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Dr. Gary Slutkin, Physician, Epidemiologist, and Founder/Director of Cure Violence

Dr. Gary Slutkin has provided counsel and advice to elected leaders and health leaders across the United States regarding COVID-19. He has advised Mayor Ron Nirenberg and other Texas mayors. He has proven that epidemiological methods for disease reduction work and they work on things like violence. This was a fascinating discussion with a very interesting guest.

Transcript:

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Justin Hill: Hello, in Bienvenidos San Antonio. Welcome to the Alamo Hour discussing the people, places, and passion that make our city. My name is Justin Hill, a local attorney, a proud San Antonian, and keeper of chickens and bees. On the Alamo Hour, you’ll get to hear from the people that make San Antonio great and unique and the best-kept secret in Texas. We’re glad that you’re here.

All right. Welcome to today’s episode of the Alamo Hour. My guest today is Dr. Slutkin. Dr. Slutkin is a medical doctor and epidemiologist. I’m stealing from your TED Talk bio a little bit. You’re an innovator in violence reduction which we’re going to talk about. Currently, founder and executive director of Cure Violence. Also, consigliere of sorts to some Metro health and mayors and city officials who are seeking your guidance on COVID.

Dr. Slutkin previously served as a medical director for the San Francisco Health Department. He’s worked for the World Health Organization. He’s worked on epidemics all over Africa which we will discuss. Importantly, he is a well sought after epidemiologist on using data and science to cure issues and specifically, issues that people probably didn’t think could be cured that way. Dr. Slutkin, thank you for being here.

Dr. Slutkin: I’m happy to be with you, Justin.

Justin: You’re in Chicago, right?

Dr. Slutkin: Yes.

Justin: All right. You are my first non-San Antonio local or someone who’s lived here for some amount of time but our show tries to have a real connection with San Antonio and Dr. Lesch, a previous guest and Mayor Nirenberg, also previously a guest have discussed COVID with you. I know you’ve provided some guidance and counsel. Talk to me about what you’re doing right now in your role as providing some guidance to cities and leaders including our very own Mayor Ron Nirenberg.

Dr. Slutkin: Well, I’m aware that the US has not really seen anything like this before, that’s to say an epidemic of this nature that’s so fast, so contagious, so lethal and many other parts of the world have. I had the opportunity to be helpful with World Health and some of the others. Although I myself have largely been working on reducing violence in this country and in other places recently, I had to quickly switch into a role of helping, supporting, guiding and training where there were needs, which is basically wherever you look and how to manage this because it’s not clear.

Besides the fact that it’s new, a lot of behaviors need to be changed. People don’t like to change behaviors, people don’t want to change behaviors and there’s so much misinformation as well. I’ve been talking with mayors and governors and the Mayor’s Associations and the Governors Associations and trying to help understand what needs to be understood here. Which is that you can’t tell who’s infectious and who isn’t, which is a really counter-intuitive thing that someone you know or someone who looks well, could be carrying it. That it’s really that serious.

That you can get it even just by talking and screaming or talking loud or it doesn’t require coughing and that the results are really quite bad. For policymakers, they need to really make this so serious, and whenever we don’t, we see the consequences and that has to do with the fact that the virus jumps when given a chance. Opening up, it means opening up for the virus and that’s what everybody saw but not everybody knew it. Then also what the people themselves have to do. I’ve been guiding and training in this arena since late February, early March.

Justin: We’ve all seen what’s in the news and we know what we’re told in the news but San Antonio did really good at first and we were all very excited and we were patting ourselves on the back. Then our state opened up fast for which San Antonio had to follow lead because mayors like Mayor Nirenberg had very limited authority to out step what the mayor says. Did you see that across the board throughout mayors and policymakers who you consult with at cities that opened faster had the bigger problem or are there still some unknowns to how it’s spreading or why it’s exploding in certain areas?

Dr. Slutkin: There may still be some unknowns but the main things are known and just weren’t paid attention to enough or taken seriously enough or confused intentionally or unintentionally. What you said about San Antonio and probably for other cities too, but San Antonio, I seem to know better because I’ve been talking with the mayor and other people there, is that it’s exactly true. San Antonio was doing terrific, amazing actually. The rates and numbers were exceedingly low and Mayor Nirenberg and the city responded extremely fast.

They’re aware of this in January. They called a health emergency in February. Restrictions in late February and early March. It seems they were being followed on the number of cases. It was maybe even the lowest of big cities in the country. Certainly one of the lowest. Contact tracing was getting going.

It seems that there was a reversal that the mayor and other mayors were not able to manage so well because of the conflicting communication and conflicting orders. It’s an exceptional tragedy. I have a lot of confidence in Mayor Nirenberg and the other mayor, several whom I met just last night that they’re going to get on this, of stopping the spread now but they are behind. It’s clear as to why–

Justin: When Mayor Nirenberg was on the show, it really opened my eyes because they started sending San Antonio some of the people from overseas that were Americans like the cruise ship. People that were infected that were Americans got brought to San Antonio and as a normal person who lives here and some of our electeds were very unhappy this was happening. Ron pointed out this allowed us to get ready. We already had people in our backyard that we knew had it. It allowed us to get ready for this coming wave. He credits a lot of that with why they were able to jump on it so fast which I thought was great.

Dr. Slutkin: Well, there’s so many things that need to be done right. They all were being done right. In terms of anticipation of visitors and in terms of tracing and in terms of restrictions. You have to do them all and they were all being done. The good news about this is if you do them all, as San Antonio was able to do, you really do control the virus and you can stop its spread. [crosstalk]

Justin: Proof is in the pudding. I hate to 101 with you but I think it’s really important for our listeners to understand who you are and your history and epidemiology. Honestly, we’re in an era of social media science and social media experts. Talk to me generally about what an epidemiologist’s real focus is and how you yourself got into it.

Dr. Slutkin: I’ll tell you that. Let me just say there are– My story is basically this. I’m a physician and I’m an infectious disease physician first, and then an epidemiologist, and then I have been working on epidemics full time for about 40 years. First, I was asked to run the tuberculosis control program for San Francisco in the early ’80s’ when they had the worst epidemic in the country of tuberculosis. I then moved to Somalia to do tuberculosis among a million refugees in 40 camps, and then we got confronted with a cholera epidemic in Somalia when I was living in Somalia.

I left that country when it was moving into civil war and got picked up by the World Health Organization and got assigned the management of the global program on AIDS which Central and East Africa, the 13 countries in Central and East Africa, Uganda, Rwanda, Burundi, and the countries around there. I co-led the cholera epidemic in Somalia. I led the TB efforts in Somali refugees. I led the efforts in Central and East Africa on AIDS. I just want to say for almost all of these things, these were problems in which behavior was all we had.

From 1980 to 1995, there was no treatment at all for AIDS and 30% of the populations in some of these cities were already infected. We had a community spread. We had a contagious virus. You couldn’t tell who was infected and all you had is behavior. We got 70%, 75% drops by behavior change, and not an easy behavior which was sexual behavior. Not an easy thing to change.

To your point about what an epidemiologist is, I want to say there’s many people who are now using this phrase, some are from biologists, and some are from our clinicians, and care for patients, and so on. The management of an epidemic, epidemic management is a subspecialty of epidemiology. We’re not the people who are doing projections or models, we’re managing epidemics, and we have to succeed at reducing them. It’s a subspecialty of epidemiology, which is epidemic management and control. That’s what I’ve been doing.

Justin: I listened to your TED Talk when you said you were going to Somalia that your boss said you made the worst decision that you could make to go over there. What was the impetus from saying, “I’m living in San Francisco and I’ve got a nice job managing something and learning, but I want to go to Somalia,” which at the time was not a nice place to be is my understanding?

Dr. Slutkin: I was asked to consult in one refugee camp, the Boho refugee camp because other people from San Francisco General, including close friends and colleagues, were working there in the refugee situation. I went there to consult and I got really excited about the people and the situation. I was then commuting between San Francisco and Mogadishu even more upcountry for a few years, and then myself and my colleague Sandy Gove, we decided to move there.

There’s over 1 million refugees in 40 camps, and there were only 6 doctors. I felt that the TB program in San Francisco was pretty much under control at the time or most of what had to be done was done. I was younger and I took it as a challenge and a necessity. We did the math as to how many cases, there were 25, 000 to 50,000 I thought. We had about 500 in San Francisco and I thought we had it managed. It was like, I felt I had to do it, that’s the way I grew up.

Justin: You then got into the World Health Organization and you had some incredible successes specifically in Uganda in addressing the AIDS epidemic. Can you talk to us about how that was approached differently or how you were able to get more success in Uganda than maybe some of the other countries?

Dr. Slutkin: These are such great questions. I’m lucky. I got picked up by World Health. Sandy and I were working on our own in a way in Somalia. I’ve been working at San Francisco General with a great team, now I’m back at a great team at the World Health Organization with the best epidemiologist in the world. My boss and mentor is Daniel Tarantola who had eradicated smallpox from Bangladesh, right down the hall was, all these superstars and I’m young. I’m in my 30s.

They gave me a very big assignment. They gave me the epicenter, the 13 countries in Central and East Africa. They were the hardest hit. I went at it and they gave me a team. I built a team. What did we do? We had to first find out how big the problem was by testing. We had to do a bunch of testing to find out where it was, how fast it was moving because it’s invisible without the test, and then we had to set up infrastructures and networks.

We saw that we had to do training and that we had to figure out a strategy. It was a brand new disease. What are we going to do? We landed on public education, information, and behavior change. Uganda is the best example because it did the best implementation public education to scale, billboards, leaflets, flyers, pamphlets, media, spokespersons, ministers, clergy, refugee situations, military, everybody trained in very, very visible public education on sticking to one partner and then on condom use.

Then we had outreach workers who can help people understand why they need to change their behavior. Now, you can recognize what’s missing here for COVID because we need very, very strong, very visible public education, on wear our mask, keep your distance, no gatherings, and wash your hands. This needs to be repetitive over and over and over and over again and we need outreach workers to reach people who might not get it, who needs it explained.

Justin: We have our own cultural pushback in America for whatever reasons are those reasons, but what was the cultural pushback you were getting in Uganda because you’re talking about sex, which every country has its own cultural hangups or different views on discussing that publicly. How were you able to overcome those, I’m sure there’s some cultural conservatism in those countries about those issues? Was it government was just fully on board or y’all had carte blanche, or how were you able to overcome those cultural hurdles?

Dr. Slutkin: You never have carte blanche in anybody’s mind. Everybody’s mind is their own, but to a certain extent, it isn’t their own because they are influenced and they’re influenced by others and they’re particularly influenced by their friends and what they think their friends are doing and what’s acceptable. We used that. There’s a science behind behavior change, just like there’s a science behind the contagion of a virus or of a behavior. This is really interesting, this question about culture.

Everywhere I would go in Africa or in Asia, they would say, “Condom is against our culture or this isn’t our culture. We’re different than that place.” That was basically overcome by allowing everybody to really understand the way this is transmitted. We underestimate how important it is for people to really understand transmission itself. I

n that particular case, it was that because they thought it was other things but in this particular case, people need to know that it’s in someone else’s mouth and you can’t tell that whose mouth it is. Then that goes into the air around them when they’re just talking to you and you just, by simply inhaling that and breathing that stuff, can get that, and it can go right into your lungs. Then you’re checking into the hospital a week or two weeks later, even though everything seemed fine, and he looked fine.

The mask blocks that and that the distance blocks that, and people need to fundamentally get transmission. That’s part of it. Then the other thing is that what they need to get is the messaging over and over, and then beginning to see that their friends are doing it. We need to actually hire friends locally. Now, in this COVID– I’m switching from Uganda to COVID because people need to know there’s certain things we all need to get.

The young people who aren’t getting this, other young people are people who are acceptable, and credible, and trusted by them need to begin to talk to them, and get them, and show them that they’re wearing and say, “Listen. We can’t be gathering like this. It is time for us to be wearing the mask. We don’t want to get it ourselves.” I don’t know if people know that half of the x-rays among asymptomatic people show something wrong and there is healthy people who are making mistakes.

One of whom I heard as he was dying said, “I made a mistake,” but basically, he was at what was called a COVID party. Then his last words to a nurse, he’s 30 years old was, “It looks like I made a mistake.” People need to understand this transmission, and so the public education to scale, and the peer– This is what we did in Uganda, and we got enormous success and the countries and places that didn’t, were lagging or they didn’t.

Justin: From that perspective of public education and getting friends to do it, it almost sounds like a little bit of a peer pressure feeling. How important were the leaders in those countries because I think just generally, those cultural boundaries and how they were overcome should give us some education on how we overcome. Were the leaders that important in that role, or was it more a neighborhood approach?

Dr. Slutkin: You get benefit from all of this. The leadership in Uganda was particularly good from President Museveni. He made sure he talked about it all the time and he made sure there was training done. We at World Health had a very good partner and they mobilized their population for the education and the training. Leadership in some other countries wasn’t so good.

With good local leadership, with a good mayor like Mayor Nirenberg or the other the mayors who I met from Austin, Houston, Laredo, Brownsville, and other places, they are able to and from what I can see, are standing up and speaking, communicating, educating, and showing the data, and showing where things aren’t going right and what we all need to do.

In the more that everybody, these multiple channels is really important. A leader can’t do it on his own. The behaviors themselves need to be done by the population themselves. It was the population of Uganda that got rid of its AIDS, and it is the population of San Antonio that we’ll get rid of it’s COVID.

Justin: I saw elected representative recently even encouraging the Freemasons and if you’re a part of a membership, all of you pass resolutions encouraging your membership to sign on that you’ll wear masks and that you’ll avoid gatherings. I hadn’t really thought about that but we are all really part of a group of probably 30 in our day-to-day life. I thought that was a really smart leadership role for one of our electeds to take.

After you left Africa, you came back to Chicago is my understanding. Then based on your TED Talk, it sounded like you almost stumbled into this idea of applying infectious disease principles to address the violence in Chicago. Can you talk to me a little bit about how that came about and what your framework was?

Dr. Slutkin: Yes. That’s really my day job is I run Cure Violence Global, which is a global NGO nonprofit, which reduces violence. It’s doing this in the US and Latin America and to a certain extent in the Middle East and some other places. We are listed as the ninth-best NGO in the world now. What we do is our workers and our partners apply epidemiology and infectious disease methods to reducing violence.

We see violence, exactly like any other epidemic disease. In other words, there’s one case which leads to more cases which leads to more cases but the interruption of the transmission of it is what controls it, and you need outreach workers just like we were talking about COVID, you need outreach workers and we call them violence interrupters.

These are specialists for stopping a shooting from happening and stopping the spread, and if there is a shooting or if there is a COVID case, to prevent it from leading to more COVID cases or more shootings depending on which epidemic you’re working on. We’ve been doing this for 20 years. There have been between 40% and 70% drops in shootings and killings with this approach.

There are 13 communities on the east coast in Latin America that have gone to zero for a year, it took three years, there from very very hard-hit communities. That’s what you actually want to do with epidemics, you want to get rid of it. My own route to this is that I wasn’t really aiming to work on violence, I was coming home to take a break and I just started to get interested in this problem and look at graphs and charts and maps, they looked to me the same as any epidemic disease. We just tried out treating it the same way with outreach workers and violence and rafters.

We got a 67% drop in the worst place district in the country on the first try. Then the funders said, “Well, maybe it was a fluke, do it again.” We just kept doing it over and over now. We’re a guiding and training organization and we’ve been working in partnership with cities and communities to get it.

Now, it’s under greater attention because the social justice movement has been pushing back on law enforcement because of some of the tactics that are used if people don’t like or want like being shot but also all kinds of daily threats. We were made for this moment for our cities but it wasn’t because of we were anticipating this moment, it’s because we thought the right approach to the problem of violence in communities was the community doing it themselves with epidemiologic tools and guidance.

Justin: Bill de Blasio, the Mayor of New York City just recently had some glowing words to say about your organization.

Dr. Slutkin: We’ve been working with the City of New York and with community partners in New York since 2009. The city Cure Violence has been in the city budget since 2009 and Mayor de Blasio is– There’s 200 workers in New York and 24 sites. By the way, they were additionally rebooted to work on violence and COVID at the peacock in early March and we’re pushing out public education materials and training in the same neighborhoods. You recall now, just let’s all reflect on the same neighborhoods, they have a lot of violence.

Black and Brown communities have a lot of COVID and not everybody knows what to do. Our workers we’re doing double epidemics which isn’t unusual. We have had to do that before. Now, we have an outreach for our second work on COVID and violence but yes, de Blasio has pushed on us to be more of a solution for violence as well as for COVID.

In other words, instead of having police enforce social distancing, our guys can say, “Listen, you guys, you can’t be hanging out like this anymore,” or, “You really should be putting your masks on. I’m wearing one.” It’s a different– Behavior change is better done by persuasion than by threats, that’s a basic social psychology 101 which America hasn’t woken up to, it’s still stuck on punishment but it’s all ideas.

Justin: I found it fascinating, you compared the cluster of violence in a city to a cluster map for disease and it reminded me of our city here in San Antonio. We have some pretty bad violence pockets in the city. Is there any discussion of your organization coming into San Antonio at any point? What does it look like when you all move into a new city?

Dr. Slutkin: My staff have been talking with the health department here, which I think is a really strong health department. I’m really excited about it. We had a program a few years ago that I think was doing well and not everything is always maintained. Nevertheless, we’re in conversation and I hope that we can be working in this way with San Antonio. It too would be an honor and a pleasure. We’d love to be helpful.

Justin: Somebody asked me and I want to walk through this. Let me say this, one thing that really stuck out with me was you talked about you wanted to get away from the epidemic, pandemic stuff in Africa and you just said the panic and fear associated in epidemics was a lot to handle. That has to be true for people who live in neighborhoods where violence is unpredictable and prevalent and it is true for all of us living in COVID hotspots right now if you’re paying attention. I found that to be a very important point that makes people do funny things. You laid out your method which is interrupt transmission, prevent further spread, change group norms. Is that the way you feel like most epidemics can be approached?

Dr. Slutkin: Yes. There’s a basic standard playbook for managing epidemics. At World Health, we’d be working on malaria and then they say, “Okay, now work on child mortality and diarrheal endemic and now there’s an AIDS epidemic.” You take the same playbook but yes, it’s about detecting a potential event, a potential violent event. How do you do that? It’s by having outreach workers who are very granularly part of the community themselves who know that an event might be happening.

Most of the starts of these things are not police issues, it’s like someone was insulted or someone who owned somebody $10 or someone slept with somebody’s girl. Now, sometimes it’s a retaliation but these things escalate to a death, and then there’s more deaths and more deaths. The playbook has to detect what we call an active case finding, looking actively for a potential problem and then preventing it from becoming a full in shooting or a full COVID case or a full, whatever. Then changing the behaviors in that situation.

What does it look like? In a neighborhood, there could be 8 to 15, sometimes less, sometimes more people who are part of a team. They operate under the auspices of a community group with a supervisor. The community group already exists, it’s not a Cure Violence group, it’s an already existing group. It has an executive director, it has a supervisor and they then have a number of outreach workers and interrupters. It’s very, very well mapped out, not just in geography but what groups or subgroups or cliques exist, who needs to be reached, who can reach them.

They get paneled with the right people hired, and then they’re trained in how to do this detection and interruption and then the prevention of spread. If there is a case that there’s no secondary cases. Then gradually, what you said, the third piece of this which is changing the norms but then it becomes more normal to not shoot, it becomes less normal to shoot.

Right now, it would not be normal for one of us to be smoking, but it might have been normal years ago. When I was in medical school, a third of us were smoking while we were watching angiograms but the norms have changed. The norms are, they’re unconsciously invisibly changed by each other. There isn’t law enforcement here telling me not to smoke, the norms have changed. If you start with this detection and interruption, you move on to behavior change, short term and longer-term.

There’s a science to each step here, persuasion, behavior change and then the whole shifting of the norms. Then you have the neighborhoods in which is no longer normal. If someone were to say, “I’m going to go get him.” His friend would say, “What are you talking about? Are you talking nuts?”

Someone pulls out a gun on the west side of Chicago, this happened years ago. A lot of people thought that this would spill out and then instead, everyone just looked at him like he was crazy and stupid. That’s when someone of my staff member said, “Now, I understand what you were talking about about norms, is that your friends now will deflect this.”

In the case of COVID, what is this? You say, “Why aren’t you wearing a mask? We’re all wearing masks now, why aren’t you wearing a mask?” Coming from a friend. “We’re all going out, we’re all going to wear a mask.” You say, Well, I think I can’t do this.” They say, “No, what are you doing?” [crosstalk]

Justin: We’ve already quit shaking hands and hugging. Some norms have already changed.

Dr. Slutkin: I hope so. That’s exactly it. I will tell you that David Lash is the last person that I shook hands with. [unintelligible 00:30:56] I gave into. It was in very, very early March, I had sanitizer and I cleaned up. I gave them [unintelligible 00:31:04], but now it’s like, some kind of go, “No, you know–.” Someone’s walking too close to me,–

Justin: I’ve seen David Lash trying to shake hands with other people since this has been going on.

Dr. Slutkin: We don’t need to.

Justin: I’m going to discuss this with him. [crosstalk] He’s coming by after the show, he wanted to ask how it went. Let’s talk about the interrupt transmission because I was talking to–

Dr. Slutkin: You’re going to be talking about this at a distance,-

Justin: Yes absolutely, for sure.

Dr. Slutkin: -and you’ll have your masks on.

Justin: Absolutely, for sure. I’m pretty good about it. I was talking about it with a colleague about how you all have approached violence and violence interrupters. You’ve touched on it, but that’s a very grassroots human being that has to be picked. You can’t hire somebody from a different part of town and send them in there, you have to find the existing community structure, is that how it works?

Dr. Slutkin: This is a really good question too. It’s a very specific and granular and local and hyper-local. You not only have the same community, you might have the same block. If you’re going to reach this group and they might have a name or something like this, you have to have one or two or three people from that group or who used to be part of their group or who used to be involved.

Who already know them, who are already trusted deeply because they used to hang out together or because they grew up together or because their cousin or one of them is a brother of a friend or their dads were friends or something. They know each other already. You cannot train the wrong worker, you have to hire the people. You cannot train for trust, you have to hire for trust, you have to hire for credibility, trust, and access so you can walk right in there and you’re not in danger.

Mom has kids downstairs who are loading up weapons, and she’s all about herself, what is she going to do? She doesn’t want to call the police on her son, she calls an interrupter. He comes in, knocks on the door, he say, “Hey, it’s Joe.” It’s not like, “Who are you?” They know who Joe is. They could still say to Joe, “Hey, this is none of your business, Joe. We know what you’re doing, we know why you’re here.” They’re not going to hurt him, but he’s going to say, “Hey, listen, just give me a minute. Listen, you guys. I know what you’re mad about. I don’t think that these guys really meant it.”

He just starts engaging them, buying time. “I got some pizza for you guys for a minute.” Do you see what I’m saying? This guy, Joe, is they know him, you have to hire people who– This is also a public health technology, you have to hire refugees to reach refugee’s moms to reach moms. It could be sex workers to reach sex workers and people used to be engaged to reach people engaged. It has to be some young people with COVID reaching young people who are gathering and ignoring.

Justin: How do you find those people? That seems to be such an important part of what you all do. How do you find those because that’s a very– you’re right, granular is a good way to put it.

Dr. Slutkin: They always exist in there. It’s more than just that they have trust and access and credibility, they have to be on this side of the line now and that they really want to help people not make these mistakes. Our staff combines with local community groups and local people to figure this out.

Justin: Does law enforcement help and say, “These guys used to be part of that group, but they turned their lives around.”

Dr. Slutkin: Law enforcement can be part of the panel for some reasons. Sometimes yes, sometimes no but the fact that they have a background would not be exclusionary from hiring people at all, most people in this situation almost need to. Many of the people, I’m sorry to say, in Black and Brown neighborhoods, you can barely survive as a young person without getting a background because people can– they’re just being arrested for who knows what. I mean, really.

Justin: That’s an interesting offshoot, you all are involved on such a granular level, I’m going to keep using the word now. In a neighborhood level, have there been instances where you all have been able to put data together about law enforcement that has been used to change the behaviors of law enforcement or has ferreted out maybe non-neighborhood based or non-local based crime that has been blamed on that neighborhood?

Dr. Slutkin: I’m not sure I understand the second part of your question but in the first part, we really want to do this more work with– be helpful to law enforcement. In particular, in trying to be helpful to how one officer could try to cool down the person who he’s with. For example, this George Floyd case, one of the other officers should have said, “Come on,” I don’t remember the guy’s name.

“Come on, this is really too much. Hey, layoff here, we got him surrounded.” Or, “You got to stop now.” To not say, so you have to– If you can say, “Give me the keys, you’re not driving drunk, buddy,” you can certainly say. They need to be able to interrupt each other from the inside from the success of behavior and feel that that’s a service. There are various things we have trained law enforcement in the way that violence works and why it is occurring and the interrupter modalities that we use.

Then they support and see it are helpful and why, how they are then allowed to do less. Then when we’re working in a neighborhood where law enforcement is, which is most of the neighborhoods, they get to the point where they say, “Do you guys got it?” In other words, have you been able to prevent the retaliation? We can say, “Yes, we got it, everything’s cool.” Generally speaking, they may or may not advertise this for law enforcement.

When they talk to me privately, they say, “How come we only have 8 workers, we need 12?” Or, “How come your workers are only working on this side of the freeway and not the other side?” Or, “How come my neighborhood doesn’t have this?” I know in Kansas City, we were walking around making to the city councilman, the head of patrol there, Major, Anthony Ell, was saying, “Police officers are safer because of pure violence.” It has a different name there, [unintelligible 00:38:16] for peace. It’s really to the advantage of everyone to have this.

Also, just to say, this is the only violence is the only epidemic, only health epidemic that isn’t managed primarily by the health sector. What I mean by health sector is the community with the epidemic control guidance because all epidemics are in the end really managed from the inside out. We on the outside help guide, we give policies, suggestions. For example, closing bars and indoor restaurants and preventing large gatherings, these are policy things that can be done but really these epidemics need to be managed from the inside.

Justin: We had something called, I think gang free-zones here in San Antonio. It was a big legal fight, constitutional fight where they just shut down portions of the east side if you had been affiliated with a gang at some point. They said they had some success on reducing violence over there but my really poorly worded question asked earlier, I guess what I’m curious about is are you all able to compile data regarding the types of crime in the neighborhood and where there are certain types of crime. Whether it’s drug-based violence or gang-based violence, whether certain types of crime has a better response to what you all are doing or a worse response or is it across the board?

Dr. Slutkin: This is a great question because it reveals a couple of things. One is our work is about violence and it’s not about many other things that are called crimes, like auto theft or burglaries, although we could, we’re very highly focused on the contagious behavior of violence, meaning shootings and killings and beatings. 

Also, let me just say that community violence is in a way what we might call our bread and butter. We have worked on election violence, prison in Kenya, prison violence in the UK cartel violence in Latin America, getting 85%, 90% on cartel violence that are very well known cartels. We’ve also worked on violence in a conflict zone and violent recruitment on hate-related violence, where we’re designing things on this. All of these things are similar in that they’re contagious.

The Institute of Medicine study of 2013 who designed our website, cvg.org, or cureviolence.org. It has a lot of the data, a lot of the different types of violence that we’ve worked on. These things lead to each other, these different types of violence. Our work is in violence of many forms, community violence being one we’ve worked on the most, but the other in a way what’s called crimes, they may take a different course. Frequently one goes up, the others goes down, and one goes down the other goes up because they are different, they get conflated. In terms of things that are called gang violence or this violence or that violence, these are really very imperfect categories that are used for making people feel certain ways about them.

Most of the violence that’s going on in communities is interpersonal violence that is related to various complaints. It isn’t all between groups, frequently it’s just between people. Sometimes it can escalate to being between or within groups, but its management is the same. You need to find out who is upset or thinking about it. Then you have to get to them by people who are trusted by them. Then they need to cool people down, buy time, change their perspective, and start to cool them down more, work with whatever else is going on and give them offerings. They didn’t really mean it, they’re scared of you, they want to apologize. You’ll get your money back, whatever it is.

Justin: Most people probably don’t want to be violent by just who they were born as, or face the consequences of it. Let’s talk about, and I talked to Dr. Lesh about, this when we were about what you’re doing with the mayors. I think the messaging of what you did in that TED Talk, discussing methods of dealing with pandemics. I’m not hearing any leaders talk about it in terms of here’s what data shows in terms of dealing with pandemics, here’s the steps we want to take. You just hear a whole lot about, now we’re all distancing, also wash your hands. Now we’re fighting about masks. I want to walk through with you if you don’t mind how your method that you’ve proven out and epidemiologists have proven out multiple times could work for COVID and walk through the way that it applies to that metric. For example, how do we start with the interrupt transmission and how do we get interrupters into the COVID context?

Dr. Slutkin: That’s great, and thank you again for alluding to this. Mayor Nurnberg last night called a conversation with a number of really brilliant and impressive mayors from around the state, and we talked about just this.

Justin: Can we talk about it on the call? Can we talk about most mayors?

Dr. Slutkin: I don’t want to remember some of their names and not all of their names.

Justin: The biggest cities and states [crosstalk].

Dr. Slutkin: The Mayor of Houston and Austin and Laredo and Bronzeville were there in-

Justin: McAllen.

Dr. Slutkin: Yes, McAllen.

Justin: El Paso.

Dr. Slutkin: El Paso, I believe, yes was there too. These are really important cities.

Justin: Kudos to Mayor Nurnberg for putting that together and getting you to have a round table with these mayors.

Dr. Slutkin: He shows himself to be a leader among a bunch of other really great leaders as well. What do we do? We talked about pretty much what you’re asking. We went over th eprine- this beginning point, which is that we have to be very clear on the goal. We talked about the goal transmission, the goal, the messaging, transmission, the interventions, and the importance of public education. Just to say a sentence about it, a goal has to be right now, stopping the transmission, stopping the spread. These other goals of bending the curve was a[unintelligible 00:45:15] celebrated half time.

You can’t just bend, you have to really get this all the way down, and opening up is not a goal, it just opens up for the virus. We have to really stay on this goal of stopping the pipeline of new cases that are going to go into the hospital, stopping the spread, stopping the virus, getting it all the way down. Everything else is in a way a distraction from that principal goal. We have to keep messaging on that and showing whether we’re doing that, because if you stop all transmission now there will be a stoppage of all new cases within the course of about an incubation period. Then you will get everything start to drop. What do we need to look at is this percent positive.

What is this the percent positive is about 23% now, and we have to look at the number of new cases per day and whether these are changes. These are the things that’ll show whether the whole population of San Antonio is doing its job of masking and distancing and not gathering, is that this percentage positive is dropping and their percent positive of 23% needs to go down five. If we get it down to 15, super, let’s celebrate, but let’s keep pushing down to 10 and five. This goal and the monitoring I have been talking about this as well.

Then in messaging around this and this indicator and the number of new cases. Then the transmission, really getting it so that everyone really gets why we’re talking about masks and testing and not gathering. Especially any indoor gathering really has got to be out, reason being you can’t tell who is infectious. Indoors, as far as can hang around for hours and you’re going to get it, and don’t be so confident that you’re going to be just fine because a lot of young people are dying. Plus the ability you have to give it to anybody else, your father or grandfather, or anyone else.

These gatherings have to stop, but people have to understand why. They need to talk and ask questions. This is outreach workers can do this. Outreach workers in communities can do this. Then we talked about public education. Public education, this is about having billboards, leaflets, flyers, pamphlets, social media, speakers over and over again saying masks, distancing, and no gatherings. Having people understand why these bars cannot be open during the most serious, contagious, lethal respiratory pandemic in 100 years, and you’re telling me we need to be in bars and beaches.

We’re asking whether schools should be open. I don’t think they should be because the thing is half contained, but people think they can go to parties and hang out as if everything is normal. Everything is different, everything is not normal until we get this percent positive down to less than five, and until we get the number of cases down to a number that everyone says, that’s fine, we can manage that, and the city is showing that it can keep it down. Then you know how to do that, we talked about what we were just saying, the intensity of the public education, and then outreach.

Now, of course, the contact tracing and isolation needs to happen. Right now you’ve got community spread, so we’re not– We are going to be behind these community workers into the places that people aren’t listening and people are at very high risk. These black and brown neighborhoods where people are living too crowded or they’re having to work, they’re having to go into stores, having the store managed. Outreach workers can be helpful here in a different flavor or complexion of outreach workers reaching out to the kids who are hanging out locally hired, trained, and this is their job. This is a behavior change.

Justin: For example, there are certain communities in which cure violence is already very involved with a bunch of outreach workers in the black and brown communities. What about communities that don’t have that framework already in place? How do they find the right community outreach workers in such a short window to try to stamp down the spread?

Dr. Slutkin: I think this is the work that would be done by some– Ordinarily we would be guiding the local health department and whatever community groups or local– I don’t know, things are more disorganized in white neighborhoods so to say, than having community groups that people relate to. There has to be some very local research done as to who has credibility? Who are the players? Who do people listen to? You might learn that by certain people asking certain people who’s already wearing a mask, who’s already talking to their friends, who already gets that that’s part of the way, and then you’d have some questions like, “Who do people listen to? How can we have a conversation with him or them for awhile? Then see if they can be recruited. Maybe they can be paid a little bit, maybe they need to be paid fully, maybe they’re volunteers, and so on.

Justin: Religious leaders in specific communities, grassroots, maybe labor, even in certain communities?

Dr. Slutkin: You could go the everything approach or you could go for just trying to figure out who is most credible in the highest risk and in the not listening but gathering.

Justin: San Antonio, the spurs [crosstalk]

Dr. Slutkin: You may or may not be listening to religious people.

Justin: Certain communities, especially on the east side here, there’s a really grassroots community around the churches on the east side, and I’m sure they have huge influence over on that part of town.

Dr. Slutkin: Yes. In many, many countries, in many, many cities, the religious community is essential. I wouldn’t lean on them to be the whole thing, but it is essential. If you look at the Uganda paper they’re a very, very critical religious community. It’s really interesting, we’ve learned that the moms and the young kids go to church, the guys don’t, but that may not be everywhere. There may be more on the black community. I have more understanding of the Latino communities where it could be that it’s way more influential there.

Justin: I think for even all of the listeners to this show, we can all be community outreach leaders on our own. At my law firm, everybody that’s here has to wear masks, and I could be a business leader that doesn’t require it, or I could be a business owner who does require it. There’s a lot for all of us to do just in our day to day in our small social circles to ensure that people are following the rules.

Dr. Slutkin: This is such a good point. Yes, 100%. It also can be systematically figured out. In other words, you can make a list. We’ve done this in other countries for various things of say 15 or 20 channels in which public education and training should go through. The school system would be one, the business community or communities would be another, the youth groups would be another, the religious groups would be another, immigrant populations and immigrant service situations would be another.

You can make a list and then figure out how to access them, invite them to a training of how it’s transmitted and how it isn’t, and what we need people to do, get their questions answered. Now they become trainers themselves, ask them who else they’re going to talk to and so on. Then you’re doing systematic public education and training. It’s really about this deeper understanding of the why, and also of the situation. I’m just reminding myself in the context of your questions how I don’t think people completely get it that things are different now, and they’re going to be different until something very specific changes that which could be a vaccine or not, but the situation is different now.

We had this for AIDS. Anybody can be with anybody without a condom anymore. The situation is different now. When the situation is different now you need to be wearing a mask and you need to be not exposing yourself close to people outside your circle now. Now, things could be different under a few other circumstances in which we don’t have. Everybody has gotten a vaccine, and it’s been shown to work would be one circumstance. Another would be it’s under control. In other words, the amount of circulating transmitting virus in our city is way, way less, and we can show that, but then the only way we’re going to be able to get to that is if we not do this now.

Just rewinding to the question that you asked about training of groups, starting from yourself and your place, the health department could systematically educate on transmission, but also on the situation is different now. We can’t do what we want to do, even though we want to disbelieve it. Now, the risk is you could make a very, very big mistake now, so don’t. Just live with this for now. You can do an awful lot of things now, outdoors with the mask at a distance. Come out. There’s a lot of things that can be done.

Justin: I’ve stolen so much of your time, so I want to ask you a few follow ups that I have before I thank you for the hour you’ve given me already. You say outdoors and you mentioned this earlier. People are going batty sitting inside, and I’ve got a big deck in my backyard. My wife, we’ve got a newborn, allows me to have people come sit on the deck. When I say people, one person. We usually sit 12, 15 feet apart, and we sit outside. Is that safe? [laughs]

Dr. Slutkin: Here’s the story. If you and your wife and your lovely child have been doing everything right, and you feel very, very confident that you’ve not exposed yourself to risk because you haven’t been in a bar, you haven’t been in an indoor restaurant, you haven’t been sitting, talking to someone who you don’t really know isn’t in your bubble let’s just say. It doesn’t matter if you know them or not. This other visitor or friend has been doing it the same, then you should be fine.

Justin: Outdoors is okay because it’s open air, some breeze. Is that the thing we’re looking for?

Dr. Slutkin: Yes. Still being masked you’re guarding against something that you don’t know, it shouldn’t be that uncomfortable. That should be fine. Now I have a friend who goes to his store and sees customers a couple times a week. I’m not 100% sure of that they’re both wearing masks when he sees the customer, and I have deprived myself of the in person contact with my best friend. If he or others have been as cautious is myself and my wife have been, then it’s fine.

Justin: All right. I feel better about that. The newborn has my wife a little uneasy, but she’s outside far apart, she’s okay with.

Dr. Slutkin: You want to be quizzing your friend and don’t be afraid to.

Justin: I know which one of my friends are irresponsible and I don’t hang out with those ones. There’s such a cacophony of data and information out there that nobody really knows what data matters. From your perspective, when you’re looking at the science, is it new infections? Is it hospitalizations? What are the data points that you find to be most telling about the spread of this virus?

Dr. Slutkin: Right now, the most scary and compelling of course are hospitalizations in ICU and ventilators and deaths, but the most important right now is that we’re stopping transmission. The best way we can see that, and that is whether these hospitalizations, et cetera, are going to stop because they’re just going to keep on going and keep on going and keep on going and keep on going for our population, unless we’re doing this masking and distancing and the not gathering. The way that we are succeeding at that is what we have to keep our eyes on and that is what is percent positive tests in new cases. If we’re really great at that, within five days, and certainly within seven days to a week, we will see that drop. Then if we stay great at that we’ll see it drop more and more and more. That’s what’s so, in a way, great about our possibility is because the virus is really very easy to stop.

It’s not existing in the water. It’s not existing in insects. It’s just a person to a person. All you got to do is keep a distance, put the mask up, and it will not go anywhere. You can, we can stop it. No gatherings, mask on, and people at a distance and this dumb virus has no other way of getting in anywhere.

Justin: Yes, I agree with you. It’s shocking to me that the people that fight the mask thing. The last thing I want to talk to you about before we get a little just parting information is you talked about a vaccine. My understanding was there never was a Spanish flu vaccine, right?

Dr. Slutkin: Right. The 1918 flu, which began in America, which was called the Spanish flu.

Justin: What is, I mean, not the worst-case scenario, obviously, the worst case could always be the worst everything but what generally does a virus do as it peters out or does it just hang around in small populations? What is the new norm if we’re unable to come up with a good vaccine?

Dr. Slutkin: Well, this virus has the potential to go through the whole population here and around the whole world so it’s just to cause more and more death. Unless it’s contained, that’s its trajectory.

Justin: Then they’re still unsure if we create herd immunity or develop immunity after we get it, right?

Dr. Slutkin: To me, this is a distraction. No, I’m not against you. It’s very common and it’s actually an important question but if we get to that in some way, because we will have lost hundreds of thousands of more people. Maybe millions.

Justin: What is your favorite source of information on what’s going on or what do you think is the best source for information for listeners who want to know more and not having the political pundits and all that? Where do you get your information?

Dr. Slutkin: All right. I go to a lot of sources and there isn’t anything singular. I would say that the CDC is still a very reliable source and the World Health is still a reliable source. I realize the World Health Organization is giving guidance to many different countries and so it has a certain practicality that considers what needs to be done in Africa and in Latin American and in many other places at the same time.

The World Health Organization has always been scientifically accurate and conservative. I would say the same is true for the CDC. Neither want to be ahead of the data. They want to be as perfect as they can be. I’m looking at a lot as I did when I was at World Health. I have a lot of sources. I’m reading a lot of papers and talking to a lot of people. I’m also trying to focus on how to have the best impact. My lens on this is how does a city or country stop this, that is slightly different and not completely from what individual guidance says?

I don’t know if that is clear or even if I can make it clear enough. I’m really trying to, like in our conversation with mayors last night, and there’s certain things that we all have to do. I wasn’t talking about care last night, and we haven’t really talked about care today. I wasn’t talking about the contact tracing which needs to go and be as strong as it can be and as fast as it can be. I was talking about what I think is missing in terms of focus now. The focus on stopping the spread. The focus on helping people really understand transmission, and the importance of getting the public education to enough scale, as well as granular. That’s what I’m trying to draw in and push out to mayors and governors.

Justin: I got to be a fly on the wall for one of your talks and it’s all been fascinating. It’s very science-based. It’s very data-driven and there’s not enough for that now. You’ve already given me more time than I thought I was going to get so I want to thank you. What you’re doing is fantastic. Thank you for helping our city. I mean, thank you for giving Ron advice and helping us make the best decisions. Your organization is cvg.org?

Dr. Slutkin: Yes, Cure Violence Global. Cure Violence, C-U-R-E Violence, a nonprofit.

Justin: Well, if you ever get into San Antonio, I hope I get to meet you in person and seriously, thank you so much for giving me an hour of your time and good luck. I hope we talk again.

Dr. Slutkin: Me too. Great talking to you. Thank you.

Justin: Take care, doctor.

Dr. Slutkin: Thank you. Bye.

Justin: All right. That’s going to do for this episode of the Alamo Hour. A big thanks to Dr. Gary Slutkin. You can learn more about him. Just google him. There’s tons of information out there. He is on his own and for free giving guidance to cities all across America, including our city here in San Antonio, to try to help us better approach and deal with the pandemic. He’s also on his own or as part of his professional job, working to stop violence in communities all over America with a science and databased approach.

Our guests wish list continues. Coach Popovich, this is a perfect time to come talk about the NBA, the bubble, the pandemic, and a president you seem to have some strong feelings about. Patty Mills, Jackie Earle Haley, Charles Butt, great guests, we’d love to get you on if we could. That’s going to do it for this episode. We’ll see you next time.

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Justin: Thanks for joining us on this episode of the Alamo Hour. You are what make the city so great. We hope you join us next week. In the meantime, subscribe to our podcast. Check us out on facebook@facebook.com/alamohour or our website alamohour.com. Until next time, Viva San Antonio.

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Justin Hill

Hill Law Firm

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