COMMUNITIES THAT BOUNCE BACK
Like the coral reefs and economic systems we discussed at the beginning of this book, every community has to respond to emerging internal problems from time to time—maladaptive behaviors, issues, or circumstances that, if left to fester, can tip it past a critical and unwanted threshold. Whether it’s stopping a behavioral contagion (like needle sharing among drug users) or challenging a social norm (like getting people to recycle their trash), social resilience often rests on the adaptive capacity of a community, or its ability to sense, interdict, and intervene.
This capacity cannot simply be imposed from above—instead it must be nurtured in the social structures and relationships that govern people’s everyday lives. Two efforts at community resilience, undertaken on opposite sides of the world—in Bangladesh and Chicago—illuminate the terrible consequences of getting such interventions wrong and the transformational power of getting them right.
In the early 1970s, Bangladesh was not a healthy place to live. Reeling from natural disasters, an exploding population, and abject poverty, the young, destitute country had nothing like the resources required to support its people. Nowhere was this seen—and felt—more severely than in access to clean water. Nearly a quarter of a million Bangladeshis died each year from diseases like cholera, typhoid, and hepatitis, the same number of people who died in all of the planet’s natural disasters—including earthquakes, heat waves, floods, volcanoes, typhoons, blizzards, landslides, and droughts—in 2010 combined.
In 1972, development circles were abuzz with the promise of a new technology that held hope for the Bangladeshi crisis: the hand pump. Unlike in other countries, where drilling through hard rock was an expensive and arduous procedure, Bangladesh’s alluvial plains consisted of soft layers of sand and clay. In only one day, three or four men could drill a 100-foot well and reach the pure water underground. UNICEF instigated a nationwide program to sink shallow tube wells across the country. Once a small hand pump was installed to the top of the tube, clean water rose quickly to the surface.
Before long, every village wanted one; the drilling teams could not sink wells fast enough. By 1978, more than 300,000 tube wells had been sunk with UNICEF’s assistance; by the late 1990s, this number had swelled to more than 10 million, surpassing UNICEF’s target of supplying 80 percent of Bangladeshis with safe drinking water by the year 2000.
The tube wells appeared to be a shining success story of modern development. With access to clean water, the mortality rate for children under five plummeted from almost 24 percent in 1970 to less than 10 percent in the late 1990s. UNICEF’s approach to the challenge was touted as a model for South Asia and the world.
To accompany the new wells, the Bangladeshi government initiated public campaigns urging its citizens to switch from groundwater to the safer tube wells. The message was so effectively communicated that the tube wells became status symbols of wealth, security, and safety, often included in a new bride’s dowry.
But in 1983, a young dermatologist, Dr. K. C. Saha at the School of Tropical Medicine in Calcutta, began to see something disturbing. Patients were walking into his clinic from nearby villages with dark markings on their skin that he noted as “black raindrops.” Researching this hyperpigmentation in his patients, Saha finally determined that the markings were the first indication of an illness called arsenicosis, or long-term exposure to arsenic.
Colorless and odorless, arsenic is impossible to detect without a chemical test, earning it a starring role in the plots of mysteries, thrillers, and political assassinations. When arsenic concentrations are high, it can quickly cause skin lesions but, in less concentrated amounts—diluted in drinking water, for example—it has a long latency period that can last years. The people of Bangladesh were drinking poison in long, slow sips. They just couldn’t taste it.
By 1987, Saha had seen more than 1,200 cases in his clinics. His patients had only one thing in common: They all drank from the same village tube wells. Sure enough, when he tested the water from these wells, Saha found arsenic in dangerously high concentrations. UNICEF had mistaken deep water for clean water and never tested its tube wells for this poison.
By 1993, forty thousand people in Bangladesh were showing skin lesion symptoms characteristic of arsenicosis, along with its other terrible symptoms: hardening of the skin, dark spots on the hands and feet, swollen limbs, and loss of feeling in the extremities. The lesions often became infected, leading to gangrene. But exposure to arsenic also contributes to more severe illnesses like skin, lung, and bladder cancer. The World Health Organization (WHO) later predicted that one in a hundred Bangladeshis drinking from the contaminated wells would die from an arsenic-related cancer.
Though Saha and his colleagues published paper after paper confirming that the drinking water was contaminated, both UNICEF’s and the Bangladeshi government’s response was glacial. A full decade later, in 1998, a UNICEF representative finally responded to the crisis by saying, “We are wedded to safe water, not tube wells, but at this time tube wells remain a good, affordable idea and our program will go on.”
By that time, it was already too late—arsenic in the tube wells had escaped and found its way into the food supply. Rice irrigated with the tube wells was found to contain more than nine times the normal amount of arsenic. Rice concentrated the poison, so even if one managed to avoid drinking contaminated well water, concentrated amounts would show up in one’s food.
By 2000, the government estimated that 40 to 50 percent of the estimated 10 million tube wells were contaminated with arsenic—one out of every two wells. The WHO made a simple but terrible pronouncement: “Bangladesh is facing the largest mass poisoning of a population in history.”
In the face of impending catastrophe, it was clear that an intervention—fast, effective, and enormous in scale—would be needed. After spending the last thirty years successfully convincing the Bangladeshis to switch to tube wells, the government and NGOs now needed to reverse course, quickly communicating that some—though not all—of these wells were in fact poisonous. How would they effectively reach out to tens of millions of rural Bangladeshis, many of whom were illiterate and increasingly distrustful of government information?
Just telling people had its limitations: The word for poison, bish, referred to things that smelled bad or conjured up a sense of disgust. The well water, on the other hand, appeared clear and clean. The Bangladeshi government needed something simpler to convey danger, something that would resonate with a largely uneducated population. It agreed upon the universal colors of red and green.
With support from the World Bank, the government initiated a countrywide testing project called the Bangladesh Arsenic Mitigation Water Supply Project (BAMWSP). After performing arsenic field tests on wells all over the country, BAMWSP workers were then tasked with painting the spout of each well red if the well was contaminated, green if it was safe.
Five years and $44 million later, BAMWSP had field tested and color coded about half the 10 million wells in many of the country’s 86,000 villages. In about 10 percent of these communities, more than 80 percent of the wells were found to be tainted—earning them the nickname “arsenic para,” or arsenic ’hoods, because so many people living in them were marked by the telltale black raindrops all over their skin.
Officially, this intervention was hailed an almost instantaneous success. Once the wells were painted, researchers estimated that use of the red wells dropped to 1 percent. The government reported that most households felt sufficiently informed of the arsenic contamination. The international development community, once again, heralded the well-painting initiative as one of the most successful public health interventions in history.
And yet, underneath the hard data and official pronouncements, a far more complicated story started to unfold.
• • •
Instigating large-scale behavior change—in this case, getting people to switch from the red wells to the safer green wells—is a complex and multifaceted undertaking, informed by a whole host of cultural norms, taboos, incentives, and mores. The BAMWSP intervention successfully communicated wells’ arsenic status to rural villagers, but the effort was implemented as a one-time testing and labeling intervention, with no corresponding measures to address the possible cultural or social implications of publicly revealing a community’s well status. Unlike Willie Smits’s reforestation project or the emergent organization of an effort like Mission 4636, this was an engineering-led, one-off approach, imposed from the outside.
In Bangladesh, water use starts and ends with women and girls. Domestic water—collection, storage, and distribution—is traditionally a woman’s responsibility. They are the ones who will determine if a switch to a green well is warranted because they are the ones who fetch the water numerous times a day.
In a country with strict norms regarding the accompaniment of women in public, successful well switching has everything to do with where the safe wells are located and whether or not women and girls can access them in a way that is deemed socially appropriate. One academic reported that a green well was conveniently located to serve several contaminated well users but the women refused to draw water from it because it was directly in front of the mosque. The religious and cultural norms impeded a successful switch.
In the early 2000s, Farhana Sultana, a human geographer at the University of Minnesota, surveyed women and men in Bangladesh regarding their water resource use. Upon learning that their homestead had a red well, half of the men interviewed were most concerned about their women and girls venturing out in public to get clean water. A third of the women were concerned that they would either have to travel farther to get water or use someone else’s well.
Negotiating use of someone else’s green well was an act fraught with potential conflict. In a village where more than 80 percent of the wells were painted red—an “arsenic para”—women complained that waiting in the lines at the safe wells took up too much time and squabbling began to occur in the courtyard around the well. The owners of the green wells often expressed indignation and anger that so many women were coming onto their property. Some even removed the hand pump, allowing only their own family access to the water.
One man told Sultana, “Too many women in one place means too much noise and squabbling; who wants to put up with that daily in his own home?” Another woman claimed that she would rather drink arsenic water than endure the constant bickering and insults while waiting in line for the green well.
Effective behavior change also requires a complete understanding of the consequences of that behavior. Although the Bangladesh Demographic and Health Survey reported that four in five Bangladeshis “understood” the status of their well, the reality was more nuanced. According to Sultana, for many uneducated Bangladeshis, the very words “arsenic contamination” were too vague and abstract. Many of them reported that they thought the contamination was a flaw in the pumping mechanism or in the well itself because scientific concepts like groundwater and aquifers were difficult to grasp. Often, instead of fully engaging with the science, villagers would speak of the “zengoo” (black raindrop spots) as curses from God.
Even those villagers who reportedly understood that victims of arsenic contamination were not contagious expressed fears that one day, they would become afflicted. The villagers often agreed that it was best to ostracize those suffering from arsenicosis out of fear that the contamination would spread.
In 2003, reports started to come in of families and communities chipping away at the red paint on their wells. Some repainted their wells green, while others just left them colorless. Such was the power of the “contagious” stigma: They knowingly drank poisoned water to hide the fact that they were now tainted.
Husbands often divorced and abandoned their wives when they learned that they had been drinking from red wells, and young girls living within the vicinity of contaminated wells suffered from diminishing marriage prospects, if they were able to marry at all. In 2001, an arsenic attitudes survey reported that only one in twenty parents would allow their child to marry an arsenicosis patient, and an increased dowry was often demanded of a family when the girl was coming from a home with a red well. Researchers noted hearing a common expression, “Beramma maiya anmu keno?” (Why bring in a sick girl?).
In many regions around the country, the intervention successfully changed behavior—but it was a change for the worse. In the most affected areas, where more than 80 percent of wells registered an unsafe level of arsenic, only an estimated 4 million out of the total 9 million residents were provided with alternative safe water options by the government. Left without a viable, safe alternative to red tube wells, many women and girls returned to surface water sources like ponds and lakes, significantly more likely to be contaminated with fecal pathogens.
Still, the surface water sources might have been safe alternatives if the practices of filtering and boiling were still in place. Decades of tube well use, however, had eroded these habits from rural culture. What’s more, the cost of fuel to burn a fire for boiling proved prohibitively expensive for most of the rural villagers. As a result of all these factors, researchers estimated that abandonment of shallow tube wells increased a household’s risk of diarrheal disease by 20 percent.
Amid the gloomy outcomes, an occasional bright spot shone. In one village, Elmdi-Kamaldi, researchers from Columbia University met a self-appointed local arsenic activist, a schoolteacher with a 700-foot deep clean well. He encouraged others to drink from his well and he led the call for installation of other deep safe wells in the community. His advocacy seemed to pay off: Three in four of the owners of unsafe wells had switched to alternate wells, the highest rate of switching recorded.
What the BAMWSP initiative measured was outputs, not outcomes—the number of wells tested, not the number of people getting access to clean water or the other complex social impacts. Worse, this was a one-time intervention in a complex social system that was constantly changing.
Without deep community engagement, these problems are unlikely to turn around anytime soon. A water quality survey in 2009 by the Bangladesh Bureau of Statistics and UNICEF found that approximately 20 million people were still being exposed to excessive quantities of arsenic. In 2009, the government of Bangladesh committed in its election manifesto that the “arsenic problem would be tackled and measures taken to ensure safe drinking water for all by 2011.”
And so, while the experts and politicians discuss how to find a solution for the unintended consequences of the intervention, the people of Bangladesh continue bringing their buckets to the wells while crossing their fingers behind their backs.
The story of the Bangladeshi wells is one of nested failures: the failure of government agencies to meet basic engineering competencies; the failure of well-meaning Western aid organizations to understand the environment within which they were operating; the deadly slowness of top-down bureaucracies and their inability to admit mistakes; the failure of a social intervention that took no account of the complex culture of the community intended to adopt it, or made any effort to involve the people most affected by it in its design; and the classist stance of organizations that assumed that poor people have little to contribute.
Now imagine what an energized and involved intervention might have looked like. Imagine women and girls consulted on the design of culturally appropriate solutions. Imagine a network of community agents, deputized and trained to support the well switch. Imagine local people, both embedded within the community and linked across it, monitoring, sensing, and addressing issues as they arrive, intervening where appropriate, and heading off problems before their consequences become deadly.
What you will have imagined looks a great deal like one remarkably successful intervention half a world away, on the streets of South Chicago.
ENDING AN EPIDEMIC OF VIOLENCE
Karon Clark keeps all her open cases filed in the top drawer of her thick steel desk. As an outreach worker with CeaseFire, a groundbreaking violence prevention program headquartered in urban Chicago, she carries anywhere between ten to fourteen open cases at any given time—each one a member of the community who is at elevated risk for committing violence. Some of her clients have drifted in and out of her files several times—caught in the vicious cycle between prison, rehabilitation, drugs, gangs, violence, and then prison again—but one client in particular causes her to hold her breath in hope.
“I just can’t wait to shut the file on Davion. We’re almost there. Davion—he’s a boy who might really make it out.”
Davion (his name has been changed) has been Karon Clark’s client since January 2008 and, by all accounts, he has the makings of a success story. Athletic and highly skilled in football, he managed to make it through high school without ever getting mired in the drinking and drug culture. He pinned all his hopes on getting recruited for a major university football team. Then, in the final round of tryouts, he was cut.
“First day as my client, he comes in to speak to me and he’s angry. ‘I’m not going to college,’ he says. But he’s from a good family. They’re not well educated but they’re a good family and I told him that he still had a shot.”
Clark has spent the last four months taking Davion to junior colleges around the state, introducing him to football coaches, and helping him navigate financial aid application forms. One day a few weeks ago, Clark took Davion to a junior college about an hour away for an interview.
“He met a cute girl in the library and she gave him her number. He seemed a lot more enthusiastic about college after that.”
Clark takes a deep breath as she contemplates the possibility: Davion might actually be headed off to college. She has every reason to believe that she’ll be removing his case file from her top drawer and putting it away in storage next year.
And yet, she’s still nervous.
Clark’s CeaseFire branch in the West Garfield Park neighborhood is located in an old storefront. Unlike other community organizations, CeaseFire stays open late for its clients—very late. The outreach workers keep their storefront door open until the wee hours of the morning, and every few hours they perform what they refer to as “the rounds,” the daily walk around the neighborhood to check in on their clients and get a feel for the happenings out in the street.
It’s a Friday night. Under normal circumstances, Clark and her fellow outreach workers would be out pounding the pavement, stopping to say hello, putting some eyes on the street. Tonight, a steady rain falls, so the group climbs into a car and starts a slow crawl through the darkened streets. At first, the corners are relatively empty. A group of young men and woman are sitting on a stoop chatting. Clark’s car pulls up and they shout out, “Thank you CeaseFire! We love the T-shirts!”
“We gave them all T-shirts at our latest event,” Clark explains.
One of Clark’s fellow outreach workers spots his client wandering through the street: a young man in a voluminous T-shirt and baggy pants. He rolls down the car window and calls out.
“How’re you doing, man?”
“Awright.”
“You come and see me this week. We need to check in.”
The rounds involve many of these types of encounters. Every evening, the outreach workers track down as many of their clients as they can find, gauging the daily progress of their group, offering each the resources and support needed to promote a life in mainstream society. The rounds offer CeaseFire a chance to take the temperature of the community. How hot is the neighborhood tonight?
Slowly, as the Friday night parties begin kicking into gear, more and more people come out on the street. This evening there are small groups gathering on several of the main corners. People are pulling up in dark-windowed cars with booming bass stereos. Some of the girls are teetering in high heels back and forth from car to car.
“The women cause some of the biggest fights around here,” Clark comments. “The men do the shooting, but the women instigate. They provoke. They sleep with their boyfriend’s friend, say. They’re caught up in the same cycle of violence.”
The outreach workers continue driving through the rain, slowly pointing out gathering groups of current and former clients. They stop every block or so to check in.
“What’s new here?” they ask a group of teenagers starting to gather in an abandoned lot.
“Nothin’. It’s cool.”
Is it cool? Is it hot? The CeaseFire outreach workers are trained to identify signs of a possible violent outbreak in the complex social fabric of the neighborhood. Like Massoud Amin’s vision of a twenty-first-century power grid, the CeaseFire outreach workers have cultivated a kind of proprioception for their own community. In this way, Clark and her colleagues make up a part of CeaseFire’s distributed sensor network.
The mood on the street tonight is relaxed; there is a palpable sense of relief from people in the neighborhood because CeaseFire just successfully mediated a conflict between two warring cliques. Community members can now walk outside their homes without fear of getting caught by a stray bullet. The peace gives the groups of gathering people on the streets a sense of solidarity. Inside the car, the outreach workers chat casually. It’s early in the night and they have many hours ahead of them, but the weather tonight is mild—high summer temperatures are another infamous trigger for instigating conflicts. There is every reason to believe that tonight will be “cool.”
Suddenly Clark rolls down the window of the moving car. There, on one of the corners, standing with some of the other early evening partiers, is Davion.
“What are you doing out here on the corner?” Clark asks.
Her voice is teasing but kind. The boy comes over to speak to her and he shrugs his shoulders and gives her a charming, capricious smile.
“I’m not doing anything. You know that.”
“You better not be doing anything.”
“I’m just hangin’ with my cousin,” the boy says, and he gestures vaguely toward the group of guys lingering on the corner. In the background, the deep reverberations of a bass can be heard.
“Get off this corner! You hear me?” Clark’s voice is joking, but there is the slightest register of tension in it.
Davion only looks at her and laughs. He gives her an affectionate wave and turns back to join his group of friends. Clark reluctantly rolls her window back up and starts driving again. “He’s got one foot in and one foot out. Just a few more months. Just a few more months and he’ll be out of here but . . . Bam! Something can always take them down and keep them trapped.”
Clark looks back one more time. In the misty distance, Davion grows smaller and smaller until he is only a blur through the foggy windows.
Before the car turns away down a side street, she takes stock and makes a mental note. Like a good sensor, she will alert the CeaseFire system of a point of vulnerability in the form of a certain boy named Davion. She will not stand for any system failure under her watch.
• • •
In the summer of 2008, 125 people were shot dead in Chicago—about double the number of American soldiers killed in Iraq during the same period. These fatalities were just a small part of an epidemic of street violence that is frequently “casual in character,” according to Clark. Guns are everywhere. Men shoot one another in disputes over women, because they feel they have been dissed, or—whether they want to or not—because they feel it’s expected by their peers. One shooting frequently leads to another, initiating an escalating cycle of violence and retribution that can send neighborhoods careening.
CeaseFire, a campaign under the auspices of the Chicago Project for Violence Prevention, is attempting to reverse this dismal trend permanently. The effort uses an innovative strategy to prevent disputes from tipping over into actual violence, and when and if a shooting occurs, they interrupt any subsequent retaliation, giving the whole neighborhood a chance to cool down. Unlike the intervention designed for the Bangladeshi villages, CeaseFire exists within a state of dynamic disequilibrium, constantly reorganizing itself to suit the needs of its communities. There is no end to this intervention, no final day when all the outside consultants pack up their bags and leave. With CeaseFire, the very people monitoring the community are the exact same people who live there.
In 2000, Gary Slutkin was ready to begin a new project. An epidemiologist by training, Slutkin was returning home to Chicago after stints with the World Health Organization in East African countries like Malawi, Uganda, and Somalia, where he had worked on some of the world’s most difficult pandemics. He knew he wanted to move back to the States, but he had no idea what he would work on.
“I really just bumped into this problem of urban violence. It was dominating the neighborhoods. I kept asking people, what is the strategy for dealing with this? There wasn’t one.”
There are two prevalent framing devices for the problem of violence, Slutkin explained. “People often speak about the need for punishment, including longer prison terms and tougher law enforcement, or people will say, ‘You have to improve education, poverty, parenting, and on and on and on.’ In public health, we call this the Everything Myth. Punishment doesn’t stand a chance because it doesn’t drive behavior, and the Everything Myth is just another way of saying that the problem is intractable. It’s framed as a choice between doing things that don’t work or doing nothing.”
Slutkin’s previous experience treating epidemics allowed him to see the problem in an entirely new way.
“Malaria was completely resistant to large-scale strategies until bed nets. And reducing diarrheal disease was seemingly intractable with a big Everything Myth attached: ‘You need to improve all the water, sanitation, nutrition, etc.’ But then they came up with oral rehydration and we have seen enormous improvement. You come up with the right intervention, tie it to the right behavior change, and things really start to move. I saw parallels with violence as a behavior and I figured we could do something using the basic behavior change methods that we already knew. I knew that much but I had no idea what it would look like.”
Slutkin spent five years with his staff going through the appropriate steps for designing a behavioral change strategy for violence in Chicago. He sent members of CeaseFire in Chicago to Boston to study what was then referred to as “the Boston Miracle,” a successful violence prevention campaign involving innovative partnerships between law enforcement, city officials, and members of the Boston inner city ministries.
“I had experience starting from scratch like this before. When designing the initial strategies for a new public health crisis, we would frequently start with very little information. That would force us to ask basic questions: What is behind this? How is this happening? How is it spreading? This was the exact same feeling. It reminded me of San Francisco when we really had to start at square one.”
• • •
On June 5, 1981, the Centers for Disease Control (CDC) released the first official document on the disease that would later be known as AIDS. The Morbidity and Mortality Weekly Report described five cases of Pneumocystis carinii pneumonia, an opportunistic infection typically correlated with a suppressed immune system. All five of the patients were young men—homosexual and previously healthy—living in Los Angeles. By the time the report was out in print, two of them were already dead.
Slutkin was working at San Francisco General in 1981. One month after the CDC’s first documentation, a member of the staff saw the hospital’s first AIDS case: a twenty-two-year-old man with a rare skin cancer, Kaposi’s sarcoma, resulting in lesions across his chest. By the end of that year, nine more people in San Francisco had passed away.
“It was mostly gay men, and we knew that gay men had different sexual practices than heterosexual couples, but why weren’t women getting it at all? It wasn’t intuitive yet.”
Slutkin’s group started to do some cluster epidemiology, a time-consuming process that involved interviewing at-risk community members and working with sample and control groups. By 1983, electron microscopes revealed that there was a virus. Less than three years later, more than 800 cases (1 per 1,000 people) had been reported at San Francisco General.
“Suddenly we started seeing some Haitians, some hemophiliacs, some drug users. It started to look like hepatitis B or C, but we still had no idea how it was transmitted. We knew we needed to screen blood, but we also knew that behaviors needed to change.”
In the 1980s, during the time that Slutkin was working on strategies for the exploding AIDS epidemic, behavior change in public health was often viewed through the lens of theories like the health belief model. This psychological model was developed in the 1950s as a means of understanding public participation—or lack thereof—in health screenings and prevention programs. The theory focused on attitudes and beliefs of the at-risk population and, as adapted to HIV/AIDS public outreach, it became a framework for understanding the sexual risk behaviors and the transmission of HIV/AIDS.
One of the great limitations of the health belief model, however, was its inability to incorporate the social norms and peer pressure that are so important to consider in any kind of public health behavior. Think of risk homeostasis discussed in the previous chapter. Culture matters. For this reason, strategies in public health were augmented by the theory of reasoned action (TRA), a framework positing that humans are rational and linked in a system of behavioral beliefs (their own attitudes) as well as normative beliefs (the influencing attitudes and behaviors of those around them). Such norms are expressed explicitly and implicitly all around us. Think of the norms dictating the lives of the Bangladeshi women and girls. Of course it would have been easier for them to go to the green well near the mosque, but social norms, informed by religion and gender, made this an unthinkable act.
Even closer to home, we can use the norm of smoking indoors in Western culture. Fifty years ago, societal norms—the cognitive cues signaling appropriate behavior—suggested smoking was an acceptable behavior in most social situations in the United States. And so people smoked everywhere and all the time, as much because they had social expectations of doing so as because they wanted to.
Yet today, smokers in the United States abstain from smoking behavior in almost all common social situations. They are guided by explicit laws and regulations that will fine them for such behavior, for sure, but the real change is one in social norms, which provide a much more powerful deterrent. The risk of a scolding look from a friend or colleague is much more likely than even the most horrific antismoking ad to keep smokers from lighting up. The perceived risk of social death is far stronger than the perceived risk of actual death.
Because they provide powerful cues for which behaviors are acceptable and which are not, an understanding of social norms played a strong role in shaping public health measures surrounding HIV/AIDS prevention in the early days of the disease.
In Thailand, for example, peer use was the greatest factor in determining whether or not a man would use a condom. Much like Cialdini’s experiments on hotel towels showed, if your friends used one, you would too. Among a different community, the norms might be very different: In American universities, for example, it was individual attitudes that gave the strongest indication of whether young female co-eds would insist on condom use from their partners. Without a firm understanding of these different communities and their different local norms, public health measures targeting an outbreak would not only be ineffective, they might make the problem worse.
When Slutkin first approached the problem of urban violence, he assumed he would be using a strategy similar to the ones he developed attacking HIV/AIDS, tuberculosis, and cholera over the last twenty years. After sorting through what was working in other cities and what was technically and financially feasible in Chicago, Slutkin and his group created CeaseFire’s intervention to tackle the transmission of violence. It can be stated in three simple tenets:
First, interrupt the contagion of violence.
Second, change the thinking of the most at-risk transmitters.
Third, change the norms of the community as a whole.
STEP ONE: INTERRUPTING THE CONTAGION
Elena Quintana, director of evaluation for CeaseFire, is sitting in her office, a room on the third floor of the University of Illinois/Chicago Department of Public Health building. The hallways outside are lined with mud-green lockers, and all of the offices inside are drab with the speckled floor tiles so often found in institutions. Quintana, by contrast, speaks with impassioned bursts of energy. She has been with CeaseFire since its very inception, coming to work with Slutkin after more than a decade of efforts in domestic violence outreach and earning a PhD in community psychology. Quintana has held a number of different positions within CeaseFire, using her academic training to bridge conversations between the various players. Today she serves as the main conduit between the CeaseFire workers on the street and the Chicago law enforcement. By virtue of her mainstream connections and social network, it is safe for her to be seen walking in and out of the police precinct every Monday. She has no street-level reputation to protect. There is no one in her community watching to see if she is snitching. For that reason, Quintana has become CeaseFire’s only public face to the Chicago Police Department.
Yet despite these and countless other efforts by the organization to establish trust, around 2004, the CeaseFire staff realized that they were not reaching deeply enough into the community of at-risk clients. In order to stave off the violent outbreaks effectively, they would need to recruit people who could actually wield insider influence in the neighborhood social networks of its most at-risk citizens.
“You hear people around CeaseFire talk about ‘the game,’” Quintana told us. “It basically refers to the way marginalized people are systematically excluded, forcing them to live through an alternative economy: ‘the hustle’ or ‘the game.’ It involves all of the illegal activity you hear about: dogfighting, prison, drugs, gangs, bootlegs, prostitution. They were born into it; they’re not a part of mainstream society. We needed to use the people already in the game, use their Rolodex to help clients build a bridge to legitimacy. The system is set up to be us versus them. That is a chasm that most marginalized people just can’t cross by themselves, and the outreach workers couldn’t span that social distance.”
In one of the biggest rooms on the CeaseFire floor, a meeting of highly trained specialists who do span that social distance every day is getting under way. It’s a gathering of the CeaseFire violence interrupters, a group comprised mostly of African American and Latino men ranging in age from early twenties to fifties, many formerly incarcerated themselves, who are working on the front lines of the violence epidemic.
Quintana begins the meeting by reading off a police report of neighborhood incidents that occurred over the last week. The men sit and listen and nod their heads, a few commenting under their breath at one detail or another from Quintana’s report.
When the report is finished, Tio Hardiman, director of CeaseFire Illinois, stands up to speak to the group. Hardiman, an African American man in his forties, sports a beige tracksuit with navy stripes up the side. He gesticulates smoothly as he speaks to the men; he has their rapt attention.
“Group A has been making trouble with Group B and we’re hearing that a shooting is set to happen at eight a.m. We all know that’s school time. Kids walking to school then.”
The men around the room nod their heads.
Hardiman reminds them of a concept he calls “the rules of engagement.” “Our biggest ally is time, remember. We’re just borrowing time to calm them down.”
Analogous to the Red Team U skeptics, the interrupters cruise the streets of the toughest neighborhoods to identify and intervene in conflicts before they intensify, providing the alternative conceptual space. If a shooting has occurred, they immediately seek out the victim and his or her friends, relatives, and associates and try to prevent a retaliatory shooting, interrupting the spread of violence and stopping it from rippling through the rest of the social network. If CeaseFire is treating violence as a communicable disease, then the violence interrupters function as its public health workers, triaging new infections and inoculating the community to lessen the likelihood of an outbreak.
“I came up with the concept of identifying a specialty unit of guys that come from pretty tough backgrounds, guys that are part of the hierarchy on the streets,” Hardiman explains. “These are the guys that have enough backbone to go and actually talk to the guy with the gun in his hand. A lot of guys will talk a good game but not many people can actually go and talk to the guy with the gun in his hand. That’s a special skill.”
Hardiman plays an essential role, if not the essential role, because of his ability to recruit and communicate with these highly influential members of the community.
“Most people would actually like to be talked down from committing a violent act if they are talked to by the right person. It has to be the right person though. If you’ve got some fluke type of person who shows some weakness, the guy is going to step on you. I’ve had to mediate conflicts right here in my office and the guys want to get loud and jump up, ‘F this and F that! I’m gonna get that chump. That’s just the way it goes!’ And I say, ‘No, that’s not the way it goes. You got your girlfriend at home; you got two kids on the way; your mother’s sick and now you’re talking about shooting someone. What is it about?’ And you get down to the nitty-gritty and it’s about some guy who owes you one hundred bucks or some guy who messed with another guy’s girlfriend or some guy who might just be messing with you, looking at you crazy and trying to intimidate you. So I say, ‘C’mon man, let’s sit and talk about this. Let’s get to the bottom of this.’”
These kinds of interventions are the result of training in an advanced form of social technology. First, it requires CeaseFire’s interrupters and outreach coordinators to keep an up-to-date mental map of the social connections in the community—a map of who runs with whom, how various members of the community are linked together, and where, in the social network of the streets, things are heating up and cooling down.
Because the community is always in flux, the map must be refreshed constantly, with highly sensitive information. If CeaseFire were a traditional law enforcement organization employing people from outside the neighborhood, it would never have the trust, credibility, and access required to do its job. And while not all of the Chicago police force is thrilled with CeaseFire’s insistence on confidentiality and neutrality when it comes to illegal activity under their watch, many have come to respect CeaseFire’s ability to do things the police simply can’t do—or to handle things that enable the police to deploy their force more effectively elsewhere.
Just having a good social map isn’t enough, however. CeaseFire workers also need to understand the logic of violence at the street level, how an act will be interpreted, not only by the victim but also by dozens of constituencies. In the complex fog of partial information that follows in the wake of a shooting, when every minute matters, where do you intervene? Interrupters need a sense that if X shoots Y, then X’s brother will shoot Z, causing Z’s friend to escalate—it’s scenario planning for the streets.
And then there’s the art of the intervention itself—a skill as specialized as talking a suicidal person off a ledge. “It requires real wisdom, authenticity, and a jazzlike set of improvisational skills to talk someone down who has the intent, means, emotional state, and social reinforcement to commit a killing,” says Slutkin, speaking of the interrupters. “These guys are masters of a craft that until recently didn’t exist.”
Like the batfish and the WIR, the violence interrupters function as a countercyclical strategy built into the system, dormant until the social system approaches or passes the critical threshold of a shooting, and then immediately dispatched to recalibrate the network back into a semistable state.
Given the work of the outreach coordinators and violence interrupters, CeaseFire doesn’t bear a lot of resemblance to a traditional social service bureau, with office hours and appointments between nine a.m. and five p.m. It’s a round-the-clock operation that is most active at night. There are other differences too: Most traditional organizations are opposed to hiring formerly incarcerated workers to do community outreach. CeaseFire, in contrast, depends on them.
“Most organizations work in a more mainstream way,” Quintana concurred. “CeaseFire is taking people from the belly of the beast to go back out there and transform lives. It’s biblical. You’ll hear them say, ‘Jesus was an outreach worker.’ The violence interrupters often frame their decision to work with CeaseFire in terms of personal redemption.”
STEP TWO: CHANGE THE THINKING
Frank Perez, director for outreach services for CeaseFire, wears a big gold cross around his neck. His black T-shirt reads “Don’t Shoot.” Perez is of Puerto Rican descent, and he grew up in the violent gangs of South Side Chicago. After years of skirmishes with the law, he had a revelatory moment that changed his life.
“I realized in my late twenties that all this, this whole broken community, this was all my mess. It was our mess and we had to find a way to clean it up. This violence? It’s my fault. My whole life now is about trying to undo the damage done.”
Perez went on to get a master’s in social work before joining up with CeaseFire in 2002. Tonight he is traveling with Kobe Williams through the Englewood neighborhood of Chicago. Williams is a violence interrupter, and Englewood is his beat. Despite the intense nature of his work, Williams seems genuinely at ease. He likes maintaining his connections and getting a chance to spend time on the street. He wears a white baseball cap adorned with the CeaseFire motto, “Stop Killing People.” A CeaseFire dog tag swings around his neck.
In the 1990s, Chicago finally made the decision to tear down its infamous Robert Taylor housing project, located in the Bronzeville neighborhood. The Taylor residents were given Section 8 housing cards, which were supposed to allow them to move wherever they wanted to go. In reality, most of the former residents lacked both the social network and financial resources to go anywhere, and the majority simply moved to the next neighborhood over: Englewood. The influx of displaced people disrupted the neighborhood and further exacerbated the problem of fractionalized, violent cliques.
“You used to be able to speak to a gang chief and he would tell his soldiers what to do, but after RICO [Racketeer Influenced and Corrupt Organizations Act] in the seventies and eighties, they got rid of all the gang leaders and put them in jail,” Perez explained. “No one wants to step forward and be a leader today. It’s too dangerous, too hot. The cops will see you or you will get shot.”
Perez feels that RICO—an attempt to empower prosecutors—was a folly of unintended consequences. “They cut off the heads but they didn’t kill the bodies, and now there are all these cliques, renegades. They don’t respect anyone.” Much as John Arquilla describes the task of U.S. forces in wars in Iraq and Afghanistan, CeaseFire is struggling to negotiate with the sense, scale, and swarm abilities of these at-risk potential offenders.
Englewood feels quiet in the early evening. Williams points to one of several empty lots and describes the most recent CeaseFire barbecue held there. “Real popular events. Sixty to seventy people turn out for the free food and they always ask us to do more.”
“We call them midnight barbecues,” Perez offers. “When an area is hot, we come out at nine p.m. and serve hot dogs as long as we can.”
Often the gang and clique members will go about the routine transactions of their drug business on the same corners where CeaseFire is having their barbecues, an example of the trust and authenticity that the CeaseFire strategy wields within the community.
“When we see the gang members selling drugs, we just tell ’em, ‘Hey, we’re here because you guys are making it too hot with your violence. Cool down.’ They know we’re right,” says Perez.
“In traditional public health, we treat a lot of diseases, like H1N1 influenza, for which we don’t yet have effective mediations,” Slutkin says. “In their absence, in the early days of dealing with a pandemic, we try to instill certain practices and change behaviors to decrease transmission. And then when we finally do get the vaccine, or antibiotic, we immediately try to get it to people who are most susceptible. This is a strategy based on the understanding of the unique characteristics of the virus and how it’s transmitted—in the case of H1N1, it’s by coughing and droplets. It’s not transmitted by bad people: It’s transmitted by air.”
And this is where Slutkin pauses in thought for a moment before speaking. He is about to tread into unchartered territory.
“And violence is transmitted by thought.”
For Gary Slutkin, violence is not like a disease in the metaphorical sense. Violence is a disease, transmitted not by germs but by thoughts, decisions, and ideas—about the nature and acceptability of violence, about the social expectations of one’s peers, and about one’s sense of hope or hopelessness about the future. It’s transmitted from mind to mind—a mimetic, rather than a microbial infection.
And it’s extremely contagious.
Many times, the violence that CeaseFire interrupters and outreach coordinators must contend with isn’t emotional—it’s a calculated necessity, a way to ensure one’s status on the streets is not being compromised. What’s underlying the violence isn’t aggressiveness, or a desire for vengeance, but an idea about how an individual will be perceived by his social group if he doesn’t act in the wake of some perceived—or impending—insult.
This fact provides just the opening that interrupters often need to diffuse a conflict before it turns deadly. According to Perez, despite the stereotypes of raging, out-of-control gang bangers, many of CeaseFire’s clients “not only come willingly when asked, they often ask for mediation themselves.”
Why are these at-risk individuals volunteering to be babysat while they cool down?
“Most of the time,” Perez explains, “they don’t want to do the deed, but they need to save face. With CeaseFire around, they can tell their friends, ‘Oh yeah, Frank talked me down. I would’ve done it if Frank hadn’t talked me down.’ And then their friends say, ‘Oh yeah, Frank, man, he’s good at that.’ And everyone gets to walk away with their dignity.”
Perez compares it to the fight at the playground: You get in a scuffle during the day with some kid and you set the fight to begin at 3:15 or 3:45. Then the time gets closer and you’re getting more and more scared but you have to follow through. “You gotta save your name.” So you go out there and all the kids are cheering you on and there’s no way to get out.
CeaseFire gives people a way out. Everybody can feel cool.
“I would’ve done it too, if it hadn’t been for CeaseFire.”
STEP THREE: CHANGE THE NORMS
Tio Hardiman’s car pulls up alongside a gathering group of mourners on the 3500 block of West Sunnyside Avenue in the Albany Park neighborhood of Chicago. A group of women are crying into crumpled Kleenex. Some of the men are sitting in lawn chairs along the sidewalk, looking and then not looking at the impromptu memorial set up under one of the trees.
ALWAYS REMEMBERED, NEVER FORGOTTEN
I LOVE YOU MY ANGIE
R.I.P. MY NIGGA
The event is honoring Angelina Escobar, nineteen, shot dead in her apartment alongside her boyfriend, Alex Santiago. Hardiman doesn’t think that the shooting is directly related to gang or clique violence in the West and South Side neighborhoods, but he is here, representing CeaseFire and offering solidarity and support in the campaign against violence.
Hardiman approaches the women, Escobar’s aunt and other extended family, standing next to the memorial site filled with flowers and handwritten notes.
“My name is Tio Hardiman and I’m here from CeaseFire to show you our support.”
Around the CeaseFire offices, you constantly hear the phrase “Credible messages from credible messengers.” Hardiman is handing out CeaseFire cards and signs to the growing group of mourners. The message written on them is only two words long: “Don’t shoot.”
“We’re not interested in trying to stop drug use and drug dealing and all of that other stuff,” Hardiman tells us. “We have a message that everyone can get behind: Stop shooting people. It’s something that everyone agrees on. That’s what gives CeaseFire its street cred.”
Hardiman points out several members of the CeaseFire Albany Park branch who are now standing in the crowd in solidarity. Before too long, one of CeaseFire’s partners in the clergy arrives, the Reverend Robin Hood, pastor of Redeemed Outreach Ministries in the Englewood neighborhood on Chicago’s South Side. He stands in front of the group and offers up his hands.
“Another senseless act of violence plaguing our communities. I didn’t know Angelina Escobar but I know that she is someone’s granddaughter, niece, daughter, friend.”
One by one, the mourners move forward to speak about Escobar, an innocent bystander caught in an act of violence. As the last mourner finishes, the reverend repeats his earlier phrase as an incantation: “Another senseless act of violence plaguing our communities.” He ends with a CeaseFire chant and the entire crowd joins in: “Stop the shooting! Stop the violence! Stop the murder! CeaseFire! CeaseFire! CeaseFire!”
The words echo through the streets. Like Ury’s third side, this public performance of a simple credible message from a credible messenger, over and over again, is intended to broadcast and reinforce a new norm: Shooting is unacceptable. It is the community calling out and responding to the community.
Like transforming the social acceptance of smoking, changing a norm is a long-term process, and it will require all of the tools in CeaseFire’s public engagement toolbox, from midnight barbecues and street marches to door-to-door canvasing and dozens of other shared rituals yet to be invented. The effort will succeed only with constant repetition, deep and authentic engagement, sustained effort, and tolerance for inevitable setbacks. And long after the final shooting has plagued the neighborhood, those norms must still be continuously reinforced, to make sure violence never returns.
Behavior change is never simple, but recent research suggests that new norms may spread through a community’s social network in much the same way as the mimetic disease of violence itself.
Using data from the famed Framingham Heart Study, an ongoing survey on residents of the town of Framingham, Massachusetts, that has been in continuous operation since 1948, researchers at Harvard University, led by biophysicist Allison Hill, recently found evidence that positive and negative emotions behave like infectious diseases, too, and spread across social networks in a community over long periods of time. Their research found that for each contented person you know, your likelihood of being contented rises 2 percent. Unfortunately, for each discontented person you know, your chances of being discontented rises 4 percent—in other words, unhappy people are twice as damaging to your state of mind as happy people are good for it. Intriguingly, however, they found that happiness “infections” may be more durable—they seem to last twice as long (a decade) as unhappiness infections do.
For CeaseFire, such research suggests not only that normative change is possible, but that the community members they reach indirectly are at least as important as those they reach directly. If violence is a disease spread by thoughts, then perhaps it can be cured by them, too.
• • •
Long before that happens, CeaseFire will have made some of the most significant impacts on gun violence ever achieved. In the year 2000, for example, CeaseFire’s approach led to a 67 percent drop in the amount of shootings in the worst police district in the city—the eleventh police district, the West Garfield Park neighborhood—in a single year. After receiving additional resources, CeaseFire applied its approach to three more neighborhoods. By splitting the money across all three communities, it achieved between 33 and 45 percent drops in all the neighborhoods. When it received funds for a fifth neighborhood, the shootings went down by 45 percent there. CeaseFire moved the number up to fifteen neighborhoods and then twenty-five neighborhoods and soon after it was witnessing a feedback system across all of the communities. Today, CeaseFire has achieved a more than 40 percent reduction in shootings throughout all of its neighborhoods in West and South Side Chicago.
All of this rests on the outreach coordinators and violence interrupters, who act like macrophages in an immune system, constantly identifying and containing threats and ensuring that the contagion of violence doesn’t spread through the larger substrate of the community.
Interventions like CeaseFire’s are never static. They require buy-in and support from the community, time to work, and constant vigilance. But, done right, these kinds of interventions build something extremely beneficial, which transcends the particular context of violence: a powerful latent social network.
As we will see in the next chapter, leaders with a particular skill set are then able to tap into this network, amplifying the benefits of the best-designed interventions across their diverse range of constituencies.