Viewpoint A Case for Studying Country Regimes in the Public Health Model of Violence a b* b Authors: James Gilligan , Bandy X. Lee , Shikha Garg , c b Morkeh Blay-Tofey , and Audrey Luo a New York University, New York, NY, USA b* Law and Psychiatry Division, Yale University, 34 Park Street, New Haven, CT 06519, USA. Email: [email protected] c University of Texas, Austin, TX, USA *Corresponding author Running title: Country Regimes and Violence Keywords: Regime type, democracy, intermediate, autocracy, violent deaths Abstract Many national and international institutions have supported approaching violence as a problem in public health and preventive medicine, in a manner similar to the way we address other disabling and life-threatening pathologies such as cancer, diabetes, and heart disease. Previous work has found evidence that economic factors, including unemployment and relative poverty, as well as political culture and values, may affect violent death rates, including homicide and suicide. Nevertheless, wider political analyses of the effects that different types of regimes have on these variables have been notably absent, for understandable reasons as the sheer complexity of patterns of governance throughout the world. Given the importance and scale of the problem, and implications of the United Nations’ 2030 Agenda for Sustainable Development, we feel it is nevertheless important to bring regime types into the conversation of elements that can influence violent death. Introduction The 49th World Health Assembly officially declared violence and its multiple forms a leading worldwide public health problem. In doing so, it encouraged the identification and understanding of social, economic, health, and other environmental factors that could prevent violence in societies all over the world.1,2 Over the past several decades, the World Health Organization (WHO) has led the way in approaching violence as a problem of public health and preventive medicine.1 Since then, we have made great strides in moving away from the conceptualization of violence as a purely individual issue to considering the role of relationships, family, community, and society as a whole. This has led to identifying ways in which we can prevent violence and address large-scale epidemics at the level of the whole society, through good governance. Most recently, the United Nations’ (UN’s) 2030 Agenda for Sustainable Development has set a new standard by placing violence prevention at the center of sustainability and the development of a healthy, prosperous society, both at national and global levels.3 It urges governments to take major steps to bolster equity and sustainability, given the critical situation in which an estimated one and a half billion people, or 21% of the world’s population, live – plagued by insecurity and fear amid conflict, organized crime, violence in the home, and disruptions of climate.3 This article highlights the importance of political environment as a potential influence on a variety of social, economic, and other conditions that may affect rates of violent death. Through the framework of public health, we now approach violence as we do chronic diseases—heart disease, obesity, and cancer—and treat them as problems we can prevent through the identification and modification of environmental and life conditions. The WHO has made major contributions by advocating that we address the different types of violence in totality, from an ecological point of view, and not just separately.1 The ecological model of violence provides an understanding of the risk factors from an individual to a societal viewpoint.4 The political environment plays a role in the emergence and interactions of different types of violence. Thus we examine here the role of governmental regimes because even when guided by the public health model of population health and prevention, we have largely overlooked the role of governmental structures. One of the reasons is the sheer complexity of patterns of governance throughout the world and the difficulty of assigning categories. For instance, there is still much debate on classifying regime types, especially about determining when a state becomes a ‘true democracy.’ Some political scientists opt for a minimalist standard for determining whether a government constitutes a democracy, often the existence of free and fair elections.5,6 Others prefer a more robust list of requirements that regimes must meet in order to be called democratic.7 These additional requirements include freedom of expression, access to information, and the ability of elected officials to act independently without coercion.5,8 Even after developing a list of qualities necessary to constitute a democracy, researchers argue about how best to define those qualities. For example, what does it mean to truly have a free and fair election? While there is much disagreement on the best ways to classify regime type, or to measure the extent of democratic functioning by regime type, there are indices that attempt to do so; they categorize countries by their system of governance.9 One measure political scholars popularly employ is the ‘Polity IV score,’ which measures levels of democracy and autocracy for each country annually.10 Polity uses a 20-point score, from minus ten to ten, to classify and compare regime types. Scores from 6 to 10 represent a democracy; scores from -6 to -10 represent an autocracy; and scores in between, from -5 and 5, are classified as mixed regimes or ‘anocracies,’ meaning they have both democratic and autocratic traits. While all regimes with a score between 6 and 10 are categorized as ‘democracies,’ it is important to note that there are gradations: those with scores of 10, for example, have more democratic qualities than countries with decreasingly democratic scores of 9 to 6. Table 1 shows the distribution of democracies, anocracies, and autocracies in 2014 (the most recent data available), 1994, and 1974.11 For years when there was no government, foreign intervention, or some other interruption, the country is included in the column of ‘Other.’ Over the past four decades, there has been a global move towards democracy, but a large number of countries are still classified as anocracies and autocracies. As more societies move toward democracy, one would expect a decrease in levels of violence, especially with the reduction of autocracies to almost a quarter of the numbers from forty years ago. Is this true? And if so, why? These would be interesting questions for future research. Table 1. Classification of Regime Types Democracy Anocracy Autocracy Other Total (6 to 10) (-5 to 5) (-10 to -6) (Interrupted) 2014 95 46 20 6 167 1994 78 40 36 9 163 1974 35 19 79 4 137 Source: Adapted from Marshall et al. (2014) Economic Policies that Affect Violent Deaths One reason we believe regime types are important is the growing recognition of economic influences on violent behavior, including suicide and homicide. In a pioneering study of the period 1936–1976, Brenner demonstrated that rates of suicide and homicide rose within a year of increased unemployment, both in the United States (U.S.) and the United Kingdom (U.K.). This reconfirmed general mortality observations in the U.S. over a longer time period (1901– 2000).12,13 Additionally, Holinger observed that, from 1900 to 1979 in the U.S., suicide and homicide rates strongly and positively correlated with each other and with unemployment (p b 0.001).14 A study in Germany found that four economic variables (growth of the economy, average real income, unemployment, and frequency of bankruptcy) correlated with suicide from 1881 to 1989, with the strongest holding for unemployment and frequency of bankruptcy.15 A recent assessment of economic correlations to violent death rates in forty countries where income levels varied widely over 46 years found that more equitable distributions of social and economic rewards can promote ‘macro-social integration’ (inclusion of people into a system), by increasing equality in providing for people’s needs.16 Obvious examples such North and South Korea but also others show that autocracy is detrimental to the economic prosperity.17 Given that inequality is one of the most potent contributors to violent death rates, nuances in this relationship would be interesting to explore. Macro-social integration suggests, for example, that economic growth, higher income levels, respect for human rights, and the abolition of the death penalty are all associated with lower homicide rates.18-20 Understandably, a relationship exists between political structures and economic factors. Policies that the ruling party pursues may affect economic indicators such as unemployment and overall economic growth,21 or whether depressions occur—and if so, how deeply and for how long—in addition to whether inequality increases or decreases.22 At the same time, the political regime (or within a democratic regime, whether the political party in power is conservative or liberal) also correlates with changes in violent death rates independently of unemployment rates or changes in gross domestic product (GDP) per capita: in the U.S., Republican (conservative) administrations were associated with increases while Democratic (liberal) administrations were associated with decreases.23 Other studies have found a correlation between inequality and country regime type.24 This, of course, is counting only behavioral (leaving out structural) violent deaths. If we included structural violence, which