Assessing rising cost of violence Most victims don't carry insurance

THE BALTIMORE SUN

WASHINGTON -- The dispatcher's voice crackled over the hospital loudspeaker: "Code Yellow. Gunshot wound to the head."

Moments later, the paramedics wheeled a young victim in. His hair was bloody and matted. His eyes, rolled upward, were fixed wide open. His mouth was agape. His heart had shut down.

The doctors and nurses scrambled. They pushed a tube down his throat, pounded on his chest, and injected him with adrenalin. They tried to jump-start his heart; his arms jerked forward wildly with each electric shock. Meantime, the dispatcher was on the loudspeaker again: "Another code yellow. Another gunshot wound will be here in a minute."

This was a slow night at Washington Hospital Center, home to one of the busiest trauma centers in the murder capital of America. Night after night, the surgeons here practice a unique brand of battlefield medicine; many of them, in fact, are military doctors who come to prepare for battlefield medicine.

But their services do not come cheap and, because the victims seldom carry insurance or are able to pay their own way, the cost of treatment falls on taxpayers.

For years, medical professionals, health economists and hospital administrators have complained that violence is taking a devastating and expensive toll on the nation's health. Many call it an epidemic, and their frustration is heightened by their belief that violence, like AIDS and lung cancer, can be prevented.

So when President Clinton complained last month in his health care speech about "the outrageous cost of violence," doctors and nurses across the land nodded in agreement.

"It's about time somebody took some note of it," declared Dr. Howard Champion, the unit chief. "This is a huge public health problem. Here they are scurrying around trying to save money on health-related issues, and doing something about this epidemic of violence is a very reasonable candidate."

The costs of violence are staggering, both in human and economic terms. It is the nation's 12th-leading cause of death and the No. 1 cause of death and disability for people between the ages of 15 and 34. Young black men are more likely to be murdered than to die of any other cause. An estimated 4 million women are raped each year, according to the U.S. Centers for Disease Control and Prevention, and 1.5 million children are abused.

As a top adviser to Health and Human Services Secretary Donna Shalala said: "Any time you have that many people dying of anything, it's a public health issue."

Depending on who is counting, the United States spends from $5.7 billion to $18 billion a year on medical care for victims of violence -- and experts agree that those estimates are conservative. By comparison, the nation spent $10 billion last year to treat people infected with the AIDS virus, $11 billion on strokes and $13 billion on diabetes.

Death is cheap

Death -- from a strictly financial perspective -- is cheap. Costs are driven up by those who survive the violence. They can spend weeks or months in expensive intensive-care units and rehabilitation facilities, not to mention the long-term costs of lost wages and productivity. Quite often, those racking up medical bills are not covered by insurance.

In Los Angeles County, a 1990 study estimated that taxpayers spent $53 million to care for gunshot victims. At County-USC Medical Center in Los Angeles, which conducted the survey, 686 patients were admitted for torso bullet wounds. Only 30 had private health insurance, and nearly half had no coverage.

In city after city, the story is the same. At Ben Taub Hospital in Houston, officials estimate that 95 percent of all victims of crime-related injury carry no health insurance. Roger Widmeyer, the hospital's public spokesman, recounted an unofficial survey he conducted.

"I just picked a day, like you'd pick a bean out of a hat, and there were 10 gunshots on that day," he said. "The cheapest one was an $8,033 bill, and that was a robbery victim and he had insurance. The most expensive bill of the remaining nine was $63,700. None of those had any kind of compensation at all. In other words, we ate it."

How do facilities cover the costs? "We cross-subsidize them," says Washington Hospital Center Vice President Mark Merrill, somewhat euphemistically. He means that the hospital jacks up the price of other services -- heart surgery, appendectomies and the like -- that patients with insurance receive.

Public health experts believe that the nation could be spared the tragedy and expense of violence if it were treated as a public health problem. This is not a new idea -- the Centers for Disease Control founded a violence prevention program a decade ago -- but it is one that is just taking hold in Washington.

Some credit Attorney General Janet Reno for bringing the concept to the public's attention and helping inject it into the health care reform debate. Shedding the traditional law enforcement emphasis on punishment and prisons, Ms. Reno has been traveling the nation talking about the "root causes" of violence, visiting hospitals and suggesting that more attention should be paid to preventing it when children are young.

Ms. Reno also has teamed up with Ms. Shalala on the issue. Next week, a new federal task force on violence, chaired by top advisers to the two women, will begin a four-month effort to draft the administration's strategy for curbing violence.

Dr. Mark Rosenberg, the CDC's top expert on violence, has been instrumental in this effort. "It's very important to do what the criminal justice sector does, to intervene after violence occurs," he said. "Our emphasis is on prevention. That's a real paradigm shift, the notion that we can prevent it not just by incarceration but by changing the behaviors of very young people."

Some public health experts and elected officials say that if the administration is serious about curbing violence, President Clinton would propose taxes on alcohol and ammunition, as well as cigarettes, to help fund his health package.

With or without fees and taxes, prevention will not be easy.

In an effort to figure out what works, the CDC has initiated pilot projects to prevent youth violence in Brooklyn, N.Y.; Durham, N.C.; and Houston. The programs, which cost $1 million a year and will last from three to five years, are designed to offer young people job training, education, recreation and counseling in how to resolve conflicts peacefully.

At Washington Hospital Center, a program has been organized to help doctors, nurses and other health education professionals teach young people how to control their anger, and explain how drugs and alcohol contribute to violence.

Yet the staff is not optimistic. They have seen too many code yellows, too many gunshot wounds in the head, too many "wooden shampoos" -- street slang for a beating with a baseball bat.

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