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Trauma surgeons are often the first point of contact with the health care system for victims of violence. However, their role can extend beyond caring for a patient's physical injuries. Trauma centers can help address root causes of violence, improve health, and reduce inequities in marginalized communities, according to the American College of Surgeons (ACS) Improving Social Determinants to Attenuate Violence (ISAVE) workgroup. The ISAVE workgroup published four strategies to help break the cycle of violence in an article published on the Journal of the American College of Surgeons website in advance of print.

Violence, in and of itself, is very much the end result of social determinants of health, structural racism, and structural barriers in our country that have existed for a long time. The strategies we propose are very action-oriented. Trauma is not just about the physical injury but has a broader definition. We need to be more comprehensive and aware of that as we treat our patients."

Rochelle A. Dicker, MD, azithromycin 1st trimester pregnancy FACS, Division of Trauma and Critical Care, University of California at Los Angeles Geffen School of Medicine

Four strategies to address the root causes of violence

The ISAVE workgroup proposes four strategies to improve health and health care for marginalized communities that are disproportionally impacted by violence:

• Development and Implementation of Trauma Informed Care in All Trauma Centers
• Integrating Social Care into Trauma Care
• The Trauma Center's Role in Investing in At-Risk Communities
• Advocacy

These strategies form ISAVE's vision of the future of care for victims of violence. These efforts extend beyond the confines of trauma centers, reaching into communities plagued by this violence epidemic.

A key feature of the ISAVE strategies is the Trauma Informed Care (TIC) curriculum. The authors note that trauma has traditionally had two definitions:

1. From the mental health perspective, a deeply distressing and disturbing experience
2. From the perspective of trauma surgery and emergency medical services, an acute physical injury

The authors note that having two different definitions of trauma can lead to a fragmentation of care. The TIC curriculum takes into account the full scope of trauma and can "foster a sense of empowerment, autonomy, and partnership in the injured person to help patients thrive, not just survive."

Focusing on at-risk communities

The authors address violence and the social determinants of health with a broad lens, noting the risk of perpetuating a cycle of inequity, disparity, and inequality if underlying causes of death and ill health are not addressed. The authors suggest a strategy to invest directly in at-risk communities to treat patients with a full scope of understanding the underlying factors.

"It is important that people have access to trauma centers, but the other piece is hospitals investing in their communities," Dr. Dicker said. "For example, putting in place vocational training programs so that the community is part of the employment process in a hospital itself. Also, whether the hospital uses local vendors for food; that's an investment in the local community. Investment truly is the ability to put dollars into the communities that are in such great need."

Health and wealth are inextricably tied to one another, the authors note. "Black and Brown communities suffer heavily from a racial wealth gap relative to white communities, although rural white Americans are also deeply impacted by this gap and share a common lack of access to mechanisms to build financial security," they write. "Creating opportunities for financial and educational inclusion may not be seen on the surface as a health-related matter but, in fact, it is at its core."

Advocacy is the overarching theme that informs the strategies proposed by ISAVE. The authors note that it is an intrinsic duty for trauma center personnel to use advocacy to address the social determinants of health that lead to violence. Specific policy suggestions include engaging hospital and health system administrators to leverage the Affordable Care Act's Community Health Needs Assessment to encourage hospitals to engage in addressing poverty and unemployment.

"Physical trauma leads to psychological trauma and psychological trauma predisposes to physical trauma. Optimally addressing one, requires addressing the other," the authors conclude. "Although complex, effective interventions for violence are not as complex as those required to combat a novel corona virus pandemic, and as the COVID-19 pandemic has plainly demonstrated, we are all in this together. What affects one of us, affects all of us."

The ISAVE workgroup was established in 2019 by the ACS Committee on Trauma (COT) and first outlined steps the medical community must take to understand and address the root causes of firearm violence at a panel presentation during the 2020 ACS Clinical Congress virtual. The ACS COT has been working to prevent firearm related injury, death, and disability by working together to address the root causes of violence and simultaneously making firearm ownership as safe as possible. Learn more about the ACS COT's efforts that focus on treating firearm violence as a public health problem.