April 6, 2009

Violence Intervention Program

What does the government want to be true?

From CNN:

[Associate professor of surgery] Cooper created the Violence Intervention Program (VIP) at the Shock Trauma Unit of the University of Maryland Medical Center, the state's busiest hospital for violent injuries. It became one of the country's first hospital-based anti-violence programs.

"We approached this problem like any public health crisis, like heart disease or smoking," he said. "We tried to work on the root causes."

Since 1998, VIP has provided substance abuse counseling, job skills training and other support services to nearly 500 trauma victims.

A 2006 study by Cooper and his colleagues, published in the Journal of Trauma, showed that people in the program were six times less likely to be readmitted with a violent injury and three times less likely to be arrested for a violent crime.

Six times?  Ok, so I'm in.  This is a program which speaks to my personal biases: social problems solved by social methods.  You take a group of people who got shot, stabbed, and help them "get out of the game" (their words.)

No one here got diagnosed bipolar, no one was put on Depakote.  Some hands-on intervention by a support team, and boom-- people die less often (and are jailed less often.)  Sounds like an innovative program with solid efficacy data. Sign me up.

Oh, wait...


Why does it work?


One might surmise that the fact that Dr. Cooper is black might have something to do with it, perhaps by encouraging more positive transference from the trauma victims.  But how long does he spend with them ,really?  Milliseconds?  Yes, his race may be helpful; but no it wouldn't be enough to explain a six fold reduction in violence.

It is, however, undoubtedly the only reason CNN chose to report on this program, and not any of the dozen others I found searching the internet.  

So now the question becomes, why CNN?  Why now?


I had to review the actual study a few times to find the explanation, and yes, it saddened me.

The patients randomized to the intervention group then met with a social worker or case worker and a parole and probation officer assigned to the program. After the patient was discharged, the social worker or case worker and parole and probation officer met with the patient (now client) at scheduled intervals. Home visits were also performed by members of the VIP team.

The control group received no organized support from the VIP team and continued with the parole and probation agent who was previously handling their case.

These victims were all supposed to be on probation/parole.  What's changed is that now they are going to see new probation/parole officers who are actually going to do their job, regularly, and someone will be coming to the house to check on the parolees.  Victims.  I mean victims. 

In other words, they're now on probation/parole. 

The program doesn't represent an innovative way of decreasing violence; it represents a failure of the regular system, that doesn't monitor anyone, ever, except when it's convenient (e.g. they want a pretext for incarceration.)


Two points.  First, this represents another example of social policy being offloaded to medicine, for the usual reasons: medicine has more money than social programs do; it taps into the intellectual expertise of doctors, instead of police, etc. 

You might say, well, what's wrong with all that?  Nothing, nor am I saying the program shouldn't be implemented, but doing so avoids the question of why it has come to pass that it needs to be implemented; why are we fixing a broken social program by adding a new medical program, instead of fixing the broken social program?  In other words, why not simply make probation more accountable, and save everyone the trouble and the cost?

Which brings me to the second point, the unspoken truth: the point of the programs is precisely the increased cost.  It is wealth transfer; Dr. Cooper just employed two new probation officers, a social worker, etc, etc.  I'm sure somewhere there's a billing code for it.  The victims are poor people, so government money is involved.

One way or another, doctors are going to get paid.  And social workers are going to get paid. And hospitals are going to get paid.  And UNH and Wellpoint are going to get paid.  And etc.  If it means medicalizing crime and welfare and climate change and Darfur to do get at some of that government money, so be it.


No, no, no, I'm not saying the doctors are trying to suck money out of the government.  I have no doubt that Dr. Cooper had the absolute noblest of intentions here, motivated entirely by a desire to help.  I'm saying the government wants to give its money away, this is how it keeps the system running.  You have the problem of black youth violence anyway, why not pay medicine to handle it?  Keep doctors happy enough that they don't notice they get paid next to nothing for actual medical care;  shift the focus away from "failure of society" to "biological underpinnings"; convert "misguided social programs" to "coordinated medical care to decrease the problem of youth violence" and prevent some riots?  Everyone's a winner.

Like an idiot, I've been yelling about the encroachment of medicine into social policy, and now I think that's been the point all along.


I'm on twitter, if enough people sign up I'll try to make it worthwhile