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COMMENTARY |
James A. Mercy and Linda L. Dahlberg are with the National Center for Injury Prevention and Control, CDC, Atlanta, Ga. Etienne Krug is with the WHO, Geneva, Switzerland. Anthony Zwi is with the School of Public Health and Community Medicine, The University of New South Wales, Sydney, Australia.
Correspondence: Requests for reprints should be sent to James A. Mercy, PhD, Division of Violence Prevention, National Center for Injury Prevention and Control, CDC, Mail Stop K-60, 4770 Buford Hwy NE, Atlanta, GA 30341-3724 (e-mail: jmercy{at}cdc.gov).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONVIOLENCE IN A GLOBAL...LEARNING FROM THE REST...CONTRIBUTING TO PREVENTION...CONCLUSIONReferences |
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Violence is a public health problem that can be understood and changed. Research over the past 2 decades has demonstrated that violence can be prevented and that, in some cases, prevention programs are more cost-effective than other policy options such as incarceration.
The United States has much to contribute to—and stands to gain much from—global efforts to prevent violence. A new World Health Organization initiative presents an opportunity for the United States to work with other nations to find cost-effective ways of preventing violence and reducing its enormous costs.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONVIOLENCE IN A GLOBAL...LEARNING FROM THE REST...CONTRIBUTING TO PREVENTION...CONCLUSIONReferences |
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The release of this report marks the beginning of a worldwide WHO campaign that will include global and national events with decisionmakers, the media, and the general public. The campaign will focus on discussing how the report’s recommendations might be implemented. As we embark on this global campaign, it is useful for the US public health community to consider its role in global efforts to prevent violence.
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VIOLENCE IN A GLOBAL CONTEXT |
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TOPABSTRACTINTRODUCTIONVIOLENCE IN A GLOBAL...LEARNING FROM THE REST...CONTRIBUTING TO PREVENTION...CONCLUSIONReferences |
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).
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The United States has very high rates of homicide- and firearmrelated death, compared with other high-income countries throughout the world.2–4 The US violent death rate in 2000 was about twice as high as the estimated rate for other high-income countries in 2000.1 However, when one considers the entire world, many nations and regions face far higher rates of violent death than the United States.5
The US age-adjusted homicide rate of 6.2 per 100 000 in 2000 was lower than the global estimated rate of 8.8 per 100 000.1,6 Moreover, estimated homicide rates for the WHO regions of Africa and the Americas were about 3 times those for the United States. Similarly, the US age-adjusted suicide rate of 10.6 per 100 000 in 2000 was lower than the global estimated suicide rate of 14.5 per 100 000.1,6 Estimated suicide rates for 2000 in the WHO regions of Europe and the Western Pacific were about twice those of the United States. In 2000, the United States suffered very few war-related deaths, in contrast to the African region, where more than half of the world’s estimated 310 000 war-related deaths occurred that year and where war-related deaths outnumber homicides and suicides.
Although the United States fares better than most of the world in the absolute rate of violent death, homicide and suicide are relatively more important as causes of death in the United States than in many other parts of the world. Throughout the world, suicide is estimated to have been the 13th leading cause of death in 2000 and homicide the 22nd leading cause.1 In contrast, in the United States suicide was the 11th leading cause of death and homicide the 14th in 2000.6
Fatal injuries represent only a small fraction of the health burden of violence. Nonfatal violence between intimate partners, for example, compromises the health of millions of women throughout the world. Population-based studies conducted in 48 countries have revealed that 10% to 69% of women report having been physically assaulted by an intimate partner during their lifetimes.7 In the United States, this figure is 22.1%.8 In cities that have conducted population-based studies, the proportion of women reporting an attempted or completed sexual assault by an intimate partner sometime during their lifetime ranges from 6.2% in Yokohama, Japan, to 46.7% in Cuzco, Peru.9 The lifetime prevalence in the United States is 7.7%.8 The percentage of female adolescents reporting that their first sexual intercourse was forced ranges from 7% in New Zealand to 47.6% in a 9-country study in the Caribbean.9 In the United States, this prevalence is reported to be 9.1%.9
Maltreatment has a severe impact on the health of children and the elderly. Limited research has shown that in some countries nearly half of children report they have been hit, kicked, or beaten by their parents,10 and about 20% of women and 5% to 10% of men report having suffered sexual abuse as children.11,12 Furthermore, 4% to 6% of the elderly have experienced some form of abuse in their homes in the previous year.13–17 These estimates are based largely on studies conducted in the United States and other developed countries.
Youth violence, suicidal behavior, and war also have significant consequences for the morbidity of many populations around the world. The proportion of 13-year-olds that report engaging in bullying once a week ranges from 1.2% in England and Sweden to 9.7% in Latvia.18 The comparable US proportion is 7.6%.18 The ratio of fatal to nonfatal suicidal behavior in the United States is estimated to be approximately 1:2–3 among persons over age 65; among people under age 25, the ratio may reach 1:100–200.19,20 These findings are comparable to parts of the developed world, but data for less developed countries are not readily available. And, although the exact figures may never be determined, huge numbers of people—very often women and children—suffer injuries and permanent disability as a result of wars and other forms of collective violence in many parts of the world.21
The health and social consequences of violence are much broader, however, than death and injury. They include very serious consequences for the physical and mental health and development of victims. Studies indicate that exposure to maltreatment and other forms of violence during childhood is associated with risk factors and risk-taking behaviors later in life (depression, smoking, obesity, high-risk sexual behaviors, unintended pregnancy, alcohol and drug use) as well as some of the leading causes of death, disease, and disability (heart disease, cancer, suicide, sexually transmitted diseases).22–30
In many nations and communities, violence and war also increase the costs of services related to health and security, thereby reducing productivity and property values, disrupting human services, and undermining governance. Between 1996 and 1997, the Inter-American Development Bank sponsored studies on the economic impact of collective and interpersonal violence in 6 Latin American countries. Expenditures just for health services related to such violence amounted to about 1.9% of the gross domestic product in Brazil, 5% in Colombia, 4.3% in El Salvador, 1.3% in Mexico, 1.5% in Peru, and 0.3% in Venezuela.31 The threat of interpersonal violence and war destabilizes the economies of nations and regions by threatening the establishment and viability of businesses and, hence, the prospects for economic growth.
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LEARNING FROM THE REST OF THE WORLD |
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Even where violence itself does not cross borders, some factors that influence it do. For example, illicit drug markets may be accompanied by violence in countries involved in the production, distribution, and sale of illegal drugs.32 Industries such as small arms trade and sexual slavery also have implications that transcend national borders.33–35 Other issues that may be more difficult to assess but are cause for concern include increased penetration of global media markets by violent programming and, in some cases, the apparent glorification of violence in sports and computer games.18
One important insight gained from looking at violence as a global problem is the importance of cultural context. Cultural tradition is sometimes used to justify social practices that perpetrate violence.1 Such practices include violence against women, female genital mutilation, and the use of severe physical means to punish children, including at school.
Cultural norms must be dealt with sensitively and respectfully in all research and prevention efforts—sensitively, because of people’s often passionate attachment to their traditions, and respectfully, because culture is often a source of protection against violence (for example, long-held traditions may promote equality of women or respect for the elderly). Prevention programs as well as mechanisms for promoting them must be tailored to their target populations. The United States will need to increase its understanding of its own cultural diversity in order to improve efforts at preventing violence domestically.
Cross-national studies show that the quality of a government—as reflected in the efficiency and reliability of its criminal justice institutions and the existence of programs that provide economic safety nets—is associated with lower rates of homicide.36–38 In Salvador, Bahia, Brazil, for example, one study concluded that dissatisfaction with the police, the justice system, and prisons increased the use of unofficial modes of justice.39 In the United States, these institutions are often taken for granted, but in examining the problem of violence globally, one becomes increasingly aware that these institutions are the first line of defense against higher rates of interpersonal and collective violence. From the perspective of violence prevention, maintaining a fair and efficient criminal justice system and basic supports for individuals and families in dire economic circumstances should remain an important priority in the United States.
In examining preventive responses to violence around the world, one is struck by the nature and resourcefulness of many of the strategies adopted in lowincome communities. For example, in some communities in India, the practice of dharna—public shaming and protest done in front of the house or workplace of abusive men—has been used as a strategy to prevent the recurrence of intimate partner violence.40 And in the Kapchorwa district of Uganda, the Reproductive, Education, and Community Health Program enlists the support of elders in incorporating alternative practices to female genital mutilation that uphold the original cultural traditions.41 Although the effectiveness of these approaches has yet to be definitively demonstrated, they are inexpensive and build on the unique nature of the communities in which they were implemented—something that is needed in low-income US communities as well, where violence is more common and prevention resources scarce.
One risk factor that appears to be universally associated with interpersonal and collective violence is income inequality.36,42 Poverty itself does not appear to be consistently associated with violence, but the juxtaposition of extreme poverty with extreme wealth appears to be a key ingredient in the recipe for violence. Given that income inequality has been growing in recent decades in many wealthy countries, it may be wise to closely examine its potential contribution to higher rates of violence in the United States and be more proactive in finding strategies to reduce its influence on violence.
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CONTRIBUTING TO PREVENTION WORLDWIDE |
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TOPABSTRACTINTRODUCTIONVIOLENCE IN A GLOBAL...LEARNING FROM THE REST...CONTRIBUTING TO PREVENTION...CONCLUSIONReferences |
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The lessons learned from US progress in building violence prevention programs at the federal and state levels can help other countries establish their own programs. Violence prevention work within the Department of Health and Human Services has greatly expanded over the past 20 years. Twenty years ago, for example, fewer than 5 people worked at the Centers for Disease Control and Prevention (CDC) on violence as a public health problem. Now the CDC has more than 70 people working full-time on violence prevention in its Division of Violence Prevention within the National Center for Injury Prevention and Control, making this the largest organized collection of experts in the world fully devoted to preventing injuries and deaths associated with violence. The division budget has grown from less than $500 000 to more than $90 million during this time.
The field of violence prevention has grown in the United States along with the CDC’s program. Two decades ago, few, if any, state or local health departments had activities addressing violence. US public health schools did not teach their students about violence prevention, and scientific articles about violence did not appear in leading medical and public health journals. Today, most US state and large city health departments have some activities focused on violence prevention. Almost every school of public health in the United States has added courses on the epidemiology of violence and its prevention or has at least integrated this issue into its existing coursework. And scientific articles on violence are regularly seen in leading journals.
The concepts, principles, and methods underlying the growth of the field of violence prevention in the United States may also be useful in establishing violence prevention programs in other countries. US public health institutions and foundations can also help stimulate and support the development of international organizations that will in turn advance evidence-based violence prevention policies and programs in other parts of the world and help nations learn from one another.
Finally, the United States should consider its role, direct or indirect, in influencing conditions that contribute to violent political conflict in many parts of the world. The United States should similarly consider how it influences globalization patterns that are associated with violence.
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CONCLUSION |
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TOPABSTRACTINTRODUCTIONVIOLENCE IN A GLOBAL...LEARNING FROM THE REST...CONTRIBUTING TO PREVENTION...CONCLUSIONReferences |
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Violence is a problem that can be understood and changed, not an inevitable consequence of the human condition. The United States has much to gain from and to contribute to global efforts to prevent violence. Policymakers and the public health community in the United States should embrace this opportunity to contribute to improving the health and quality of life of people throughout the world through violence prevention.
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Footnotes |
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Accepted for publication September 7, 2002.
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References |
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