Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary (2008)

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8 Opportunities and Challenges for U.S. Agencies and Organizations to Focus on Violence Prevention in Developing Countries Fran Henry moderated this session and began by explaining the dif- ferent format of the session, as well as its objectives to hear about oppor- tunities and obstacles to advancing violence prevention from people who administer U.S. federal agency programs and from representatives of a multilateral bank and an international nongovernmental organization. This is the last opportunity in context of this Institute of Medicine (IOM) work- shop to interact with the people who can influence policy, programming, and funding on all kinds of issues that can relate to violence prevention. Unlike the previous sessions, the representatives from these agencies and organizations presented a brief overview of their organizational activity related to domestic and international violence prevention, followed by a dialogue around questions posed by the moderator. This section first pres- ents the overview of each organization, followed by a summary for each question posed. ORGANIZATIONAL PROFILES OF VIOLENCE PREVENTION ACTIVITIES Tom Insel of the National Institute of Mental Health (NIMH), one of the 27 institutes and centers of the National Institutes of Health, explained that its mission is to reduce the burden of mental disorders through research on the mind, brain, and behavior. Much of the focus is on curing disease with an interest in autism, schizophrenia, and mood and anxiety disorders. NIMH is not a service delivery agency, but it does conduct studies of what the evidence base will be for specific services that could be delivered. The 89 

90 VIOLENCE PREVENTION IN LOW- AND MIDDLE-INCOME COUNTRIES NIMH has an annual budget of nearly $1.5 billion, much of which comes from Congress, to conduct research within the United States for cures that will make a difference to the American people. This being said, about 220 grants each year—as of 2006—were international grants and many of them were concerned with HIV. These grants were made partially because the principal investigators were domestic, but working in an international or global context. Perhaps 10 percent of those grants were actually to princi- pal investigators outside the United States. For the most part, that 10 per- cent was funded outside the United States because there was some special expertise or some special value to the United States in supporting someone in Iceland, South Africa, or China to do the research. In the context of this meeting, much of NIMH research really looks not so much at violence per se, but at the consequences of violence, which he stated is also true for its international portfolio. NIMH stud- ies post­traumatic stress disorder in Israel, mothers and children following C ­ hernobyl, the effect of HIV infection on mothers and children in South Africa, the influence of torture in Nepal, and the victims of war in Kuwait. He described a second component relevant to how they engage in violence prevention with long-term NIMH funding for projects such as the nurse visitation studies of David Olds for nearly 30 years. He stated that there are now several replications of this nurse visitation intervention in pregnancy and postdelivery that show the efficacy and the cost-effectiveness of reduc- ing violence both of children and to children. The greatest impact of the past and current NIMH work is a focus on self-directed violence. He reiter- ated the statistic of 54 percent of violent deaths globally being related to suicide. This remains a problem of great and often understated importance in the United States with 30,000 suicides each year, relative to about 18,000 homicides, and of global importance with 800,000 deaths annually. NIMH has projects in Russia, China, and Scandinavia—three of the countries with the highest rates of suicide—examining how suicide can be reduced and how to improve monitoring. In conclusion, he stated that a great deal of the suicide rate in both the United States and the rest of the world is related to mental illness and there is abundant evidence that treating depression, sub- stance abuse, and mental illness reduces the rate of suicide. He also stated that reducing access to weapons is equally important to this goal. Kent Hill, of the U.S. Agency for International Development (USAID), stated that the agency considers violence to be a pervasive public health and human rights problem and that, programmatically, USAID has been making efforts to respond to victims’ needs, as well as to prevent violence, since the early 1990s. He identified three important areas of its work: (1) conducting demographic and health surveys, particularly for the issues of female genital cutting and domestic violence to support accurate data collection; (2) pro- viding grants for building global capacity to address violence prevention and 

OPPORTUNITIES AND CHALLENGES 91 for working with service providers, program managers, and policy makers in various countries; and (3) programmatically addressing the connection of HIV to violence because of the gender issues involved in human rights violations and gender-based violence. He stated that it is not possible to address gender-based violence unless the right to abstinence and the double standards that are often involved in male behavior, let alone coercive male behavior, are addressed and that USAID hopes to make an impact on HIV prevention. It also attempts to address victims’ needs in dealing with the tragic consequences of gender-based violence. He mentioned that in 2002, the President’s Emergency Plan for AIDS Relief (PEPFAR) spent $104 mil- lion for 240 activities to address gender-based violence. While he thinks this amount was too low, it was at least movement in the right direction. Pro- grams in Rwanda, South Africa, and Uganda—costing $1.8 million—were offered as examples to address gender-based violence and to assist survivors in accessing comprehensive treatment. Hill stated that more work could be done to address male behaviors. Finally, Dr. Hill mentioned that USAID tries to work within the interagency cooperative process and the PEPFAR Gender-Based Violence Working Group that deals with this, so that agency programs do not overlap unnecessarily. He encouraged participants to refer to USAID’s publication Addressing Gender-Based Violence Through USAID’s Health Programs for more information about its programs, as well as to PEPFAR’s report on gender-based violence and HIV/AIDS. These documents are available from PEPFAR and USAID websites. Stephen Blount from the U.S. Centers for Disease Control and Preven- tion (CDC) said CDC recognizes that violence in developing countries has an important impact on U.S. citizens and therefore our national interests. CDC attempts to be a resource to the World Health Organisation (WHO), the international community, and developing countries. In the area of i ­nsecurity, Blount stated that it is clear to CDC that violence breeds chaos and chaos breeds violence. Additionally, it recognizes the impact of violence on economic growth in developing countries and therefore the impact on commerce and trade for the global community, including the U.S. econ- omy. CDC also recognizes the safety risks to U.S. citizens who travel and work abroad. Blount acknowledged the link between violence and other health problems in developing countries, and because of this, CDC works very closely with USAID in PEPFAR activities. Through CDC’s program- matic activities abroad and its extensive history and experience of work- ing in developing countries, it addresses the unfortunate link of violence with broader reproductive health issues, issues of refugee health, substance abuse, and many other problems. Dr. Blount also acknowledged that some Available at http:// www.pepfar.gov and http://www.usaid.gov/. 

92 VIOLENCE PREVENTION IN LOW- AND MIDDLE-INCOME COUNTRIES of the lessons learned in the United States can help inform the research agenda and programmatic work in developing countries. For all of CDC’s recognition and programmatic efforts, he acknowl- edged that with an agency budget of $9 billion, it invests about $1 billion in international activities. However, less than $1 million of that amount is invested in activities related to violence prevention (compared to zero dollars five years ago). Blount explained that this investment supports part- nerships with the Inter-American Coalition for the Prevention of Violence, WHO, the Pan-American Health Organization (PAHO), and the Violence Prevention Alliance. CDC attempts to make contributions to the four steps of the public health approach described by Mark Rosenberg. To define the problem, it works closely with WHO and, in 2004, collaboratively published guidelines for conducting community surveys on injuries and vio- lence. In 2007, the first expert meeting on improving collection and analysis of data on violence and injuries would be held. CDC has recently completed a report on sexual violence against female children in Swaziland based on the first national survey to be conducted on this topic in that country. This report documents the magnitude of the problem and subsequent analyses will address risk and protective factors. In 2004, it supported another WHO publication The Economic Dimensions of Interpersonal Violence, which it hopes will be a key step to speaking the language of decision m ­ akers, particularly ministers of finance, who will be making the important investments in violence prevention at a national level. To develop and test prevention strategies, proven and promising prevention practices in the WHO handbook are currently being piloted in a number of countries. CDC also supported the 2003 PAHO publication Violence Against Women: The Health Sector Responds and is now working with the its Chinese counter- part on a national plan for suicide prevention. To ensure widespread adop- tion of proven policies, CDC is working with the partnerships mentioned above to advance and make available these best practices. Marco Ferroni of the Inter-American Development Bank (IDB) described the operational institution that finances projects and investments, provides technical expertise and assistance in the design and implementation of policies and programs, and offers platforms for learning in many different sectors, including this particular sector of citizen security and crime and violence. The Inter-American Development Bank is a regional development bank that works around the world, and his focus is in Latin America and the Caribbean—a region where crime and violence are endemic and grow- ing and where the problem of crime and violence is increasingly recognized as a development problem. IDB recognizes violence as both a public health and a law enforcement problem and even concedes that, sectorally speak- ing, it may be many other things; but its perspective is that violence is a development problem that affects the business climate, and therefore the 

OPPORTUNITIES AND CHALLENGES 93 growth potential, of the countries in the region. Like Bell, Ferroni explained that violence also affects the scope for human development aid by infringing on the factors that determine social cohesion, affecting how societies oper- ate. The learning platforms that he mentioned have shown that there are thousands and thousands of municipalities and small towns in the region where the authorities and the population in general do not know what they can do or what has already been achieved in the very region—for example, in Colombia. Therefore, he explained that these communities often address the problem of crime and violence by means of populist measures that have little chance of getting at the multiple, often subtle, and usually very complex roots of the problem. He proposed that more outreach and more platforms for learning are needed. The IDB is currently engaged in 12 countries, with projects that have been requested by the countries’ governments. Dr. Ferroni noted that government demand for these projects is increasing. He described its approach as holistic, since this is a multidimensional and multicausal challenge and said it seeks to address causes rather than symptoms. The approach is intended to be epidemiological in nature in the sense that dif- ferent risk factors are assessed and factored into an integrated risk manage- ment approach that relies on contributions from many departments and many sectors—health, education, family welfare, urban infrastructure, law enforcement, justice sector reform, police reform, and the role of the media. The IDB approach recognizes that data and information systems are needed to inform policy and communication strategies and that programs have to be monitored and evaluated in order to create a basis for learning and do better next time around. The approach, which he also described as being about building citizenship, substantive democracy, and democratization, also calls for an engagement of the community and all stakeholders—that is, civil society, neighborhoods, the business sector, opinion leaders, gov- ernment at all levels, the media, police, and law enforcement. Ferroni also stated that this approach rests on the belief that violence is often a learned behavior, thereby positioning domestic violence as a precursor of violent behavior in the street. IDB projects, therefore, in many cases address issues or aspects of domestic violence, youth violence, and violence in schools, which can condition young people for violent behavior. Holly Burkhalter of the International Justice Mission (IJM), a faith- based nongovernmental organization based in the United States, described its function as a law firm for poor people by providing free legal assistance to victims of violent abuse and injustice. It has 14 overseas offices, largely staffed by nationals who are members of the bar associations in their own countries and employs an unusual casework model. The types of crimes addressed in their 14 offices in Latin America, Africa, South Asia, and Southeast Asia are forced labor, police abuse, seizure of widows’ land, 

94 VIOLENCE PREVENTION IN LOW- AND MIDDLE-INCOME COUNTRIES child rape, and child prostitution. IJM lawyers represent the victims and help them access services, take their cases to the authorities, and help investigate those cases—basically “walking alongside the authorities”—to attempt national court prosecution of “crimes that would never have seen the light of day.” She described the IJM work in Guatemala with a staff of about six people, including lawyers, investigators, and social workers, as a concrete example of its operational model. This small staff undertook the exclusive prosecution of cases of child sexual abuse and child rape (some of them involving foreign pedophiles). Since October 2006, of the 11 cases IJM inves- tigated, brought to the authorities, and helped to prosecute, there have been convictions and jail time in all 11 cases, which she described as an “unheard- of record in a country that can barely prosecute anything.” She said that there was will and conviction on the part of the authorities to ­prosecute, but they just didn’t have the resources or the knowledge to accomplish this. In all cases, Burkhalter stated, the idea was to bring immediate relief to the victim, followed by securing perpetrator accountability, and finally, attending to the aftercare needs of the victim, which in the particular case of child rape and child prostitution could go on for many, many years. Through its efforts, IJM hopes to create a social demand for seeing the system work for the poorest and, eventually, to assist the government’s response by developing the skills it needs to do the job of governance. IJM also hopes to scale up and replicate its work when a working model has been proven. IJM has received a $5 million grant from the Bill and Melinda Gates Foundation for a study in a new location, which will include an eval- uation component to measure the impact on the incidence of the crime itself in a high child-trafficking incident area, and also to measure the impact on the local police and justice system. The larger implications of successful prosecution of many child prostitution cases, which are basically economic crimes since sex trafficking is a “money maker” accompanied by debt bond- age and enforced labor, may force adjustments in the brothel community and among traffickers. In the area of child prostitution in Cambodia where IJM has been involved the longest, it has helped bring 85 cases to convic- tion with serious jail time. IJM is also now engaged in trying to study the implications on the crime itself—researching whether deterrence can occur in real time (not waiting until poverty has been eradicated and a functioning justice system created) in countries, even given their flawed justice systems, many of which are corrupt, all of which are poor. Anecdotally, Ms. Burkhalter stated that IJM believes this to be the case in Thailand and Cambodia where it has done work. Thomas Feucht of the National Institute of Justice (NIJ) of the U.S. Department of Justice described the sole function of the institute as the 

OPPORTUNITIES AND CHALLENGES 95 independent research, development, and evaluation arm of the Department of Justice. NIJ is housed in a family of agencies that are focused princi- pally on state and local issues, including the Office of Justice Programs, the Bureau of Justice Statistics, and the Office of Juvenile Justice and Delinquency Prevention. It has an annual budget for social and behavioral science, which is Feucht’s area of responsibility, of approximately $14 mil- lion. To this workshop audience, one of the most important contributions of NIJ is its violence against women research portfolio, which over the last 12 years he thinks has made huge strides in understanding and solving problems of victims of violence against women in the United States. NIJ also conducts basic research that is focused on the operation of justice—how police operate and issues of corrections and sentencing. Some- times, Feucht stated, this puts NIJ on the side of more law, less order. He identified this research as perhaps one of the most important contributions that NIJ can make and an important commodity that can be of great value as this effort goes forward—NIJ’s familiarity with and investments in the way in which police operate, understanding how police have changed in this country, for instance. During the workshop breaks, Feucht’s discussions reaffirmed the important transition that police have made in this country from crime control to crime prevention. In some important ways, he stated, police have embraced their principal responsibility not as catching crimi- nals, but as preventing people from engaging in criminal behavior. Feucht observed that the notion of community policing, which is not more than 15-20 years old, has reshaped policing. In conclusion, Dr. Feucht also noted that the National Institute of J ­ ustice has an extremely slender window through which it is able to con- duct international activities and international research since it cannot make grants to non-U.S. taxpaying entities. It does, however, have an inter­national center and a very slender statutory mission, but he stated that the federal government was built principally of inward-looking domestic agencies and all agencies within it act accordingly. He encouraged participants to think about what kinds of resources, expertise, knowledge, research, and evidence these inward-looking, domestically oriented agencies might be able to bring to bear on international issues if the agencies were statutorily licensed and directed—not just encouraged, but ordered or expected—to think and act globally. ROUND-ROBIN QUESTIONS WITH THE PANELISTS The panelists were engaged in dialogue with questions posed by the moderator, based on the assumption that agencies would need larger bud- gets but that this issue would not be the premise of the questions. Rather, Ms. Henry first asked whether the organizations had the authority to “go 

96 VIOLENCE PREVENTION IN LOW- AND MIDDLE-INCOME COUNTRIES upstream” to focus on violence prevention, if this were something they would indeed be interested in doing, and whether they needed advocacy from civil society groups to obtain the authority if they did not currently have it. In response, Dr. Insel stated that NIMH has authorization to engage in violence prevention research and has been doing so for 40 years. He believes that there is sufficient evidence from studies conducted in the United States to know how to prevent violence, especially in the family set- ting, but the question is how to disseminate and implement what is known. Insel also stated his belief that many of the interventions are cost-effective and not high-tech interventions; he would expect cultural variations in the programs but thinks they would look basically the same everywhere and that it’s worth the investment to begin to try. Dr. Ferroni agreed with Insel in that we have enough evidence, but that the issue is about how to bring together a community of practice that involves many different types of actors—from government officials to civil society in its many expressions of the private sector, the business sector, and so on. This coalition would need to rally around a concept that might work in a particular society, a particular culture—coming up with action and an evaluation framework that would enable those who are participat- ing to know whether progress is being made during the process of imple- mentation. Ferroni stated that talking about how to create the authorizing environment is essentially how the problem seems to be presenting itself to his institution. He also mentioned that latent demand needs to be developed into explicit needs and explicit designs of projects and operations; depend- ing on who is being engaged for participation, you may run into a whole range of opinions that are not compatible with each other, at least not in the short run, and a lot of discussion will be needed. For example, when talking about police reform for response and prevention, multiple issues must be addressed including improving police effectiveness and capacity for response, the need for civilian and social control, and accountability. Ms. Burkhalter responded that for the types of crimes and violence the International Justice Mission addressed, she is unsure whether there is a way to focus on prevention without deterrence. She also stated that the human rights community has not looked to national governments and local public justice systems and judiciaries as a form of deterrence and protec- tion. Rather, her lifelong experience in the human rights field, until now, has been that the authorities are the source of human rights abuses, and in some of the countries where IJM works, this is indeed the case. Even if the authorities are often the source of abuse, they are also the only recourse, which means there is not a “workaround for the poorest.” By showing that the system can work, IJM eventually hopes it will be possible for people to actually think of going to the police when they need the help, instead of running from the police. She argued that this will not happen without some 

OPPORTUNITIES AND CHALLENGES 97 form of carrot-and-stick and pressure on international donors to make resources available, as well as a sense of communal expectation that the police will do the job they are supposed to do. As a nongovernmental orga- nization, IJM can help with this but cannot be a substitute for it. Burkhalter does not believe that prevention is achievable through public education, and this makes the success of IJM’s work even more essential; but she firmly stated that the major donors and other nongovernmental organizations can- not “hang back forever waiting to prove that a local justice system should be expected to protect the poorest. . . . We have to test that system, make demands on that system, and help that system do that job.” Dr. Hill agreed with Burkhalter’s assessment of “not putting teeth to the rhetoric and working on a prosecution system” as a recipe for failure. He stated that USAID certainly has the authority to move ahead and in his opinion—with its decades-long expertise in social marketing, whether condoms, water sanitation tablets, or insecticide-treated nets—ought to use that expertise to work on behavior change in other areas, such as male norms. Hill predicted that to successfully engage lawyers and police to do what they should or lawmakers to put the right laws in place, need to aggressively attack the issue of changing male norms—which is an example of pushing ahead on several fronts simultaneously. In response to the query of authorization to work in the area of vio- lence prevention, Dr. Blount stated it is very clear that over the last 10 years, CDC’s role as a technical agency has evolved, first and foremost in the area of HIV. AIDS has been defined as a national security issue for the United States, as well as a development issue, which has helped shape CDC’s col- laboration with USAID on PEPFAR and the President’s Malaria Initiative. He stated that CDC “feels fully authorized, but . . . not appropriated very much,” which means it makes contributions to the global effort in the set- tings in which it works collaboratively. Dr. Feucht replied that the idea of moving upstream has a couple of connotations, in terms of moving from response and treatment to preven- tion. Over the last couple of days of the workshop, he has noticed a theme emerge—maybe not a sense of despair, but a sense of willingness to move ahead without justice agents—without police, without courts, without prosecutors—because they are just not making the move; they are the drag effect; they are the source of the problem, which he agreed is true in a lot of places. However, he offered the story of domestic violence in the United States over the past 30-40 years, and the police response to domestic vio- lence in this country, as a hopeful story to tell. Feucht characterized it as a story of the professionalism of the police in agencies across this country, where communities that would never have taken their problems to the police now go directly to them. The success includes community oversight boards and methods of accountability. Dr. Feucht stated that “the bad 

98 VIOLENCE PREVENTION IN LOW- AND MIDDLE-INCOME COUNTRIES news is that it has not been so long that policing and justice agencies in the United States have begun to emerge from the dark ages, but the good news is that it can be done.” Before turning the panel over to questions from the participants, Ms. Henry asked if there were some way we could form better partnerships between the federal agencies and the experts here in this room or among the recipients of the workshop report. She asked how the panel would best like to work with people who are interested in the report. She also queried about the kind of interaction that has been lacking to date and how to facilitate what is needed. Dr. Ferroni replied that this is linked to how he thinks about going upstream. IDB is an intergovernmental institution that works with govern- ment, but it consults with many others, including civil society. Many on the staff are development economists that are used to analyzing developmental issues. Traditionally the problem of crime and violence was not considered a developmental issue, but rather more the quintessential issue of infra- structure. Ferroni stated that the work of nongovernmental groups, such as what Ms. Burkhalter has been talking about, can over time widen the range of topics that those in the agencies can discuss officially with other governments. Dr. Blount reiterated CDC’s more circumscribed role of helping to build a case, testing interventions, monitoring and evaluating those interventions, and sharing that information with the public health community. He stated that using the Institute of Medicine’s workshop report to garner support and interest, both internationally and domestically, will be very important. Blount suggested that it is time to take what we already know, what we have reviewed together here over the last couple of days, and move toward both an international strategy, perhaps developed via the convening of WHO and others, and a domestic U.S. strategy, so that those in the United States can contribute to meeting the goals of an international strategy. He stated that the broad strategy would have to address the interests of the business community, the faith community, foundations, and nongovern- mental organizations. These are the people, in his estimate, who will make things happen, including at the level of the federal government. Blount stated that “the case has been made, but it needs to be made better.” Dr. Hill proposed the adoption of more inclusive strategies to address gender-based violence in both male and female behaviors and norms in several contexts. These contexts include health, human rights, educational needs of women and children, and participatory civil society. For example, the evidence suggests that women and girls who are abused don’t go to school. If interventions that focused on addressing the factors that promotes the violence against girls (i.e. sexual assault at or on the way to school), were integrated with programs that address the needs of women and girls, 

OPPORTUNITIES AND CHALLENGES 99 the likelihood of girls attending school may increase. Hill acknowledged that large, well-funded interventions already exist for many activities that address the needs of women and girls. He suggested that the group develop proposals in those areas that have a gender-based violence component, explaining how an intervention here will help them reach the objectives of those other interventions. Dr. Insel reminded the group about the tragic April 2007 shooting on a university campus by a young, psychotic student who killed 32 people, then himself. While many in the audience may be familiar with this story, Insel stated that what is probably not known is that in the same week, the same number of people died, at the same age—that is, college-age people—from suicide. Dr. Insel stressed that the same number of students die from ­suicide every week throughout the year but that these facts are not in anyone’s headline or on anyone’s newscast. He emphasized that there is a need to make sure that people understand what the data tell us, which is that when talking about violent death, whether in the United States or globally, it’s more likely to be self-directed than other-directed, and continued ignorance of this fact is at our own peril. Addressing this does not require a criminal solution, and 90 percent of these suicides are a reflection of having an ill- ness of the brain that is treatable. He identified this issue as a potential point of influence for the group where it could have a major impact by renewing the focus on thinking about this part of the problem, which is correctable, not so much through criminal deterrence as through simple medical intervention. For the most part, Insel noted that these interventions do not exist in the United States and aren’t even on the agenda in much of the developing world. Ms. Burkhalter replied that she would like to see the kind of rigor that was developed in the HIV/AIDS treatment movement and response applied to the kind of human rights interventions and infrastructure devel- opment that is required in judiciaries in poor countries. She stated that while many may be critical of the president’s global AIDS program, it has totally changed the landscape in terms of the rights of poor people to anti­ retrovirals and health. If donors could make that same kind of rigorous demand on justice systems that they want to help, then the question of human rights won’t disappear and an infrastructure can be built as we are doing for HIV/AIDS interventions. She identified the protection of orphans and vulnerable children as the area in which this can be done most quickly. Hundreds of thousands of children are grieving and they are uniquely vulnerable to abuse. From its work in the AIDS-burdened countries in sub- Saharan Africa—Rwanda, Uganda, Zambia, and Kenya—IJM sees govern- ments with some willingness to comply, good laws, and some infrastructure, but they lack a child protection system. Weekly, IJM receives multiple cases of children in foster care and institutional settings who are victims of sexual 

100 VIOLENCE PREVENTION IN LOW- AND MIDDLE-INCOME COUNTRIES abuse. She noted that Kenya, a case in point, has authoritative will, but no resources, no database, no capacity for follow-up, and no training or ­ability to recognize child sexual abuse. The WHO World Report on Violence and Health didn’t have much to say about deterrence and justice systems, but it did talk about the need for national planning. Burkhalter reiterated that lessons from the AIDS prevention and treatment movement showed that national planning, accountability, metrics, baselines, and money are neces- sary to build the infrastructure and capacity. QUESTIONS FROM PARTICIPANTS This section highlights the questions and the discussions around them. One question addressed the need for integrating efforts and developing a common agenda for violence prevention. While there seemed to be agree- ment on this notion, it was emphasized that a common agenda and strat- egy for violence prevention does not have to obliterate the differences between dealing with self-directed violence and other-directed violence: that is, between treating suicide as an illness of the brain, and requiring a criminal justice response and prevention work for issues of sexual violence and partner violence. It was suggested that this is one of the challenges of this workshop and figuring out how to use the subsequent summary to build this common agenda, while still respecting the individual differences that each of our agencies and perspectives brings. The issue of how much evidence is needed for action sparked further discussion since many of the presenters identified the need for more rigorous data collection and evalua- tion and pleaded for greater collaboration and funding from CDC, NIMH, and other government agencies to do this. The clarification provided by some panelists was that there is enough evidence, especially for prevention, to implement and test interventions in the United States and in developing countries without having to wait for all of the research related to these issues to be conducted. The evidence, it was pointed out, also makes a case for cost-effectiveness, as well as an ability to reduce family violence and improve outcomes even for the next generation, but this simply is not done—which is a tragedy—knowing something can be done and not apply- ing it. It was also suggested that if translation from research to practice cannot be pushed forward, then examining why it can’t could also be a research question that should attempt to resolve the conundrum. The next question that garnered a good deal of discussion dealt with the issue of agency and organizational flexibility in providing funding to civil society, nongovernmental organizations, and small communities and municipalities that have great initiatives and are trying to find solutions on their own, but need funding for implementation and evaluation. Some of the panelists indicated that they do have flexibility, but underscored 

OPPORTUNITIES AND CHALLENGES 101 the importance of working through central governments and ministries of finance to try to build capacity and sustainability, despite the bureaucracy and corruption that sometimes exist. In response to a query from the audience about collaboration, it was acknowledged among the panelists that their participation in this workshop session was the first time they have been “in the same room at the same time.” Multiple comments made it apparent that many in the room, includ- ing participants, were captivated by the potential of what could be accom- plished with a concerted amalgamation of the panelists’ programming and research portfolios, budgets, and expertise. The last question addressed the issue of ignoring the data about self-directed violence by asking about the potential impact of the Wellstone bill for mental health parity and the president’s New Freedom Commission report on the need to transform the mental health system of the United States. The response indicated that there are a great number of people in the mental health workforce, but the ­majority of them are not trained to do anything that has an evidence base to it. Addressing this workforce issue will not be easy and will require bringing on a new cohort of people who are actually trained to do what needs to be done. The importance of integrating mental health into the umbrella of primary health care, in a way that has not previously occurred, was also identified. In one panelist’s opinion, the irony of this workshop meeting did not go unnoticed because this integration happens much better in some countries than it does in the United States, which he likened to a Third World country in terms of the quality of care that is developed and the access to care that people have. This workshop meeting was one place where, interestingly, we could actually learn from other opportunities in global health, and he mentioned that an awful lot can be learned from the rest of the world about how to do this better. Lastly, it was commented that the human rights-based work that is being done should not be overlooked as part of the common agenda in terms of the opportunities it creates for recovery from trauma, healing, justice, and accountability for victims of violence.