I'm a physician trained in infectious diseases, and following my training, I moved to Somalia from San Francisco. And my goodbye greeting from the chief of infectious diseases at San Francisco General was, "Gary, this is the biggest mistake you'll ever make."
Ja sam doktor, specijalista za infektivne bolesti i nakon svog usavršavanja preselio sam se u Somaliju iz San Franciska. Oproštajna poruka koju sam dobio od načelnika infektivnog odeljenja u San Francisku, glasila je: "Gari, ovo je najveća greška koju ćeš ikada napraviti."
But I landed in a refugee situation that had a million refugees in 40 camps, and there were six of us doctors. There were many epidemics there. My responsibilities were largely related to tuberculosis, and then we got struck by an epidemic of cholera. So it was the spread of tuberculosis and the spread of cholera that I was responsible for inhibiting. And in order to do this work, we, of course, because of the limitation in health workers, had to recruit refugees to be a specialized new category of health worker. Following three years of work in Somalia, I got picked up by the World Health Organization, and got assigned to the epidemics of AIDS. My primary responsibility was Uganda, but also I worked in Rwanda and Burundi and Zaire, now Congo, Tanzania, Malawi, and several other countries. And my last assignment there was to run a unit called intervention development, which was responsible for designing interventions.
Ali sam sleteo u izbeglički kamp, gde je bilo milion izbeglica smešteno u 40 kampova, i nas šest doktora. Bilo je dosta epidemija tamo. Ja sam uglavnom bio zadužen za tuberkulozu, nakon čega je udarila epidemija kolere. Dakle, dalje širenje tuberkuloze i širenje kolere sam imao za zadatak da sprečim. I da bi se ovo obavilo, naravno, zbog ograničenja u broju zdravstvenih radnika, morali smo da regrutujemo izbeglice za specijalizovanu novu kategoriju zdravstvenih radnika. Naredne tri godine rada u Somaliji, izabran sam od strane Svetske zdravstvene organizacije, koja mi je dodelila novi zadatak, epidemiju AIDS-a. Moja primarna odgovornost bila je Uganda, ali takođe i Ruanda i Burundi, Zair, sada Kongo, Tanzanija, Malavi i još nekoliko drugih zemalja. Moj poslednji zadatak tamo bio je da vodim jedinicu zvanu Razvoj intervencija, koja je bila odgovorna za dizajniranje intervencija.
After 10 years of working overseas, I was exhausted. I really had very little left. I had been traveling to one country after another. I was emotionally feeling very isolated. I wanted to come home. I'd seen a lot of death, in particular epidemic death, and epidemic death has a different feel to it. It's full of panic and fear, and I'd heard the women wailing and crying in the desert. And I wanted to come home and take a break and maybe start over.
Posle 10 godina rada u inostranstvu, bio sam iscrpljen. Jako malo stvari mi je ostalo. Putovao sam iz jedne zemlje u drugu i osećao sam se emocionalno izolovanim od svega. Želeo sam da se vratim kući. Video sam dosta smrti, naročito smrti kao posledice epidemije a epidemijska smrt je drugačija. Prepuna je panike i straha i čuo sam žene kako tuguju i plaču u pustinji. Želeo sam da se vratim kući i odmorim i možda počnem od početka.
I was not aware of any epidemic problems in America. In fact, I wasn't aware of any problems in America. In fact -- seriously. And in fact I would visit friends of mine, and I noticed that they had water that came right into their homes. How many of you have such a situation? (Laughter) And some of them, many of them actually, had water that came into more than one room. And I noticed that they would move this little thermoregulatory device to change the temperature in their home by one degree or two degrees. And now I do that.
Nisam bio svestan bilo kojih problema epidemije u Americi. Zapravo, nisam bio svestan ikakvih problema u Americi. Zaista. I zaista, kada bih posetio svoje prijatelje, primetio bih da imaju vodu koja dolazi direktno do njihovih kuća. Koliko vas ima sličnu situaciju? (Smeh) I neki od njih, zapravo mnogi, su imali vodu koja dolazi do nekoliko soba I primećivao sam da bi pomerili taj mali uređaj za termoregulaciju kako bi promenili temperaturu u svojim domovima za stepen ili dva. I sada i ja to radim.
And I really didn't know what I would do, but friends of mine began telling me about children shooting other children with guns. And I asked the question, what are you doing about it? What are you in America doing about it? And there were two essential explanations or ideas that were prevalent.
I zaista nisam znao šta bih učinio po tom pitanju, ali moji prijatelji su počeli da mi pričaju o tome kako deca pucaju na drugu decu oružjem. Pitao sam ih: "Šta radite u vezi toga? Šta vi u Americi radite povodom toga?" Izdvojila su se dva esencijalna objašnjenja, ili ideje koje su prevagnule.
And one was punishment. And this I had heard about before. We who had worked in behavior knew that punishment was something that was discussed but also that it was highly overvalued. It was not a main driver of behavior, nor was it a main driver of behavior change. And besides that, it reminded me of ancient epidemics that were previously completely misunderstood because the science hadn't been there before, epidemics of plague or typhus or leprosy, where the prevalent ideas were that there were bad people or bad humors or bad air, and widows were dragged around the moat, and dungeons were part of the solution.
Jedna je bila kazna. O tome sam već čuo ranije. Mi koji imamo iskustva sa ljudskim ponašanjem znamo da se kazne primenjuju, ali i da su jako precenjene. One nisu glavni pokretač ponašanja, pa samim tim ni glavni uzrok promena u ponašanju. To me je podsetilo na stare epidemije koje su u početku potpuno pogrešno shvaćene, jer nauka nije bila razvijena, epidemije kuge, tifusa ili lepre, gde su prevladavajuće ideje bile da se dešavaju zbog loših ljudi, loše volje ili lošeg vazduha i udovice su vučene po rovovima, a tamnice su bile deo rešenja.
The other explanation or, in a way, the solution suggested, is please fix all of these things: the schools, the community, the homes, the families, everything. And I'd heard this before as well. I'd called this the "everything" theory, or EOE: Everything On Earth. But we'd also realized in treating other processes and problems that sometimes you don't need to treat everything.
Drugo objašnjenje, ili na neki način rešenje koje je predlagalo prvenstveno rešavanje sledećih problema: školstva, društva, domova, porodica, svega. I za ovo sam već bio čuo ranije. Zvao sam ga "teorija svega". ili TSNS - teorija svega na svetu. Ali shvatili smo, prilikom rešavanja drugih procesa i problema, da nekad nije potrebno rešavati sve.
And so the sense that I had was there was a giant gap here. The problem of violence was stuck, and this has historically been the case in many other issues. Diarrheal diseases had been stuck. Malaria had been stuck. Frequently, a strategy has to be rethought. It's not as if I had any idea what it would look like, but there was a sense that we would have to do something with new categories of workers and something having to do with behavior change and something having to do with public education.
Zato sam imao utisak da tu postoji veliki propust. Problem nasilja je zastao sa svojim rešavanjem i to je u prošlosti bio slučaj i sa mnogim drugim problemima. Sa oboljenjem creva. Malarijom. Posle nekog vremena, strategija je morala da se ponovo osmisli. Nije da sam imao bilo kakvu ideju kako će se stvari odvijati ali postojao je osećaj da treba raditi nešto vezano za nove kategorije radnika i nešto sa promenama u ponašanju i nešto sa javnim obrazovanjem.
But I began to ask questions and search out the usual things that I had been exploring before, like, what do the maps look like? What do the graphs look like? What does the data look like? And the maps of violence in most U.S. cities looked like this. There was clustering. This reminded me of clustering that we'd seen also in infectious epidemics, for example cholera. And then we looked at the maps, and the maps showed this typical wave upon wave upon wave, because all epidemics are combinations of many epidemics. And it also looked like infectious epidemics. And then we asked the question, well what really predicts a case of violence? And it turns out that the greatest predictor of a case of violence is a preceding case of violence. Which also sounds like, if there is a case of flu, someone gave someone a case of flu, or a cold, or the greatest risk factor of tuberculosis is having been exposed to tuberculosis.
Počeo sam da postavljam pitanja i istražujem standardne stvari koje sam radio i ranije, kao na primer, kako izgledaju mape. kako izgledaju grafici. Kako izgledaju podaci. I mape nasilja u većini gradova u SAD izgledale su ovako. Pojavljivalo se grupisanje. To me je podsetilo na grupisanje koje bismo viđali i kod infektivnih epidemija, kao što je kolera. I posmatrali smo mape, pokazivale su nam tipičan talas nakon talasa, nakon talasa, jer sve epidemije su zapravo kombinacija više epidemija. I izgledalo je isto kao kod infektivnih epidemija. Zapitali smo se šta zaista predviđa slučaj nasilja. I ispostavilo se da je najveći pokazatelj nasilja prethodni slučaj nasilja. To je isto kao i kad postoji slučaj gripa, neko je nekom preneo grip, ili prehladu, ili to što je najveći rizik od tuberkuloze prethodna izloženost tuberkulozi.
And so we see that violence is, in a way, behaving like a contagious disease. We're aware of this anyway even in our common experiences or our newspaper stories of the spread of violence from fights or in gang wars or in civil wars or even in genocides.
Tako vidimo da se nasilje na neki način ponaša kao zarazna bolest. Svakako smo svesni ovoga čak i u našim zajedničkim iskustvima ili pričama u novinama o širenju nasilja, od tuča, ratova bandi ili građanskih ratova ili čak genocida.
And so there's good news about this, though, because there's a way to reverse epidemics, and there's really only three things that are done to reverse epidemics, and the first of it is interrupting transmission. In order to interrupt transmission, you need to detect and find first cases. In other words, for T.B. you have to find somebody who has active T.B. who is infecting other people. Make sense? And there's special workers for doing that. For this particular problem, we designed a new category of worker who, like a SARS worker or someone looking for bird flu, might find first cases. In this case, it's someone who's very angry because someone looked at his girlfriend or owes him money, and you can find workers and train them into these specialized categories.
Ipak, ima i dobrih vesti, jer postoji način da se preokrenu epidemije i zapravo postoje samo tri stvari koje se rade da bi se preokrenula epidemija, a prva je prekidanje prenosa. Kako bi se prenos prekinuo, morate da otkrijete i nađete prve slučajeve. Drugim rečima, kod tuberkuloze morate pronaći nekoga ko ima aktivnu tuberkulozu i inficira druge ljude. Ima smisla? I za to postoje posebni radnici. Za ovaj poseban problem, smislili smo novu kategoriju radnika koji, poput radnika za SARS ili nekoga ko traži ptičji grip, možda pronađe prve slučajeve. U ovom slučaju, to je neko ko je veoma besan jer je neko pogledao njegovu devojku ili mu duguje novac, i možete pronaći radnike i obučiti ih za ove posebne kategorije.
And the second thing to do, of course, is to prevent further spread, that means to find who else has been exposed, but may not be spreading so much right now like someone with a smaller case of T.B., or someone who is just hanging out in the neighborhoods, but in the same group, and then they need to be, in a way, managed as well, particular to the specific disease process.
Druga stvar je naravno, sprečavanje daljeg širenja, to znači pronalazak drugih koji su bili izloženi, ali kod koga se to ne širi toliko, poput nekoga sa blažom tuberkulozom ili nekoga ko samo visi po komšiluku, ali unutar iste grupe, i na neki način, i oni moraju da budu procesuirani, po procesu za određenu zarazu.
And then the third part, the shifting the norms, and that means a whole bunch of community activities, remodeling, public education, and then you've got what you might call group immunity. And that combination of factors is how the AIDS epidemic in Uganda was very successfully reversed.
Treći deo je pomeranje normi, a to podrazumeva puno aktivnosti u zajednici, ponovnog modeliranja, javnog obrazovanja, i onda dobijate nešto što bi se moglo nazvati grupnim imunitetom. Tom kombinacijom faktora je epidemija AIDS-a u Ugandi bila uspešno preokrenuta.
And so what we decided to do in the year 2000 is kind of put this together in a way by hiring in new categories of workers, the first being violence interruptors. And then we would put all of this into place in one neighborhood in what was the worst police district in the United States at the time. So violence interruptors hired from the same group, credibility, trust, access, just like the health workers in Somalia, but designed for a different category, and trained in persuasion, cooling people down, buying time, reframing. And then another category of worker, the outreach workers, to keep people in a way on therapy for six to 24 months. Just like T.B., but the object is behavior change. And then a bunch of community activities for changing norms.
U godini 2000. smo odlučili da ovo sklopimo na neki način zapošljavanjem nove kategorije radnika, gde su prvi zaustavljači nasilja. Onda bismo sve ovo stavili na jedno mesto u jedan komšiluk, u najgori policijski distrikt u SAD u to vreme. Zaustavljači nasilja zapošljeni su iz jedne iste grupe, naspram kredibiliteta, poverenja, pristupa, isto kao zdravstveni radnici u Somaliji, ali s namerom za drugu kategoriju i obučeni su da ubeđuju, smire ljude, kupe sebi vreme, stvore novi okvir. Tu je i druga kategorija radnika, radnici za povezivanje, koji ljude drže na terapiji od 6 do 24 meseca na neki način. Kao kod tuberkuloze, ali cilj je promena ponašanja. A tu je i hrpa aktivnosti za zajednicu za menjanje normi.
Now our first experiment of this resulted in a 67-percent drop in shootings and killings in the West Garfield neighborhood of Chicago.
Naš prvi eksperiment s ovim za posledicu je imao pad od 67% u pucnjavama i ubistvima u oblasti Vest Garfild u Čikagu.
(Applause)
(Aplauz)
And this was a beautiful thing for the neighborhood itself, first 50 or 60 days, then 90 days, and then there was unfortunately another shooting in another 90 days, and the moms were hanging out in the afternoon. They were using parks they weren't using before. The sun was out. Everybody was happy.
Ovo je za sam komšiluk bila divna stvar, prvih 50 ili 60 dana, onda 90 dana, i onda se nažalost desila još jedna pucnjava za drugih 90 dana i majke su se družile popodne. Koristile su parkove koje nisu nikada pre. Sunce je izašlo. Svi su bili srećni.
But of course, the funders said, "Wait a second, do it again." And so we had to then, fortunately, get the funds to repeat this experience, and this is one of the next four neighborhoods that had a 45-percent drop in shootings and killings. And since that time, this has been replicated 20 times. There have been independent evaluations supported by the Justice Department and by the CDC and performed by Johns Hopkins that have shown 30-to-50-percent and 40-to-70-percent reductions in shootings and killings using this new method. In fact, there have been three independent evaluations of this now.
Ali naravno, investitori su rekli: "Stani malo, uradite to opet." Onda smo na sreću opet morali da dobijemo sredstva da ponovimo ovo iskustvo, i ovo je jedan od sledeća 4 komšiluka koji su imali pad od 45% u ubistvima i pucnjavama. Od tada, ovo je ponovljeno 20 puta. Radile su se nezavisne procene koje je podržalo Ministarstvo pravde i Centar za kontrolu i prevenciju zaraza i koje je vršio Džon Hopkins, koje su pokazale smanjenja od 30-50% i 40-70% u pucnjavama i ubistvima koristeći ovaj novi metod. Zapravo, urađene su tri nezavisne procene do sada.
Now we've gotten a lot of attention as a result of this, including being featured on The New York Times' Sunday magazine cover story. The Economist in 2009 said this is "the approach that will come to prominence." And even a movie was made around our work. [The Interrupters]
Kao posledica ovoga, dobili smo dosta pažnje, uključujući i to što smo bili glavna priča u nedeljnom magazinu Njujork Tajms. 2009. Ekonomist je rekao da je ovo "pristup koji će doći do izražaja". Na osnovu našeg rada je čak napravljen i film. [Zaustavljivači]
However, not so fast, because a lot of people did not agree with this way of going about it. We got a lot of criticism, a lot of opposition, and a lot of opponents. In other words, what do you mean, health problem? What do you mean, epidemic? What do you mean, no bad guys? And there's whole industries designed for managing bad people. What do you mean, hiring people who have backgrounds? My business friends said, "Gary, you're being criticized tremendously. You must be doing something right."
Ipak, ne tako brzo, jer se dosta ljudi nije slagalo sa načinom na koji se ovo radilo. Dobili smo dosta kritika, dosta protivljenja i dosta protivnika. Drugim rečima, kako to misliš, zdravstveni problem? Kako to misliš, epidemija? Kako to misliš, nema negativaca? A postoje čitave industrije osmišljene za baratanje negativcima. Kako to misliš, zapošljavanje ljudi koji imaju pozadinu? Moji prijatelji iz sveta posla su mi rekli: "Gari, izuzetno snažno te kritikuju. Mora da radiš nešto kako treba."
(Laughter)
(Smeh)
My musician friends added the word "dude."
Moji prijatelji iz sveta muzike dodali su reč "brate".
So anyway, additionally, there was still this problem, and we were getting highly criticized as well for not dealing with all of these other problems. Yet we were able to manage malaria and reduce HIV and reduce diarrheal diseases in places with awful economies without healing the economy.
Kako god bilo, pored svega još uvek je postojao ovaj problem, i takođe su nas žestoko kritikovali jer ne rešavamo sve ove druge probleme. Ipak, uspeli smo da se izborimo s malarijom i smanjimo HIV i bolesti izazvane dijarejom na mestima sa užasnim standardima bez popravljanja ekonomije.
So what's actually happened is, although there is still some opposition, the movement is clearly growing. Many of the major cities in the U.S., including New York City and Baltimore and Kansas City, their health departments are running this now. Chicago and New Orleans, the health departments are having a very large role in this. This is being embraced more by law enforcement than it had been years ago. Trauma centers and hospitals are doing their part in stepping up. And the U.S. Conference of Mayors has endorsed not only the approach but the specific model. Where there's really been uptake even faster is in the international environment, where there's a 55-percent drop in the first neighborhood in Puerto Rico, where interruptions are just beginning in Honduras, where the strategy has been applied in Kenya for the recent elections, and where there have been 500 interruptions in Iraq.
Zapravo se desilo to, da iako još ima neke opozicije, pokret očigledno raste. Mnogi veliki gradovi u SAD, uključujući Njujork, Baltimor i Kanzas siti, njihova odeljenja za zdravstvo trenutno koriste ovo. U Čikagu i Nju Orleansu, odeljenja za zdravstvo imaju veoma veliku ulogu u ovome. Ovo organi reda prihvataju više nego pre nekoliko godina. Domovi zdravlja i bolnice daju svoj doprinos u poboljšavanju. Savez gradonačelnika SAD-a je podržao ne samo pristup već i specifični model. Najbrži napredak se zapravo vidi u međunarodnom okruženju, gde se desio pad od 55% u prvom komšiluku u Portoriku, zaustavljanja tek počinju u Hondurasu, strategija je primenjena u Keniji za skorašnje izbore, a u Iraku je bilo 500 zaustavljanja.
So violence is responding as a disease even as it behaves as a disease. So the theory, in a way, is kind of being validated by the treatment. And recently, the Institute of Medicine came out with a workshop report which went through some of the data, including the neuroscience, on how this problem is really transmitted.
Nasilje odgovara kao zaraza isto kao što se i ponaša kao zaraza. Tako se na neki način teorija potvrđuje kroz lečenje. Institut medicine je skoro objavio izveštaj sa radionice kroz koji su provučeni neki podaci, uključujući neurologiju, a radilo se o tome kako se ovaj problem zapravo prenosi.
So I think this is good news, because it allows us an opportunity to come out of the Middle Ages, which is where I feel this field has been. It gives us an opportunity to consider the possibility of replacing some of these prisons with playgrounds or parks, and to consider the possibility of converting our neighborhoods into neighborhoods, and to allow there to be a new strategy, a new set of methods, a new set of workers: science, in a way, replacing morality. And moving away from emotions is the most important part of the solution to science as a more important part of the solution.
Mislim da su ovo dobre vesti, jer ovo pruža priliku da se izađe iz Srednjeg veka, gde mislim da se nalazilo ovo polje. Ovo nam daje priliku da u obzir uzmemo mogućnost da se neki od ovih zatvora zamene igralištima ili parkovima i da se obzir uzme mogućnost preokretanja naših komšiluka u komšiluke i da se dozvoli postojanje nove strategije, novog skupa metoda, skupa radnika: na jedan način, nauka zamenjuje moralnost. Najbitniji deo rešenja je odmicanje od emocija, nauci kao bitnijem delu rešenja.
So I didn't mean to come up with this at all. It was a matter of, I wanted actually a break, and we looked at maps, we looked at graphs, we asked some questions and tried some tools that actually have been used many times before for other things. For myself, I tried to get away from infectious diseases, and I didn't.
Uopšte nisam nameravao da smislim ovo. To je bilo stvar toga da mi je zaista trebala pauza i pogledali smo mape, grafikone, postavili neka pitanja i isprobali neke alate koji su se koristili mnogo puta pre toga za druge stvari. Što se mene tiče, pokušao sam da pobegnem od infektivnih zaraza, a nisam uspeo u tome.
Thank you.
Hvala vam.
(Applause)
(Aplauz)