As bullets pierced the car window, inches from her head, the 23-year-old woman instinctively crouched down, knowing her life was on the line. But she couldn’t escape the gunfire that struck her friend’s car that morning in 2021.
Shot in the shoulder, she was rushed to Sunnybrook hospital, where some of the city’s most seriously injured patients receive life-saving care. She survived, and was swiftly treated and released.
Until recently, that would have marked the end of her care. Instead, hours after arriving home, she got a call from a man who’d soon become a crucial support, someone who’d help her navigate the dizzying aftermath of being shot.
For the next six months, Sunnybrook social services worker Michael Lewis was available at the drop of a call or text message. He linked her to mental health support. He sent her job postings when she was out of work. He bought her lunch to mark her final hospital appointment. (The Star is not naming the woman, or providing identifying details about the shooting, due to ongoing concerns for her safety).
“After you see something so traumatic, you’re kind of like, in your own little bubble and you’re afraid to reach out to other people,” the woman said in an interview. “The experience I endured was something I never thought I could go through, so it was really nice to have such a strong support.”
The young woman is one of the 77 patients who have participated in Sunnybrook’s Breaking the Cycle of Violence with Empathy (BRAVE). The program is the first of its kind at a Canadian trauma centre; an attempt to change how hospitals treat young people who’ve been shot or stabbed.
And there are a lot of them. Amid Toronto’s rising gun violence, the number of people injured or killed in shootings has more than doubled in less than a decade, from 103 in 2014 to 217 in 2020. At Sunnybrook, that’s translated into a dramatic spike in patients: last year, the hospital treated 129 gunshot victims, roughly one every three days. In 2014, there were 63.
Instead of just tending to the physical wounds then dispatching the patient, BRAVE tries to treat the underlying causes of the violence. It’s the same philosophy that sees a heart attack patient discharged from hospital with preventative medication.
The belief is that violent incidents open a brief window of opportunity to intervene in the patient’s life. For many, medical care is a chance to change the circumstances that contributed to their victimization — and could risk them getting hurt again. Those things could include unemployment, lack of access to housing or education, mental health issues, drug and alcohol challenges, or negative, perhaps dangerous peers.
“We get people out of hospital. But then a year later, they’re back, shot again. And you know, they either come back dead, or they come back paralyzed,” said Dr. Avery Nathens, the medical director for trauma and surgeon-in-chief at Sunnybrook.
Simply “patching people up and sending them home” wasn’t working, he said.
Nathens realized he was seeing many of the same gunshot victims returning to the trauma bay because their environment hadn’t changed, an observation that aligns with research that has found young victims of shootings or stabbings are almost twice as likely to suffer another violent injury than those who were never injured.
One of the most emotional parts of the job is telling a mom that her son is going to be paralyzed or has died in the operating room, Nathens said. “But imagine doing it a second time to a family. We’ve done that. And it’s terrible.”
Many patients are racialized young men. In the first year of the BRAVE program, the hospital found more than 85 per cent of participants were racialized, with more than 50 per cent identifying as Black.
Speaking to city council’s executive committee in January, where he urged councillors to help secure funding for BRAVE, Nathens stressed that while COVID-19 has been top of mind for many, community violence has continued on a “path of destruction” — and the “epidemic of violence disproportionately affects young, racialized males.”
There have been early signs of success since BRAVE’s launch in September 2020, funded through a $100,000 grant from the city. A recent evaluation of the program by a York University-based research hub found participants who had been inspired to make big life changes, such as pursuing education and cutting off “stupid friends” who were a bad influence.
In their comments to the researchers, the participants said BRAVE made them feel they mattered. One parent said her son forgave the person responsible for his injury rather than retaliating.
“I didn’t know I’d be more motivated to go back to work,” one participant said. “It’s the encouragement, it’s someone pushing me, someone always checking up on me, someone always saying, ‘You good?’ ”
Earlier this year, Toronto city council voted to continue funding BRAVE and expand a similar violence-intervention program to St. Michael’s Hospital, the city’s other level-one trauma centre, where the most seriously injured patients are brought. City staff will also explore the potential of launching the programs at hospitals in Scarborough and Etobicoke.
But the money is a one-time cash injection, and long-term funding is unclear. City council said it will ask the province to provide ongoing funding to support a network of hospital-based intervention programs in Toronto. But earlier this year, Ontario’s Ministry of Health told the city it did “not have an existing funding envelope” for BRAVE.
The funding issues, Nathens believes, stem from confusion over who should support a hospital program that connects youth with city services, within a broader system where health is a provincial responsibility.
“We’re thrilled that we got the level of support,” he said, “but I will say, no one really owns this.”
BRAVE is modelled after programs in the United States that started as early as the 1990s — “we’re late to the game for this,” Nathens said — and although detailed studies are limited, evaluations have found both reductions in violence and cost-savings to the health and justice system.
In general, hospital-based intervention gives “a good return,” said Ottawa-based criminologist Irvin Waller, author of “Science and Secrets of Ending Violent Crime” and a longtime proponent of hospital-based intervention.
“It’s clearly cost-effective in terms of saving lives, in terms of saving police times, in terms of hospital resources. It’s all around a win-win situation,” he said.
The program is also simple to run — just one additional employee working with a team of existing staff and resources. At Sunnybrook, that employee is Lewis, the case manager whose primary task is being available to provide the patient with support for between six months to a year after injury.
It’s more than a 9-to-5 job.
“That call, or that need, could come at any time. The number one thing in this role is being available to the client,” Lewis said.
Lewis’s first task is to reach out to patients quickly after their injury. If a patient is shot or stabbed and under age 30, Lewis tries to make a connection.
“There’s no one way to do it; you have a conversation,” he told the Star.
In the end, patients choose whether to participate. Lewis said it’s not a question of convincing anyone, but informing them about his role and asking what they need to recover. The majority want the help.
If the patient signs on, Lewis will work with them to identify the risk factors that may have contributed to their violent injuries. Some of the most common factors are unemployment, drug and alcohol use, negative peers, mental health challenges and housing issues. Together, Lewis and the client then work to build a path forward.
“It could be employment, employment training, it could be going back to school, it could be finding new housing,” said Brandy Tanenbaum, an injury-prevention co-ordinator at Sunnybrook.
To get to those goals, Lewis helps connect patients to a range of services, including referrals to youth violence and justice programs. He also links patients or their families to mental health supports, such as counselling for anger management, substance abuse or post-traumatic stress disorder.
One of the most important supports the BRAVE program offers may be simply providing someone to listen and give guidance.
An evaluation by the York University-based Youth Research and Evaluation eXchange (YouthRex) — based on interviews with clients, family members and hospital staff — found that patients “perhaps primarily” benefited from the psychological support.
“Simply having someone present, who was invested in their well-being, and interested in their thoughts and feelings bolstered their self-esteem and provided hope and motivation for the future,” reads the report, led by Uzo Anucha, an associate professor of York University’s School of Social Work.
One participant told researchers: “When you feel like oh, I have no one to talk to and I’m f—ing getting pissed. I would just message the guy about what my problem is, and he would try and help me figure it out.”
For the woman shot in her car in 2021, Lewis was a source of encouragement. Not only was she recovering from the shooting, she was also grieving a friend — another person inside the car with her that day had been shot, too, and died. There were days when she thought what happened was the “end-all, be-all,” but Lewis motivated her to keep going.
“If I was like, ‘Oh, I’m applying for a new job.’ He would follow up and ask me, ‘How’s that going?’ You know, and just other aspects of my life to make sure that like I’m progressing forward,” she said.
The companionship Lewis offered was particularly critical amid COVID-19, when other city and provincial services supporting youth closed in-person programs and hospitals restricted visitors. Despite the pandemic, Lewis conducted nearly 300 in-person home visits, with safety protocols in place, the hospital said.
“Honestly, I’m doing well now, you know,” one participant told YouthREX. “I’m doing this training; I’m staying out of trouble. I moved out of the place I was living before, cut off ties with stupid friends that were causing and jeopardizing my freedom and well-being.”
For Nathens, each time a patient returned to hospital with another shooting injury, it represented a missed opportunity.
But BRAVE has changed those emotional conversations with families outside the trauma bay.
“It’s nice to be able to say now: ‘We managed to, you know, to save your son. He’s going to be OK. And we’re going to try to set him up with somebody so that there was a better path open to him,’ ” he said.
Wendy Gillis is a Toronto-based reporter covering crime and policing for the Star. Reach her by email at firstname.lastname@example.org or follow her on Twitter: @wendygillis