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
"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."