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Violence: a Public Health Epidemic

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Violence: a Public Health Epidemic HEALTH POLICY Violence: A Public Health 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. Joycelyn Elders, 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 Bill Clinton 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
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