[MUSIC PLAYING]
- Thank you, and welcome back.
Our last panel of the day is one
I'm particularly excited about.
In the morning and a little
bit earlier this afternoon,
we talked a lot about
pathogens that cause disease.
This afternoon,
we're going to talk
about pathogenic
social processes that
also cause disease epidemics.
To lead that panel,
we're honored
to have Dean Michelle Williams.
She's Dean of Faculty at
Harvard T.H. Chan School
of Public Health.
She's an internationally
renowned epidemiologist
and public health scientist,
an award-winning educator,
and a widely recognized
academic leader.
Before becoming dean, she
was professor and Chair
of the Department
of Epidemiology
at the School of Public Health.
Her scientific work
focuses on integrating
genomic sciences and
epidemiologic methods
to identify risk factors,
diagnostic markers, treatments,
and prevention
targets for disorders
that contribute to maternal
and infant mortality.
She's published more than
450 scientific articles
and received numerous research
and teaching awards, including
President Barack
Obama's Presidential
Award for Excellence
in Science, Math,
and Engineering Mentoring.
Please welcome Dr.
Michelle Williams.
[APPLAUSE]
- Thank you, Janet.
Thank you.
And good afternoon, everyone.
It's really been
a pleasure for me
to be here to participate with
this panel, the last panel
of this wonderful day.
In this panel, we're
going to explore
the social roots of epidemics.
The contagion model
of infectious disease
is a very powerful
framework, as you've seen,
one that we can
use to illuminate
far broader phenomena.
This afternoon, we're going
to explore three of these,
all pressing public
health issues.
They include the opioid
crisis, gun violence,
and the race and gender
aspects of mental health.
The conversation we are
about to embark upon
is truly extraordinary.
Our three panelists span
a range of disciplines,
as you will hear.
Andrew Kolodny is a
physician and scientist.
He comes to us from the
Heller School of Social Policy
and Management at
Brandeis University,
where he is co-director
of opioid policy research.
He's also executive
director of Physicians
for Responsible
Opioid Prescribing.
We have on our panel
also Andrew Papachristos
who will speak
about gun violence.
He is a professor of
sociology at Yale,
where his research focuses on
social networks, neighborhoods,
street gangs, and
interpersonal violence.
Also among us is
Daphne Watkins who
studies mental health
disparities over the adult life
course.
She is an associate
professor of social work
at the University of Michigan
and an assistant professor
of psychiatry at the
university's medical school.
So our panel this afternoon
includes opioids, guns,
mental health.
How remarkable.
What breadth.
In a single session, we will
be able to think through,
to think about
all three of these
from such diverse perspectives.
Actually, when you
think about it,
it's a testament to the
fact that the amplitude
of public health is so large.
We draw on diverse data streams.
Some of that, you
heard a discussion
about in the previous panel.
These data streams
include biological data,
behavioral data,
social network data.
And we also have, in
this panel, a discussion
of how a robust set
of analytic tools
can be brought to use on these
rich and diverse data streams.
It's layers on top
of layers on top
of layers, layers of richness.
And it's a pretty exciting
and instrumental way
for addressing complex
public health problems.
This afternoon, we're
going to explore
how we might translate and
transfer methodologies used
for complex disease
contagion models
to equally complex social
and environmental problems.
Here is the cycle
of inquiry that
will frame our conversation.
For example, we start with
surveillance, identification,
of the presence of an epidemic.
Next, we come to risk
factor assessments.
What populations are
vulnerable to the epidemic
that we have identified?
Why are they vulnerable?
It's based on this that
we develop interventions.
Finally, we assess
these interventions.
This entails
choosing and applying
an evaluation methodology.
Here the possible
paths are many,
but the goal remains the same--
to determine the success
of any given intervention.
Does it reduce risk factors?
And does this attenuate
the contagion?
Our answers then feed back into
an ongoing and unending cycle
of discovery and implementation.
The most urgent issues of our
day are enormous and complex.
They sprawl across
disciplines without regard
to academic silos.
To address them, we
must talk to each other,
not briefly every now
and then, but often
and at length and with purpose.
This is how we will leverage
our collective expertise.
This is the way, and I
would argue the only way,
that we can hope
to find solutions
for these complex,
intersecting problems.
This insight was beautifully
expressed very recently
in a New York Times
letter to the editor
by seven Nobel laureates
shortly after this year's awards
were announced.
They wrote, and I quote,
"These landmark achievements
are rarely the work
of one individual.
Collaboration across
disciplines and borders
lies at the heart of
scientific discovery."
This recognition, so elegantly
stated by the Nobel laureates,
is also at the heart of
President Drew Faust's vision
of one Harvard.
And it is at the very heart
of today's conversation.
I don't need to tell you
that the issues we are now
turning to are among
the most critical
that we face in our society.
The terrible
tragedy of Las Vegas
earlier this month was
yet another reminder
of how completely we failed
to address the gun violence
epidemic that has long
plagued this country.
The opioid epidemic continues
to ravage our communities.
Last June, The New
York Times reported
that drug overdose deaths
in 2016 most likely
exceeded 59,000, the largest
annual jump ever recorded
in the US's history.
Drug overdoses have become
the leading cause of death
among Americans
under the age of 50.
Less visible, but
no less pervasive,
is the national epidemic
of mental health issues.
While mental health problems
occur throughout populations,
risk factors vary
in kind and degree--
ethnicity, culture, age, gender.
All of these come into
play as social determinants
of mental health.
So with these remarks,
what I'd like to do
is that we now dive in.
And I will ask our
first speaker--
and do we have a specific order?
Our first speaker to present.
And that will be Daphne Watkins.
Dr. Watkins.
[APPLAUSE]
- So just as your
lunches are settling in,
I'm also hoping that
the coffee kicks in
and you will stay with me as
much as you can this afternoon.
I'm really happy to begin
the social roots panel.
And in many ways, I
would consider myself
an interdisciplinary
scholar, one
who studies men's mental health
from a variety of perspectives
and using pearls of
wisdom from a variety
of different disciplines.
And in the spirit
of reflexivity,
I'll say that I was born female.
And I identify as a
black woman who studies
black men's mental health.
And this has involved everything
from community-based surveys
and qualitative interviews and
focus groups with black men
to interactions with black
men in psychiatric settings
and even more recently providing
a mental health education
and social support program
via Facebook that's
five weeks long that I will
speak about a little bit later
towards my talk.
Now my work focuses primarily
on defining mental health
with black men and having
them define it for themselves.
And then I use that definition
to improve mental health
for black men so that the
positive effects are really
experienced by them, their
families, and their communities
as a whole.
So my 15 years of
studying gender
has taught me that the
gender epidemic is real.
And it's an epidemic
that you really
wouldn't think is an epidemic.
But in my world,
it truly exists.
The gender epidemic is
a modern day epidemic
that often goes overlooked.
And like most
epidemics, ignoring it
can be harmful to those
who are suffering.
And it could even be deadly.
But we will not truly understand
the gravity of the gender
epidemic until we realize
the role that we all
play in it, specifically, how
we are socializing our youth
and how we, as the adults, are
helping them make connections
from their past and their
present, their right
now and their soon-to-come.
And I'm hopefully here,
today, to do this for you.
And to do this, I'd like to
start with this statement.
So men who adhere to traditional
definitions of manhood
have poorer mental
health than men
who adhere to more
progressive definitions.
And to be honest with
you, this statement
is pretty much a hot
topic right now in the men
and masculinities literature.
Specifically, my colleagues in
psychology and public health
and in gender studies have
known this for some time
and are working to understand
this in more depth.
But what they're
trying to understand
is not necessarily how does
the overall, traditional
definitions of manhood play out
when it comes to mental health,
but specifically how do certain
dimensions of manhood result
in poor mental health for men.
And let me be clear that,
today, I'm talking about gender.
I'm not talking about sex.
And there is a difference.
The terms are often
used interchangeably,
but there is a clear difference
between gender and sex.
So sex is what we
assign babies at birth.
The gender is who and what
those babies grow up to be.
So the who and the what they
assign themselves, if you will,
which is often
influenced by society.
And who are we really
kidding anyway?
Right?
Society does influence
who we are as people.
Society really plays a role by
subscribing or making the rules
that we follow as men and women.
And this is an
iterative process that
happens with children,
with young adults,
as well as with older adults.
Society influences how people
interact with the world,
as well as how the world
interacts with people.
So today, I'm talking
about gender, not sex.
And specifically, I'm
talking about men.
So looking at this statement
that I've placed here,
I think in order to
really understand
my argument we're going
to need to pull out
some of the key terms
from this statement here.
So if I'm saying
that men who adhere
to traditional
definitions of manhood
have poorer mental
health than men
who adhere to more
progressive definitions,
I would say those
key terms are men,
traditional
definitions of manhood,
poor mental health,
and progressive.
So let's discuss each
of these in turn.
So it is no mystery that,
from the moment parents
realize whether they're
having a boy or a girl,
the gender socializing begins.
We treat boys differently
because, well, that's
what we've always done.
We dress them differently.
We even relate to
them differently,
not just as children, but
as youth, as well as adults.
For example, parents
tend to be less concerned
about the safety of
their boys compared
to the safety of their
girls because boys are
supposed to be tough anyway.
Right?
They're supposed to be able
to fend for themselves.
And our girls need a little
more coddling, cuddling,
a little more nurturing.
Right?
Of course, this is debatable.
This even translates into
help-seeking behaviors
for boys and girls.
Because when it comes to the
anticipated developmental
challenges with regard
to health and well-being,
boys are often discouraged
from seeking help.
Even girls' interactions
with the health care
system tends to occur a
little earlier compared
to boys, particularly
around the time when
both reach developmental
milestones such as puberty.
We often encourage girls
to seek health care
during that transition
into womanhood,
but we rarely encourage
boys to also seek
health care during their
transition into manhood.
So gender, as we know it,
has a place in society
and has held this position in
society for a very long time.
The implications of
gender tends to manifest
through behaviors like
masculinity and femininity.
And just as there are
traditional definitions
of femininity, there are
also traditional definitions
of masculinity or manhood.
Now these traditional
definitions
have answers to several
different names over the years.
We've called them hegemonic
definitions of masculinity
or manhood,
mainstream, dominant.
And by traditional,
though, here I'm
speaking of that
alpha man, right,
that poised, being
stoic, oftentimes,
the breadwinner,
the strong person,
excuse me, in the
relationship in the family.
But at the root of
it all, masculinity
is a social construct that
outlines the shared experiences
and the shared expectations
about social and cultural
behaviors for both boys and men.
Boys are taught how to
be men at an early age.
And it's expected that they
hold on to those definitions
throughout their life
transitions and trajectories.
More than anything,
these definitions
are focused on not
who boys and men are,
but on what boys and men
do in their interactions
with their families, their
friends, and their communities
as a whole.
For men and
masculinity scholars,
you know, we tend to refer to
masculinities in a plural form
because there are multiple and
multifaceted options that fall
along the masculinities
continuum,
which you see here
on the screen.
From a social perspective,
the diagnosis is clear.
Gender is problematic,
especially
when it comes to mental health.
But I have to be honest, from
a more clinical perspective,
maybe men aren't
suffering as much as
much as we think they are.
As you can see, these
statistics paint such a picture.
You can see from these data
from the Center for Behavioral
Health Statistics and Quality
that past-year serious mental
illness among adults who are
18 years and older is higher
for women compared to men and
higher for whites compared--
I'm sorry-- and higher for
whites compared to blacks,
Asians, and Hispanics.
So based on the
numbers, perhaps, men
should not get a lot
of our attention.
Right?
Based on the
statistics, it looks
like men are doing just fine.
But in actuality, they should
get a lot of our attention
right because not all
of these statistics
always capture the
kinds of information
that we hope that they
capture to give us
some direction for
how to move forward.
First, there is
substantial evidence
on mistreatment and misdiagnosis
among black Americans.
And studies also show
that people of color
are misdiagnosed
with more serious
psychological conditions, even
when they have similar symptoms
as whites.
I also worry a little
bit about the measures.
I wonder if we're asking
the right questions
to get the right answers
that we need in order
to take into consideration
things like race and gender
and sexual orientation even.
So while I believe this
is a problem for men,
and specifically
black men, I can
admit that the numbers
say something differently.
So you may be wondering,
given the numbers,
you know, why do I focus
my efforts on black men.
Well, many black men in our
country experience injustices
related to police
aggression and brutality.
And I believe that
we are failing
in helping to understand the
connection between these events
and their mental health.
So research shows
that people who
report more of these
interactions with police
do experience more
symptoms of anxiety
and post-traumatic
stress disorder.
Research also confirms
that few black men
seek mental health treatment for
their mental health conditions.
And we know that
black men are less
likely to seek mental health
treatment due to stigma
associated with
mental health care,
the mistrust of the mental
health care providers,
or even a lack of more
gender-specific and culturally
relevant attention to their
mental health care needs.
Studies also show
that black men often
experience the kind of
gender socialization
that may look very
different compared
to men of other racial
and ethnic groups.
Oftentimes, black
men are socialized
to be more masculine or
hyper-masculine, if you will,
than men of other
racial and ethnic groups
so as to combat
racism and oppression.
But what ends up happening is
these hyper-masculine behaviors
result in black men
acting out in ways
that are actually
counter to what
are genuinely healthy
and authentically human.
And it would be remiss
of me not to acknowledge
that hyper-masculinity may
manifest in unique ways
among boys and men of other
racial and ethnic groups.
And so while I often use the
term progressive to describe
more mainstream definitions
of masculinities and manhood,
here, I actually
want to talk about it
and contextualize
it as a way that we
think about our methods,
research methods to be exact.
Because progressive, more
advanced research methods
are important in
research overall,
but especially in
research that we
conduct with our
under-represented populations
and underserved groups.
Historically, and I'm sure
many of you in the room
can either agree or disagree
with this statement,
but researchers
typically choose a camp.
Right?
Which a lunch table
where we want to sit.
And it's often based on our
philosophical perspective
in how researchers determine
what is scientific truth.
So quantitative researchers
tend to have a--
there we go.
Quantitative researchers tend
to have a valuable contribution
to science.
They feel like they see
the importance of numbers,
large samples, and have
a hypothesis to test.
Quantitative researchers
also acknowledge the value
of being objective and
generalizing their work so
that we can infer what they
uncover from the sample
to the larger population.
But then on the other
side of the camp
or maybe on the other side of
the lunchroom, if you will,
are these qualitative
researchers
who make valuable
contributions to science,
contextualizing what they
find from smaller samples,
and going deeper into
their level of discovery
to unearth meaning from
their work with people.
So just by a show
of hands, can I
see how many people are in
the room sort of identify
as quantitative
researchers, definitely
in love with the statistics?
OK, nice group.
How about my
qualitative researchers?
Oh, the hands shoot
up fast when I
ask about the
qualitative researchers.
So I would argue that while
both types of research
are needed in scientific
inquiry, definitely,
I tend to sit right
in the middle.
Because I would argue that the
combination and integration
of both qualitative and
quantitative research
has been around for some time.
And we call that mixed
methods research.
At its foundation,
mixed methods research
involves the intersection
of both qualitative
and quantitative methods
into a single study
to generate a more comprehensive
understanding of the topic
under study.
It is the combining
of both qualitative
and quantitative
methods that expand
the scope of the research.
There are several advantages
to mixed methods research,
but I'll just name
a couple here.
First of all-- oh, wow, it
looks like my PowerPoint slides
are moving too quickly here.
OK, pardon me.
They must be on a timer.
So let's get back to the
advantages of mixed methods
research.
So mixed methods
research, it really
is about using both
methods together and really
using them so that
the strength of one
offsets the weaknesses
of the other.
And I think in order
to really unearth
the stories or the words
behind the numbers,
it's really important to
contextualize your work
and really think about
providing a language
for the true lives of the
people that you want to help.
And in my case, that just
happens to be black men.
So this brings us back
to where I started
that men who adhere to
traditional definitions
of manhood tend to have
poorer mental health
than men who adhere to more
progressive definitions
of manhood.
Now, again, this is where
I started this talk.
But the reason why I
wanted to start here
is because so much of
our research on gender
and ethnicity and public
health and psychology
really kind of
highlights this idea
that there are behaviors that
result in certain mental health
outcomes.
Now why this statement is
particularly important to me
is because we find that black
men, in particular, tend
to adhere to more traditional
definitions of manhood
when compared to men
of other racial groups.
So if a socially rooted
construct is the problem,
then we have a sense for
the diagnosis if you will.
But how should we go about
combating a problem like this?
How do we talk about resolving
or trying to remedy something
that is socially oriented?
And I definitely give
a nod to my colleagues
earlier who talked about
getting into the field
and certainly trying
to solve the problems
with these modern-day epidemics.
But in my world, this socially
constructed epidemic of gender
is something that
I'm trying to combat.
And the way that we
try to combat this
is we start somewhere.
And so I choose to start
working towards changing
the narrative around
black men's mental health.
I choose to work
towards reducing
the harmful effects of the
gender epidemic, at least
for young black men.
And as with any
narrative change,
you have to really be
willing to put something out
into the world that you believe
in and hope that something
positive comes back from that.
One of my contributions to
changing this narrative is
a program that I developed
called the YBMen Project,
which stands for the Young Black
Men Masculinities and Mental
Health Project.
I conceptualized
this project in 2008,
but it was launched in 2013.
And the YBMen
Project was created
to address the
masculinity, mental health,
and social support needs
of young black men.
This age-specific,
gender-appropriate,
and culturally
tailored intervention
promotes mental
health education,
transformative
definitions of manhood,
and social support
for young black men.
Now, in any way, this
is not e-therapy.
So I always tell people
that I am not a clinician.
I only play one on television.
So I'm not trying to diagnose
men with this kind of work.
But we find that men who are
interested in this particular
intervention are
usually the men who
may be less likely to
discuss their mental health
face to face.
They may be the men
whose distress may not
have reached clinical severity.
And they desire mental health
education and social support
in an internet-based setting.
So to date, the
YBMen Project has
been implemented across
college and university campuses
in the Midwest.
So this mental health
education program
is particularly attractive to
colleges and universities who
want to improve and maintain
positive mental health
and well-being for black
men by using popular culture
references and
leveraging social media.
And our social media
of choice is Facebook.
So this is a sample
six-week curriculum
for the YBMen Project,
as our intervention
can be as short as five weeks
or as long as eight weeks.
The content is delivered through
a private Facebook group.
And we use popular
culture references
to deliver the mental
health education,
progressive definitions
of masculinities,
and social support content to
the young men who participate.
This is a screenshot
from a previous iteration
of the intervention.
And what the YBMen
Project does is
it helps us
understand black men's
attitudes towards mental
health, masculinities,
and social support.
Our participants think Facebook
is the most appropriate vehicle
for our work and that we provide
thought-provoking content
that open black men's eyes to
a range of issues they had not
really thought about before.
Participants enjoyed the
exclusive and non-judgmental
space, as it provides
them with the opportunity
to process mental
health, masculinities,
and social support in
the context of the world
around them and in the virtual
presence of other black men,
which is so key.
Because when you think
about socialization,
you realize that, women, we
tend to be sort of taught
to socialize with girls nights
out and things like that.
But men are often not
socialized to convene
to get together and discuss
some of their life experiences.
So quantitatively, our data
has showed promising results.
We usually collect both
pre and post-test data
to measure change over time and
whether participants' scores
on their mental health
and masculinity measures
have changed.
And as you can see, depressive
symptoms did decrease for men
in our Facebook group.
And they did increase
ever so slightly
for men who did not
participate in our groups.
We also have interview
data that helps
to demonstrate participants'
more progressive definitions
of manhood, more deliberate,
intentional considerations
for social support.
And I have to be honest and
say that this is obviously
not a change that
happened overnight,
but rather men tend to
be more open to thinking
about various definitions
of masculinity
and the benefits of social
support in their lives post
intervention.
So as I bring this
to a close, what
I want you to take away
from this presentation
is that gender is
a social construct.
Do men have privileges
that women do not have?
Absolutely.
But I would be
doing a disservice
if I led you to believe
that men are not suffering
in some aspects of their lives.
And a part of that
suffering does
happen when it comes to mental
health and mental health care.
We have more power
in the development
of how we socialize boys
and girls than we may think.
The moment that I
realized my power
in shaping the narrative and
the experiences of black man's
mental health was the moment
I realized my purpose.
And you don't have to have a PhD
or an MD to do this, certainly.
But you can actually do
more in your communities
around encouraging
those little boys who
may want to pursue careers
that may be women's work
or what could be
considered women's work,
like nurses and dancers, to
really have them do something
that makes them happy.
So as I bring this
to a close, I'm
going to remind you
of the statement
that I showed you
at the beginning.
And I do believe this is a hard
and fast statement right now.
But I want to just leave
you with an edited version
of this statement
that I'm striving
to support in my own research
and that I hope to someday read
at the beginning
of a presentation
on how we together
combated the gender
epidemic during our generation.
And with that, I thank you for
your time and your attention.
[APPLAUSE]
- Thank you.
We are definitely
launching this panel
with a lovely presentation.
Thank you, Daphne.
Now I'd like to ask Andrew
Kolodny to join me here
at the podium who will
present his remarks.
- Your presentation
is down there.
I apologize. this wasn't here.
- That's fine.
That's fine.
So it's a pleasure to
have this opportunity
to talk with all of you about
our opioid addiction epidemic.
I'm going to be helping you
better understand what's
happening right now with
prescription opioids, heroin,
and fentanyl.
I'm going explain to you how
we got into this mess, which
I think is important for
understanding strategies
for bringing it under control.
And I will go over, briefly,
some of those strategies.
I have a lot I want to cover.
So I'm going to be going
very quickly because there's
only 20 minutes.
I have no financial
relationships
with any pharmaceutical
companies.
After you hear my
talk, I think you'll
understand why no
pharmaceutical companies want
a relationship with me.
When we talk, well, actually,
when we use the term opioid,
the term opioid includes
naturally occurring
opioids that come from opium.
And you know inside opium,
you have morphine and codeine.
Those are totally natural.
Another term for the totally
natural opioids is opiate.
We also have
semi-synthetic opioids,
which are made from opium.
And you treat the
opium chemically
to make them get to
the brain faster.
You're making them
more lipophilic.
Some semi-synthetic opioids
that you may have heard of
include hydrocodone,
which is in Vicodin,
oxycodone, which is an
OxyContin, and heroin.
Heroin is also a
semi-synthetic opioid.
Something many
people don't realize
is that the effects that
heroin produces in the brain
are indistinguishable
from the effects produced
by hydrocodone and oxycodone.
An experienced heroin user
can't tell one from the other.
And then, lastly, we have the
completely synthetic opioids,
which you don't need to start
with opium to make them.
And that would include fentanyl.
Methadone is also a
completely synthetic opioid.
This is an old slide.
I updated it with the
number of Americans
who died of a drug
overdose in 2016, which
the preliminary figure
is 64,000 Americans who
died of an overdose.
Otherwise, it's an old
slide that the CDC came out
with in 2010.
And there was a three-year
lag in the data.
When the CDC put
out this slide, they
had started to use
the term epidemic
to describe our opioid crisis.
And when they used the term
epidemic, they were criticized.
The criticism was
really mainly coming
from pain organizations that
were getting funding from drug
companies that make opioids.
s pain organizations
said to the CDC stop
calling this an epidemic.
It's not an epidemic.
You're exaggerating.
And by calling it an epidemic,
you're going to scare doctors.
And they'll be afraid to
treat pain with opioids,
and you'll make the problem
of untreated pain worse.
So knock it off.
Don't Stop calling
it an epidemic.
And the CDC responded
by saying we're the CDC.
We don't use the term
epidemic lightly.
This is an epidemic.
And then they went even further.
They said not only
is this an epidemic.
This is the worst drug addiction
epidemic in the United States
history.
And that's the point that
we're making with this slide.
So if you see the
box that says heroin,
that's showing you the rate
of drug overdose deaths
during the height of the
heroin epidemic of the 1970s.
And the box that
says cocaine, that's
the crack cocaine epidemic.
And you're seeing that drug
overdose deaths are higher
today, far higher, than they
were at the height of those two
epidemics combined.
And I mentioned this is old.
So I'll show you what's happened
in terms of the rate of drug
overdose deaths since 2007.
In 2008, they went higher, 2009,
up again '10, '11, '12, '13,
'14, '15.
And the preliminary data from
'16 is that it went up again.
Every year for
the past 20 years,
we've set a new
record for deaths
from drug overdoses
in the United States.
And then the next year,
we break that record.
Not all of these deaths
are opioid overdoses.
But what's really
driven the increase
are overdoses involving opioids.
So these are some headlines from
just the past several weeks,
headlines from newspapers.
One year, drug overdoses
killed more Americans
than the entire Vietnam War.
44,000 Americans died in 20
years of the Vietnam War.
For opioid overdoses
alone, we may
have surpassed that figure,
more than 44,000, last year.
We're seeing a soaring
increase of infants
born opioid dependent,
children in foster care.
Fentanyl deaths are
going up very rapidly.
And we're now-- we heard from
Janet Yellen a few months ago
that the opioid crisis is having
an impact on the workforce
and on our economy.
What it is all of this?
What is the opioid crisis?
What's going on here?
How do we frame it?
How do we understand it?
Well, let me start by
saying what it isn't.
It is not a drug abuse crisis.
It's not an epidemic of
prescription or heroin abuse.
If you use the term abuse,
what that, I believe, suggests
is that the problem we're
dealing with is a lot of people
out there are behaving
badly, taking dangerous drugs
because it feels good.
And they're accidentally
killing themselves.
And the challenge is
how do we stop people
from taking these dangerous
drugs and behaving badly.
That isn't it.
The opioid crisis is
an addiction epidemic.
Once somebody becomes
addicted to opioids,
they're not doing
it because it's fun.
Once you're addicted, you
have to keep using opioids
to avoid feeling awful.
And while it's true some people
became addicted because they
were taking opioids
to enjoy the effect,
there are also many people who
became obese addicted taking
opioids as prescribed
by doctors.
So the right way to
define the problem
is as an epidemic of addiction.
And I'm going to show
you that happening
with a succession of maps.
I believe our opiate addiction
epidemic began in 1996.
This is three years
into the epidemic,
and you're looking
at the rate of folks
showing up at state licensed
drug and alcohol treatment
programs saying that the primary
drug that they're addicted to
is a prescription opioid.
And the states with the highest
rate of people showing up
addicted to
prescription opioids,
they show up as red
or maroon on the map.
I want you to watch what
happens to the color of the map
as we go forward and
in two-year increments.
So this is '99, 2001,
2003, 2005, 2007, and 2009.
What you can see is
that even by 2009,
in every state in
the country, we
had seen a sharp increase
in the prevalence,
the number of people with the
condition of opioid addiction.
And when you see
a sharp increase
in a disease over a
short period of time,
that is how you would
define an epidemic.
This is interesting.
This is the demographics
of those folks showing up
who are addicted to
prescription opioids.
You see that it's, for
both males and females,
you see it tends
to be young adults.
That doesn't mean that older
people aren't getting addicted.
Older people are less
likely to wind up
in an addiction treatment.
But something that's
really interesting here,
I think striking, is
the racial breakdown.
You're pretty much
looking at a blue line.
If you try to find other
racial groups showing up,
African-Americans
would show up as red.
You barely see it register
at the bottom of the graph.
And if you're
thinking, well, maybe
that means that
African-Americans are less
likely to get
addiction treatment,
and that's why we
don't see them here,
that's not the explanation.
This is data from the
state licensed system where
you tend to see
lower income groups
and nonwhite groups
overrepresented.
If I showed you the
smoked cocaine slide,
you'd see a red line
bigger than the blue line.
This is real.
The racial differences are real.
And if we have time
during the Q&A,
I can share with you my
theory for why the epidemic is
so strikingly white.
What caused our epidemic?
The CDC has been very
clear about the cause
of our opioid addiction
epidemic for a while.
And this has been one of
their chief speaking points
about what's caused
our epidemic.
The green line on this slide
represents opioid consumption
in the United States, really
prescriptions for opioids.
The red line represents deaths
involving prescription opioids,
and the blue line
represents addiction.
And what the CDC is saying is
that, as the green line went
up, the red line
and the blue line
went up, right along with
the increase in prescribing.
They're saying this
is an epidemic that's
been caused by the medical
community over prescribing.
And their message to
us is perfectly clear.
We may not be able to bring
the epidemic under control
until that green line
really comes down.
It can't come all the
way down because opioids
are essential medicines
for palliative care.
They also play an important
role when used for a few days
after major surgery.
But the bulk of
our consumption is
for conditions where opioids
may be more likely to harm
a patient than help a patient.
So the CDC is saying that
that green line really
needs to come down if we're
going to end the epidemic.
I can tell you that
drug companies that
manufacture opioids
don't agree with the CDC.
And I'm not just saying that.
For a while, they
denied the association.
They said, you know, you're
not accounting for pills that
get stolen from pharmacies.
How do you know it's
doctor prescribing
that that's fueling this?
And they've stopped
denying the association.
They now acknowledge
that these three lines
have gone up together.
But what they're saying
is that if we make
the pills hard to crush
for snorting or injecting,
so-called abuse
deterrent formulations,
and if we teach doctors to
monitor their patients more
closely, we can have
our cake and eat it too.
The green line
can keep going up,
and it should because
millions of people
have chronic pain
is what they'll say.
But if we do the
right things, we
can make the red line and
the blue line go down.
I don't think that will
work, unfortunately.
Why did that green
start to go up?
In 1996, a multifaceted campaign
was launched, underwritten
originally by one pharmaceutical
company, Purdue Pharma,
the manufacturer
of OxyContin, when
it put OxyContin on the market.
And ultimately, other
opioid manufacturers,
other drug companies, would
fund this campaign as well.
But beginning in 1996,
the medical community
starts hearing that we've been
under prescribing opioids.
We're allowing patients
to suffer needlessly
because of an overblown
fear of addiction.
We start hearing that the
risk of addiction, when
you put a patient on long-term
opioids, is much less than 1%
and that opioids are a
gift from mother nature.
They should be used much
more for people with pain.
And as I tell you this,
you may be thinking,
you know, how could
you guys be so stupid.
You went to medical school.
How would you fall for this?
And what you have
to understand is
that we didn't hear this
just from a drug company.
We were hearing it
from pain specialists
eminent in the field.
We were hearing it from
our professional societies.
We were hearing it from our
hospitals and the accreditation
agency for our hospitals.
We even heard from state
medical boards that told us
that the policies changed.
We started to hear
that you will not
be sanctioned based on the
quantity of pills that you're
prescribing or the doses
that you're giving,
but you will be sanctioned
for under-treatment of pain.
Now I don't want you
to think that this
was all about drug
companies putting money
in people's pockets
and saying these are
the lies we want you to tell.
It really didn't
happen that way.
The vast majority of people
involved in this movement,
and it really was a
movement, I think truly
believed what they were
saying, truly believed
that an overblown
fear of addiction
was leading to suffering.
So prescribing has
come down a bit.
We peaked around 2011, and
then it started to come down.
This is oxycodone prescribing.
The blue line is in the
United States consumption.
The red line is
consumption in Europe.
And you can see despite
the fact that we've
come down a little bit, we are
still way higher than Europe.
And this is oxycodone.
If I showed you hydrocodone,
which is in Vicodin,
the difference would
be even more striking
because the United States is the
only country in the world that
has Vicodin.
In other countries,
if hydrocodone
is prescribed at all, it's
only in a cough syrup.
So we've come down a bit.
You're starting to hear
that there's a crack down,
and patients can't get
their pain medicine anymore.
Clearly, the data does
not support that view.
So here's what's
happening right now.
You can see total opioid
overdose deaths are soaring.
Prescription opioid
overdose deaths,
the purple, dark blue
line, you see a flattening.
And heroin deaths have
begun to skyrocket.
And because these trends
have occurred together,
the flattening of
the prescription
opioids while we've seen
heroin deaths soaring,
there's a popular narrative to
explain this, which is wrong.
What you're hearing is that
the crack down on painkillers
has led the drug
abusers to switch
from using the pills to heroin
and that the pain killer
problem turned into a heroin
problem because of a crack
down on the pills.
And it makes for a good media
story because, you know,
government tries to
tackle one problem
and inadvertently
creates another problem.
But that really isn't
what's going on.
There's a kernel of truth.
The true part is
the switching part.
But what's not true is that the
switching has started suddenly.
If you look at young
whites, ages 20 to 34,
which is the red
line on the left,
you'll see that heroin use
among young white people
in the United States began
rising rapidly, actually,
in the late '90s.
This graph begins in 2003.
But it's really, from the
beginning of the prescription
opioid crisis, young people
who are becoming addicted
to the pills, pills
that they were
taking either medically
or recreationally
or sometimes both--
a brief medical exposure for
wisdom teeth or sports injury.
They don't get addicted from
the brief medical exposure.
But they're basically getting
their first taste of the drug
from a doctor or a dentist.
And if they like the effect, and
they're not afraid of the drug
anymore, a period of
recreational use may ensue.
So the young people,
once they get addicted,
they have a hard time
maintaining their supply
visiting doctors.
And again, it isn't that
doctors and dentists
don't like to give young
people lots of pills.
Unfortunately, we're too
comfortable doing that.
But doctors don't
like to give healthy
looking 25-year-olds a large
quantity on a monthly basis.
Unless the doctor
is a drug dealer,
they don't like to do that.
So young people who
became opioid addicted,
they'd wind up on
the black market.
The pills are very
expensive on the street,
have always been
expensive on the street.
They didn't suddenly become
expensive in the context
of a crack down.
From the beginning, an
80 milligram OxyContin
sold for $80, $1 a milligram.
And that's still the price
today-- $1 a milligram.
So if the young person was
in a region of the country
where heroin was
available, they switched.
And what's happened steadily
over the past 20 years
is we've seen heroin
move into more
regions of the country where
it wasn't previously available.
Quaint New England
towns that did not
have a heroin
problem in the past
now have a heroin problem
because it's flooded in
to meet the demand
for it by this growing
number of young people who have
become addicted to prescription
opioids.
What about middle-aged people,
the green line, 45 years
and older?
You don't see heroin use rising.
Why not?
Does that mean
they've been spared
from the opioid
addiction epidemic?
Unfortunately, they
haven't been spared.
But they don't have
to turn to heroin.
The older group people in
their 40s up through their 80s
are developing opiate
addiction almost entirely
through medical use.
Sometimes, it starts
as an acute pain
problem or post-surgical pain.
And they're put on opioids,
and they never come off.
And we may call them a chronic
pain patient after that.
And they're continuing
to get opioids.
This older group, when they
become opioid addicted,
they don't have a
hard time continuing
to get a large
quantity of opioids
from doctors on a monthly basis.
Even if the patient
starts to come in early
and asks for higher
doses, and there
are signs that the
patient is addicted,
the doctor doesn't want to
put a label like addiction
on the patient.
And since the patient is
attributing the behavior
to a worsening of pain, when
they get referred anywhere,
it's to pain management.
And then it's hit or miss.
There are pain
management doctors
who do a phenomenal job of
working with these people
to get them off of the opioids
and to treat their pain
with other modalities.
And when you can get these
people off of their opioids,
you'll often see that
their pain improves,
and their quality of life
and function improves.
But there are pain
specialists out there as well
who have no qualms
about going even
higher and higher on the dose.
Something that many
people don't realize
is that, up until recently, we
were seeing far more overdoses
in the older group that gets
pills more easily from doctors
than we were seeing in
the younger group that's
been switching to heroin.
This is data from 2010 to 2012.
I can tell you it's changed
because of fentanyl.
But in that time
frame, the age group--
it was middle-aged
folks that had
the highest rate of opioid
overdose in the United States.
If you look specifically
for heroin, the dark blue,
you'd see it was 25 to 34.
This has changed
because of fentanyl.
The younger group, as
of 2016, has caught up.
We are now seeing more deaths
in heroin users because
of fentanyl that's
in the supply.
So the reason we're seeing
the soaring increase in deaths
in heroin users is
because of the heroin
supply became much
more dangerous.
Increasingly, it has
fentanyl mixed into it
or fentanyl sold as heroin.
And fentanyl is 50
times more potent.
So it's very easy
to overdose on it.
Something that's interesting
is you don't even
see a bar for people over 65.
When it comes to the
overdose deaths for seniors,
we're not really
finding very many.
But that probably does
not mean that they're not
dying of overdoses.
When a senior dies
of an overdose,
they're very rarely
recorded as an overdose.
If grandma doesn't
wake up in the morning
because she took
too much OxyContin,
and grandma had multiple
medical problems, even
in a situation
where everybody knew
grandma had a problem
with her pills,
nobody wants grandma to
have died of an overdose.
And what typically happens is
the patient's primary care doc
or geriatrician is called and
asked for a cause of death.
And that's what goes on
the death certificate.
You can see in the
state of California,
the age group green
here, 65 and up,
you see is the age group with
the highest rate of people
showing up in emergency rooms
being treated for an overdose.
It's just when it comes to the
deaths, we don't see seniors.
We have three
groups of Americans
who are opioid addicted,
just to clarify,
that younger group that's
been switching to heroin.
Then we've got the
middle age group
that I mentioned that
doesn't have to switch
and has been
overdosing on pills.
And we have a third
group, which really
became infected from a much
earlier epidemic in cities that
were hit hard with
heroin in the 1970s
is where you'll find them.
And in that group,
we're also seeing
deaths going up right
now because the heroin
supply is so dangerous.
How do we bring the
epidemic under control?
The strategies are
similar to the strategies
for responding even to a
communicable disease epidemic.
What would we do to
stop an Ebola outbreak?
Really two things,
you'd contain it
to preventing more people from
getting the Ebola infection.
And you'd see that the
people who are infected
are getting treatment
so they don't
die from there Ebola infection.
That's what we have to do for
our opioid addiction epidemic.
We have to prevent more
people from getting addicted.
More than anything, that's
cautious prescribing.
It's not just say
no, which is what
Donald Trump said yesterday.
You know, tell kids
just say say no.
That isn't going to
get us out of this.
We need much more
cautious prescribing.
We have to see that the
millions who are addicted
get access to
effective treatment.
And you know, the war on drugs
rightly has a bad reputation.
It led to mass incarceration.
But there is a role for making
pills and heroin and fentanyl
more difficult to access,
while making treatment easier
to access.
We haven't responded
appropriately because,
for many years, the opioid lobby
framed the problem this way.
This was a slide shown
at an FDA meeting
to argue against
closing a loophole that
had Vicodin in the
wrong category where
it could be prescribed six
months worth of Vicodin
at one visit.
And the argument
was made to the FDA
that, if you put Vicodin into
a more restrictive category,
you'll be penalizing this pain
patient for the bad behavior
of these drug abusers.
And so, therefore, you
need to be balanced.
And for many years,
that's worked, the notion
that the harms were somehow
limited to so-called drug
abusers and that
millions of patients
were being helped by
aggressive prescribing.
Obviously we don't have
these two distinct groups.
There's tremendous
amount of overlap.
And it's not much less
than 1% of patients
who are treated with long-term
opioids that become addicted.
We see that about
a third of patients
who are on long-term opioids
meet criteria for addiction.
And if you look at the
deaths and people who
are dying of the prescription
opioid overdoses,
in the state of
Utah, in one study,
they found that
92% of the patients
were receiving
legitimate prescriptions
from doctors for a
diagnosis of chronic pain.
The next of kin believed that
their loved ones were also
addicted, but these were
legitimate patients.
And I'm just going
to start to end here
by making a final point.
This is the AIDS epidemic.
The AIDS epidemic
peaked in 1995.
It starts around 1980.
And then you see deaths plummet.
And why did we see
deaths from AIDS plummet?
We had the introduction of
antiretroviral therapies.
We turned HIV infection
from a terminal disease
into a chronic disease.
And the trajectory for the
opioid addiction epidemic
is similar, only we've
surpassed deaths from AIDS.
And it doesn't look like we're
turning the corner on this.
But I do believe we have
a medication that if there
was better access to it today
we could turn the corner.
I'm talking about buprenorphine,
which is also called suboxone.
And I'm not just speculating.
In France, it was
released in the mid '90s
without many of the restrictions
we have in the United States.
A fair amount was diverted
onto the black market.
But it's a very
different type of opioid.
Even when it's misused
on the black market,
even when it's injected, it's
quite difficult to overdose on.
And it is a medicine
that if taken the way
it's supposed to be,
the way it's prescribed,
and many people
do, more than half
of patients treated
with buprenorphine
have good outcomes.
They have a good improvement
in their quality of life.
They can function.
They can do well--
79% drop in overdose deaths
in France within six years.
So I'm going to finish up here.
If you are interested in what
the federal government should
be doing about the opiate
addiction epidemic,
I've got a paper in the
current issue of JAMA,
coauthored with Tom Frieden,
our former CDC director.
Donald Trump
mentioned-- actually,
he announced yesterday
that our opioid crisis
is a public health emergency.
What we didn't hear
from Donald Trump
was a plan for addressing it,
and we haven't had a plan yet,
unfortunately.
So in summary, the
United States is
in the midst of the
worst drug addiction
epidemic in its history.
To bring the epidemic under
control, to bring it to an end,
we have to prevent more
people from getting addicted.
We have to see that
those who are addicted
receive access to
effective treatment.
Thank you.
[APPLAUSE]
- Thank you, Andrew.
I hope you're keeping
your questions,
you're getting your
questions ready,
and that you are
recognizing some
of the very important themes
that have already been
expressed by our two speakers.
The next speaker, our final
speaker in this panel,
is Dr. Andrew Papachristos.
And we're going to
have an opportunity now
to hear about the emerging
epidemics in gun violence.
- Thank you.
So just let's get into this.
Setting aside mass shootings,
which is hard to do,
given sort of
recent events, there
are two types of
violence, gun violence,
that occupy sort of center
stage right now in this country.
The first is what I'm going
to call neighborhood violence.
And usually, by
this, what we think
about the staggering loss
of life in our cities,
mainly of young men of color.
And typically, in
presentations like this,
this is where I show you a
series of depressing figures
that point out to you the
massive inequalities associated
with being young, living in
a disadvantaged community,
being a person of color.
And I'm not going
to do that, only
to say that tens of
thousands of lives
are affected each year,
not only as victims
of fatal and non-fatal
gunshot injuries,
but those experiencing violence.
So the other type of
violence that's on center
stage these days is
police violence, which
also disproportionately
affects young men of color
in particular communities.
And each new case
of police violence
reminds us that we are dealing
with different types of reality
in a post-Ferguson era, in
particular the re-invoking
of law and order
rhetoric and what
this will mean for
the future of policing
in the current
political climate.
And we have lots of
us sort of that work
in the criminal justice
domain trying to figure out
what reform or what
types of policies
can look like in this domain.
But at times, when we
talk about these two
forms of gun violence,
they're often sort of pitched
as at odds with each other.
We count the number of bodies,
say, in a city like Chicago.
At the same time, we talk
about these dramatic acts
of essentially sort
of state violence
that happen in this country.
And we get sides
talking past each other.
So we can see like Heather
Mac Donald on this side,
other people on this side.
And are saying, oh,
they all matter.
But they of course both matter.
Understanding neighborhood
violence and police violence
both matter.
And in particular, I'm going
to argue and have argued
in my work that they
actually both stem
from some of the
same social problems,
in particular
inequality and power.
Right?
In this large
sociological sense--
I'm a sociologist by the way--
we're talking about inequality
in resources, access
to resources, opportunities,
wealth, health, education,
and social capital.
And when we talk
about power, we're
talking about systems of
power and relationships
and who has power, who
doesn't have power,
how these things play out.
And I could give you a 20
minute lecture on this,
but that's not what
I'm going to do today.
Instead what I want
to talk about are
the commonalities
in these behaviors
and the micro-level
human social behavior
that I think contributes
to the patterns of violence
we see both in
neighborhood gun violence
and police-involved
gun violence.
And I'm going to
argue, in particular,
that I think when we look at
human social relationships,
the ties between yourselves,
your friends, your friends'
friends, your neighbors, that
that can tell us something
about neighborhood violence and
police violence, which can help
us understand how they may or
may not be contagious and then,
importantly, what we might
be able to do about it.
So I'm going to argue that,
in fact, network science is
one of these sets of tools,
especially how it's been used
in epidemiology, that
can help us unpack
these sorts of
issues, in particular
how gun violence works.
So you've actually silently
been digesting network science
all day with that
graphic with the nodes
and talking about contagion.
Right?
The nodes and the
lines, that's what
we're talking about when we're
talking about network science.
If I say social network, some
people think social media.
And that's of course
a type of network.
But what I'm going
to talk about are
they actual ties
among human beings--
social relationships, neighbors,
coworkers, friends, partners,
even your enemies, in fact.
And so network
science is the study
of how these social
relationships affect
what you feel, think, and do.
They affect what you buy.
They affect who you marry.
They affect the votes you cast.
They affect how you get
a disease, whether you're
susceptible.
They affect how
revolutions start.
They affect how street
gangs fight each other.
And there's lots of different
science for all those topics
that I've mentioned that
I'm happy to point you to.
So when we talk about gun
violence as an epidemic,
we're generally talking about
what I'd already mentioned,
trying to explain these big
gaps in these graphs over time
across populations
and across space.
And so sociologists,
criminologists,
epidemiologists, have used
spatial diffusion models
to point out that gun violence
does indeed sort of spread
through time and space with sort
of signatures of an epidemic.
Here's what I want
to put in your head.
Our models almost inevitably
model gun violence
like an airborne
pathogen, tracking
how rates go from a
high crime neighborhood
to the next neighborhood.
And if you believe
this, you catch
a bullet like you catch a cold.
Stray bullet
shootings are tragic,
but they're not the majority of
gun violence in this country.
So all of these
deaths are tragic.
But they're decidedly nonrandom.
So if it's an epidemic,
what type of epidemic is it?
How is it transmitted?
Right?
I'm going to argue that it's
transmitted more like an STI
than it is like a cold per se.
Right?
And I specifically want to look
at the types of behaviors that
connect people
that can facilitate
the diffusion of
neighborhood and gun violence
within populations.
As an aside, if we're
talking about gun violence,
you need something
like a gun and bullets
for that gun to actually
become infected as it were.
Even the language we use around
guns follow the language we use
around needles-- clean
guns, dirty guns--
so the same sorts of principles.
So I'm basically
stealing all this stuff
that we used sort of in HIV
research and Hep-C research
and needle exchange and
trying to think about how this
can help us understand that.
So in your head, I want you to
think about a certain behavior
that 100 years of
criminology and sociology
has told us is associated
with victimization, which
is risky behavior, doing
things that put you
at risk with other people.
I'm going to use largely when
I'm talking about neighborhood
violence arrest records.
Right?
So Michelle and I
rob someone together.
We're committing a
risky behavior together.
And then I'm going to link
individuals over time and space
through these sorts of
networks, sort of one by one.
So if Michelle and I
committed sort of a crime
or offended together,
and then she
committed one with Daphne
and then with Andrew,
we'd have like a chain.
All right?
And then we're going to
something very similar
when we talk about police and
their bad behavior by the way.
So for anybody who
wants to read anything,
just Papachristos is
pretty easy to find.
There aren't many of us.
And these are the papers
that will put you to sleep.
But visually, I'm
going to show you
something slightly different.
And I'm going explain
the first graph.
And hopefully, it'll make sense.
And then we'll move
to a much larger one
that won't make sense.
So one of our key findings
from all this research
is that all those
dramatic disparities
you've seen across populations
are worse within populations.
So violence concentrates
just like an epidemic
within populations.
Our first study was actually
here in Boston-- well,
I guess we're in
Cambridge-- was there
in Boston, sort of in
the uppermost corner
area and Mattapan area.
And what you're
looking at is a network
of 763 largely young black
and Cape Verdean young men.
Every one of those
dots is a human being.
They're not a
statistical summary.
They are a person.
Right?
There are largely men.
About 30% are members of
street groups or gangs.
Those ties are those
links I described,
tied to each other
in time and space
by a particular behavior that
was observed and recorded.
Those red dots, as
you probably guessed,
are the victims of fatal and
non-fatal gunshot injuries,
excluding self-harm and
police shootings in this case.
So the nontechnical thing you're
seeing with all those red dots
is clustering.
Right?
Like my kid, probably
the 11-year-old,
took a handful of
Christmas ornaments,
threw it in the same spot
of the Christmas tree.
There's only one
instance that you
see in here of an
isolated gunshot victim.
Right?
More importantly, and here's
what I want you to remember,
this is about 6% of the
community's population.
And it's 85% of all the fatal
and non-fatal gunshot injuries.
The other 15%, does anybody want
to guess what type they are?
Domestic and then actually
two stray bullet killings that
occurred in that community.
Right So domestic violence
follows a slightly different
pattern.
So we're focusing right
now on those red dots.
But the other thing I
want you to focus on
are all the places
where there are
no shootings in this
population that has all
of the aggregate risk factors.
They all live in
the same community.
They're largely young.
They're largely men of color.
All right, there are
some women in there.
But they have all
the risk factors.
But even within this
population, your risk
of being in these
clusters is astronomical.
In this case, being in this
network, being part of the 6%,
increases your risk
over 600% of being
a victim of a gunshot injury.
So this is Boston.
This is Chicago.
It's not a brain scan.
This is a network
of some 107,000
individuals with all of the
same patterns we see in Boston--
intense clustering.
90% of the gunshot victims
in the city of Chicago
are in a single social network.
It's a very big one.
Right?
But again, even within
populations with all these risk
factors, we see this
intense clustering.
Just a few more cities, here's
the city of East Palo Alto.
Again, you see sort of
a string of shootings
going across the middle
almost like an equator.
And in Newark, New Jersey, you
see very intense clustering,
which is actually
the product of people
who serve housing projects.
We can talk about what
creates these networks
if there is time.
Right, so you see this
intense clustering.
That's the first
thing we've learned.
The second thing we've learned
is that exposure matters.
So we know exposure to
violence matters a lot.
It actually changes your brain.
It affects all sorts of things.
But it also increases your
risk of being a victim.
It makes sense.
How did we study this?
So here's a
particular individual,
one of those 107,000 people
in the Chicago graph.
This person has a certain
number of associates.
Their linked to each other.
And some percentage
of those associates
have been gunshot victims.
So we did this sort
of for everyone
in that big network I showed you
that looked like a brain scan.
And here's what we found.
So the x-axis going from 0 to 1
is how many of your associates
were gunshot
victims, so exposure,
crude measure of exposure.
And the y-axis is your
individual probability
of being a victim from 0
to essentially a coin toss.
And you can see it right
away, the baseline probability
for a young, black gang member
in Chicago is about 11%.
All right, and then once you
teeter over to the 40% area,
your odds of being a
victim are about 20%.
And I was going to put this
in context of other epidemics,
but I couldn't do the
math quite correctly.
So let me give you
a different way
to look at this because 1 in
6 is pretty easy to calculate.
So if you're a young, black gang
member who 20% of your friends
have been shot, you are
playing Russian roulette sort
of in terms of
your level of risk.
Finally, these things
cascade over time.
So I get shot.
Then my associate gets shot.
Then my associate's
associates get shot.
So it looks something like this.
And in a recent JAMA study
with two students from Harvard,
we did this for Chicago.
Here are three
cascades from Chicago--
one with 12 victims, one with
34 victims, one with 64 victims.
Now here's the thing,
if it's an epidemic,
I want you to remember.
Almost 2/3 of all shootings
in Chicago happened in one
of these cascades.
Someone gets shot.
One of their friends gets shot.
Another friend gets shot--
63%.
The average time
between those shootings?
83 days.
So we know who's at risk.
We know that timing,
essentially, between events.
Looks like an epidemic to me.
What about police violence?
What about police
misconduct and violence?
This is new research.
I don't have any
published papers yet.
We're about six months in
on this and like six years
in on the other sort of work.
But police, here's our theories
of police violence summarized
in one slide.
That person has a kid who's
seen the Lego Movie a bunch.
We've got a bunch of bad apples,
or we've got a bad department.
That's the patch that the
officers from the LAPD Rampart
Division made.
So when you start making
patches and t-shirts,
you're more than
a few bad apples.
Right?
There's some kind
of system involved.
So this is our theory--
bad apples, bad system.
And how we affect change
will matter dramatically.
Right?
Weed out the bad apples.
Change the system.
By the way, the answer is
it's a network, in case
you wanted the punchline.
But more importantly,
if we think
how police officers
learn, every cop
hears this their first
day out of the Academy.
Forget everything you
learned, and we're
going to show you what
real police is about.
And the first time I gave
this talk in a class,
there was some student.
She was texting away She
was nodding like this.
Right?
She came after me after class.
Turns out her dad
is an LAPD officer.
She showed me her phone.
Her dad had said this.
Look, it's not training day.
But yeah, that's pretty much it.
That's how it happens.
That's how we learn this stuff.
We learn it on the job.
We learn it from our partners.
Right?
So I took publicly
available data
by the way from the
Chicago Police Department
and every single complaint
filed against police officers
during this six-year period.
It's about 170,000 complaints.
We also looked at every
incidence of a police shooting.
And there are about
405 of them that we
can locate in the data itself.
This is what the data looks
like because this is all
made available by the
Invisible Institute.
It's fantastic work.
I can click on any
police officer.
Here Here's one who
had 36 complaints.
You can see when and
where those complaints.
But more importantly, from
the network perspective,
you can see who that
cop was with when
someone complained against him.
So just like I
did before, we can
look at how officers
are linked by doing
risky things or bad things.
So when we do that, I'm
going to zip through these
and just let you know that
we're going to be looking
at about 7,000 police officers.
This represents basically the
demographics of the police
force of Chicago by the way.
It's about 50% white,
20% black, 20% Hispanic.
And this is what the
network looks like.
It's about 7,000 police
officers, about half
the Chicago Police Department.
And those colors you
see are just clustering.
So there's just clumps of
sort of groupings of officers
if you will.
So if you you're
all the same color,
you have the same ties,
the same other peoples.
So if Daphne and Michelle and
I are all tied to each other,
we would all be
purple for example.
And if you had ties to
each other, but not to us,
you'd all be a different color.
Importantly, most officers
have one complaint.
OK, so they have one complaint,
and then some officers
have 120 complaints.
In fact, one officer
has 120 complaint.
The last complaint he had, which
were he was finally fired over,
DNA evidence of a
suspect was recovered
on the barrel of his gun.
He was acquitted and is now
suing the city of Chicago.
But the good news is most
police only have one complaint.
OK, so this distribution
is something
we can talk about as well.
Here's the makeup
of a gang unit.
Again, even within divisions
of the police department,
you see clumping,
which we see in sort
of normal human social networks.
This is the narcotics unit.
And I could do this sort
of on and on and on.
Here's where we're
going with this.
We want to know where
these networks come from.
We're working on a
series of model that
predicts why police officers
form these sorts of ties
and with whom they
form them with.
We're already seeing
some very interesting age
and racial differences
within the network.
We're looking at what officers
co-offending careers look like.
So the people that
have one offense
and don't do anything
again, that's good.
Right?
The people that
have 120, we want
to know how they got to be 120.
We want to know, as
this title suggests,
is this bad behavior
contagious in and of itself.
And just to show you
some descriptive ideas
of where we're going--
I don't have any numbers yet--
I'm looking at only the
complaints made by citizens.
So lots of complaints
are also made
about officers against each
other or sort of a superior
making a complaint
against an officer.
But the ones we
really care about
are when citizens complain
sort of against officers.
These are 6,000 officers.
We put all of the gunshot--
excuse me.
Now this is slightly
different because we're
talking about the
officers who shoot people.
So the red dots in this
case are the officers
who shoot, pulled their
weapon and fired their weapon.
And, you know, there's
some clustering, not quite
as tight as we saw in the
neighborhood victimization one.
We're looking at this right now.
They're statistically
rare events.
So they're actually
pretty hard to model.
We're seeing some evidence
of contagion at the moment.
We're looking to add in
non-fatal events like tasers
as well.
So hopefully, I'll
have some more
to say on that sort of
in the years to come.
So what does this mean
for violence prevention?
It means a couple of things.
And as I was sitting
here today, I'm
going to say a word that's
going to make you uneasy.
But when everybody
else said it, it's
not going to make you uneasy.
Surveillance.
Right?
All of y'all get to talk
about health surveillance all
the time, and
nobody bats an eye.
And if I say surveillance,
people are like no no, no.
It should make you
uncomfortable because
of the hyper-surveillance of
essentially young men of color
in this country and people
of color in general.
That's actually not
what I'm talking about.
And I should say
also, in general,
everything I'm going to
tell you would be an effort
to remove this sort
of violence prevention
from the domain of police
and move it into a broader
public health or
even municipal system
in which we can use
this information
to divert people and services
to those who are most at risk
in between those 83
days from gunshot victim
to gunshot victim.
And we know-- we know
stuff that works.
How do we get a trauma
care specialist?
How do we get a health
care professional?
How do we get a priest, a
football coach, an educator,
and, yes, sometimes a cop,
into those networks when
they're needed?
Right?
So sort of a shooting-- let's
call it a monitoring system
if I can't use the
word surveillance.
And let me just say,
to go back to some
of the comments that were made
earlier, it should be local.
It should be open.
And it should be
responsive, which
will also help police
violence, which
we'll talk about in a minute.
I will tell you this.
On the policing side
of things, there
have been multiple studies
and systematic reviews that
show you, if you have
focused policing efforts,
you can actually see
gun violence reduction
with fewer arrests.
So if anything, when
we're talking about it's
application to policing, it
is not to broaden the scope,
but rather to focus the scope.
When we talk about
policing, I just
want to say a couple of things.
Do you know we actually
had another period
in this country when we reduced
police-involved shootings
by more than 50%?
Does anybody know when that was?
It was in the late
'60s, early '70s--
Garner versus Tennessee, which
involved a very specific policy
intervention.
Anybody?
Fleeing felon, fleeing
felon, not Miranda rights.
Fleeing felon, before
Garner versus Tennessee,
police used to do two things,
which were really bad.
They used to fire
warning shots, not good.
And they used to shoot
people in the back
when they were running away.
All right, so policies reduced,
after Garner versus Tennessee,
that basically diffused
through police agencies,
saw a massive drop in
police-involved shootings.
In New York City alone,
it went from about 100
to a year to about 10 a year
within a nine-year period,
simply by instituting two
internal sorts of changes
within the police department.
All that said, I want to close
on the thing I started with,
which is, look, you
didn't tell us anything
about inequality and power.
Well, right, because that's
what creates the networks.
You know what's
really hard to do?
Change networks.
It's really hard
to change networks.
It's like a highway system.
Once you build it,
it's pernicious.
It's hard.
You don't have an off ramp here.
You have one here.
You can change the rules of
the road and the speed limits
and improve safety in vehicles.
We talked about that as an
effort of public health.
We can start there.
But ultimately, we have to
think about the ways which
we can think about things,
again, about transparency.
What do we know about
what's creating?
I mentioned Newark in passing.
Public housing projects are
really bad for creating really
dense networks
because people are
forced to interact with each
other and all other sorts
of things they're bad for.
Correct?
I'm talking about
high-rise public housing
projects in particular.
And Those were built in
particular times and places
for particular reasons.
I'm happy to go on about
some of these other dynamics.
But really, we also have to
think about those big things.
We have to think
about all the things
that aren't going to
help the victims who
are in those networks today and
were the red dots, but in fact
sort of there other else.
And the last bit
with the new work
we're doing in New
Haven, is, of course,
we're now going in there in
a mixed methods approach,
not looking at
those who got shot,
but those who seem
to be resilient.
And we're doing a mixed methods
study where we're interviewing
these individuals who by every
metric should have been shot,
that are surrounded by
gunshot victims, and aren't.
We're doing this with a
community based project,
working with interviewers
we've hired and trained.
And they're helping
us develop questions.
And we're going to
use that to then build
sort of the next iteration
of gun violence in New Haven.
So thank you for my
collaborators, my funders,
and the panel.
[APPLAUSE]
- Thank you to our panelists.
We've just heard three
really fantastic,
stellar presentations.
And I want us to get
directly to our Q&A session
with you, the audience.
But just quickly, I hope
that you appreciated
from these presentations
where I started by describing
the richness and the layering
of research methodology,
qualitative and quantitative
research methodology
hearkened by all
of our speakers,
the richness and the
diversity in the data
streams that our presenters
deployed to tell the stories
and share the
narratives with you
today and also the
diversity and the richness
of the analytic
approaches that are used,
that are brought to bear to help
us understand complex, truly
complex, problems
of public health,
population-level magnitude
that has characteristics
and features that include
social, behavioral,
and environmental determinants
of these health outcomes
and risk factors.
And finally, what I thought
was really remarkable about all
of the talks was to begin
a truly informed narrative
requires a framing, and the
framing in a public health
approach that opens up
pathways for identifying
vulnerable groups
and beginning to do
what is necessary to develop,
to design interventions.
So with that, what
I'd like us to do
is to start with our
Q&A session involving
and engaging our audience here.
And I'll just ask each
of you if you could just
tell us your name and then pose
your questions and comments.
Thank you.
- Marcia Castro.
So Dr. Kolodny, could
you say a little bit more
why the opioid epidemic
is mainly among whites?
- Sure, I'll share with
you my theory about why
the epidemic is so white.
And I think I showed you the
data, treatment admissions
data, that showed you how
white the epidemic is.
But if you look at the mortality
data, it's also very white.
If you look at
hospital admissions,
every way you look at
this, it's striking
how white the epidemic is.
What I believe is happening--
and this is a theory,
but it's based on evidence.
Something we do know is that
doctors prescribe narcotics
more cautiously to
their nonwhite patients.
If a patient is
black, the doctor
prescribes opioids
much less frequently.
It would seem that if
the patient is black,
the doctor may be more worried
about the patient becoming
addicted, or maybe
they're more worried
about the patient
selling their pills.
And if the patient
is white, they're
prescribing as if there's
nothing to worry about.
And of course, we should
be prescribing cautiously
to all of our patients.
So that the black patient
is less likely to wind up
getting addicted to
medicine prescribed to them,
and the black household
is less likely to have
a highly addictive drug
in the medicine chest.
So what I believe
is happening is
that racial stereotyping is
having a protective effect
on nonwhite populations.
- If I may, framing
it another way,
is it possible then because the
argument the industry would use
is that possible pain
management is not
equally met, as well addressed
for nonwhite populations?
- Yes.
- Are there evidence?
- There is.
And so, in fact,
some of the studies
that proved that doctors
prescribe narcotics
less frequently to
their nonwhite patients
were sponsored by
pharmaceutical companies that
were trying to get the
prescribing to go up
for nonwhite populations.
So the argument has
been made that we're
under treating
pain in non-whites
or African-Americans.
The problem is that opioids
are very good medicines
for palliative care.
And I think they are--
I would hope that they are
prescribed more appropriately.
If they're not prescribed
to black patients
in palliative care
settings, that
would be very inappropriate.
And there is the
possibility that we
are under prescribing opioids
in cases where we should.
But overall, I think
that's why they've
been spared the epidemic.
- Thank you.
- Does any of our other
panelists want to comment?
Well, let's go to the next.
- Hi, there.
My name is-- excuse me.
My name is Eric Mooring,
and I'm with the School
of Public Health.
And my question is
also for Dr. Kolodny.
You mentioned how many people
who become addicted to opioids
never were using
opioids recreationally,
that it was a result of
the medical interventions.
But you also said
that, in some cases,
there was an element
of recreational use
or a combination of medical
initial exposure followed
by recreational use
followed by addiction.
And I wonder if you could
quantify to any degree
the relative proportion
going forward of or currently
of incidence of
opioid addictions.
What proportion do you
think recreational use
plays some role?
- I can't really.
And you're asking a
few questions there.
You know, there's the
question about what percentage
of patients with repeated
use wind up getting addicted
and how many don't.
It's very difficult to say.
What we do know is
the common pathway
to becoming addicted to
opioids is repeated use.
And it doesn't really
make a difference
if you're repeating
use because it's fun,
or you're repeating
use because you're
self-medicating dysphoria.
Maybe you're in a community with
a lack of economic opportunity,
and there's despair.
And it's making you feel better.
Or you're repeating use because
a doctor told you to take it.
It really does
make a difference.
Once you repeat use regularly,
you can become addicted.
And although we don't have
good data on the development
of addiction with
repeated use, we
do have good data on the
development of long-term use
in pain patients.
And we know that a patient
who takes an opioid every day
for 10 days, 1 in 5
become long-term users.
And if the patients are
prescribed opioids every day
for 30 days, about 40% are
still on opioids a year later.
- Paul Bettinger from Tufts.
This question is for Andrew.
There is a very
recent publication
about the total lack
of usefulness of body
cameras for the police force.
So the primary question is
how did they get it so wrong,
given your available
information here on networks.
- I mean so it's
a good question.
You know, the one
report that I would say
did that was because
they did it in a already
fairly progressive
police department that
had taken lots of
steps to reduce
these sorts of encounters.
Another way of putting this
is there are 18,000 police
departments in this country.
The average size of a police
department in this country
is 43.
And the mode is four officers.
Right?
So the metro PD--
most of the police shootings
happen in the like 40 to 50
officer department range.
There's no
standardized training.
There's no standardized
sorts of licensing.
It's all done by every state.
And so going to the metro
PD and doing it is great.
That as a null finding
is not shocking.
The one they did in
Mesa, Arizona that
had positive results
was also a city in need.
So you know one
study does not make.
But I'll also say
one other thing.
I don't think technology
is the answer.
I don't think anybody
who sort of knows
the policing literature
thought that technology
was going to be the answer.
We thought it would actually
be more related to issues
of transparency.
The other thing that we
don't know from that study,
of course, is officer
discretion of when
the camera is on or
off, which is also
a big deal in the meta-review
of these body camera studies.
When officers have no discretion
about when the camera is on,
we see positive effects.
And we tend to see null effects
when they have discretion
about when they can turn it
on or off or fudge with it
a little bit.
So that's my take on it.
You know, I don't think one
study is going to make it.
- Hi my name is Sarah
[? Altschuller ?]
And I'm from Northeastern.
I also have a question
for Andrew Papachristos.
And I'll say I'm a humanist.
So I'm wondering a little
bit about the language
and the kind of paradigms
that you're using and thinking
specifically about--
I understand that we
all speak in analogies.
So I'm just wondering about
the use of AIDS and HIV
as a paradigm and,
specifically, about the move
to kind of think about
contagious disease
as a paradigm, as a kind
of metaphor for thinking
about gun violence.
And I understand the sort
of rhetorical efficacy.
So I'm also asking about
what potential pitfalls are
of doing that.
- Well, the pitfalls, of course,
those other epidemics also
deal with super
vulnerable populations.
So I get that.
What I'm actually trying
to work against is the--
I don't want to say
baseless, but more empty
political rhetoric.
So if anybody is looking for a
master's thesis in this room,
March, there's going to
be a call for the National
Guard in Chicago after the first
kid that's walking to school
is sort of shot and killed.
And in fact, what I'm trying to
do with the metaphors is really
trying to make people understand
that the majority of victims
are not the kid going to school
or the grandma going to church,
but young men of color
who have criminal records.
And the media needs to be
held accountable, as well
as the academics and the public
health officials and everybody
else.
But specifically, it's to
remove the discussion out
of the criminal
justice language.
And that's the big jump.
Right?
Because we're not going
to arrest ourselves out
of this problem.
And in fact, any police
chief in this country
will tell you you're not
going to arrest yourself out
of a gun violence problem.
And so it's just
a conscious effort
to try to move it more to
the public health problem,
but also, from the data
analytics perspective,
to know that, as
we've seen here,
we can use similar techniques
with highly vulnerable
populations in ways that are
moral, in ways that are just,
and in ways that
can be transparent.
It can also go horribly wrong.
But there are ways we can reduce
Hep-C with needle exchange
programs or condom
distribution or working
with men who have sex with men
and drop rates of infection
very dramatically and work
with these populations
and treat them first
and foremost as victims.
So that's my intentional use.
But other pitfalls
I already mentioned.
It clearly can also become
racialized or politicized.
Like the word gun
itself is politicized.
- Hi, my name is Mika Kunieda.
I'm a Takemi Research
Fellow at the Harvard Chan
School of Public Health.
I have a question
for all three of you
and then one question
for Dr. Papachristos.
- If I may, because we have just
about a minute and a half left,
pick your top question.
And we'll do our best
to answer briefly
so we can get to our final.
- I heard very briefly at the
end a positive deviant example.
Is this not a sexy topic?
Or is it very hard
to find funding
for the studying
positive social norms?
- Oh, it's next to
impossible to find funding
for positive social norms.
I will say that the
resilience grant
was funded by the NIH RO1.
I'm not going to tell
you the horror stories
we heard about it and that the
subsequent efforts were not
funded, but it was
next to impossible.
We were one of the last gun
grants that got through,
essentially, like by a day.
Everything else was done
by private foundations
to be clear--
MacArthur, Joyce,
others, very hard.
- It's a very sobering and
very important point you make,
Andrew, because when I think
about injury prevention centers
across the United States over
the arc of my 25-year career
as an academic in public health,
there's been an attenuation
and a winnowing of these
centers just at the time
as injury-related
deaths are going up.
And it's a very unfortunate
set of circumstances
that didn't happen randomly.
And so your point
is so well taken.
And it reminds me of
just how important it is.
Philanthropic
support for the work
that we all are doing at this
table is critically important.
But it does require the
leadership and the investment
from all sectors,
including our government.
With that, I'd like
to thank you all.
I'd like to thank my
speakers for really
a set of stellar mini
lectures that packed
in a lot of information
and to the audience
for your great questioning.
Thank you very much.
[MUSIC PLAYING]
[APPLAUSE]
