A 17-year-old black male arrives at a city hospital at 11 p.m. with a gun shot wound to his arm. An emergency room physician stitches him up, then wags her finger and says, “If you don’t change your ways, you will die.” Rather than admit the teenager, the doctor discharges him—back to his neighborhood, where he was shot less than five hours earlier.

Soon the young man experiences bouts of emotional numbness, hyperactivity, flashbacks, nightmares—the classic symptoms of post-traumatic stress disorder. Without any understanding of why he feels this way, and without health insurance, he begins to self-medicate with alcohol and drugs. Feeling jumpy, he buys a gun to protect himself. And so the cycle continues.

“If you were shot, would you want to be sent back to the street, the ‘crime scene,’ so soon?” asks Dr. John Rich, who has told this story dozens of times. “It’s not an unusual scenario, though. Not for this population.” Rich, a 1990 graduate of the Harvard School of Public Health’s Department of Health Policy and Management and a 2006 recipient of a MacArthur Foundation grant, grew up observing his father, a dentist, work with patients from poor neighborhoods around Shea Stadium in Queens, New York. For nearly 20 years, Rich has chosen to integrate public health’s mission into his role as a physician, not just by treating young blacks’ health problems, but also by considering what other factors might be at play.

Cases of Neglect
In 1990, after completing a fellowship in general medicine at Massachusetts General Hospital, Rich joined the staff at “Boston City” (now Boston Medical Center), a publicly funded hospital that serves thousands of minority patients, many of whom are poor and uninsured. He noticed how few young black men came to the hospital for primary care. This meant a host of psychological and physical issues were being neglected—stress, poor nutrition, hypertension.

Rich asked colleagues throughout the hospital, “Why are we only seeing these people who have preventable illnesses in the ER or in orthopedics or surgery, and not in primary care?” From this question surfaced the idea for the Young Men’s Health Clinic—a place where men ages 17 to 30 could receive basic care and psychiatric treatment, as well as referrals to community-based services, such as parenting help, all in an effort to identify and address the larger issues plaguing these men.

When the clinic opened, in 1993, referrals came from within the hospital. Over time, the clinic began to also see patients referred by other organizations in the community. “It may not have offered the full array of services my colleagues and I had hoped for— I would have liked to have added a nutrition and fitness component, for example. But funding becomes a crippling issue when so many of the patients are uninsured.” Despite the tight reins of limited resources, Rich still felt they were making a difference by reaching men who would otherwise have remained lost within the health care system.

Around the time of the clinic’s inception, Rich began collecting detailed histories from patients victimized by violence. “As an undergrad at Dartmouth College, I’d learned that language and medicine fit together in a logical way. Ultimately, medicine is about stories,” Rich says. Through the narratives, he uncovered tragic patterns of trauma and myriad undiagnosed physical and mental health problems that help explain why being shot or stabbed once dramatically increases the likelihood of its happening again. He began to consider whether getting these men into the health care system earlier through primary care could both better their health and prevent further violence.

A selection of the nearly 100 life trajectories he gathered will be published by Johns Hopkins University Press in 2008. “Rich’s narratives reveal how vulnerable these young men really are, and shows why they feel compelled to respond to their situations in harmful ways,” says Dr. Hortensia Amaro, Distinguished Professor of Health Sciences at Northeastern University and vice chair of the Board of the Boston Public Health Commission, where Rich served as medical director for seven years.

An Unexpected Blessing
It was Rich’s creative approach to combating violence and spotlighting a neglected, stigmatized group that caught the attention of the MacArthur Foundation. “By linking economic health, mental health, and educational and employment opportunities to physical well-being, Rich’s work on black men’s health is influencing policy discussions and health practice throughout the United States,” Foundation trustees stated in announcing the grant.

On the subject of his award, Rich is humble. “It is hard to feel worthy—but it is a tremendous blessing,” he says. “Without this recognition, I would have had to fight that much harder for my voice to be heard.”

The grant comes at an auspicious time. Rich, now the chair of the Department of Health Management and Policy at Drexel University’s School of Public Health, is facing a new set of challenges in Philadelphia, a city with high levels of youth violence and vast health disparities. His latest project, the Philadelphia Collaborative for Violence Prevention Center, focuses in part on the effects of trauma in communities devastated by violence. The Center will identify models of primary prevention for 10- to 14-year-olds that account for all children in a community, not just those labeled “high risk,” in an effort to curb violence and bolster resiliency.

This six-month-old initiative, supported by the Centers for Disease Control and Prevention, will be the first Urban Partnership Academic Centers of Excellence based in Philadelphia. (There are eight others, including centers in Boston, New York, Chicago, and Berkeley.) Philadelphia’s Children’s Hospital and several universities and grassroots organizations in the city, including Drexel, are participating.

Rich is optimistic about the project’s potential for making an impact in Philadelphia’s neighborhoods. Violence is not an end point, Rich believes. Instead, it is an initial response to the trauma of living in an unsafe environment, being marginalized, and having no sense of a future. And he hopes pro-jects like this one will bring the needs of a long-neglected population into sharper focus.

Jesse Nankin is the development communications coordinator for the Office for Resource Development at HSPH.

Silhouette image, Getty Images, Photograph. John D. and Catherine T. MacArthur Foundation