HEALTH POLICY

Violence: A Epidemic

BY JANE H. WHITE

he nation's epidemic of violence has the most preventable is the epidemic of violence finally captured the attention of poli­ sweeping across the nation."1 Surgeon General cymakers in Washington, DC. , MD, testified before Congress T Significantly, in the final hours before this fall on violence and health, particularly the us year-end recess, Congress passed the Brady effects of television violence. The Atlanta-based Bill, instituting a five-day waiting period on the Centers for Disease Control and Prevention purchase of handguns nationwide and requiring (CDC) has placed a top priority on violence pre­ states to conduct computerized background vention. At the provider level, hospital trauma checks on the purchasers. This legislation, named centers nationwide face daily the health implica­ for President Ronald Reagan's press secretary, tions of violence. James Brady, who was critically wounded in the Ms. White is This article sets out the parameters of the pub­ assassination attempt on the president, has been lic health approach to violence prevention as introduced in nearly every session of Congress developed by leading CDC researchers. It also executive editor, since 1987. The powerful gun lobby had prevent­ describes the attention to violence and the health­ ed passage until now. care community's role in helping stem the tide of Enactment of the Brady Bill, signed into law Health Affairs. violence. on November 30, continues the historical focus on violence as an issue for the criminal justice A PUBLIC HEALTH APPROACH TO VIOLENCE community. In her role as the nation's chief law A new vision for violence prevention has emerged enforcement officer, Attorney General Janet from within the public health community. Many Reno has brought increasing attention to the dire policy observers cite the October 1985 problems of violence in her outspoken testi­ Workshop on Violence and Public Health con­ monies before Congress and interviews with the vened by then Surgeon General C. Everett Koop, press. MD, ScD, as the public health community's first Moreover, attention to the growing epidemic major consideration of violence prevention. In of violence has spread beyond the criminal justice 1991 CDC formed its National Center for Injury community to the healthcare sphere. President Prevention and Control, which includes in its linked violence to healthcare reform mandate the monitoring and researching of vio­ when he presented his reform proposal to lence. Congress on September 22, 1993, referring to Mark L. Rosenberg, the national center's act­ "the outrageous costs of violence in this coun­ ing associate director for public health practice, try." The president has convened the articulates the parameters of the public health Interdepartmental Work Group on Violence approach to violence prevention. In essence, Prevention, which brings together leaders from "CDC has diversified its portfolio" to include seven cabinet agencies, including the Department many other issues besides traditional disease con­ of Health and Human Senices (HHS), to work trol, such as the prevention of smoking, injury, on the problem. and violence, he said at a late October 1993 Healthcare leaders are stepping forward to meeting in Washington, DC, on "Mass Com­ offer a public health approach to preventing and munication and Social Agenda-Setting," cospon- "treating" violence, building on and comple­ sored by the Annenberg Washington Program menting the criminal justice approach. HHS and the Harvard University School of Public Secretary Donna E. Shalala recently noted, "Of Health. all the health and human services challenges we Violence as a Public Health Issue Violence has become face, perhaps the most devastating and, ironically. a public health problem for several reasons,

18 • JANUARY-FEBRUARY 1994 HEALTH PROGRESS Rosenberg told participants at the October meet­ criminal justice approach. We focus on the pre­ ing. First, the magnitude of the impact of vio­ vention side," while criminal justice deals with lence on the nation's health makes it a public the perpetrators of violence after the fact. Lastly, health problem. The statistics are numbing. In violence is a problem to be solved, "not a condi­ the 1980s more than 215,000 Americans died, tion we have to accept," said Rosenberg. The and 20 million received nonfatal physical injuries, public health community brings a rigorous scien­ as a result of violence.2 tific and epidemiological approach to problem Violence affects certain population groups dis­ solving and can offer new ways of looking at this proportionately. For instance, Rosenberg said, issue. homicide is the number one cause of death for Principles of the Public Health Approach The healthcare young black men and black women. Adolescents research community can bring an important, and young adults in general are another subgroup fresh perspective to the crisis of violence. that violence disproportionately affects. Rosenberg set out three principal contributions Homicide is the second leading cause of death for Violence of the public health approach at the October Americans aged 15 to 34, and "the average age of meeting. both violent offenders and victims has been is a problem First is a "paradigm shift to primary preven­ growing younger and younger in recent years," tion" of violence, injury, and death, said note CDC's James A. Mercy and colleagues.' to be solved, Rosenberg. The criminal justice model reacts to Other groups increasingly affected by violence violent activity. The public health approach aims include women, children, and the poor. For "not a to understand root social and behavioral determi­ example, more than 1.5 million women seek nants that may lead to violence and then takes medical treatment annually for injuries related to steps to prevent such violence. 4 domestic violence. condition we A second principle of a public health approach The health-related cost of violence to society is is to draw on and develop the scientific basis for staggering. For instance, the lifetime cost of all have to effective prevention—"something that has been firearm-related injuries in 1990 was estimated at missing from this field."" S20.4 billion by University of California, San accept," said This scientific approach to prevention has four Francisco, health services researchers Wendy Max basic steps. These steps are not necessarily linear; and Dorothy P. Rice.5 Ted R. Miller, who directs Mark L. public health policymakers and researchers may the Safety and Health Policy Program at the work on all four at once, explained Rosenberg at National Public Services Research Institute in Rosenberg of the October meeting. The steps arc: Landover, MD, and colleagues have developed • To define the problem, which includes data lifetime cost estimates by crime category (rape, the National collection and surveillance activities robbery, assault, arson, and murder). In total, • To identify risk factors and to ask the "why" they estimated that the medical and psychological questions costs per year for people aged 12 and older aver­ Center for • To develop interventions, ask what might aged S10 billion (1989 dollars) for these five work, and then test the interventions 6 crime categories during 1987-90. Physical- and Injury • To implement effective interventions, which mental-health-related productivity losses result­ includes demonstration programs, training, ing from these violent crimes totaled $23 billion; Prevention increased public awareness, and, most important, and reduced quality of life was estimated at nearly evaluation to understand the intervention's true S145 billion, according to Miller and colleagues. and Control. effectiveness Although some researchers in the criminal justice The third important contribution of a public community believe these numbers are overesti­ health approach to violence is that it brings mates, they have been widely cited by CDC, the together a diverse array of scientific disciplines, National Research Council of the National organizations, and communities, working on a Academy of Sciences, and other healthcare common goal. The tradition in public health of groups. "integrative leadership can [be important in help­ Beyond the sheer magnitude of the impact of ing] to build a national network" to work together violence on the public's health, at the October on the epidemic of violence, said Rosenberg at meeting CDC's Rosenberg cited two additional the October meeting. "This approach," he reasons why violence is a critical issue for the noted, "is in direct contrast with our society's healthcare community. He said that the public traditional response to violence, which has been health approach to violence "complements the fragmented along disciplinary lines and narrowly

HEALTH PROGRESS JANUARY-FEBRUARY 1994 • 19 HEALTH POLICY

focused in the criminal justice sector."'1 gested that a public health approach to reducing Public health advocates point to the recent suc­ gun violence will more likely follow "the paradigm cesses of this collaborative approach in preventing of trying to persuade people to give up ciga­ motor vehicle deaths, promoting designated rettes." drivers, and reducing cigarette smoking. For vio­ lence prevention, "the bad news is that there are INCREASING POLICY LEADERSHIP ATTENTION no designated drivers in the gun area" and no easy The urgency of the violence crisis in America has prevention target, said Franklin Zimring of the most recently gained the attention of policymakers University of California, Berkeley, at the October in Washington, DC, and healthcare leaders nation­ meeting. Zimring is widely cited for his pioneer­ wide. Through a nationwide campaign to educate ing scientific work on firearm research. He sug­ physicians and heighten public awareness, the

ROLE OF THE HEALTHCARE COMMUNITY

Former Surgeon General C. Everett prevention. Prevention also would have Violence: Challenges for Prevention," Koop. MD, ScD, issued a call to the a profound impact on early and late Health Affairs, Winter 1993, pp. 154- healthcare community in 1991: "The pro­ deaths within the hospital and would 161). A positive step in this regard was fessions of medicine, nursing, and the even reduce permanent disability," con­ the formation of the National Coalition health-related social services must come tinued Trunkey. of Physicians against Family Violence, forward and recognize violence as their Thus strengthening the U.S. trauma with more than 75 member organiza­ issue and one that profoundly affects the system would be one step forward for tions. public health" (see C. Everett Koop, the healthcare community in address­ Secondary prevention occurs at the "Foreword," in Mark L Rosenberg and ing violence. Currently only about 25 doctor-patient encounter level and Mary Ann Fenley, editors, Violence in percent of the country's geographic includes identification, validation, America: A Public Health Approach, area is served by trauma systems. appropriate early intervention, assess­ Oxford University Press, New York City, Additionally, Trunkey noted that a num­ ment and treatment of medical needs, 1991, p. v). Since then, some progress ber of hospitals have closed trauma and referral to law enforcement and/or has been achieved; in particular the units in recent years, primarily for eco­ community-based domestic violence American Medical Association has nomic reasons, including perceived services. Flitcraft urges a broad range mounted a nationwide campaign to cost of uncompensated care, high oper­ of healthcare disciplines, including increase physician recognition of vio­ ating costs, inadequate reimbursement nursing and social work, to work togeth­ lence. But much remains to be done. from public assistance programs, and er to improve interventions. For hospitals, the trauma center is reduced compensation for trauma Hospitals and systems become the point of entry for most violence vic­ patients under the Medicare prospec­ involved at the level of tertiary violence tims. "Although the delivery of trauma tive payment system. Among the top prevention. However, Flitcraft noted, care to the victims of violence does not five reasons for closing trauma centers "The role of health care organizations in address any of the underlying social is that physicians are unwilling to be on a comprehensive response to domestic causes of that violence, the trauma sys­ call. violence is the least developed." The tem is an essential component of a uni­ Anne Flitcraft, MD, of the University Joint Commission on the Accreditation fied response to violence," explained of Connecticut Health Center, calls on of Healthcare Organizations expanded trauma surgeon Donald D. Trunkey, the medical community to take primary, its guidelines in 1992 to encourage hos­ who is professor and chairperson of the secondary, and tertiary prevention pital staff education and protocols on Department of Surgery, Oregon Health steps to address domestic violence. For domestic violence. Beyond these guide­ Sciences University ("Impact of Violence primary prevention, she says, the lines, however, Flitcraft believes that on the Nation's Trauma Care," Health healthcare community must address "tertiary prevention of domestic vio­ Affairs, Winter 1993, pp. 162-170). barriers to physicians' participation in lence will require health care organiza­ "Nearly 55 percent of trauma deaths recognizing and treating domestic vio­ tions to incorporate and invest in crisis occur instantly after injury. Since it is lence and must "recognize ways in intervention, emergency hospitalization impossible to treat these fatal injuries which the medical profession may be for shelter, counseling, support groups, in a timely fashion, the only practical helping to perpetuate a harmful envi­ and advocacy, rather than simple iden­ way to address these deaths is through ronment" ("Physicians and Domestic tification and referral."

20 • JANUARY-FEBRUARY 1994 HEALTH PROGRESS American Medical Association (AMA) is placing a If we are successful in these efforts, the priority on violence as an issue that affects the pop­ benefits will be enormous. Most important ulation's health. At its June 1993 house of dele­ will be the lives saved, the injuries and dis­ gates meeting, AMA presented two major reports abilities prevented that would have resulted on family violence: first, relating it to alcohol and from violence, and the improved quality of drugs; and second, setting out a framework for life in our communities. There will also be understanding the psychological impact of vio­ economic savings. . . . These benefits will lence on individuals. A year earlier, AMA devoted be immediate; we will not have to wait 20 two issues of JAMA to violence and health. or 30 years to see the results of prevention Congress convened several hearings in fall 1993 efforts as we do with other public health 10 on the health implications of violence, particularly ft public problems such as heart disease and cancer. relating to the impact of television violence. Congressional activities culminated in the passage health NEW IDEAS AND PEOPLE of the Brady Bill in late November —a Many leaders in the criminal justice sector wel­ Thanksgiving gift to the nation, representing a approach come the addition of the healthcare community loosening of the gun lobby stranglehold on as an ally in addressing violence. A public health Congress. approach "brings a new set of ideas and, impor­ The Clinton administration has also placed a "brings a tantly, a new set of people getting involved in the high priority on violence prevention. The presi­ issue of violence," said Mark Moore, professor of dent's Interdepartmental Work Group on new set of criminal justice policy and management, Harvard Violence Prevention will coordinate federal anti- University, at the October meeting. A heavy violence efforts and will report to the president ideas and, emphasis on prevention may be easily miscon­ early this year. The group is cochaired by Peter strued as "blaming the victim"; thus care is need­ Edelman, counselor to the HHS secretary', and importantly, ed in implementing violence-prevention activities. Philip Heymann, deputy attorney general. This is not to suggest that solving the problem The violence prevention group is subdivided a new set of of violence is the sole responsibility of the health­ into six areas: youth violence, family violence care community. Rather, what we in healthcare (including child abuse, domestic violence, and can do is to build on the efforts of the criminal elder abuse), intercommunal or hate violence, people getting justice sector and offer new insights and perspec­ sexual assault, firearms, and positive and negative tives into this dire societal issue. The highest lev­ influences of media. Each subgroup is preparing a involved in els of government are now taking steps to tackle report that will cover the problem's size and this public epidemic. It is critical that the health­ scope, current policies and programs (both public the issue of care community be part of this effort as well. • and private), proposed federal and other sector remedies, and a research and evaluation agenda. violence," According to Shalala, some goals of the vio­ NOTES lence prevention group are to improve antivio- said lence curricula and mediation training in schools, 1. Donna E. Shalala, "Addressing the Crisis of Violence." Health Affairs, Winter 1993. pp. 27-30. create youth development initiatives, improve the Harvard 2. James A. Mercy et al., "Public Health Policy for use of alternative interventions and sentencing for Preventing Violence," Health Affairs, Winter 1993, youth showing promise of changing their violent pp. 7-29. behavior, support community-based efforts to University's 3. Mercy etal. prevent violence and eliminate hate crimes, pre­ 4. Anne Flitcraft, "Physicians and Domestic Violence: Challenges for Prevention," Health Affairs, Winter vent family violence through a stronger emphasis Mark Moore. 1993, pp. 154-161. on family preservation, support strategies to 5. Wendy Max and Dorothy P. Rice, "Shooting in the reduce gun violence, work with the media to Dark: Estimating the Cost of Firearm Injuries," Health deliver antiviolencc messages, examine the con­ Affairs, Winter 1993, pp. 171-185. nection between substance abuse and violence, 6. Ted R. Miller, Mark A. Cohen, and Shelli B. Rossman, "Victim Costs of Violent Crime and Resulting support evaluations of prevention strategies to Injuries," Health Affairs, Winter 1993, pp. 186-197. learn what works best, and assist local law- 7. Mercy etal. enforcement efforts.'' 8. Mercy etal. 9. Shalala. Edelman and CDC Administrator David 10. Peter Edelman and . "Violence Satcher discuss the hopes of the federal task Prevention as a Public Health Priority," Health force: Affairs, Winter 1993, pp. 123-125.

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