago Public Schools between 1994 and 1998,
1,2
and
protective factors were placed into the lives of “at risk”
middle school students. These protective factors were: 1)
rebuilding students’“village”which cultivates the stu-
dent’s social and emotional support and builds an adult
protective shield for youth; 2) providing opportunities to
increase connectedness and self esteem (a sense of power,
uniqueness, models, and connectedness
3
), and 3) teaching
youth social and emotional skills such as affect regulation.
The outcomes revealed there was reduced growth in vio-
lent behavior, school delinquency, drug use, and recent
sexual intercourse by at least one-third.
1,2
Findings from
the research suggest risk is not just the presence of a bad,
toxic influence, but also the absence of a good, protective
influence. Due to the complexity of the Aban Aya research
model (Triadic Theory of Influence
2
), Seven Field Prin-
ciples were developed to make implementation easier to
cultivate resiliency, generate hope, and provide protective
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factors that could prevent negative outcomes among youth.
These principles were used to guide violence prevention
activities in Chicago Public Schools with some success.
4,5
This paper proposes that the issue of violence prevention
has already been partly solved through years of research
and, in some cases, implementation. This paper also pro-
poses that the same principles that help prevent violence
also help to prevent other risky behaviors such as risky
sexual behaviors resulting in HIV infections,
6
child abuse,
7
and teen pregnancy.
8
Risky behaviors and protective
factors are multi-determined and dependent on biological,
psychological, sociological, and cultural forces that
weave a complex tapestry of etiology. The Seven Field
Principles ecover these complex etiologic factors and will
be discussed with examples of their historic operations to
strengthen or weaken outcomes such as violence toward
others (at its extreme ehomicide) and violence toward self
(at its extreme esuicide) in the African American
community.
HISTORICAL CONTEXT
Homicide
The Black Psychiatrists of America was spearheaded by
Dr. Chester M. Pierce, M.D. from Harvard University in
1969. Of the organization Dr. Pierce said, “It was born to
be action oriented.”
9
He also noted “.we the Blacks had
no choice, given the conditions of our people, but to opt
for action programs far beyond the walls of the consulting
room and the clinic.”
9
From these efforts Dr. James Ralph,
M.D. was appointed the Chief of the Center for Minority
Group Mental Health Programs in 1970. In his role,
Dr. Ralph began going to work on the behavioral issues
affecting public health issues for African Americans, and,
as homicide rates were disproportionately higher in Afri-
can Americans than in European Americans, the problem
of homicide in African Americans became a major priority.
Dr. Ralph was instrumental in funding Ruth Dennis at
Meharry Medical College to study black homicide and in
1977; Dr. Dennis noted homicide had become the leading
cause of death for black males 20-34.
10
Dr. Ralph also
successfully funded Dr. Dennis
11
and Dr. Rose,
12
to do
research on the issue of African American homicide and
they both published results in 1981 noting most of the
circumstances in Black homicide involving Black males
were interpersonal altercations between family and friends.
Furthermore, both studies advised at the beginning of the
altercation the victim and the perpetrator could not be
identified until after the homicide. As a result of this new
information, the National Association of Social Workers
and the National Institute of Mental Health (Office of
Prevention and the Center for the Study of Minority Group
Mental Health) held a conference in 1984 to ferret out the
causes for this problematic behavior occurring between
two people who knew one another as family, friends, or
acquaintances. To date all the drivers of homicidal be-
haviors were characterized as: 1) cultural (e.g. it was said
African Americans had a culture of violence
13
); 2) socio-
logical (as exemplified by Dr. Dennis’
11
and Dr. Rose’s
research
12
); 3) psychological (exemplified by the psycho-
dynamic contributions by a founding member of the Black
Psychiatrists of America Dr. Alvin Poussaint
14
); or 4)
biological (Lewis et al,
15
Bell
16e19
as a result of head
injury). Part of the problem prior to the mid 1980s was the
lack of statistical sophistication to extricate the effect size
of the factors involved in generating behavior. However,
with a greater appreciation for the complex nature of
behavior (behavior is multi determined) and more so-
phisticated statistics it became possible to consider the
contribution of the various factors generating the risk for
homicide.
Suicide
The history of research on African American suicide rates
has been less robust owing to the reality that, although
overall suicide rates have always been higher than overall
homicide rates, the suicide rates in the African American
have always been lower than the White rates of sui-
cide.
20,21
In fact, African American male and female rates
of suicide have tended to run half that of the rates of White
suicides (slightly below 10/100,000 and 2/100,000,
respectively), with African American women having the
lowest rates of suicide in the US.
20,21
Like homicide,
suicidal behavior is very complex making it a difficult area
of investigation, resulting in many of the publications on
African American suicide being clinical and anecdotal in
nature.
22e26
In 1999, Dr. Satcher released his The Surgeon
General’s Call to Action to Prevent Suicide,
27
and this
document raised the issue of risk and protective factors,
but the protective factors were focused on mental health
interventions to prevent suicide. However, in the Institute
of Medicine’s landmark report on Reducing Suicide,
21
the
critical question of what non-mental health interventions
were protecting African Americans from higher suicide
rates, compared with European and Native Americans, was
proposed. This spurred scientific research on this question,
which will be reviewed below.
One other issue regarding African American suicides
deserves mention e“suicide by cop.”Since the Rodney
King beating video in 1991, videos have been increasingly
used to document the allegedly illegal victimization of
African-Americans by the police. Videos of the police
using lethal force have raised the question regarding
whether or not African Americans are using the police to
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kill them in what has been dubbed “Suicide by Cop.”
Although not a random sample, one study outlined the
frequency and characteristics of “suicide by cop”in 707
officer-involved shootings.
28
In this nonrandom sample,
the authors report that 36% of the officer-involved shoot-
ings were “suicide by cop.”Another study investigated
death from the use of lethal force by law enforcement from
the National Violent Death Reporting System from 17 US
states from 2009 to 2012.
29
In this study, there were 812
deaths and although the majority of victims were White
(52%), African-Americans had a disproportionate rate of
32%.
29
The authors four case subtypes (one of which was
“suicide by cop”suspected at 18%) could not classify
more than half of the cases.
29
Twenty-two percent of these
incidents were thought to be mental health related.
29
One
other study examined the racial/ethnic disparities in the use
of lethal force by US police from 2010 to 2014.
30
This
study found the mortality rates among non-Hispanic Black
and Hispanic individuals was 2.8 and 1.7 times higher,
respectively than among Whites.
30
Accordingly, the
concept of “suicide by cop”is fraught with difficulties as
the category of “suicide by cop”could be used to blame
the victim for illegitimate use of excessive police force.
How do you tell whether the death of an African-American
victim is a result of lethal use of police force as a result of
racial stereotypic assumptions by the officer involved in
the shooting or if was a legitimate use of force which was
due to the victim wanting to be killed and used the police
as their instrument. Fortunately, the National Medical
Association prepared a thoughtful position on “Police Use
of Force”,
31
which called for more data to fully understand
the extent of the police’s use of force.
TRENDS IN HOMICIDE RATES AND
SUICIDE RATES
Homicide rates
The homicide rates of African Americans has been 6-12
times higher than Whites since the FBI began collecting
homicide statistics in 1929.
32
An examination of the ho-
micide rates show they bounce up and down randomly, but
there are various notable trends. For example, the national
homicide rate prevailing in 1965 was 6.2 per 100,000, but
by 1975 it had climbed to 10.2 per 100,000.
33
The black
homicide rate in 1965 was 30.1/100,000, but by 1973 it
had risen to 44/100,000.
33
Accordingly, it is clear that the
increased risk of homicide victimization for African
Americans, already serious problem, was getting worse,
and by 1972, it had become the single leading cause of
death among black males ages 20-34.
10
By 1983 the ho-
micide rates were the leading cause of death in black males
15-34 and by 1986 the black male homicide rates had risen
to 55.9/100,000 with the female rates at 11.8/100,000.
20
As the ages of homicide victims and perpetrators has
decreased over the years, greater attention was paid to
youth homicide and we observed that homicide rates for
non-Hispanic Blacks ages 10-24 dropped from 62.6/
100,000 in 1991 down to 32.8/100,000 in 2005,
34
a
decrease of nearly 50%. By 2010, the rates for non-
Hispanic Blacks ages 15-19 were 52/100,000, and for
older non-Hispanic Black, youth ages 20-24, the rates
were 28.8/100,000.
35
Suicide rates
The trends in African American suicide rates are equally as
interesting. Since 2000, African American rates run half of
European American rates (averaging 11-13/100,000)
averaging 6.14-6.53 per 100,000.
21
In addition, there is a
striking contrast in age distribution of African American
and European American suicides eAfrican American
peak rates are in the 25-34 year age group and the peak for
European Americans is in the 65 years and older category
(60/100,000).
20
Unlike homicide rates, the overall suicide
rates have been relatively stable, however in 1999 when
the rates were less than 11/100,000, the rates went up to
13/100,000 in 2014.
36
However, there was a small increase
in African American youth suicides in the 15-24 ages from
1993 to 1994, but which quickly disappeared.
37
Thus, we see that both the homicide and suicide rates
have, despite some fluctuations, been fairly consistent.
This finding is not puzzling because there really is not any
statistical difference in the rates. The reality is that homi-
cide rates that range between 62/100,000 and 11.8/100,000
is not statistically significant. The same holds true for
suicide rates that range between 60/100,000 and 2/
100,000.
21
The denominator of these rates is so large
(100,000) the numerator could be 100, and we would be
talking about a percentage of 0.1 percent of the population,
and comparing that low rate to a rate of 2/100,000, or a
percentage of 0.002 percent of the population makes such
comparisons spurious. These low rate behaviors make it
even more difficult to ferret out prevention strategies to
combat these serious public health problems.
PREVENTION EFFORTS FOR HOMICIDE
AND SUICIDE
Homicide and violence
As mentioned above, early efforts to prevent homicide
tended to follow the “magic bullet”approaches to public
health problems. For example ‘If we could only find the
main cause of the problem it would be solved’egun
control, alcohol restriction, exposure to violence creating a
violent nature, mental illness, etc. Unfortunately, behavior
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is multi-determined and there is no “magic bullet,”and
such thinking is generally indicative of an unsophisticated
approach to behavior change. Rather, there are biological,
psychological, social, and cultural factors that contribute to
afinalized behavior such as homicide, however, some of
these factors carry more weight than the others do. Of all
of them, the biological may be the most malleable if it is
acquired biology instead of genetic biology. An example
of acquired biology is a flu shot. Sure to avoid getting the
flu, washing your hands and keeping them out of your
nose and eyes would prevent the flu, but it is easier to get a
flu shot.
In trying to unravel the issue of homicide, it first
became clear there were many different types of violence
that generated homicide. These were:
1) Group or mob violence;
2) individual violence;
3) systemic violence, such as war, racism or sexism;
4) Institutional violence such as preventing correc-
tional inmates from getting the benefit of prophy-
lactic medications to prevent hepatitis, or social
determinants of health that harm people, such as
the plethora of liquor stores in some communities;
5) Hate crime violence, such as terrorism;
6) Multicide such as mass murder, murder sprees, and
serial killing (which used to be defined as 3 people
being killed, but which has been increased to
4 people killed);
7) Psychopathic violence;
8) Predatory violence also know as instrumental or
secondary violence;
9) Interpersonal altercation violence, also known as
expressive or primary violence (e.g. domestic
violence, child abuse, elder abuse, and peer violence;
10) Drug related violence, such as systemic drug related
violence (where drug dealers kill to sell drugs),
pharmacological drug related violence (where an
individual perpetrates violence because of drug
intoxication), economic compulsive drug related
violence (where a drug addict uses violence to
obtain drugs), and negligent drug related violence
(such as a drunk driver who kills a pedestrian);
11) Gang related violence;
12) Violence by mentally ill individuals;
13) Lethal violence directed toward self (suicide);
14) Lethal violence directed toward others (homicide);
15) Violence by organically brain damaged individuals;
16) Legitimate/Illegitimate violence (e.g. true self
defense verses a policeman shooting an unarmed
teenager);
17) And nonlethal violence.
38e40
It was clear that different types of homicide required
different prevention, intervention, and postvention strate-
gies.
40
However, regarding prevention efforts, as the ma-
jority of homicides in the African American community
were interpersonal altercation homicides, the dictates of
public health demanded this type of homicide get the most
attention.
In 1985, US Surgeon General Koop declared violence as
public health problem.
41
This re-conceptualization of
violence was intended to shift the public’s perception that
violence was primarily a problem of predatory aggression.
In a corollary public health strategy, the women’s movement
had shifted the public perception that rape was mostly a
stranger rape issue when it was really in large part a family,
friend, acquaintance problem. Accordingly, there was a shift
in women’s perception of the danger of being raped. Un-
fortunately, the same shift has not happened with homicide
as the fear of being killed is still dominated by a ‘stranger
danger’fear when it is largely a family, friend acquaintance
problem similar to rape. The goal was properly to charac-
terize most homicides as interpersonal altercation aggres-
sion, because the approach to predatory aggression was law
enforcement, i.e. after the fact (postvention) while a new
approach to interpersonal altercation aggression might
result in universal homicide prevention, i.e. preventing
violence before it escalates into homicide thus preventing
homicides before they occur. Also, in the mid 1980s, the
research team at the Community Mental Health Council,
Inc. (CMHC) in Chicago began exploring children’s expo-
sure to violence as a cause for the future perpetration of
violence.
42
The National Medical Association got involved
with the public health approach to violence,
43
Dr. Prothrow-
Stith, and internist at Harvard, had developed a violence
prevention curriculum for adolescents.
44
It was also during
this time CMHC started a “Stop Black on Black Murder”
campaign with a catchy logo on T-Shirts and Posters to
publicize the problem (Figure 1), an effort that got national
media attention for several years.
It was also in the mid 1980s that Congressman Louis
Stokes held the Congressional Black Caucus “Mini-Health
Braintrust”, in Washington, D.C., May 12-16, 1986. It was
at that meeting that plans began to form for the Family and
Community Violence Prevention (FCVP) Program, an
initiative established in 1994. The program was funded by
the Federal Government (thanks to Congressman Stokes’
behind the scenes work) and used the infrastructure pro-
vided by the Historically Black Colleges and Universities
(HBCUs) to do family and community violence preven-
tion.
45
The 4th National Conference Family and
Community Violence Prevention in Houston, TX October
17-19, 1997, highlighted the “Seven Basic Principles of
Violence Prevention”and provided a blueprint for the
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Family Life Centers at 19 Historically Black Colleges and
Universities and Minority Institutions to work within
predominately African American communities doing
violence prevention.
46
However, it was not until the late 1980s and early 1990s
that modern statistics allowed researchers to examine the
complex interactions between various biological, psycho-
logical, sociological, and cultural factors that generated
behavior. That development held out the promise that
public health might finally engage in health behavior
change.
4
Rather than study one factor that seemed to
generate behavior, researchers were finally beginning to
research multiple factors that had a role in generating
behavior.
During President Clinton’s term in office, he directed
his entire White House Cabinet to work on the issue of
violence against women,
35
this along with previous efforts
to provide battered women’s shelters resulting in a
decrease in intimate partner homicide rates from 16.5/
100,000 in 1976 down to 3.5/100,000 in 1996.
47
In 2001,
Dr. David Satcher, the US 16th Surgeon General, released
his landmark Youth Violence report.
48
This report, plau-
sibly the most comprehensive written to date, on the topic
of youth violence, does an admirable job of explaining
there are risk and protective factors that determine
behavioral outcomes such as youth violence. The report
destroys several common myths about youth violence,
e.g. urban youth homicide rates are increasing dramatically
and youth violence cannot be prevented. Myths that persist
despite Centers for Disease Control and Prevention’s
(CDC) evidence that youth homicide has decreased
steadily from 1994 (when it peaked at 15.2/100,000) until
Dr. Satcher’s report was published in 2001, and continued
until as late as 2010 when it was 7.5/100,000,
49
a decrease
of 50%. Myths that endure despite evidence programs
aimed at decreasing youth violence have been shown to be
effective for more than 100 years.
35,50
In this report, Dr. Satcher also debunked the impact risk
factors had on putting youth at risk for juvenile violence.
48
Specifically, his report noted for juveniles 12-14 years of
age, risk factors such as: a) Psychological condition;
b) Restlessness; c) Difficulty concentrating; d) Poor parent
child relations; e) Harsh, lax discipline; f) poor monitoring,
and supervision; g) Low parental involvement;
h) Aggression; i) Being male; j) Poor attitude toward and
performance in school; k) Academic failure; l) Physical
violence; m) Neighborhood crime and drugs; n) Neigh-
borhood disorganization; o) Antisocial parents; p) Anti-
social attitudes and beliefs; q) Crimes against persons;
r) Problem (antisocial) behavior; s) Low IQ; t) Broken
home; u) Low family socioeconomic status/poverty;
v) Abusive parents; w) Other family conditions; x) Family
conflict; and y) Substance use all had individual small
effect sizes of less than 0.2.
48
So, all of the things we
stereotypically associate with the causes of youth violence
are not accurate according to scientific study. Furthermore,
for youth in that same age range, weak social ties, anti-
social, delinquent peers, and gang membership had a large
effect size of greater than 0.30.
48
This groundbreaking
report also outlined the protective factors that buffered
against youth violence. In the individual domain,
Dr. Satcher’s report proposed protective factors were:
intolerant attitudes toward deviance; high IQ; being fe-
male; warm, supportive relationships with parents or other
adults (known as connectedness in the seven field principle
model
4e6
); and having a positive social orientation.
48
In
the family domain, the report suggested protective factors
were parents’positive evaluation of peers; and parental
monitoring
48
(conceived in the seven field principles as the
adult protective shield
4e6
). In the school domain, the
projected protective factors were commitment to school;
and recognition for involvement in conventional activ-
ities.
48
And, finally, in the peer group domain the protec-
tive factor was friends who engage in conventional
behavior.
48
Figure 1. Stop Black on Black Murder.
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Evidence for the principle of rebuilding the village
and providing an adult protective shield. Dr. Satcher’s
Youth Violence Report’s protective factors overlapped
nicely with the protective factors mentioned earlier in the
various research projects the author has been personally
involved with doing,
1,2,4e8
and there is historical evidence
that each of these various protective factors have been
instrumental in helping diverse communities overcome
public health challenges. Regarding the protective factor of
“rebuilding the village”(what Dr. Satcher’s youth violence
report refers to as “warm, supportive relationships with
parents or other adults”), consider Nobel Prize winning
Jane Addam’s work over 100 years ago. Right after the
Chicago fire, Irish, German, and Italian immigrants moved
to Chicago and it was 75% immigrant. It was a challenging
time as parents were working all the time and youth were
essentially unsupervised and without a village to raise them
so “warm, supportive relationships with parents or other
adults”were few and far between. As a result, Chicago had
a juvenile delinquency problem
51
and there was a fair
amount of European immigrant’s domestic violence in
Chicago from 1875 to 1920.
52
None of the families were
protected by social fabric that comes from “rebuilding the
village.”Addams and her colleagues established Hull
House in Chicago and in 1889, they went on to establish
the first Juvenile Court
50
that differentiated between
criminality and delinquency. Finally, 10 years later these
visionary women established what is now called the
Institute of Juvenile Research (IJR) ean organization
whose purpose was to find the causes of delinquency. By
1942, IJR researchers asserted delinquency was less due to
biological, ethnic or cultural risk factors but was more due
to social disruption or a lack of social fabric so there was
limited formal and informal control in neighborhoods they
referred to as delinquency areas.
53
Of course, the statistical
methodology more than 60 years ago was far less sophis-
ticated than today. However, using more refined technol-
ogy Sampson et al’s research
54
observed that of the 49
equally poor African American neighborhoods in Chicago,
six had the highest rates of violence and were responsible
for the lion’s share of violence in Chicago and the differ-
ence was generated by the lack of “social fabric”.
54
James
Comer, another founding member of the Black Psychia-
trists of America delineated the issue of “rebuilding the
village,”in his work in New Haven, CT. Dr. Comer spent
years going around from neighbor to neighbor re estab-
lishing village and as a result he was able to document
significant changes both in educational achievements and
violence related behaviors.
55e58
The Aban Aya project
took a lesson from Dr. Comer’s“play book”when we
sought to reduce violence in Chicago public schools.
1,2,4e6
Such efforts also provide an adult protective shield for
youth until they “learn how to act”. Scientists are now
clear that children do not fully mature until around 26
years of age.
59
To put it succinctly, adolescents are “all
gasoline, no brakes, and no steering wheel.”,
60
and,
accordingly, they need adults to protect them from them-
selves. By “rebuilding the village”using various strategies
that fit the community and the interventionists, it becomes
possible for all of the adults in the community to raise each
other’s youth and also increase the “connectedness”within
that community so that risky behaviors such as violence
are frowned upon.
Evidence for the access to modern and ancient
technology. Being a physician, the author is clear that
biology has a strong influence on behavior, however, this
field principle, until recently, has been elusive. Initially,
when the field principles were being developed from the
Theory of Triadic influence,
4
the truncated principle “ac-
cess to the modern technology”covered access to health
care as it seemed clear that youth with neuropsychiatric
issues, e.g. ADHD, were predisposed to being diagnosed
as having conduct disorders. Further, there was evidence
that these disorders were associated with violence from
work in Chicago Public Schools.
61
Initially, we thought it
might be exposure to violence and trauma that caused
African Americans to engage in risk taking behaviors such
as violence, unsafe sex, dropping out from school, sub-
stance abuse, etc. Further, we hypothesized treatment for
these problems that delivered trauma informed care would
be helpful. However, although feasible, we had seen too
many African American children that were exposed to
violence and trauma who seemed resilient.
50,62e64
Since
that did not pan out, we next thought it might be head
injury as there was clinical evidence head injury might
generate violent behavior,
19
but that did not seem as
prevalent. Subsequently, prematurity seemed a viable
biological risk factor for unsafe behaviors that people took,
and there were potential protective factors that could buffer
against that risk factor, e.g. prenatal care, but things still
did not add up.
Finally, the author stumbled upon prenatal alcohol
exposure that lied at the root of the high prematurity rates
in African American youth, and the more we investigated
this phenomena and talked to patients with prenatal
exposure to alcohol, the more it became clear this was a
risk factor for perpetration of violence.
65e67
What is
happening is many African-American women do not
realize they are pregnant until the 1st or 2nd month, and,
during the time they do not know they are pregnant, they
may engage in social drinking. Although, it is important to
again note that behavior is multi-determined and just
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because a patient has been exposed to alcohol as a fetus
does not automatically mean they are prone to violence
because protective factors can neutralize this risk. Yet,
consider the most common cause of homicide, interper-
sonal altercation eit begs the question e“Who has such
poor affect regulation that they would harm someone they
presumably loved or who was their friend?”Prior to the
drop in homicide among intimates,
47
homicides were an
extraordinarily easy crime to solve, the murders were
usually spur of the moment, impulsive events that were not
being planned, so police had an easy time of identifying
likely suspects. However, since intimate altercation ho-
micides have decreased and gang related homicides have
had a relative increase,
35
the crime of homicide, especially
youth homicide, is more difficult to solve.
35
Ancient technology is included in this field principle
because it has also become increasingly clear that much of
what modern public health practitioners are observing and
doing in the 21st century was being done in ancient times.
For example, the emphasis on social and emotional skills
(a technology) has been emphasized in many ancient
spiritual texts, such as the Bible or the observation about
the dangers of prenatal alcohol is also found in the Bible
(Judges e13). So, much of public health interventions is
“old wine in new bottles.”Exploring the histories of low
income African American patients with prenatal exposure
to alcohol reveals clinically histories replete with violent
behaviors in their lives and sometimes such violence has
been as extreme as homicide. It is now clear that the
problem of fetal alcohol exposure with its attendant poor
impulse control and frustration tolerance is at the root of
many risky behaviors within African American commu-
nities, one of them being violence toward others (at its
extreme ehomicide). Fetal alcohol spectrum disorder,
now proposed being called Neurobehavioral Disorder
associated with Prenatal Alcohol Exposure (ND PAE) by
the American Psychiatric Association in DSM 5,
68
is
partly caused by alcohol denaturing choline in pregnant
women when they unwittingly drink socially. Accordingly,
a protective factors for this biological, etiological factor for
violence might be increasing choline intake in pregnant
women. This effect has been shown in animal studies,
69
but it has yet to be shown conclusively effective in
humans although there are promising studies that illustrate
how choline helps with prenatal alcohol exposure pre- and
post-natally in humans.
70e74
Unfortunately, prenatal vita-
mins do not contain the necessary daily required dose of
choline (450 mg/day).
75
Only two of the top 25 prenatal
vitamins have 50 mg of choline, six have less than 30 mg
of choline, and the rest have no choline.
75
Even if this
hypothesis turns out to be true, it will be years before
society sees the protective virtues of increasing the access
to choline in the diets of women. It turns out such long
term prevention strategies are difficult to implement as
many are looking for simple, short term fixes to the
problem of violence prevention. Accordingly, it is difficult
to generate a critical mass of political will to implement
such a long range prevention. Although, there are cultures
that recommend pregnant women eat two egg yokes a day
(a great source of choline), to have healthy children born to
them.
Connectedness. Another field principle to prevent risky
behaviors of violence is the principle of trying to increase
connectedness in at risk communities. Although, all of the
seven field principles are interdependent (to some extent
by “rebuilding the village,”and providing youth and adults
with the ‘access to the technology’of mentoring, increases
connectedness), this field principle needs explication to
ensure it is highlighted as a guiding protective factor
principle. Early on the principle of connectedness was
emphasized.
4
Parental warmth and affection was shown to
protect boys living in disadvantaged environments from
criminal behavior.
76
Improving closeness, positive state-
ments, communication clarity, and emotional cohesion in
families reduces the risk for grave antisocial behavior and
violence.
77
There have been several large empirical studies
that reveal family variables of children being connected to
their parents and schools are associated with reduced risk
taking.
78
This principle has been shown to be protective in
subsequent studies as well,
1,2,5e7
and has been hypothe-
sized to be a major factor in protecting people from
exposure to trauma.
79
Self esteem. As mentioned earlier self esteem was
operationalized as a sense of power, uniqueness, models,
and connectedness.
3
It is clear that youth violence is
sometimes driven by low self esteem.
80
There are multiple
ways of helping children and adults develop self esteem.
Willis et al
81
tested a model of how ethnic pride and self
control were related to risk and protective factors. The
result of this study highlighted good parenting was related
to self control and self esteem, and racial socialization was
related to ethnic pride. Certainly, this was a major
component of the Aban Aya prevention intervention
1e3
and the other successful prevention interventions that
used the seven field principle model.
5e7
Social and emotional skills. Teaching youth social and
emotional skills such as affect regulation, conflict resolu-
tion, refusal skills, ewere placed into the lives of “at risk”
middle school students.
1,2
This aspect of the model was
supplied by the work of Weissberg’s team.
82e85
Of course,
in the jargon of ancient technology in the African Amer-
ican community this was known as “home training,”or in
Black urban Chicago it was also referred to as “finesse.”
There are multiple ways to work with youth to teach them
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social and emotional skills, but one of the better ways is to
provide them with adult supervised sports.
63,86,87
Minimize the effect of trauma. Having done a fair
amount of research on the issue of children exposed to
violence and trauma,
40,88e94
we understood how trauma
was potentially a major cause of youth engaging in risky
behaviors such as violence. Accordingly, when we were
designing the Aban Aya research intervention, we spent a
considerable amount of time trying to figure out how to
help youth minimize the effects of trauma in their lives.
64
The impressive interventions of Pynoos and Nader,
95
and
the principle based guidance by Apfel and Simon
96
have
been particularly helpful in this regard. Unfortunately,
efforts to make Pynoos and Nader’s Psychological First
Aid technology ubiquitous were not completely success-
ful. Accordingly, the US imported Mental Health First
Aid, which was informed by the Psychological First Aid
model, and it is now widely available as training can be
obtained on line (https://www.mentalhealthfirstaid.org/cs/).
Independent evaluation of the model
being proposed for violence prevention
The Aban Aya research project,
1,2,4
was independently
reviewed along with 53 universal school based violence
prevention projects that met their inclusion criteria.
97
The
median sample size of the studies was 5563 (sample sizes
in the studies ranges from 21 to 39,168 students). Violence
or aggression was assessed by direct measures in 75% of
the studies, and the others used proxies for violence and
aggression. The median follow up time to measure
violence prevention was six months (the range was be-
tween immediately after the intervention up to six years
after the intervention). Aban Aya was one of the studies
classified as having the greatest design suitability as it was
an experimental design with intervention and control
subjects with the data being collected prospectively, and it
was one of seven with the greatest design suitability and
good execution. Aban Aya was identified as desirable
because the experimental condition showed a decrease in
violent behavior compared with the control condition and
it was classified as effective as it was tested in diverse
settings, populations, and circumstances.
97
Suffice it to
say, the seven field principles,
94
have been used in various
prevention interventions and has been shown to reduce
violence.
Suicide
The issue of suicide prevention in the African American
community is even more complex than the issue of
homicide prevention. Other than the reality that histori-
cally, very little research is done on African American
issues,
98
the suicide rates in African Americans have
generally run half that of European Americans making
African American suicide rates even rarer and more
difficult to study. Accordingly, most of the early articles on
African American suicides have been anecdotal or have
small sample sizes, however, since the Institute of Medi-
cine’s“Reducing Suicide”report was released in 2001,
21
there has been more work in this area. It was during the
Committee on Psychopathology and Prevention of
Adolescent and Adult Suicide’s deliberations that several
interesting paradoxes were pointed out. The first being the
extraordinarily low rates of completed suicide in African
American women e2/100,000,
21
quite an interesting
phenomena considering all the difficulties African Amer-
ican females experience in the US. Secondly, the facts
revealed the prevalence of depression was about 20% or
20,000/100,000/year in the population, and suicide at-
tempts in youth were about 7000 per 100,000 in the
population (7%) per year, yet the actual youth suicide rates
were at the time 11/100,000 people/year.
21
Accordingly, it
was pointed out that something must be protecting people
from committing suicide, and since the decades of taking a
deficit approach to suicide prevention, it might be more
fruitful to take a protective factor approach to the problem
of suicide. The 18th US Surgeon General, Dr. Regina
Benjamin, in the 2012 National Strategy for Suicide Pre-
vention,
99
continued this approach as protective factors
were also emphasized in this report. This report found
“More than 8 million adults report having serious thoughts
of suicide in the past year, 2.5 million report making a
suicide plan in the past year, and 1.1 million report a
suicide attempt in the past year.”
99,p. 10
Yet, the total
number of suicides per year in the US hover around
30,000, which begs the question “How does one identify
that 30,000 per year in the 2.5 million making plans and
1.1 million people that actually attempt suicide?”Again,
indicating it may be more productive to take a protective
factor approach to the problem of suicide. Another
perspective on the lower rates of suicide in African
Americans comes from a national study of jail suicides
(suicide is a leading cause of death in jails) where 67% of
suicide victims were White and 15% were African
American.
100
Dr. Satcher’s National Strategy for Suicide Prevention
26
and the Institute of Medicine’s seminal report
21
spurred
more research on African Americans by the researchers at
the University of Michigan’s Program for Research on
Black Americans and Emory University that explored
increasing protective factors as a prevention strategy in
suicide. For example, using a sample of 3263 African
Americans in the National Survey of American Life
(NSAL), Nguyen et al
101
determined “Subjective close-
ness to family and the frequency of contacts with friends
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were negatively associated with suicide ideation and at-
tempts.”Another study by the Michigan team using a
sample of 5191 Black Americans from the NSAL explored
the prevalence of suicidal ideation and attempts among
Black Americans in later life and found the estimated
lifetime prevalence of suicidal ideation and attempts was
6.1% and 2.1% respectively.
102
Kaslow’s team at Emory
also began exploring the use of culturally informed in-
terventions on suicidal African Americans.
103
This
research group has also been exploring protective factors
and have discovered motherhood as a reason for living
which and which protects African American women who
have attempted suicide.
104
Both studies containing ele-
ments of the Seven Field Principles. The Seven Field
Principle model also has relevance for the field of suicide
prevention and was used to culturally inform prevention
interventions for African American women.
103
and to
develop interventions for depressed African American
teens.
105e107
The model was also used to inform a primary
care internet based intervention to prevent depression in
emerging adults.
108e117
Several studies have upheld the field principles
of “rebuilding the village,”“connectedness,”and “re-
establishing the adult protective shield”.
118e120
For
example, one study showed increased family and peer
support were associated with decreased suicidality, and
peer support and community connectedness moderated the
relationship between depressive symptoms and suicidality;
with over 1/3 of the variability in reasons for living was
predicted by family support, peer support, and community
connectedness.
118
Additionally, the University of Michi-
gan team used cross-sectional epidemiologic data from the
NSAL and multivariate logistic regression analyses to
examine the association between perceived emotional
support, negative interaction, and suicide behaviors among
3570 African Americans and 1621 Caribbean blacks age
18 and older.
119
They found negative interaction was a risk
factor for suicide ideation and emotional support was a
protective factor for attempts and ideation.
119
These as-
sociations were observed even after controlling for any
mental disorder. In an HIV prevention study in Baltimore,
819 African Americans were examined to see if social
network density was associated with suicidal ideation and
plan after three years. Controlling for sociodemographic
characteristics and depression symptoms, revealed in-
dividuals with lower levels of social density were three
times more likely to report suicidal ideation and plans.
120
Unfortunately, there are other studies that conflict with this
support of the Seven Field Principles to cultivate resiliency
to prevent suicide. The Michigan University team found
frequency of interaction with church members was posi-
tively associated with suicide attempts, while subjective
closeness to church members was negatively associated
with suicide ideation.
121
In addition, West et al
122
found
emotional support, service attendance, and negative inter-
action with church members were unrelated to both suicide
ideation and attempts.
Other studies support the notion of giving African
Americans a sense of models (an aspect of the promoting
self esteem field principle) as a way to reduce suicidal
ideation among African Americans in the US.
123
There is
also assistance for the field principle of “Minimize the
effect of trauma.”One study examined the relationship
between hope and suicide in African Americans. Hope was
hypothesized to negatively predict the interpersonal sui-
cide risk factors of burdensomeness, thwarted belonging-
ness, and suicidal ideation.
124
As pointed out by the Institute of Medicine’s“Reducing
Suicide,”suicide prevention research is especially difficult
owing to the rarity of the behavior.
21
Specifically because
the suicide rates are so low, in order to develop a scien-
tifically valid suicide prevention study, the study would
need approximately 100,000 participants to achieve sta-
tistical significance.
21,p. 410
So, there is more research to be done on preventing
African American suicide. In addition, with the recent
discovery of the high rates of fetal alcohol exposure in low
income African American communities,
66
this is more
fertile ground for research in suicide prevention in African
Americans. It turns out from birth, the life expectancy of
subjects with fetal alcohol syndrome is 34 years old, and
one the leading cause of death in this population is suicide
at a rate of 15%.
125
CONCLUSIONS
Unfortunately, despite the media’s alarmist headlines, the
low rates of homicide and suicide do not easily lend
themselves to scientific study using the gold standard of
randomized, double blind, placebo controlled trials.
Fortunately, this is not the only evidence scientists mea-
sure to determine if an intervention works at reducing
violence against others or self. When the Institute of
Medicine released its 2nd prevention report in 2009,
126
it
was pointed out e“Although their internal validity makes
them valuable science, randomized control trials do not
always have good external validity.
126, p. 331
”The report
also points out academic research is rarely applied in the
day to day world. However, science can often benefit from
the experience of everyday clinical observations, e.g.
clinical observations in a community mental health setting
found large numbers of youth being exposed to violence.
Furthermore, a plethora of scientific research projects
confirmed this observation, encouraging several large scale
strategies designed to address this problem.
91,127e129
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The exploration of these issues for the last 50 years,
suggests that we have a relatively firm science base from
which to launch preventive interventions for homicide and
suicide. In addition, there are various systems that have the
infrastructure to deliver the prevention interventions,
e.g. schools, child protective services, juvenile detention
facilities, sports venues, mentoring programs, etc.
Although various communities often implement programs
because of some perceived need and often in response to
unflattering media about their community and not on
sound public health epidemiology and scientific under-
standing, there is still a lot of good work being done in
various places. However, like politicians, such programs
come and go depending on the strength of the political will
of the people and in this day and age, political will is very
capricious. Findings from the research suggest that risk is
not just the presence of a bad, toxic influence, but also the
absence of a good, protective influence. Accordingly, as
we design programs, hopefully based on the Seven Field
Principles as theoretical guidance, we will keep this in
mind and take a protective factor approach rather than
using a deficit model. To withhold violence prevention
programs that have been shown to be effective from
communities that need them is unethical.
130
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