When Alice Oaks' older son was shot to death in Baltimore in 2008, she said her goodbye at the Maryland Shock Trauma Center. He lay there, a tube still in his mouth, and it seemed to her that his body was glowing. She felt numb. She bent over and kissed him softly on the forehead and the cheek.
Then, this past May, driving home from a seafood dinner, she got a phone call that her other child, also a son, had been shot dead. She screamed and beat her hands on the steering wheel, so hysterical that she stopped the car in the middle of the road.
"Not my only son," she cried out over and over. "Not again."
Her words could be a refrain for Baltimore, which has the fifth-highest homicide rate of major U.S. cities. The brutal killings leave behind thousands of families who must grapple with the debilitating aftermath. Like the children exposed to violence, or the caregivers tending sons disabled by shootings, the grieving relatives of the murdered are little noticed after the funerals and the candlelight vigils. But their suffering is part of the devastating domino effect of violence in the city.
For Oaks, 61, and other relatives, the holiday season is especially painful, and the fallout from a violent death goes far beyond what most people imagine. Numerous studies show that the relatives of homicide victims suffer in a different and often more intense way than those who have lost a loved one through natural causes, or long illnesses — partly because they must deal with the criminal justice system.
Every part of their lives is affected. Some can't hold jobs, and families break apart. Grieving parents may not realize their own children are also suffering. They often develop mental and physical health problems, including eating disorders, insomnia, depression and paranoia. They get pain in the arm or chest, where their loved one was shot. In a phenomenon known as "broken heart syndrome," intense grief can weaken the heart and lead to heart attacks. So can the anger, scientists say. In certain cases, some researchers believe, the burden of grief — if not treated — can kill people.
In one of the largest studies ever done on the bereaved relatives of homicide victims, the findings were striking: 100 percent reported that the murder of a loved one had affected their health, 25 percent stopped working permanently, and 25 percent suddenly gained responsibility for a child. All of them suffered significant financial burdens, according to the 2011 government report from the United Kingdom, which involved interviews with more than 400 families.
"I don't want to do anything. I just want to withdraw into a cocoon," said Oaks, who experiences heart palpitations, anxiety attacks and headaches. She takes antidepressants but finds herself sometimes crying uncontrollably about the deaths of her sons. Both had been convicted of minor drug offenses, but she felt they were working to build better lives.
Researchers estimate that every homicide has a direct impact on 10 other people, which means nearly 24,000 Baltimoreans have been affected by homicides — just in the past decade. And that's on top of other decades of loss.
"This has been going on for 30 or 40 years if not longer. This has been two or three generations of death," said Phil Leaf, a professor and director of the Center for the Prevention of Youth Violence at the Johns Hopkins Bloomberg School of Public Health.
At the state level, there is a growing awareness of the toll. The General Assembly, noting that many areas of Maryland lacked necessary counseling and follow-up services, passed a law this year to provide funding to better support these relatives. So far, the funding has paid for police sensitivity training, more support groups and home visits from social workers.
"The old saying 'Hurt people hurt people' is so true,'" said Annette March-Grier, president of Roberta's House, a grief center in East Baltimore. "We need to address the rippling effect and the emotional scars that are left behind from violence — because it will only replicate violence again. Anger turns to rage, and then it becomes self-destructive if that anger is not resolved in a healthy way."
City health and public health officials have long seen violence as almost an infectious disease, because of the way it can spread through the community. Two local violence prevention initiatives, Operation Ceasefire and Safe Streets, have had varying degrees of success. Still, more than 200 people have been killed in Baltimore this year.
Particularly hard hit in Baltimore is the African-American community, which accounted for 90 percent of the homicide victims so far this year. Most of the 600 clients who use grief counseling and other services through a program at the Baltimore City state's attorney's office are African-American mothers. The problem is so severe that a sociology professor moved here in 2007 to work at the University of Maryland School of Social Work so she could study how African-Americans are affected by homicide and how to help them.
"There is a culture of homicide," said Tanya L. Sharpe, the associate professor who moved here from Boston. The survivors' grief is often mixed with the shame, blame and stigma that may surround crime, even if the loved one was an innocent victim.
It is not uncommon for mothers in Baltimore, like Oaks, to have more than one child who was murdered. A trauma surgeon at Johns Hopkins Hospital recalls walking out of the operating room last year to tell relatives that a young man, shot in the heart, had died.
An elderly woman looked at the surgeon, Dr. Adil Haider, in recognition and said, "Oh thank God, it's you again."
The woman, the grandmother of the shooting victim, explained that Haider had operated on two other grandsons who had been shot within the past year. One managed to pull through. A second, shot in the head, died. And by the look on Haider's face the third time, she knew this grandson was also dead.
Some of Baltimore's homicide victims have been involved in criminal activity. Many others are innocent victims. Either way, their deaths have an impact, Haider says.
"People don't realize that behind every person who dies is a loving family, and the people who saw this child grow up," said Haider, who operated on hundreds of young male gunshot victims in his six years at Hopkins, and is now at Brigham and Women's Hospital in Boston. "There are a lot of people who love that person."
Heartbroken families must make their way through the criminal justice system, which often interferes with the way they process their grief. Funerals are delayed while autopsies are completed. People's homes can be closed off as crime scenes, and when killers are unknown, family members become suspects.
Even when killers are caught, trials make families relive the ordeal. Many cases are heard numerous times because of hung juries and appeals, prolonging the sorrow.
"It's like opening the wound and closing it, opening the wound and closing it," said Kim Holmes, director of the Family Bereavement Center at the Baltimore state's attorney's office, which tries to help families navigate the criminal justice system.
In the case of Oaks' first son, Irvin Lawson, 31, the killer was quickly arrested and brought to trial, eventually sentenced to life plus 20 years in prison. Knowing that the man who murdered her son was brought to justice eased some of Oaks' grief.
When her second son, Larry Henderson, 30, was killed, his body was taken to the morgue for an autopsy before she even learned of his death. Oaks said she wasn't allowed to see him for another two weeks — just before he was buried.
His body was found in the Westport area of South Baltimore. Six months later, no one has been charged in the murder.
Today, the two brothers are buried side by side, and the combination of losing a second son and not knowing the killer has made Oaks' sadness almost debilitating, she said. Even though she runs a support group for survivors like herself — called Survivors Against Violence Everywhere — she often feels isolated, as if no one understands. Even Oaks' husband once asked her why she hadn't gotten over one of the sons' deaths.
Relatives report feeling stigmatized and judged because of the way their loved ones died. People would insinuate that the victims were to blame, according to research published in June from York College in Pennsylvania. That may cause survivors to lie about the death and afterward feel guilty for not being true to the victim, according to the research. One survivor said that after telling a co-worker about her son's death: "I could tell she was judging me and judging my son, and that hurt. I thought, 'Why the hell did I put myself out there?'"
Other survivors find that close friends become uncomfortable, and rather than say something wrong, they say nothing. One woman told researchers she wanted to put a big sign on her forehead that said, "Talk to me please."
Dealing with the ups and downs can take a toll on relatives' emotional and physical health.
It took Nichole Parrish months before she finally faced the death of her mother, who worked in the bail bonds business. The Baltimore woman, 42, was shot in the chest in the fall of 2011 by a client who left her bleeding in a Columbia parking lot.
Parrish's breaking point came in court, during the trial, when she saw her mother and namesake, Nichole Bernadette McNair, limp and lifeless in the autopsy pictures. She tried to walk out of the courtroom but was frozen in place and found herself sobbing uncontrollably.
The killer was convicted, but it was the beginning of a downward emotional spiral for Parrish. She suffered panic attacks and didn't sleep for days at a time. The University of Maryland, Baltimore County student stopped going to a job she had just started, working with children with autism, and missed some days of class. When the semester ended, she had no reason to get out of bed at all.
Parrish's condition got so bad that she was admitted to Johns Hopkins Hospital for three months. She was diagnosed with post-traumatic stress disorder, a trauma-induced disorder often found in soldiers who come back from war, but now more commonly diagnosed in people who experience other tragic events.
Parrish, 23, has since graduated from UMBC, found a job in customer service and lives with her father in East Baltimore — but deals with her mother's death every day. She finds herself crying at work sometimes. She has recurring nightmares of her mother getting shot in different places around town. And the panic attacks recur.
"I get really scared," said Parrish. "I just get panicked that something is going to happen. Then I wonder if something happens, 'Where will I go? What will I do?"
Research shows that Parrish's experience is common among the relatives of homicide victims.
In the York College study, Jeanna M. Mastrocinque, an assistant professor of criminal justice, and her colleagues conducted focus groups with nearly 30 relatives in Rochester and Albany, N.Y., and parts of Indiana. They found that anxiety and paranoia took over the lives of some relatives. They adopted quirks to help them feel safer, including switching to a sheer shower curtain to see intruders, sleeping with the lights on or always keeping the blinds closed. For those notified of the death by someone who came to the house, or called, a knock on the door or ring of the phone triggered anxiety attacks.
Scientists at Johns Hopkins and other institutions have found that grief can cause biological changes. The immediate grief after a death can weaken the heart and increase the risk of heart attacks. The lingering anger associated with this grief can also cause heart problems, a Harvard University study found. Other research connects intense grief to high levels of stress hormones, a weakened immune system and trouble sleeping.
Relatives interviewed in Mastrocinque's study attributed illnesses such as cancer, heart attacks and death to their grief. Many complained of feeling physically sick, and some lost so much weight that they dropped three or four clothes sizes. One described it this way: "I think this has changed me on a molecular level."
Mastrocinque's study recommended that primary care physicians pay more attention to the health status of the relatives of the murdered, given all the problems they reported.
"Homicide is one of the leading causes of death for many age groups," Mastrocinque said. "I don't think people think about how much homicide ripples through communities."
Michelle Randolph considered herself fairly healthy before her only child, Wesley Lewis, 19, was found murdered in August 2010. After his death, the Baltimore woman couldn't control her blood pressure and suffered from panic attacks and depression.
"My chest tightens and my heart starts to work [hard]. It's like it's flooded," she said. "They say it's just stress."
Many health problems can last months after the initial grief, a study by researchers at the University of Wisconsin-Milwaukee School of Nursing found.
Within the circle of victims' relatives she knows, Oaks believes she has seen grief kill. She remembers a mother who never seemed to get over her child's death, who suffered from depression, then a stroke and ended up in a wheelchair. A few years ago, she died in a bathroom during a birthday party.
In her work, Sharpe, of the University of Maryland, has interviewed 300 people in several cities, including more than 80 in Baltimore. She found that, on average, African-Americans nationwide have experienced the homicide of a loved one at least 2.5 times in their lifetimes — much more than other groups. Yet African-Americans are often neglected in research about this issue, something Sharpe is trying to address in her work.
She discovered that African-American families often suppressed their feelings, either because of the stigma of being associated with such a horrific crime, or to deal with everyday life, such as working and putting food on the table.
"The way we deal with grief and loss as a people is to suck it up, move on and deal with it, and pretend as if nothing has happened. That has been our culture — the African-American culture — to not show emotions," said March-Grier of Roberta's House.
Gaining the trust and drawing out feelings of her clients, many who are African-American, can be difficult, she added.
Recently, Roberta's House got funding from the new state legislation to enhance its grief services, to help make recovery less difficult for African-American survivors and figure out ways to help them. At an evening session last week, tears flowed as the relatives shared their stories. One mother blamed herself for not doing enough to protect her son, while another talked about being angry at God for allowing the killing. Others talked about the rise and fall of emotions that made it hard to get out of bed.
Other grassroots support groups have formed to help survivors. Activist Millie Brown started A Mother's Cry in 2007 after seeing traumatized families at Johns Hopkins Hospital, where she cleaned operating rooms. She discovered that 50 fellow employees had relatives who had been murdered. Now she tries to tell survivors they need to live, even if their kids didn't.
"The pain never goes away," Brown said. "I am there to give them something better. The only thing I want is to see them smile and to see them laugh."
This week, around the holiday season, much of the hurt intensifies.
Oaks isn't sure what she'll do on Christmas. Her brother is trying to persuade her she shouldn't be alone.
Parrish, who lost her mother, also agonizes from day to day about whether to spend the holiday with family or not.
Randolph can't stand to be around people who have their families when she no longer has hers. So she'll spend the day by herself and light a single candle for her son.
Some bereaved relatives find solace in an annual ceremony that helps them honor their loved ones. Started several years ago by Survivors Against Violence Everywhere, the ritual was held this month on a chilly, rainy evening at City Hall. Even the band that was playing at the event had been affected by homicide — three of the musicians had lost relatives to violence.
As a member of the group read the names of those who had died, family members came up, one by one, to hang an ornament on a tree. Most of them were mothers, and many of the ornaments were adorned with the names and pictures of the victims. They cried and hugged each other. Oaks sat in the front row, dabbing her eyes, rocking back and forth with another mother.
It didn't bring back their loved ones. But for at least a night, it let them remember they weren't alone.
Full coverage: Collateral Damage series and related stories
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