BETHESDA, MD—It is relatively common knowledge among physicians that young black men living in urban environments are far more likely to be victims of violence than other groups. The cycle of violence that frequently erupts in their lives is often a result of undiagnosed emotional and mental trauma, and is a phenomenon that remains misunderstood.

Dr John Rich, professor of health management and policy at Drexel University in Philadelphia, is an expert in inner city health problems, particularly in men’s health and racial disparities. A former NIH grantee, in 2006 he was awarded the MacArthur Foundation “Genius” Award for his work using epidemiological research tools on the effects of street violence—something he talks about in his new book, Wrong Place, Wrong Time: Trauma and Violence in the Lives of Young Black Men.

Rich explained that the title of the book came from something that he heard often when talking with victims of trauma in emergency wards—“I guess I was in the wrong place at the wrong time.”

“I have to admit to you that I and many of my colleagues interpreted that as the offering of an excuse for ‘bad behavior.’Young black men didn’t just get shot ... they got themselves shot. But that has to do with their life experiences being so much different than our own. We have to think about what ‘wrong place, wrong time’ really is and how we can create a right and safe space for these young people.”

Living Very Different Lives

Rich illustrated just how different the lives of young black men are from what they would consider “normal.” While working at Boston City Hospital, Rich began the Young Men’s Health Clinic, with the idea of bridging the gap between pediatric and adult care for this patient population. When he quizzed patients about their histories, he found that the majority had a dysfunctional or nonexistent relationship with health care and existed in a community where violence was the norm: over 80% were uninsured; 20% had never seen a doctor; 25% had never seen a dentist; 45% were victims of violent injury in the past; 51% witnessed a shooting or stabbing; and 25% freely offered that they did not feel safe.

“Black men suffer from a range of ill health issues. They have the worst health status of any other race/sex group and the second lowest life expectancy at birth—second only to Native American men. They are also more likely to be stopped, mistreated, and killed by the police; and more likely to be dehumanized or objectified in the media. They carry this stigma into health care. I’ve observed a tendency to believe that all victims must be perpetrators. So, in the health care system, where we are duty-bound to treat victims as victims, we still have this dichotomy of how we approach them.”

The biggest concern is recurrent violence. A study looking at the recurrence rate for penetrating injuries, such as stabbings or shootings, was 44%. Examining possible risk factors for recurrence, researchers found that young African-American males who are unemployed, lack medical insurance and are poor are far more likely to be reinjured. They also found that unsafe neighborhoods and past psychological trauma were predictors for recurrent injury. This meant that those young men most likely to be the victims of an initial violent act were even more likely to experience a repeat occurrence.

Stories of Stress

Rich began a study looking at young black men between 18 and 30 who had been shot, stabbed, or assaulted, to determine why this population can find themselves caught in a cycle of violence. They were recruited while in the hospital, interviewed within two weeks of discharge, and again at one to three months post-discharge. Rich and his colleagues asked open-ended questions, designed to elicit narratives from the participants. The result was a collection of stories that presented researchers with far more nuance, and far more useful information, then a simple data-set.

“We found there was more complexity here than would be held by the assumption that these were just bad people behaving badly. Many of the participants described a life where, if they are insulted or disrespected, they are encouraged to react violently or become targets of continual violence themselves.

As for seeking protection from the police, most considered the police something to be avoided at all cost, regardless of their guilt or innocence. Rich quoted one patient who was shot while sitting in a car as saying, “Police are the last people I’d call. I feel nauseated even when I talk to them.”

The most startling result of the study was evidence of traumatic stress that researchers were seeing in the patients. Follow-up interviews indicated that 65% of the study participants were found to meet the full criteria for PTSD. “These symptoms, that are common in combat veterans or victims of sexual assault, are present in every form in these young people. Hypervigilence, depression, flashbacks, anxiety—young people talk about them in clear terms.”

All the Criteria for PTSD

A recording of one patient interview conducted by Rich and his colleagues reveals a young man saying, “A lot of the things that made me scared or nervous don’t make me scared anymore. [It] used to be if a whole bunch of dudes werelooking at me, I’d get nervous. If a guy was looking at me mean, I’d get nervous. They don’t affect me now. [It’s] like some of the feeling is just gone.”

It is as clear a description of the emotional numbing that can come from PTSD as researchers are likely to hear from a patient. And it is one of the many factors linked to traumatic stress that contribute to the cycle of violence, Rich explained. “If you think about this, this young man had a sense of what was dangerous or what was safe in the inner city. After his trauma, he lost that sense. And so he found himself in a position of confronting others that he wouldn’t have before his injury.”

This sense of emotional emptiness is often coupled with hypervigilence and nightmares, two symptoms that, without treatment by a physician, can often lead to self-treatment by the person suffering from them. “As you can imagine, someone who doesn’t have access to health care might look for some substance in the environment—alcohol or marijuana—to deal with those symptoms.” Many patients would drink or smoke heavily before bedtime in an effort to prevent the disturbing dreams they found themselves having after being injured.

Alongside of the long-term physical consequences, alcohol and substance abuse have immediate social consequences. For someone already involved in the criminal justice system, substance abuse can land them back in jail. It also diminishes their employment prospects, as many large, minimum-wage employers require urine samples prior to hiring. Then there are those that seek safety in a gun. “Faced with a gunshot wound and an acutely disturbed sense of safety, many to turn to weapons. And while a gun might be obtained for the perceived protection it might provide, the presence of a gun, especially in the settings these young men are in, puts them at further risk of injuring others or being injured themselves.”

Traumatic Stress Driving the Cycle of Violence

“These symptoms of trauma can often drive the cycle of violence,” Rich explained. “But there’s a disconnect because of a lack of education among providers about these symptoms.” Because there is no recognition of the traumatic stress these patients are under, there is never any discussion with them about the symptoms, about available treatment, or about how not to deal with the symptoms. The majority of patients admitted to hospital emergency rooms with stab wounds or gunshot wounds are never even admitted to the hospital. “They go home, and there is no discussion with them about these injuries. No one tells them, you may have nightmares. Don’t smoke weed. Don’t get a gun. No one talks to them about safety. There’s an opportunity here that may be lost.”

Beyond the immediate effects of traumatic stress, the kind of childhood and young adulthood these men are experiencing will have adverse health consequences further down the line. The Adverse Childhood Experiences Study conducted by the CDC has found evidence that childhood adversity can contribute to a laundry list of health problems, including smoking, heart disease, diabetes, COPD, obesity, hepatitis, alcoholism, substance abuse, attempted suicide, and teen pregnancy. “Prolonged stress can be toxic and trigger emotional behavior and physiological responses. And we know these stresses can be greater at the lower end of the social ladder.”

At Hahnemann University Hospital, Rich is taking what he hopes is a first step in intervening early in this cycle with Healing Hurt People, an intervention he helped initiate. Physicians ask victims of trauma coming into the emergency room about past incidents of violence in an attempt to better understand the patient’s situation and use the incident as an opportunity to help. “The intervention comes from an acknowledgement that trauma does feed the cycle of violence.” Its goals are to identify and treat trauma-related symptoms, decrease re-injury, decrease involvement with the criminal justice system, and create best practices for hospitals across the country.

Rich also hopes that this work, coupled with further research by CDC and others, will help physicians understand the prevalence of PTSD in this population and its relationship to chronic disease. “We need to evaluate health care-based interventions. We need to think about what the health care system can do as a participant in the city to decrease violent injury.”

At the very least, Rich’s work has shown that getting full narratives from patients—a practice that many doctors are discouraged from in medical school—has definite benefits. “Telling stories, particularly about difficult circumstances, is a way of healing and creating order and containing emotions. How can we incorporate victim testimony in our interventions? How can we use their voices to inform policy-makers about not only adversity in trauma, but the social conditions that perpetuate this and transmit it from generation to generation?”

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