Harvard Public Health Review
Fall 2004

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Canaries in the Coal Mine

Growing youth violence mirrors society's ills

The young are dying in Boston, Massachusetts, where the murder count is at its highest in nearly a decade. In the first 31 weeks of 2004 there were 40 homicides, 24 of them committed against males age 25 and under. Boston has seen this trend before--through the late 1980s and into the 1990s, until the city cut its homicide numbers in half by 1999, then saw no youth homicides for three years running.

Some say this earlier "Boston Miracle" was the result of hard work by government, police, schools, churches, and community organizations. Many also point to the influence of HSPH's Deborah Prothrow-Stith, who as Massachusetts' health commissioner in the late 1980s set up the nation's first office of violence prevention within a state health department.

While she denies being that powerful, Prothrow-Stith has joined with adjunct faculty member Howard Spivak, chief of pediatrics and vice president of community health programs at New England Medical Center, to write Murder Is No Accident: Understanding and Preventing Youth Violence in America (Jossey-Bass, 2003). The book, which frames youth violence as a major public health issue, is also a guide for those hoping to stem the bleeding. This spring, Boston's newly appointed police commissioner, Kathleen O'Toole, incorporated some of Murder's recommendations into her own five-point plan to head off violence in the steamy summer neighborhoods of Dorchester, Mattapan, and Roxbury. O'Toole is working hard to forge positive relationships between youth and police, encourage religious leaders to build their own prevention programs, and expand programs that rehabilitate and find jobs for former convicts who return to the neighborhoods.

Recommit to young people

The message of Murder Is No Accident is being heard around Boston and beyond in op-ed pieces, interviews, and speeches. Over and over, Prothrow-Stith and Spivak clearly state their message: The Boston community, and American society, must recommit to young people and their safety. Recommit through action, which includes increasing--not cutting--funding for summer jobs and other youth programs; expanding--not reducing--mental health programs; and generously supporting the few grassroots organizations that have courageously attempted to halt the killing among young people.

"A lot of what pushed us in the 1980s and 1990s was the passion to do something about the problem, even though there was no roadmap in front of us," says Prothrow-Stith. She has written and spoken widely on the issues of youth violence for the past 20 years, working with local groups to put research into practice, leading a national anti-violence movement--and simultaneously serving as associate dean for faculty development, founding director of the Division of Public Health Practice at HSPH, and director of programs for the Harvard Youth Violence Prevention Center (HYVPC).

"We were willing to join in with the community, take risks, grow into things we didn't even know before," she says.

"Everything we did wasn't super human, it was just work."
Adds Spivak: "This book reflects the overlap of our experience and thinking on the issues over the 20 years we've worked together."

Recently Prothrow-Stith read this passage at the 6th annual National Survivors of Violence Conference at HSPH, co-sponsored by the HYVPC and Survivors for Violence Prevention: "Tanya, almost seventeen, had attended more funerals than dances. Sixteen that she could recall. All were for children: family members, friends, classmates, and neighbors. …The number of deaths this child experienced during her childhood is startling to begin with, but the fact that her story is far from unique is the real tragedy."

Children like Tanya are at increased risk for problems at school, for depression, suicide, and even for becoming victims themselves through child abuse, or by becoming the victims of spousal abuse. Or, they might empower themselves by joining gangs, explains Prothrow-Stith. "We know that children who are victims may become part of the problem. As a caring community, we have to help these children turn that pain into something productive."

Beware of complacency

Beware of complacency, Spivak told those at the conference. We as parents, and as community leaders, must not wait until kids are in trouble before attempting to strengthen school and community resources. "There's real success in understanding the importance of community empowerment and stakeholder involvement," he says.

In their book, Spivak and Prothrow-Stith note four major risk factors for an uptick in street, domestic, and school violence perpetrated by young people: the stark reality of poverty, the availability of guns, the preponderance of alcohol in the lives of children, and the media, which often serves as parent/babysitter/friend. When you consider how many children witness or are the victims of violence committed in their homes or on their streets, you have to wonder how any child would grow up with a "normal" reaction to conflict, they say.

Not surprisingly, the authors condemn television for immersing children in violent programming that affects their attitudes, values, and behavior. Television paints a false picture of the world, they say. Kids see cartoon characters hit each other over the head, but those characters never experience pain. What's more, the cartoon laugh-track tells kids violence is funny. The long-standing debate over the impact television violence has on children should have ended years ago, Prothrow-Stith insists, "and corrective action should have been taken in full force."

Denying the "bad apple" theory of youth violence, she says street and school violence is not an aberration, but the consequence of children growing up in unhealthy environments. Our children are the canaries in the coal mine, Prothrow-Stith says, and we should view such behavior as the symptom of a toxic environment. Just look at the seedy, tough images Madison Avenue uses to sell young people everything from pants to snacks. Children are not just buying pants, she says, but the whole "gangsta" or "gothic" persona, images that provoke dangerous situations that put their lives--and the lives of others--at risk. Consider Columbine.

"While children were being shot and killed, adults were creating these ads," she says. "What will it take to cause us all to feel responsible, and to change?"

Violence as health risk

Prothrow-Stith has no memory of anyone at Harvard Medical School mentioning violence as a health risk during her training there. But that didn't stop her. She collected data on deaths and injuries, researched capacity to prevent and treat homicide (the tip of the iceberg of interpersonal violence, she says), and came up with a rationale to view violence as a public health risk, especially for the very young. Taking on the role of activist, she wrote even more and participated in a series of national prevention programs that sprang up in the mid-1980s in the wake of a surge of urban gang violence.

"My personal experience caused me to question the inevitability of violence and the neglect of major health problems for young black men. I started questioning the lack of prevention protocols. I became attracted to public health, where the focus is on prevention and on whole communities," she wrote in one of her books.

In 1987, she published a health curriculum focusing on homicide prevention, written for high school students. That same year, as she turned 33, Massachusetts Governor Michael Dukakis named her public health commissioner, the youngest person ever to hold that post in the U.S. In that role she focused on prevention and treatment tangential to communities dealing with violence, drug addiction, and AIDS. At the same time, she set up the first office of violence prevention within any state health department. In 1990 she joined the HSPH faculty. As head of the School's Division of Public Health Practice from 1997 to 2003, she began channeling public health resources to underserved communities.

To alert the nation to the problem of youth violence, especially in inner cities, Prothrow-Stith and Michaela Weissman co-authored Deadly Consequences: How Violence Is Destroying Our Teenage Population and a Plan to Begin Solving the Problem, published by Harper Collins in 1991. Today, she wishes that book had put her out of business. Because it didn't, she pressed forward, serving in 1995 on the National Commission on Crime Control and Prevention. These days, she teaches, researches, and writes. Sugar and Spice and No Longer Nice, her latest collaboration with colleague Howard Spivak, which is slated for publication later this year, zeros in on aspects of bullying and other violent behavior more and more evident among girls and women.

"People are pretty shocked," Prothrow-Stith says, "because they never really expected girls to do the same things as boys. In reality, we're all vulnerable."

She herself is shocked by recent increases in arrest rates among girls. Between 1990 and 1999, 28 percent of adolescents arrested for violent crime were female. Again, she blames the media, this time for feminizing the superhero. "If adults put down forgiveness, compromise, and remorse but admire in-your-face violence, that's what kids are going to do. Any kids, even girls."

"We don't live in a society that teaches children how to use emotions," she says. "Relationships are difficult, and not enough people know how to deal with relationships without violence."


HOW TO RAISE VIOLENCE-PROOF KIDS

Keep kids busy with healthy activities, especially at ages 12 to 15. "Get them involved in something active--like sports, or art, or music--from sunup to sundown," Prothrow-Stith says. "Set a schedule and help them stick to it."

Talk to your children, but also listen well. Parenting may not be any harder today than it ever was, but it definitely is different, she says. "Remember when people were too shy to ask others to stop smoking around them? Well, today they're too shy to ask if there is a gun in homes their child is visiting, but unfortunately, that's part of parenting."

Become friends with the parents of your children's friends. "Don't get out there on your own with your kids," Prothrow-Stith advises. "The parents of the friends generally want the right thing for their children, too, and you'll need their support. Plus, you'll learn different strategies from them."

Kids need additional, positive adult influences. Enlist support from your extended family, and from friends who share your values. "I tell people: To be my friend, you have to be my kids' friend," she says.

Respect children's privacy. If you want them to confide in adults, you must be willing to adhere to strict rules of confidentiality. "I told my kids' pediatrician not to share things they say unless they're life-threatening," Prothrow-Stith says.


Paula Hartman Cohen has written about science and health for Newsday and other national publications. She is a regular contributor to HSPH's newsletter, Harvard Public Health NOW.

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