Interpersonal Violence: A Global Health Priority PDF

## CHAPTER 1 Interpersonal violence: a global health priority **Peter D. Donnelly and Catherine L. Ward** ### Violence in Pre-History The perpetration of violence is the stuff of human history. (Moreno 2011) From our earliest days as a species, humankind has had to fight: for survival, against...

## CHAPTER 1 Interpersonal violence: a global health priority **Peter D. Donnelly and Catherine L. Ward** ### Violence in Pre-History The perpetration of violence is the stuff of human history. (Moreno 2011) From our earliest days as a species, humankind has had to fight: for survival, against predatory animals, against rival bands and clans, and even perhaps against competing sub-species of hominid. Competition for food and resources could be so extreme in some circumstances that the losers literally became the food (Saladié et al. 2012). But more generally, competition for resources whether territory, materials, access to strategic or sacred places or reproductive partners, or the work of enslaved labourers placed an early evolutionary premium on an ability to fight and when required to kill. As we move forward into the recorded period, history books are replete with tales of vicious battles, genocide, and global wars-but also tell of individual acts of barbarism driven by ambition, self-interest, and greed. Our catalogue of literature over the ages frequently depicts vengeful, resolute, and unforgiving leaders whose success is often judged by their ability to subjugate and conquer through violent means. And yet, it is humankind's ability to form cooperative communities rather than the ability to fight that has provided our species with a distinctive and definitive evolutionary advantage. Such social altruism may itself be the product of genetically conserved traits advantageous in primitive environmental conditions (Baschetti 2007). Without it, a move from small hunter-gatherer bands to settled agricultural communities would not have been possible. In its absence the division and specialization of labour central to economic and intellectual progress would have been inconceivable and the first faltering steps in the creation of civic society and rational governance could not have been taken. ### The Development of Law and Justice Systems It is in that development of civic society and structural forms of government that one can detect the earliest attempts at regulating, if not overtly attempting to reduce, violence. As the capricious ‘justice’ of the warlord or absolute monarch is gradually replaced by state-sanctioned systems, the cultural requirement to exact revenge and engage in vendettas is reduced and the temptation to use violence in pursuit of personal gain has to be balanced against the possibility of apprehension, trial, and often severe, sanction. As systems of government and criminal justice progressed so a focus on deterrence and punishment became balanced with a concern for rehabilitation. The extreme nature of the legal sanctions (e.g. crucifixion, hanging, drawing, and quartering or being stoned to death) is gradually replaced by lengthy imprisonment or at least less gruesome (but still objectionable) means of administering judicial execution. A general international acceptance emerges that prisoners do not forfeit all of their human rights upon conviction and international standards have come to require that judicial decisions should be politically independent. However, in many parts of the world these precepts do not apply and injustice and cruel and arbitrary punishment remain common (http:// www.amnesty.org). More philosophically the debate on the purpose of sentencing for crimes of violence remains contested. The correct balance between deterrence, punishment, and the exercise of natural justice (with its implied beneficial effect in reducing private revenge) on the one hand and rehabilitation on the other is a live political issue in many countries around the world. So too is the issue as to whether violent perpetrators are ‘mad’, i.e. mentally ill in some way, or ‘bad’, i.e. morally reprehensible. Even in cases where mental illness is excluded there will be debate about whether we are dealing with bad behaviour or a bad person and whether the origins of either or both are to be found in nature or nurture. The judicial treatment of juveniles is particularly contentious in that regard (New York Times 2012). It is against such a complicated historical, legal, moral, and sociological backdrop that those who set out to reduce violence in the twenty-first century must operate. And even if one accepts Stephen Pinker's assertion that when considered over a 10,000-year period ‘The decline in violence may be the most significant and least appreciated development in the history of our species’ (Pinker 2011, p. 692) and that today ‘we may be living in the most peaceable era in our species existence’ (Pinker 2011, p. xxi), with over half a million homicides a year (Krug et al. 2002) there is clearly still much work to be done. Nor can we assume that societies will automatically continue to progress towards reduced levels of violence; for as we will see later in this book some of the inherent drivers of violence: poverty, inequality, injustice, and discrimination, remain firmly in place, and in some instances are increasing. ### SECTION 1 AN INTRODUCTION TO THE STUDY OF VIOLENCE AS A PUBLIC HEALTH ISSUE #### Why Violence should no Longer be Needed At its simplest the argument for seeking to further reduce violence is that we no longer need violence. Where there are systems in place to ensure that people have at their disposal the means for survival then the immediate recourse to violence to achieve survival is unnecessary. The means for survival however are more than just shelter, warmth, food, and security. It must involve the right to fully participate in society including, but not limited to, the right to vote in a functioning democracy and to have access to impartial, fair, and affordable justice. Many would also argue that meaningful citizenship requires fair access to education, healthcare, and essential social services, and that in most societies that dictates realistic opportunity for paid employment for those who are able and access to appropriate benefits for those who are not. The absence of these factors can logically be considered a form of structural violence against individuals or communities. Corruption and prejudice may focus that structural violence upon certain disadvantaged groups identified by race, age, or gender. Many diseases and health-related conditions, not simply violence, cannot be fully understood without recourse to the concept of structural violence and the historical context within which it operates (Farmer 2004). So how should ‘violence’ be defined? Behavioural definitions tend to concern themselves with the difference between aggression and violence, with aggression being a broader category. Both concepts have three essential features: the intent to cause harm, the belief that the behaviour will cause harm, and the belief that the victim would wish to avoid the aggressive behaviour. Violence is at the more serious end of this-while all violent behaviour is aggressive, the reverse is not true: an adult beating up another is violence, while a toddler’s hitting her mother is aggressive but not violent (Anderson and Bushman 2002). Aggressive young people can of course grow up to become perpetrators of violence, as Tremblay argues in Chapter 5 of this volume, and this is an important argument developmentally-but it remains that not all aggressive acts are violent. The World Health Organization (WHO) approaches this from a public health perspective, and provides the definition that is central to how we have framed this book: ‘The intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation’ (Dahlberg and Krug 2002, p. 5). These definitions all rule out accidentally causing harm: the central concept is the intention to cause harm (Anderson and Bushman 2002; Dahlberg and Krug 2002). The WHO definition of course leaves the door open for three types of violence: self-directed, interpersonal, and collective violence (Dahlberg and Krug 2002). Here, we focus only on interpersonal violence: while there is some overlap in the risk and protective factors that influence self-directed and interpersonal violence (Krug et al. 2002), it is worth a book on its own; and while we acknowledge that collective violence is an important problem, we only address it in the form of gang violence, where it too shares risk and protective factors with interpersonal violence (see Gebo, Chapter 29, this volume). It is no coincidence that if one wishes to find the highest rates of homicide in the world one only has to look at areas where such structural violence is in place; for murder is in practice largely a disease of poverty and inequality. So to find the world’s epicentres of untimely and unnecessary death it is only necessary to seek poverty, inequality, social exclusion, and injustice. In truth the early deaths from homicide of over 500,000, mostly impoverished young men, each year constitutes the world’s most inexcusable health inequality. But what is the role for health in reducing violence in such circumstances? Traditionally health has held a somewhat marginal role. It has concerned itself with the process of picking up the pieces; that is, caring for the wounded. The specialist field of forensic psychiatry would be brought in to adjudicate sanity, particularly in relation to an accused’s ability to plead or in an attempt to assess culpability. However, increasingly clinicians began to ask questions about whether medical conditions caused by violence could be prevented in the same way as the prevalence of medical conditions caused by other factors could be reduced. ‘Medical’ metaphors for understanding violence prevention are implicit in many violence prevention activities (Dodge 2008): if the spread of measles can be prevented by quarantining the ill, can we prevent violence by quarantining deviant youth from prosocial young people? If preventive surgery can straighten a leg and so prevent a child from limping, can corrective interventions ‘straighten young people out’, so that they are no longer aggressive? If a polio vaccine can prevent children from contracting the disease at all, are there early interventions that prevent children from becoming aggressive? Or is aggression a chronic disease (like asthma), and interventions should be targeted towards ameliorating symptoms and helping children and parents cope? #### A Public Health Approach to Violence They were aided and abetted in this endeavour by specialists in public health. Public health as a specialty is variously defined and sub-classified (Griffiths et al. 2005) but in general can be seen as the art and science of delaying death and preventing ill health through the organized efforts of society. It has its origins in the control of outbreaks of communicable disease but now works across all diseases and underlying causes of ill health as well as playing a significant role in planning, organizing, and evaluating health service provision and outcome. Although grounded in the science of epidemiology and originally medically dominated, public health has greatly benefitted in recent decades from an approach that embraces a variety of disciplines and methodological approaches. And so taking a modern public health approach to a problem as complicated as violence reduction may for example involve blending qualitative and quantitative methods and calling on the skills of an anthropologist to work alongside an epidemiologist. This inter- (or even trans-) disciplinary approach is gaining popularity in many disciplines, but particularly those that address complex problems (Kessel and Rosenfield 2008) such as violence, where (for instance) brain structure and genetics (with the roots of scientific understanding in the ‘hard science’ end of biological sciences), early child rearing (typically studied by behavioural scientists), and social norms (the domain of social scientists) all come together to influence the likelihood of aggression. #### Programmes Focused on Violence Reduction The inspirational work of Homeboy industries in Los Angeles (http://www.homeboyindustries.org) is at least in part captured by one of their slogans: ‘Nothing stops a bullet like a job’. In Glasgow, UK, (http://www.actiononviolence.com) they may worry more about knives and machetes, but the sentiment rings true. Young people want meaningful work. Having a job is shorthand for so many things. It is a reason to get up in the morning, a reason not to be stoned or drunk the night before, a source of self-respect, a way to have money and thus autonomy, and a stake in society. The only mystery is why this surprises us, for this is what we all sought as graduates or school leavers. The truth is that young men and women involved in gangs are much more like those of us who write and read books like this than most would imagine. They want many of the same things we do but whilst we organize society in a way that fails to protect them in their earliest years and allows them to be damaged as young children and then compounds matters by excluding them from their legitimate needs, then it is perhaps not surprising that they sometimes feel they need to resort to violence. To seek to understand is certainly not to condone, but it is a necessary first step in developing a Public Health-driven approach to prevention. A number of chapter authors in this book refer to the ecological model, a model which originated in developmental psychology (Bronfenbrenner 1979; Figure 1.1). Its power lies in placing the violent behaviour exhibited by an individual within a series of widening contexts, thus allowing us to understand that multiple influences may operate on an individual at once: * The Macrosystem * Government social programmes and policies, socioeconomic factors, attitudes and ideologies of culture * The Exosystem * Neighbourhoods, extended family, health, social and legal services, media * The Microsystem * Family, peers, school * Individual child * Gender, age, temperament **Fig. 1.1 The ecological model.** Reproduced with permission from Ward, C. L., and Bakhuis, K., Intervening in Children's Involvement in Gangs: Views of Cape Town's Young People, Children and Society, Volume 24, Issue 1, 2010, pp. 50-62, Copyright © 2009 The Author(s). Journal compilation © 2009 National Children's Bureau. Based on conceptual model by Bronfenbrenner, U., The ecology of human development: Experiments by nature and design, Harvard University Press, Cambridge, MA, USA, Copyright © 1979. * But what exactly is a public health approach to the prevention of violence? And how does that differ from a health perspective? Public health is collectivist by nature and draws on the organized efforts of society. Unlike a standard health approach with its focus on therapy and cure, public health has a leaning towards prevention and the minimization of harm. Great store is placed on avoiding the blaming of victims. Individual autonomy is respected but those who choose to expose themselves to risk are not condemned as stupid or feckless. Rather the working assumption is always that the situation in which they find themselves makes healthy choices hard to make. In terms of violence there are striking overlaps between risk factors for perpetration and victimization. Poor childhoods scarred by physical, emotional, and sometimes sexual abuse are often compounded by parental substance abuse, desertion, or incarceration. Poor educational provision and low educational attainment limits further education and employment opportunities. Communities where violence is tolerated drive young men and sometimes women into gangs in search of protection and a sense of belonging. The interpersonal resources to avoid peer pressure are often lacking and the perpetration of violence can become a way of earning respect. It is all to easy to see the downward spiral of exposure to poor parenting and domestic abuse, early oppositional disobedience, school truancy, early drug and alcohol use, and escalating involvement in violence when one looks at individual case studies. And yet as societies somehow we miss, or perhaps choose to ignore, the structural violence imposed on the communities from which these young people come. * First the individual concerned who like all of us is a complicated mixture of nature and nurture, who may have been exposed to alcohol and drugs even before birth, whose earliest experiences may be damaging, and whose epigenetic inheritance is still poorly understood. * Secondly the ‘everyday’ contexts that are most influential-family, school, peer groups-the contexts in which we have our daily interactions. For instance, many young men grow up without satisfactory male role models. The feminization of the caring workforce in troubled areas (probably partly because of poor pay) compounds the absence of males in lives typified by absent fathers. * Thirdly, we need to consider the community in which the individual lives, often typified by poverty, social exclusion, and low educational attainment. * Finally, the society in which that community exists, which all too often exhibits disastrous flaws such as corruption, administrative incompetence, and institutional racism thus compounding the structural violence imposed on individuals. In interacting with each other, influences from these various contexts may increase the effects of others (for instance, child-rearing environments-father’s criminality-may interact with genes to multiply the likelihood of the child’s obtaining a criminal record; a stable family living situation can reduce the effects of family socioeconomic status on the likelihood of a poor outcome for children; Bronfenbrenner 1986). But a public health approach does not need to fully understand the complex bio/psycho/social basis of the problem; no more than did John Snow-in many ways the Father of public health-need to understand the details of the causation of cholera to stem the 1854 London epidemic by removing the pump handle from the contaminated source so that it could no longer be accessed. It was enough for him to know that it was something to do with that particular source of water. If we are inspired by his example we can make progress now even whilst we fill in the details of what precise insult causes which deficit-a tactic typical of a public health approach that does not regard pragmatic as a dirty word. But what then in practical terms does a public health approach involve? * Firstly, there is a need for a formal assessment of the problem. This usually involves defining and counting cases, whether those be deaths or incidents of assault. But it may equally well involve listening carefully to typical young people living their lives in these troubled communities, or observing and carefully mapping spirals of violent action and reaction in the endless and pointless dance of retaliation driven by (usually) young men’s perceived need to maintain status in the eyes of others. This is not just about counting instances, but also about understanding those factors that cause the problem (or cause good outcomes). Traditionally, the terms ‘risk’ and ‘protective’ factors have been used to indicate those that increase (risk factors) or decrease (protective factors) the likelihood of a poor outcome (risk factors). Often risk and protective factors are the opposite poles of a continuum-for instance, aggressive peers increase the likelihood of violence while prosocial peers decrease its likelihood. More recently, however, there has been a move to differentiate between factors that decrease the likelihood of a poor outcome in a context of risk (protective factors) and those that increase the likelihood of a good outcome in any context (promotive factors), although considerable definitional confusion remains (Stouthamer-Loeber et al. 2004). * Next one needs to learn what works. Fundamentally prevention science assumes that this means targeting risk factors (to decrease them) and protective/promotive factors (to increase them; Mrazek and Haggerty 1994). Studies need to be well designed and conducted. There are well-understood scientific principles that govern this. But studies also need to be grounded in reality and thus ultimately scalable if we are to make a real difference to sizable vulnerable populations. Whilst, as this book will show, the volume of work published about what interventions are effective is steadily increasing, in contrast the science and art of understanding and facilitating governments' adoption of evidence-informed policy really is in its infancy. In this area in particular we have much still to learn. #### The Challenge of Evaluation A public health approach to violence is thus focused on pragmatically making a difference. It has no slavish adherence to a fixed philosophical model and it does not require us to fully understand the basis of the programmes success. It is, at least initially, enough simply that something works and that we can get it in place on a scale commensurate with the size of the problem and at a cost realistically affordable by the responsible administration. Yet such an approach can bring a clash with standard reductionist scientific method, as the perfect experiment is rarely possible in this field. And even if it were, one would have to question what would it really tell us if its methodology was not useable at scale. None of this is an excuse for bad science. Rather it is a reason to do studies carefully, appropriately and with an eye from the start on implementing those programmes and bits of programmes that work-and then working to understand how and why they do work, and so improving them. However violence reduction also faces a well-recognized funding challenge. It has yet to discover (and probably never will discover) a ‘magic’ intervention such as the seat belt, the airbag, or the helmet that together have put road safety on the funding map. With violence reduction more imagination and a longer time perspective is needed. The urgency for prevention in this area is no doubt in part driven by a realization of the costs involved. Some of these are obvious and direct, for example in the expensive care of the seriously wounded. But some are large and insidious. For example, the costs of caring for those with psychiatric problems as a result of assault or for those who turn to alcohol, drugs, and tobacco as self-medication in the face of domestic abuse and childhood maltreatment. There are the unseen opportunity costs such as the cancer care work or cleft palate repairs that the maxillofacial surgeons could be doing if they were not treating wounds resulting from nightclub brawls. Finally there are the societal costs: in terms of policing, justice, and jails; in terms of labour and taxes lost; and, all too often in the developing world, in terms of economic development forgone. None of which really touches upon the most important cost of all that is the incalculable suffering imposed on those who are left behind. The family and friends of homicide victims have traditionally received little in the way of attention or support. They are encouraged to take solace from the workings of judicial systems that typically impose lifetime imprisonment or worse on perpetrators. Ironically, at which point the families of the perpetrator and those of the victim will be sharing a sense of bereavement and loss. The fact that solving a murder and imprisoning the perpetrator did not prevent the next murder was a major consideration in inspiring John Carnochan, an experienced homicide detective, to found the Scottish Violence Reduction Unit along with Karyn McCluskey in 2005. The work of this police-led unit in seeking to prevent violence through the deployment of a public health approach has inspired many in Scotland and further afield to believe that violence can be prevented. John and Karyn were themselves encouraged by the work of a small but dedicated team at WHO HQ in Geneva and by the efforts of pioneers in this field across the world. We have been very fortunate that many, perhaps most, of those pioneers have agreed to contribute to this book. #### The Rationale for this Book Which brings us to the issue of why bring this book together now and why in this format. It seems to us we are at an important and exciting time in the development of violence prevention science, policy, and practice. We have an increased recognition of the scale of the issue and a growing body of evidence about what works. We also benefit from the beginnings of an understanding of how to help administrations mobilize that evidence base and this therefore seemed the right time to pull together this collection. The book is deliberately not a textbook of how to do violence reduction work but rather a vehicle for presenting cutting-edge global violence reduction research; an exploration of progress and challenges and a sharing of thoughts. We wish to provide a stimulus, for researchers, policy-makers, and practitioners, to work collectively to make violence a less obvious part of our shared world. Eliminating violence from global society is not possible in the way small pox was eliminated. We simply don’t yet understand the underlying mechanisms well enough to come anywhere close to elimination. But, we have good reasons to believe that very substantial reductions in homicide and deliberate injury rates are entirely possible. The book seeks to take a logical approach in its layout. After this single chapter opening section of context setting and explanation, in which we have also explained what in practice we mean by the adoption of a public health approach to violence, there follows a series of sections of related chapters. * Section 2 (Chapters 2-11) covers the descriptive epidemiology of the problem and reminds us of the scale of the burden of morbidity and mortality that we impose on humankind by wrongly accepting the inevitability of violence. * Section 3 (Chapters 12-16) takes the argument for prioritizing this area further by laying out the consequences of violence. * Section 4 (Chapters 17-34) explores what we know about what works by looking at the published literature on evidence informed programmes to reduce violence. * Section 5 (Chapters 35-44) tackles the challenging issue of creating contexts that inhibit or prevent violence, through taking a careful look at national and international policies to reduce violence. * Section 6 (Chapters 45 and 46) seeks to summarize and review the main challenges and priorities facing researchers, practitioners, and policy-makers. In coming together as a team to edit this volume we deliberately sought to blend a northern and southern hemisphere perspective. We have tried to reach out through contacts and in some cases cold calling eminent individuals in our field. We strived for geographic spread and were frequently frustrated by the dominance of a few northern western nations as the location of research studies. But things are changing and the work of the WHO-coordinated Violence Prevention Alliance is potentially important in facilitating research collaborations and policy development on a mutual aid basis. We are optimistic that future editions of this volume will enjoy an even more diverse authorship than that which we have been privileged to work with on this occasion. They stand ready with us to help and learn from colleagues in parts of the world where violence reduction work is still in its infancy. Together we can use scientific enquiry and shared experience to reduce global levels of violence. We hope this book helps with that important collective endeavour. #### Acknowledgement The writing of this chapter was supported in part by a grant from the University of Cape Town’s Research Committee (URC) to the second author.