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1 Roundtable discussion WORLD REPORT ON VIOLENCE AND HEALTH In 2002 the World Health Organisation launched the World Report on Violence and Health. The comprehensive report details the global burden of violence and presents options for prevention policy and practice. The Report makes a case for public health to play a crucial role in addressing its causes and consequences. We bring together a group of safety promotion and injury prevention experts who offer diverse opinions and perspectives on the value of The World Report on Violence and Health. Each of them examine implications for the prevention of violence, particularly in South Africa. The roundtable discussion proceeds with a WHO Communique on Violence and Health, and a response to the discussants which was prepared by the Department of Injuries and Violence Prevention, World Health Organisation Discussants: Mohamed Seedat Craig Higson-Smith Shahnaaz Suffla and Martin SchoÈnteich 26

2 WHO COMMUNIQUEÂ ON VIOLENCE AND HEALTH Department of Injuries and Violence Prevention, World Health Organisation (WHO) 1 Every day around the world over 4,000 people die from homicide, suicide, and war-related violence. After AIDS, violence is the second leading cause of death for people aged years worldwide, accounting for 14% of deaths among males and 7% of deaths among females. For every death, there are a great many more individuals that suffer severe physical injuries, often resulting in chronic physical disability. Beyond the millions of deaths and physical injuries that it causes each year, violence has profound health and psychological implications for victims, perpetrators of violence and witnesses to violence. These include mental illness, behavioural disorders, and reproductive and sexual health problems, some of which are themselves the cause of more violence. The costs of the consequences of violence are enormous. Alongside the annual financial costs to health care systems, estimated to be in the thousands of millions of United States dollars, violence has even larger indirect and human costs that result in untold damage to the economic and social fabric of communities around the world. During the last few decades the attention devoted to violence prevention by public health experts has increased significantly. During this time, several countries have developed activities, mainly in the area of data collection and services for victims, although also including a number of successful or promising prevention programmes. These efforts were globally acknowledged in 1996 through the adoption of Resolution WHA by the World Health Assembly, the annual meeting of health ministers from WHO member states. This resolution declared violence a major global public health problem and called for increased prevention. Between 2000 and 2002 the WHO has worked with more than 170 experts from about 60 countries ÐÐÐÐÐÐÐÐÐÐÐ 1 The World Report on Violence and Health can be ordered from WHO Marketing & Dissemination, 1211 Geneva, 27, Switzerland; Tel ; Fax ; Publication information: 2002 publication, approximately 350 pp. [English, French, Spanish, Arabic, Russian and Chinese] ISBN Swiss francs 30.-/ US $ In developing countries: Swiss francs 15.-; Order number Please direct all correspondence to S. van Tuyll; or visit 27

3 on the development of the first World Report on Violence and Health (Krug, Dahlberg, Mercy, Zwi, & Lozano, 2002). As stated by Nelson Mandela in the foreword of the Report: this report makes a major contribution to our understanding of violence and its impact on societies. It illuminates the different faces of violence, from the `invisible' suffering of society's most vulnerable individuals to the all-toovisible tragedy of societies in conflict. It advances our analysis of the factors that lead to violence, and the possible responses of different sectors of society. And in doing so, it reminds us that safety and security don't just happen: they are the result of collective consensus and public investment. GOALS OF THE REPORT There is a common perception that violence is an inevitable part of the human condition, that action to prevent it is the responsibility of the criminal justice system, and that the principle role of the health sector is the care and rehabilitation of victims. The World Report on Violence and Health challenges this perception and calls for a much wider and more comprehensive role for public health in the response to violence. In moving from problem to solution, the public health approach to violence has four interrelated steps. The first step is to define the problem through the systematic collection of information about the magnitude, scope, characteristics and consequences of violence. The second step is to establish why violence occurs, using research to determine the causes and correlates of violence, the factors that increase or decrease the risk for violence, and the factors that could be modified through interventions. The third step is to find out what works to prevent violence, by designing, implementing and evaluating interventions. The fourth step is to implement effective and promising interventions in a wide range of settings and, through ongoing monitoring of their effects on the risk factors and the target problem, to evaluate their impact and cost-effectiveness. The main message of the Report is that violence can be prevented. Rather than simply accepting or reacting to violence, the field of public health, together with the police, criminal justice systems, education, welfare, employment and other sectors must collaborate to prevent violence. Definition of violence Considering the cultural, social and moral implications of what is acceptable behaviour and of what constitutes harm, there are many ways of defining violence. WHO defines violence as: 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 (Krug et al., 2002, p.5). The WHO definition of violence encompasses interpersonal violence as well as suicidal behaviour and armed conflict. It covers not only a wide range of acts such as threats and intimidation but also the consequences of violent behaviour such as psychological harm, deprivation and maldevelopment. 28

4 The roots of violence In its analysis, the World Report on Violence and Health uses an ecological model which takes into account the multitude of biological, social, cultural, economic and political factors that influence violence. The model examines violence firstly at the individual level, looking at elements such as age and sex, psychological and personality characteristics, substance abuse, aggressive behaviour, and exposure to violence. At the relationship level, the model explores how immediate relationships, such as between intimate partners, parents and children, friends and work colleagues influence violent behaviour. The third level explores the community context in which social relationships occur, and addresses factors such as social cohesion and social capital, crime levels, gangs, and the characteristics of schools, workplaces and neighbourhoods. Finally, the fourth level looks at the broad societal factors such as social norms, educational and welfare policies and economic and social forces that create a climate in which violence is encouraged or inhibited. Clarifying the causes of violence and their complex interactions is an essential precursor to prevention, following which the ecological model is used to suggest what should be done at various levels of government and society to prevent violence. The forms and contexts of violence The Report divides violence into three sub-types defined with reference to the entity that commits the violence. Interpersonal violence refers to violence between individuals where there is no clearly defined political motive, and is subdivided into family and community violence. Child maltreatment, intimate partner violence and elder abuse occur under family violence, and community violence is broken down into acquaintance and stranger violence. Self-directed violence refers to violence in which the person who commits the act and the victim are the same individual, and is divided into selfabuse and suicide. Collective violence refers to violence committed by larger groups of individuals or by states to advance a social agenda, and is broken down into social, political and economic violence. Cross-cutting each category of violence are four modes by which violence may be inflicted: these involve physical, sexual, psychological assault, and deprivation. Interpersonal violence Interpersonal violence occurs between individuals. It happens in different contexts, throughout every minute of the day, leaving an impact on every person involved. Examples include child abuse and neglect by caregivers; violence between adolescents and young adults; domestic violence between intimate partners; violence associated with property crimes; rape and other kinds of sexual violence; and the abuse of the elderly by their relatives and other caregivers. In 2000, an estimated people were killed as a result of interpersonal violence worldwide Ð a rate of 8.8 per population. Many more suffered non-fatal and very often repeated acts of physical or sexual violence. Violence among young people is one of the most frequent forms of interpersonal violence. In 2000, an estimated youth murders took place globally, equivalent to an average of 565 children and young people aged years dying on average each day. While violence in the community, particularly youth violence, is highly visible and often gets labelled as 29

5 criminal, violence within the family (including child and elder abuse and violence between intimate partners) is more hidden from public view. Data from the Report illustrate however, the magnitude of the problem: about 20% of women and 5-10% of men report having suffered sexual abuse as children; in a survey in the United States, 36% of nursing-home staff reported having witnessed at least one incident of elder abuse; and one in four women may experience sexual violence by an intimate partner in their lifetime. Underlying the different forms of interpersonal violence are a number of common risk factors, many of which predict both victimisation and perpetration. Some are psychological and behavioural characteristics such as poor behavioural control, low self-esteem, and personality and conduct disorders. Others are tied to early developmental experiences, such as lack of emotional bonding, exposure to violence in the home (both as victims and as witnesses of family violence), and family or personal histories marked by conflict, separation and divorce. Abuse of drugs and alcohol is frequently associated with interpersonal violence, and poverty as well as income and gender inequalities stand out as important community and societal factors. Suicide and self-harm Globally, an estimated people killed themselves in 2000, making suicide the thirteenth leading cause of death. The highest rates of suicide are found in Eastern European countries. The lowest rates are found mainly in Latin America and in a few countries in Asia. The Report also shows that suicide rates increase with age, with rates among people aged 75 years and older approximately three times the rates among people aged years. A combination of stressful events and predisposing factors put people at increased risk of harming themselves. Stressful circumstances include poverty, loss of loved ones, arguments with family or friends, a breakdown in relationships, legal or work-related problems, economic recessions, and political instability. Predisposing risk factors include alcohol and drug abuse, a history of physical or sexual abuse in childhood, and social isolation. Psychiatric problems, such as depression and other mood disorders, schizophrenia and a general sense of hopelessness also play a role. Collective violence Collective violence (armed conflict, genocide, terrorism and some types of organised crime) is the instrumental use of violence by people who identify themselves as members of a group against another group or set of individuals, in order to achieve political, economic or social objectives. During the 20th century, one of the most violent periods in human history, an estimated 191 million people lost their lives directly or indirectly as a result of armed conflict, and well over half of them were civilians. In 2000, about people died as a direct result of conflict-related injuries Ð the majority of them in the poorer parts of the world. A range of health problems, including depression and anxiety, suicidal behaviour, alcohol abuse and post-traumatic stress disorder, have also been linked to conflict. 30

6 Factors that put states at risk for violent conflict include:. a lack of democratic processes and unequal access to power;. social inequality marked by grossly unequal distribution of, and access to, resources;. control of valuable natural resources by a single group; and. rapid demographic change that outstrips the capacity of the state to provide essential services and job opportunities. WHAT CAN BE DONE TO PREVENT VIOLENCE? As violence is a multifaceted problem, there is no simple or single solution. Rather, as emphasised by the Report's ecological model, violence must be addressed on multiple levels and in multiple sectors of society simultaneously. This includes addressing individual risk factors, influencing close personal relationships, and addressing the larger cultural, social and economic factors that contribute to violence. For each of the different types of violence it covers, the Report critically reviews the various preventive responses that have been attempted, and summarises what is known about their effectiveness. Some of the successful programmes highlighted in the report include early developmental interventions involving parent training and home visitation; youth mentoring programmes; and comprehensive city-wide interventions that reduce gunshot homicides through a combination of community mobilisation and directed policing. Interventions that the Report concludes have been shown to be ineffective include individual counselling, programmes modelled on basic military training, peer mediation, and gun buy-back programmes. Most of the findings underlying these conclusions derive from studies in high-income countries, and the Report highlights the critical importance of intervention evaluation in low- to middle-income country settings. LESSONS LEARNED Despite major gaps in knowledge and a pressing need for improved violence and injury surveillance systems and for more research into risk factors and effective prevention strategies, the scientific literature and prevention experiences reviewed in the Report provide some important lessons about preventing violence and mitigating its consequences:. Violence is often predictable and preventable. Certain factors appear to be strongly predictive of violence, even if direct causality is sometimes difficult to establish.. Upstream investment brings downstream results. There is a worldwide tendency on the part of authorities to act only after violence has occurred. But investing in prevention, especially primary prevention activities that operate upstream of problems, may be more cost-effective and have large and long lasting benefits.. Resources should be focused on the most vulnerable groups.. Political commitment to tackling violence is vital to the public health effort. 31

7 RECOMMENDATIONS Based on its review of current knowledge, the Report calls for increased efforts in several areas. The Report proposes that national and local plans of action be developed in collaboration with all sectors involved to ensure that governmental and non-governmental agencies agree on a set of joint priorities, objectives and principles for evaluation. The Report also calls for a review and strengthening of the services that are provided to victims of violence. Emergency and long-term care services need to be improved so that they offer a comprehensive response to the vast needs of victims. Furthermore, the Report draws attention to the need for greater investment in primary prevention: intervening early before the acts of violence occur. Finally, in many parts of the world, greater efforts are needed to strengthen our knowledge about the magnitude and risk/protective factors for violence to ensure that the right priorities are set for interventions. CONCLUSION Violence is not an intractable social problem or an inevitable part of the human condition. We can do much to address and prevent it. The World Report on Violence and Health attempts to contribute to a knowledge base on violence and violence prevention. It is hoped that the Report will inspire and facilitate increased co-operation, innovation and commitment to preventing violence around the world. REFERENCES Krug, E.G., Dahlberg, L.L., Mercy, J.A., Zwi, A.B., & Lozano, R. (Eds.). (2002). World Report on Violence and Health. Geneva: World Heath Organisation. 32

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