Bleeding Out

CHAPTER 1

BLEEDING OUT

IMAGINE THIS: YOU ARE A TRAUMA SURGEON WORKING THE MIDNIGHT shift in an urban emergency room in the United States of America. A young man, unconscious, lies before you on a gurney. He has been shot in the thigh and is bleeding profusely. Judging from the entry and exit wounds, as well as the amount of hemorrhaging, the bullet most likely sliced the femoral artery, one of the largest blood vessels in the body. Without assistance, this young man will die within minutes. As his doctor, what do you do? Or, more precisely, what do you do first?

The young man’s clothes are old and dirty. He may be jobless, homeless, lacking a decent education. Do you start treatment by finding him a job, locating an apartment, or helping him get his GED?

The young man has also been involved in some sort of altercation and may be dangerous. Perhaps precautionary measures are in order. Before he wakes up, do you put him in restraints, alert hospital security, or call the police?

Of course not. Instead, you take the only sensible and humane course of action available at the time. First you stop the bleeding, because unless you stop the bleeding, nothing else matters.

In 2017, 17,284 people were murdered in the United States. That is more than forty-seven per day. Americans are killed at a rate roughly seven times higher than people in other high-income countries, driven by a gun homicide rate that is twenty-five times higher. As citizens, we do not bear this risk equally: the nation’s number one victims of violence are disadvantaged and disenfranchised young African American and Latino men. For young Latino men, homicide is the second-leading cause of death. For young black men, it is not just the leading cause of death; homicide accounts for more deaths than the nine other top causes combined.¹

Every murder causes immeasurable suffering. No statistic can capture a child’s lost potential or a mother’s grief, but when the collective costs of murder are estimated, they are staggering: anywhere from $173 billion to $332 billion in criminal justice and medical costs, lost wages and earnings, damaged and devalued property, and diminished quality of life. That’s between $531 and $1,020 per American, paid out in higher taxes, higher insurance premiums, and lower property values. And that is just the price of homicide—the human and economic costs of all violent crime run even higher.²

Urban violence, also described as street, gang, youth, community, or gun violence, accounts for more violent deaths than any other category of crime. It is the violence that plagues the most disadvantaged communities in our cities. It involves, for the most part, young men killing or wounding other young men in tragic and brutal cycles of retribution. Disputes that were once decided with words or fists now result in gunfire that claims not only combatants but also bystanders who just happen to be nearby when one enemy spots another.

It has become fashionable in some circles to describe urban violence as an infectious disease, spreading from person to person like the flu. This comparison has been helpful in reframing urban violence as a matter of public health, but it lacks one thing: urgency. Some diseases require immediate action, but many do not. Urban violence is better understood as a grievous injury, a gushing wound that demands immediate attention in order to preserve life and limb. A life-threatening injury is an acute emergency, while a disease can be a chronic condition that demands a less vigorous response.

In this book, I propose a series of lifesaving treatments to address urban violence, right now, without further delay. Urban violence is the most widely studied form of crime, and there is enough reliable research out there to provide a strong sense of how best to tackle the issue today. Murder on the streets of our cities is a deadly serious problem, but it is also a solvable one.

Recognizing that the fastest route between two points is a straight line, these treatments address urban violence by focusing attention and resources on the most dangerous people, places, and things—the factors driving the majority of the mayhem. An approach the experts call the Gun Violence Reduction Strategy reduces gun and gang violence by confronting would-be shooters with a double message that pairs offers of assistance with threats of punishment. Hot spots policing temporarily cools crime locations, getting guns off the streets and giving neighborhoods an opportunity to recover.

These efforts also balance punishment with prevention. Cognitive behavioral therapy helps high-risk adolescents manage their emotions, address conflicts constructively, and think carefully about the consequences of their actions. Investing in crime-prone places by removing blight and restoring services makes them less susceptible to violence.

Finally, just as treatment for injuries requires partnerships between patients and their health care providers, peace in the streets requires cooperation between communities and criminal justice authorities. A lasting peace cannot be achieved without improvements in the perceived fairness of criminal justice institutions, especially the police. The principles of procedural fairness, by which criminal justice officials learn to treat residents with respect, offer them opportunities to be heard, and become more transparent about what they do and why they do it, can rebuild confidence and renew partnerships while restoring public safety.

This book concludes with a concrete proposal that combines all these strategies into a single effort that can reduce homicide rates by over 50 percent in eight years—just two mayoral or presidential terms. In Chicago, this proposal would prevent more than fifteen hundred murders. In Baltimore, it would avoid almost eight hundred. Nationally, these efforts would save more than twelve thousand lives and avoid approximately $121 billion in social costs. Put these proposals into place and in a decade the US murder rate will resemble Canada’s.

In short, this is a book about how to stop the bleeding. It offers a new paradigm for addressing urban violence in America, examining it as if it were a young man hemorrhaging on a hospital gurney. The metaphor of a patient passing through an emergency room is fitting, as urban violence is in fact a national emergency that demands our urgent attention.

BEFORE GOING FURTHER, it may be helpful to explain what I mean by urban violence. Violence here means physical force that results or could result in serious injury or death. This definition includes only the most concrete and potentially lethal forms of violence. This book measures urban violence primarily in terms of homicides, its most important and reliable indicator.

Urban means, literally, something relating to cities or towns. Violence can happen anywhere, but in 2017, 70 percent of all homicides in the US happened in cities with populations of 25,000 or more. In this book, urban also means something more: it refers to violence that generally occurs outside the home, on the streets or in other public spaces where people congregate.³

Urban violence is largely the province of young men. One of the most consistent findings in criminology is that age and lawbreaking are strongly related, and especially so for violence. The likelihood and frequency of violent offending rise in late adolescence, peak during the late teens to early twenties, and then begin a steady decline. Violence is also overwhelmingly perpetrated by men, who are also its primary victims. In 2017, 88 percent of homicide perpetrators were male, as were 79 percent of homicide victims.⁴

Urban violence is committed with hands and feet as well as bottles, bats, sticks, knives, and other deadly instruments, but when it comes to murder, firearms are by far the most frequently used. In 2017, 72 percent of all homicides were committed with a gun, typically a handgun, and in the most violent cities the rate can reach as high as 90 percent.⁵

Urban violence can occur in the course of other street crimes, especially robbery, but often it is sparked by arguments, conflicts, or “beefs” of some kind. These disputes often involve long-standing rivalries between groups known as gangs, cliques, sets, crews, and so on. In 2017, 64 percent of all homicides where a motive was identified were the result of disputes of some kind, and with stronger data the percentage would probably be higher. Many of these conflicts are connected to cycles of retaliatory violence that go back years, even generations. In these instances, today’s perpetrator is likely to be tomorrow’s victim, with the next shooting planned in the emergency room of the last one. For many who commit murder, it’s all about payback.⁶

Race matters when it comes to urban violence. African Americans, particularly men, are disproportionately impacted by deadly violence: in 2017, homicide victimization rates for black men were 3.9 times higher than the national average and black people accounted for 52 percent of all known homicide victims, despite representing only 13 percent of the US population. As we will learn, high rates of violence in poor communities of color come not from deficiencies in culture or values but from long legacies of racial persecution that have resulted in concentrated poverty and disadvantage.⁷

I should also explain what I don’t mean by “urban violence.” For the purposes of this book, urban violence does not include nonlethal violence, such as slaps, pushes, or punches, that do not risk sending someone to the hospital or the morgue. Nor does it mean nonphysical verbal or emotional abuse; or nonphysical forms of injustice and oppression, such as economic violence; or violence that generally occurs in private locations such as homes or schools.

Urban violence, as I use the term, does not include sexual violence or violence between intimate partners and family members. It also excludes violence perpetrated by the state or by highly organized criminal groups. These kinds of violence, although they may involve serious injury or death and occur in a city in public, are important but not the focus here.

The justification for all these exclusions is simple: to address different kinds of violence, different approaches are required. There is no universal anti-violence strategy; what works in addressing one form of violence may not work with another. A key question for any anti-violence effort, for example, is deciding how many and what kind of partners should participate. The answer will vary widely depending on the kind of violence: preventing bullying in schools involves partnerships between educators and parents, while combating organized crime requires the coordination of traditional law enforcement institutions.⁸

WHY SHOULD WE as a society prioritize reducing violence? And why should we focus on urban violence in particular? The reasoning is simple but powerful: the most urgent and fundamental human need is to be secure, free from the dangers that might suddenly end our lives. We all need food, water, and air to survive, but we can live for roughly three weeks without food, three days without water, and three minutes without air, whereas violence can kill in a second.

Violence, or the threat of it, is ubiquitous. It is in us, around us, and has been with us since time began. In nature, plants are eaten by animals, which are preyed upon by other animals along the ecological food chain, and violent competition among animals is routine. We humans have only recently distanced ourselves from the natural world, and so, not surprisingly, our history and prehistory is filled with murder and mayhem. Many regions of the world remain plagued by civil war, sectarian strife, ethnic cleansing, terrorism, transnational organized crime, and other kinds of violent conflict. According to cognitive psychologist Steven Pinker, scientists have not discovered a single source for violent impulses in the brains of humans and other mammals. Instead, they have identified many, mirroring the many reasons why we resort to violence. Humans and animals use violence as a tool to achieve status and dominance, to deter predators, and to prey on others, among other motivations. Psychological research shows that we are at our most violent not as young adults but as unsocialized toddlers, when we fortunately lack the capacity to effectuate our often-murderous intentions.⁹

As observed by former crime reporter and writer Jill Leovy, “The safe take safety for granted. They assume that they are safe because safety is a state of nature, and that violence is an aberration.” But the peace and tranquility enjoyed by many is a relatively recent development, painstakingly produced over centuries, even millennia, of institution- and system-building. Even this progress remains strikingly uneven and unequal, with the wealthy and privileged able to insulate themselves from violence while the poor and powerless remain in peril. According to Gary Haugen, a human rights lawyer and activist who has documented the devastating impact of everyday violence on the world’s least fortunate, protecting the poor is the most effective anti-poverty measure available today. “If you are not safe,” he argues, “nothing else matters.”¹⁰

Murder is the most serious form of violence and the most direct threat to personal safety. It is the pinnacle of social injustice; it is simply the worst thing one person can do to another. This understanding of murder is shared across regional, national, cultural, and religious boundaries, and it is based on the near-universal recognition that a single homicide causes more human suffering on average than any other individual act of wrongdoing. Empirically, the social costs—for victims and perpetrators, law enforcement, the health care system, and society more generally—of homicide far exceed those of other crimes. One frequently cited study estimates the cost of a single murder to be 51 times higher than an armed robbery, 119 times higher than an aggravated assault, and an astounding 420 times higher than a burglary.¹¹

Importantly, homicide is also the best-measured form of crime and violence. While other violent crimes may go unreported, virtually all murders are known to the authorities because they produce an undeniable piece of physical evidence: a dead body. In low-income nations with scant crime statistics, homicides are often the only category of crime for which there is even semireliable information, and even in the US, homicide is the only category of offense where we know the numbers with absolute confidence. Homicide is also a useful indicator of trends in violent crime generally, as other offenses tend to rise and fall in unison with homicide over the medium and long terms.¹²

Here in the US, urban violence accounts for more homicides than any other type of violence. Since October 2001, over four hundred people have died in domestic terrorist attacks and over five hundred have died in mass shootings. During that same period, at least one hundred thousand lost their lives to urban violence. In 2017, urban violence accounted for approximately 88 percent of all murders, although this figure should be taken with a large grain of salt given that the circumstances of more than 40 percent of murders are unknown.¹³

One might believe, given how crime and violence are often portrayed in the media, that murder rates have never been higher. This is not the case. In 1964, homicide rates in the US began to climb steadily, rising from a rate of 4.9 murders per one hundred thousand residents to 9.8 murders in 1991. From there, rates dropped dramatically until 2000, then decreased modestly until 2014, reaching a floor of 4.5 murders. After that, rates rose dramatically in 2015 and 2016, then plateaued in 2017 at almost exactly the same levels as they were in 1964. Violent crime and property crime rates have risen and fallen roughly in tandem with homicide rates.¹⁴

Looking back, one might observe that the US experienced a remarkable decline in violence and crime over the past twenty-five years. Another equally valid observation is that after more than fifty years we have made no progress whatsoever. This failure has cost hundreds of thousands of lives, trillions of dollars, and immeasurable pain and suffering. The nation remains an ugly outlier among wealthy countries, infamous for its bloody violence, as it has been for decades.¹⁵

If homicide is simultaneously the most serious and best-measured form of violence, and urban violence is associated with more homicides than any other, then there is a strong case for urgently addressing this form of violence. By focusing on urban violence, we can save lives and keep families and communities intact while bringing the nation into parity with its wealthy peers. Providing public safety is the most fundamental priority for any society, and collectively we are failing to fully meet our obligations to our fellow citizens, especially for the least powerful and most persecuted among us.

THIS BOOK IS a work of forward-looking pragmatism. It offers concrete recommendations on what to do about urban violence now. It collects the most reliable evidence currently available and also draws on the real-world experiences of those who have faced violence firsthand. This book, in short, is both evidence- and community-informed. Evidence-informed means making recommendations that are informed by the best evidence and data currently available. Community-informed means giving voice to those most impacted by urban violence and meaningfully including them in the decision-making process for addressing it.

The recommendations in this book are primarily based on impact evaluations. Lots of them. Impact evaluations do what their name implies; they evaluate things to see whether they had an impact. They are designed to answer a simple question: “Did this program or policy reach its intended goals?” The evaluations in this book all concern programs and policies designed to reduce crime and, especially, violence. In this book, I ask a simple but powerful question: “When trying to reduce urban violence, what works?”¹⁶

Most of the impact evaluations in this book are drawn from systematic reviews—a relatively recent development in the social sciences. Originating in medicine, these reviews exhaustively gather and rigorously interpret the results of multiple evaluations. They set clear goals, use transparent methodologies, and focus only on the most reliable studies. Systematic reviews are now widely regarded as providing the strongest evidence of “what works” when evaluating programs and policies. In some areas, however, there are no systematic reviews. There may not even be impact evaluations. At times, then, I’ve had to rely on the best evidence available while offering cautions as to the confidence one can have when coming to conclusions.¹⁷

Even when plentiful, such evidence only goes so far. To truly understand urban violence, research must be blended with practice; book smarts must be blended with street smarts. In preparation for this book, I traveled across the country interviewing current and former shooters, gang members, mothers who had lost sons to violence, police officers, outreach workers, social service providers, and others. In Baltimore, Boston, Chicago, Los Angeles, and New York, among other places, I conducted dozens of face-to-face interviews. Some of these conversations were inspiring, others were sobering, and many were both. Here are a few examples.

Erik King is an educator, helping to keep youth engaged and successful at school. As a child, he learned the language of violence, enduring abuse, loss, isolation and poverty. As a young man, he spoke the language himself, becoming an enforcer for a number of New York City gangs. He was shot, stabbed, and beaten, but ultimately Erik turned away from violence because of the love and support of a few friends and family members who believed in him, even when he did not believe in himself.

Like his father before him, Deputy Chief Phillip Tingirides always wanted to be a cop. Once he joined the Los Angeles Police Department, he saw that some officers treated people with respect while others looked for conflict. He decided to emulate the officers who forged strong connections with the neighborhoods they served. “If you have the trust of the community, they’ll help you, but not if they think you’re only out to lock them up.” Tingirides now leads one of the most successful neighborhood-policing initiatives in the nation.

Few meeting Eddie Bocanegra, an executive at a large nonprofit in Chicago, would believe that he served fourteen years in prison for first-degree murder. Since then, he has spent his life in service, pioneering a number of community-based programs to build resiliency among those impacted by violence. Eddie now leads READI Chicago, an ambitious initiative to provide jobs, skills, and treatment for those at the very highest risk for violent offending and victimization, leveraging his years as a gang member and inmate to help others find safer and better futures.

These accounts, and others like them, bring home the humanity of those impacted most by violence. Too often, Americans believe that violence is a problem that “other” people face. Those caught up in the cycle of violence are simply different from the rest of us, the thinking goes—and of course race fundamentally shapes such thinking. One of the goals of this book is to help those of us who are safe to realize that we are not so different from those who live their lives under the constant threat of danger. Real stories, from real people who have experienced or witnessed violence up close and personal, help to bring this point home.

Some might believe that the academic and community perspectives are too different to be reconciled, but that has not been my experience. Over the years, I have constantly compared what I learn from researchers with what I hear and see in neighborhoods. Perhaps surprisingly to some, social scientists and the street are largely in agreement on urban violence, one reinforcing the another as they see the same phenomenon through different lenses, with each perspective being necessary but not sufficient for a full understanding of the issue.

This book also draws upon my own background and experiences. For more than twenty years, I have worked as an educator, prosecutor, policy maker, and now researcher focused on urban violence. I have worked cases, pushed programs, looked at the numbers, and read studies. While I was teaching high school in Washington, DC, one of my favorite students was murdered. As an assistant district attorney working in New York City, I prosecuted criminals and comforted victims. While working for President Barack Obama and New York governor Andrew Cuomo, I advocated for policies to address these issues. Now, at the Harvard Kennedy School of Government, I mix research with real-world experience in order to better understand what can be done about crime and violence.

LIKE A PATIENT in an emergency room, this book begins with triage, proceeds to diagnosis, continues with treatment, then ends with prognosis. Triage ensures that we treat the most urgent injuries and illnesses first. A diagnosis is necessary to determine the origin of a patient’s symptoms. Treatment describes the care that must be provided. Finally, a prognosis forecasts the patient’s future progress.

Chapter 2, “Triage,” describes the tremendous toll urban violence takes on individuals, communities, and the nation, illustrating the centrality of violence and the fear of violence to urban life. It also documents society’s collective failure to prioritize urban violence, arguing that decision-makers, like doctors in the ER, must urgently attend to the enormous harm it causes.

Chapters 3, 4, and 5—which together form part 1, “Diagnosis”—examine urban violence in America. Chapter 3 explores a fundamental finding related to urban violence: that crime and, especially, violence are “sticky,” meaning that they tend to cluster around small numbers of dangerous people, places, and behaviors. Chapter 4 examines a second fundamental finding: that a balance of punishment and prevention works far better to reduce urban violence than either approach in isolation. Chapter 5 investigates the ongoing crisis of confidence in criminal justice to uncover a third fundamental finding: that in order to promote safety, we must build legitimacy—and vice versa.

Chapters 6, 7, and 8—which form part 2, “Treatment”—are about the policies proven to actually reduce urban violence. Chapter 6 examines people-based strategies that deter dangerous offenders and prevent young people from becoming dangerous in the first place. Chapter 7 describes place-based strategies to lower violent crime in the locations where it happens the most. Chapter 8 identifies behaviors that facilitate and aggravate violence—gun carrying, gangbanging, and violent drug dealing—and identifies concrete strategies to address them.

Chapters 9, 10, and 11—which form part 3, “Prognosis”—collectively offer a positive vision for a safer and more peaceful urban America. Chapter 9 explores how to change the national narrative around urban violence to better promote smart policies and successful strategies. Chapter 10 provides a series of inspiring stories from real people about how they struggled, survived, and ultimately succeeded, despite being deeply impacted by the violence surrounding them. Chapter 11 culminates with two concrete plans—one local and one national—to reduce homicide rates by over 50 percent over eight years. The first plan is for a single locality; the second includes the forty most violent cities in the country.

THIS IS NOT a book about where we end up; it is about where we begin, and on that it does not equivocate: we must start with violence itself. High rates of violent crime are the structural linchpin of urban poverty, trapping poor people in neighborhoods of concentrated disadvantage. Violence is not simply a manifestation of poverty; it is a force that perpetuates poverty as well. Poverty might precede violence, but reducing poverty requires working backward, beginning with the violence we experience today. Similarly, while high rates of gun ownership—more than one for every adult American—have an undeniable impact on deadly violence in our cities, we need not wait until the national debate on gun control is resolved to act. By beginning with the guns in the hands of the most dangerous people, in the most dangerous places, we can make an immediate difference.

To get started, we must stop seeing urban violence as an argument to be won and instead look at it as a problem to be solved. On the right, racist blame-shifting and fearmongering must be rejected. On the left, race-based mistrust of law enforcement must be addressed. A diverse new political constituency must be created to demand practical solutions to the pressing challenge of urban violence. This movement should bring together those who have suffered from violence with those who wish to help them. Fortunately, this group does not need to be large; it just needs to be loud.

If we can stop the bleeding, redemption and recovery are possible. The proposals in this book are modest in scope but potentially transformative in impact. With violence under control, we could unleash the potential of millions of people while saving billions of dollars. We could also build bridges over the divides that separate cops from communities, the privileged from the poor, and whites from their fellow African American and Latino citizens. Anti-violence efforts are not a substitute for broader and deeper efforts to remedy economic and social injustice—they are, rather, an essential aspect of them.