Published by: michadmin on April 26th, 2012
By: Carolyn Snider
I’m an emergency physician. We spend a lot of time trying to fix or mitigate people’s health problems and I, like all emergency physicians, love the adrenaline rush that comes with it. Whether it is a major resuscitation which results in a life saved or sending someone home with their arm stitched up – it can be a pretty satisfying career.
More and more we are recognizing that it is also our job to try and prevent future visits to the emergency department. Every time we send someone home, we do some sort of discharge planning. Perhaps we change their medication, set them up with an outpatient appointment with a specialist or make sure that their home is safe.
Early in my residency I noticed that our prevention activities excluded certain patients – youth injured by violence. This doesn’t make sense. Homicide is the fourth leading cause of death in Canada for youth aged 15 – 19 and homicide is only the tip of the iceberg. For every youth homicide there are 6 admissions to hospital and 148 emergency department visits. And even more concerning is that over 50% of youth injured by violence have been in the emergency department for an injury due to violence in the year prior! Yet when they come to the emergency department we don’t do anything to help them avoid future violence! (For comparison, 10% of people who come in with a transient ischemic attach (TIA a.k.a. “mini-stroke”) will have a stroke in the next 90 days – for these patients we have developed extensive risk stratification tools, medication protocols and rapid follow-up clinics). So I started to feel frustrated with our practice of “Treating and Streeting” our youth who have been injured by violence and thus my career as a clinician-researcher began. I moved here to Winnipeg in September and am excited that my research program has been embraced here at MICH.
Children aren’t born violent. They are just as cute as the next kid – soft and cuddly (and creating lots of poopy diapers and sleep-depriving their parents). So why does a child become violent? There are some clear trends that point to the social determinants of health – socioeconomic class, lack of housing, lack of family support, lack of education, lack of employment, substance misuse, concentrated poverty, neighbourhood collective efficacy and many more. These aren’t traditional health measures like heart rate and blood pressure but they sure have a big impact on people’s health. And we need to start identifying and fixing these issues early or we put our children and youth at higher risk of health problems. This isn’t just for violence – but for diabetes, cardiovascular and many of the health problems that our children face.
Some have wondered about race – that depends on the health problem. Some conditions have a genetic component and thus may put certain races at higher risk but in studies on youth homicide in the US, race has been shown to be irrelevant when you include socioeconomic class in the equation.
As you can see violence is a pretty complex problem to try and fix. So as a physician who believes that prevention is part of my job, I need to help tackle this problem from multiple levels. We need to look at this from the macro level and from a micro level.
We are fortunate in Manitoba to have access to an immense amount of data at the Manitoba Centre of Health Policy (MCHP). We are going to look at both the risk factors for our youth in Manitoba. Unfortunately, Manitoba is perhaps the best place in the country to examine this issue. Manitoba has the highest homicide rate in Canada, double the national average at 3.64 per 100,000. In Winnipeg there were 39 homicides in 2011, a record number ever recorded. Even more concerning is that over ½ involved youth. The data at MCHP will allow us to examine both the risk factors as well as some of the protective factors (i.e. why do some children do really well despite having all sorts of risk factors?)
Additionally, we need to start helping those individual youth who come into our emergency departments with injuries due to violence avoid future violence. I am proposing a case management system where youth are met in the emergency department or hospital by a social worker who has “lived experience” – i.e. someone who has been in or close to a gang in their lives (someone who “gets” what they are going through). This social worker would provide them with case management and mentorship for a number of months as they try to help the youth make changes in their lives that will help them avoid future violence.
The injuries are costly. In Manitoba, estimates of total costs of interpersonal injury are $72 million annually (direct costs $32M, indirect costs $40M). Beyond the millions of dollars that might be spent on a single injured youth, there is also a huge emotional cost to the individual, their family, communities and society as a whole. So instead of viewing violence as purely a criminal issue we need to start finding ways to prevent it.