According to the Centers for Disease Control and Prevention, homicide is the second leading cause of death for youths ages 10 to 24 years old.
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Published 2/1/2013
Maureen Leahy

Taking Aim at Youth Gun Violence

Orthopaedist-led grassroots effort focuses on education

In 2012, shooting tragedies in smaller towns such as Aurora, Colo., and Newtown, Conn., raised the profile of efforts to curb gun violence in the United States. Media attention focused on the number of dead in each incident, resulting from a single shooter using a semiautomatic assault weapon with a large capacity magazine. But such events are rare and account for only a small fraction of total firearm-related deaths and injuries in the United States.

According to the New England Journal of Medicine, 88 Americans died every day from firearm-related violence in 2011, and the number of firearm-related homicides and suicides in 2012 is likely to surpass the number of motor vehicle traffic fatalities for the first time ever. Orthopaedic trauma surgeons, who are often on the frontline of treating such injuries, have long been concerned about the issue. But while politicians debate what to do about the proliferation of guns, two orthopaedic surgeons in Nashville are going beyond the rhetoric to address deeper issues of youth violence.

Manish K. Sethi, MD, and A. Alex Jahangir, MD, are trauma surgeons at Vanderbilt University Medical Center (VUMC). Recently, they spearheaded an intervention program, in partnership with the Nashville public school system, to reduce youth gun violence in the community.

“I grew up in Tennessee,” said Dr. Sethi. “When I returned to Tennessee to practice after my medical training, I noticed a growing number of gunshot wounds in kids—particularly African-Americans. I saw very serious injuries—ballistic fractures of the femur, tibia, pelvis, and spine—injuries that can really deform a person and change his or her life forever.”

Concerned, he and his colleagues from the Vanderbilt Orthopaedic Institute Center for Health Policy (VOICH) studied emergency department visits at VUMC between 2004 and 2009 to analyze trends in gunshot wounds. Consistent with Dr. Sethi’s observations, the findings showed a sharp rise in youth gun violence in Nashville during that time frame, specifically among African-Americans aged 18 to 25. Armed with this data, VOICH applied for—and received—a grant from the Robert Wood Johnson Foundation (RWJF) to implement a gun violence intervention program for Nashville youth.

Early intervention is key
According to the Centers for Disease Control and Prevention (CDC), youth violence is the second-leading cause of death for young people between the ages of 15 and 24. In 2010, an average of 13 young people each day were victims of homicide.

Dr. Sethi and his team began by reviewing a database of 26 highly respected gun violence intervention programs in the United States to find a classroom program that focused primarily on violence prevention. They also interviewed 19 leaders about their programs.

“Surprisingly, we found that educating middle-school–aged children is the most powerful deterrent to gun violence,” Dr. Sethi said.

After evaluating 30 different curricula and analyzing feedback from two focus groups of young gunshot victims, they selected an evidence-based program that emphasized peer-to-peer learning.

“Aggressors, Victims, and Bystanders (AVB),” is a teenage health teaching module created by educational scientists at Harvard Medical School. AVB’s premise is that violence is learned and can, therefore, be unlearned. According to the AVB website, the backbone of the program is its four-step think-first model of conflict resolution, which provides students with a framework for dealing with and changing the habits of thought that can lead to violence. The four steps are as follows:

  • Keep cool.
  • Size up the situation.
  • Think it through.
  • Do the right thing.

“Many of our youth today don’t have the tools to deal with conflict and unfortunately resort to gun violence,” said Dr. Sethi. “AVB is a case-based program designed to give kids the tools to deal with difficult situations they may encounter in and outside of school. The kids act out different scenarios and discuss nonviolent ways to handle the situations.”

According to the CDC, several prevention strategies can be used to help stop youth violence before it starts; the AVB employs many of them, including teaching social development strategies to enable children to handle tough social situations and resolve problems without violence.

Pilot project
With support from the superintendent of Nashville public schools, VOICH introduced the program at a local middle school in the fall of 2012. The pilot project involved 100 children who completed the curriculum over a 3-month period. Students took a pretest before the start of the program and a posttest at its completion.

The curriculum was administered by classroom teachers who had undergone a program orientation; VOICH representatives attended one class weekly to ensure the program was progressing appropriately.

“Results of the pre- and posttests clearly demonstrated that kids had a better understanding of conflict resolution after completing the curriculum,” Dr. Sethi said. “Their perceptions, attitudes, and behaviors toward violence, including gun violence, had also significantly improved.”

VOICH is currently in the process of preparing the pilot data to apply for the next round of RWJF funding. With the funding, Dr. Sethi is hopeful that the program can be implemented across all public middle schools in Nashville in 2013.

“I believe that we can curb the tide of gun violence if we partner with educators,” Dr. Sethi said. “Not only is it a moral imperative, but with healthcare costs accounting for 20 percent of our national gross domestic product, it is also a cost issue.” According to the CDC, each year, youth homicides and assault-related injuries result in an estimated $16 billion in combined medical and work loss costs.

“As physicians,” said Dr. Sethi, “I believe it is our role to be leaders in society and to think more broadly about how to effect change in health care. The bottom line is that we need to get involved in our communities.”

In addition to Drs. Sethi and Jahangir, members of the VOICH include Jordan C. Apfeld, BA; Vasanth Sathiyakumar, BA; Mallory Powell, BA; Tait Danhausen, MEd; and Shaka Mitchell, JD.

Maureen Leahy is assistant managing editor of AAOS Now. She can be reached at

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