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

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9 Taking Global Violence Prevention to the Next Step: Questions for the Workshop Participants Specific actions, tasks, and considerations were suggested by the p ­ anelists, but this chapter summarizes the suggestions from participants for moving violence prevention forward. Although the Institute of Medi- cine (IOM) does not make recommendations in workshop summaries, the participants were asked to provide feedback and suggestions for facilitat- ing global dialogue about violence prevention dialogue and movement on the global public health agenda. The suggestions that follow should not be construed as recommendations of or endorsement by the IOM and are the opinions of the workshop participants. The suggestions for action were obtained during group sessions in which participants were asked to respond to the following specific questions: (1) How do we make a strong case that the United States has an interest in preventing violence in the rest of the world in general and in developing countries in particular? (2) How do we get sustained commitment and support from funders, especially the U.S. government agencies and foundations that fund global health work, and expand the purview of key U.S. agencies that now focus solely on violence prevention within the United States? (3) What are the important research and programmatic priorities that should be undertaken to cre- ate a solid foundation for successful violence prevention? (4) How do we encourage collaborative efforts among nations, U.S. agencies, international agencies, and private enterprise to engage in the work of violence preven- tion? (5) What steps should be taken by U.S. agencies to truly implement the public health approach to violence prevention in developing countries? The sections that follow are summaries of the groups’ responses to those questions. 102 

TAKING GLOBAL VIOLENCE PREVENTION TO THE NEXT STEP 103 MAKING THE CASE FOR THE U.S. INTEREST IN PREVENTING GLOBAL VIOLENCE To address global violence generally and particularly in developing countries, participants suggested that economics, health, and security must be added to the moral imperative. These elements mirrored the presenta- tions of several of the panels. Several workshop presentations showed that violence affects trade and tourism, and diminishes economic viability and market stability. Participants made the economic argument that the U.S. is part of the global economy which depends on stability. Since violence hinders investment, especially foreign investments that are more likely to be made in stable, nonviolent states, which would be seen as “better investment climates,” violence prevention could be a compelling reason for greater U.S. economic interests. The groups felt it important to strengthen the “business” argument with more concrete figures for a country’s invest- ment in violence prevention (similar to World Bank and World Health Organisation [WHO] data). The health arguments were to portray violence as a risk factor and burden for other health issues (e.g., the huge impact on the spread of HIV/AIDS and its prevention, almost everyone acknowledged, cannot be accomplished without violence prevention). It was also suggested that violence prevention be incorporated into the public health agenda for maternal and child health. Popular messaging in the past around infectious disease management has stated that “viruses know no borders.” A tag line that includes violence was suggested: “Bacteria do not have passports, nor does violence.” In terms of human security, the participant groups focused on the role of violence as a destabilizing force for nations and how a cycle of vio- lence—interpersonal violence, collective violence, and terrorism—is created among unstable countries. Participants suggested that dialogue to confront the failed state argument for lack of intervention (e.g., Somalia) could be heightened and Rwanda could be seen or used as an example for success in acknowledgment of what transpired during the genocide, the provision of trauma counseling, and other activities. The groups noted that high-violence regions may cultivate individuals who reject U.S. or other outside inter- ventions, which necessitates collaborating with local leadership to avoid negative impressions and fear of what the U.S. motives are in supporting violence prevention measures. Migration was also added as an issue to be addressed in making the case since violence cannot be expected to remain localized and isolated, which underscores the vital interest in preventing violence in the United States. Additionally, the participants suggested that violence serves as a stimulus for illegal and legal immigration, and while greater countrywide stability discourages some citizens from leaving, the “brain drain” created by those who do leave paralyzes countries that most 

104 VIOLENCE PREVENTION IN LOW- AND MIDDLE-INCOME COUNTRIES need citizens in their technical and professional capacities. Finally, the par- ticipant groups stated that it can be important to address migration as part of the business argument because the U.S. workforce overseas incurs high costs on behalf of global violence. Communication strategies were also identified as part of the case- building argument and included things such as adding global violence as a focus to the upcoming Institute of Medicine (IOM) study on global health, a sequel to its previous report America’s Vital Interest in Global Health (IOM, 1997). Convention of an IOM consensus committee to study the issue of violence prevention in developing countries was suggested even though it takes time to organize, fund, and conduct such a study. This committee would be able to make recommendations that oftentimes carry more weight than a workshop of this nature. Other strategies sug- gested included establishing definitions that build on those of the World Report on ­Violence and Health (WHO, 2002a) to foster unity and facilitate m ­ ultilateral-­interorganizational dialogue and promote coalition building. In making a unified and consistent argument for violence prevention, it was emphasized that the argument must be tailored to those to whom the case is being made, with precise definitions of key issues and terms. GARNERING SUSTAINED COMMITMENT AND SUPPORT FROM U.S. AGENCIES AND ORGANIZATIONS This question asked participants to explore how to expand the purview of key U.S. agencies and organizations in the public and private sectors that may or may not focus solely on violence prevention within the United States or abroad, and how to secure sustained commitment and funding for global violence prevention. The groups’ suggestions for securing sustained funding commitments are targeted to three actors—the U.S. government, corporate and private philanthropy, and the advocacy community. For government, suggestions included taking advantage of the govern­ ment’s propensity to follow public opinion and establish a five-year advocacy strategy for major congressional commitment, advocacy for tax structures (federal and state) to have specific revenue attached to violence prevention (i.e., tourism tax), latching onto current initiatives already on the drawing board for government that can become the focused attention of grassroots advocacy, resurrecting the work done by government organizations to pre- vent gender violence, and considering the possibility of modifying the statu- tory authority with regard to federal agencies’ abilities to act globally. For corporate and private philanthropy, they suggested developing critical collaborations for capacity building and dissemination of tools Available at www.nap.edu. 

TAKING GLOBAL VIOLENCE PREVENTION TO THE NEXT STEP 105 and skills for long-term sustainability, identifying key stakeholders and sources of funds that can develop a viable business plan and measures to illustrate the value of violence prevention to their own corporate interests, and illustrating how sustained commitment can be conceptualized and made more manageable “in pieces” that make it attractive to potential funders. Other suggestions included broadening the focus of potential and emerging funders (i.e., women’s and human rights groups who might con- sider violence prevention as an area in which to “make their mark”) and recognizing good will, innovation, and effective interventions and efforts with global awards. For advocacy, the ideas included strategic use of alliances and interest groups by pairing professional associations with grassroots organizations, putting a human face on violence prevention when making the case and using the media to gain more widespread support, building a broader con- stituency, supporting Fran Henry and Global Violence Prevention Advocacy by formalizing relationships with an advisory board, and broadening the coalition (i.e., Carnegie Endowment). Other examples included support for the International Violence Against Women Act, which will be introduced in Congress, as well advocacy for the creation of a cabinet-level Depart- ment for Peace in the U.S. government, which is a current focus of the U.S. Institute for Peace. Finally, the groups suggested creating a national, government organiza- tion or agency dedicated to violence prevention that would serve as a unify- ing force and interact on an international level (i.e., partner with WHO), speak to national security issues internally and externally, address all types of violence, and have the seed money with which to start. They acknowl- edged that this entity would not necessarily have to be a government agency and queried whether it could be a business in the corporate sector with an appropriate plan similar to business plans for other ventures. IDENTIFYING RESEARCH AND PROGRAMMATIC PRIORITIES To create a solid foundation for successful violence prevention, the participant groups prioritized evaluating the cost-effectiveness and success of outcomes, meta-analyses of current data, archiving current international violence prevention data to serve as basis for future efforts, and listen- ing to people on the ground—learning from what has been successful in developing countries and what has been successful in the United States with symbiotic translations from “practice to research and research to practice.” Additional ideas included developing true partnerships, increas- ing investment in training for research and programs, assessing root causes of violence and the benefits of prevention, and compiling country-level data so that countries can make evidence-based decisions with the ­ethical 

106 VIOLENCE PREVENTION IN LOW- AND MIDDLE-INCOME COUNTRIES framework and capacity-building aspects for studies on suicide and child maltreatment using WHO (2005) Multi-Country Study on Women’s Health and Domestic Violence Against Women as a template. Other suggestions included an overall effort to create an infrastructure for a violence preven- tion movement by building a field or discipline, pursuing research infrastruc- ture grants and funding streams, archiving or warehousing best practices from around the globe, creating a pipeline for instituting relationships and collaborations between researchers and community members, and fostering a research infrastructure of those who are interested in inter­disciplinary violence prevention. Finally, the groups queried whether there is a need for a specialty—which they termed “vioelentology”—to provide interagency details to promote knowledge and dialogue that would include conferences to assess the impact of violence across the life span, including its economic burden and implications as a part of the specialty. ENCOURAGING COLLABORATIVE EFFORTS Participant suggestions included appealing to specific interests in varied sectors for violence prevention including faith-based organizations, civil society organizations, corporations, and government agencies; advocating for interagency details to promote knowledge and dialogue; and advocat- ing for a 10-year formal and funded cooperative agreement from the U.S. Agency for International Development to the Centers for Disease Control and Prevention (CDC), similar to the funding for the reproductive health agreement that would give CDC more funds and more of a mandate to pro- vide aid and tactical assistance to developing countries. The United Nations Special Representative on Violence Prevention was identified as a potentially important voice and platform to utilize. The participants’ most compre- hensive suggestion seemed to be to develop a plan of action that identifies countries that have supported violence prevention work to date and ensures that advocates and effective populations are “at the table” with businesses, nongovernmental organizations, governments, and ­others. The plan would also call together a representative sample of groups (not solely of academics) under the “violence umbrella” and ensure that research is participatory and would recognize the need for findings to be communicated in the vernacular back to the target community so that they are usable in real time. NEXT STEPS FOR U.S. AGENCIES TO IMPLEMENT THE PUBLIC HEALTH APPROACH The participants concluded their group work by making suggestions for specific next steps for U.S. agencies to implement the public health approach in violence prevention. To top the list, they suggested that con- 

TAKING GLOBAL VIOLENCE PREVENTION TO THE NEXT STEP 107 gressional, executive, or administrative authority and appropriations be given to U.S. agencies that engage in violence prevention work domestically to expand to an international focus. Next, conduct in-country analysis and use it as a guide for capacity building, inventory current efforts to document progress, identify gaps, and bring in other groups and other countries to develop more encompassing definitions and program efforts. This would ensure that there would be one place in which all of this information could be found, including the research and findings presented during this work- shop. Next, they suggested coordinated meetings between key agencies and serious consideration of establishing an interagency task force to focus on violence prevention. Lastly, they suggested targeting PEPFAR (President’s Emergency Plan for AIDS Relief) countries for violence prevention effort “add-ons” to current AIDS work. CONCLUDING OBSERVATIONS Pat Kelley, Mark Rosenberg, and Etienne Krug offered some thoughts about the workshop and the next steps. Dr. Kelley stated that the IOM report of this workshop’s proceedings would capture many of the ideas presented that might serve the larger scientific and implementing communi- ties in their efforts to move the agenda on violence prevention forward. He mentioned that the report might also serve the upcoming dialogue around the reauthorization of PEPFAR, as well as the IOM’s Board on Global Health for consideration in its future study portfolio. Dr Krug, on behalf of the World Health Organisation, stated this was a very important meeting because the latest evidence on what is known in the United States about violence prevention and the study of violence is of great interest to him and his colleagues. He also suggested that the way in which this workshop meet- ing was organized and done could become a model for repetition in other countries, because, he noted, the lack of involvement of the U.S. govern- ment can also be said for the governments of the United Kingdom, France, and many other donor governments. Dr. Krug stated that the follow-up to this meeting would be critically important and expressed his hope that the momentum and networking created during the workshop would spur Congress to empower U.S. agencies to do more in this field. He stated that the suggestions that the participants generated were considered valuable, but the most important to WHO would be for the United States Agency for International Development, the National Institutes of Health, the ­Centers for Disease Control and Prevention, and many other U.S. government agencies be empowered to technically, politically, and financially support international violence prevention efforts. Dr. Rosenberg talked about John Seely Brown’s four stages of knowl- edge development, through which he generated a scorecard to rate the 

108 VIOLENCE PREVENTION IN LOW- AND MIDDLE-INCOME COUNTRIES c ­ urrent violence prevention movement’s efforts. The first stage is generating knowledge—it involves research, discovery, and finding new things. In this stage, he gave a rating of “A–” because of the impressive findings of the last two decades to move this field forward. The second stage of dissemination is the spread of what we know—communications. This received a rating of “B–.” The World Report on Violence and Health was published and a lot of copies were disseminated, but he stated that most policy makers in the United States and around the world don’t really understand violence prevention; he acknowledged that adding the knowledge from the Institute of Medicine might help. Integration is the third stage, where existing knowl- edge on the same issue is brought together from different studies and fields. It involves bringing together different types of violence and the knowledge from violence prevention in different countries—the global south together with the global north, and the low- and middle-income countries with the wealthy countries. Finally, it involves integrating what we know about vio- lence prevention with what others have learned about other diseases. He gave this a “C” rating because of the great deal of work that remains, in his estimate, for knowledge integration. Rosenberg stated that this workshop meeting was good in bringing people together from different fields, but that integration of the National Institute of Justice, the people who work in policing and law enforcement, those who prosecute people after violence has been done, the people who build justice systems, those who work in health and public health, the people who work in sociology, and the anthro- pologists and psychologists is still needed to break down programmatic and institutional silos. Finally, Brown talked about application—using this knowledge to improve the world. Rosenberg rated this area a “D” because he stated that there is much to be done to counter both the madness that engenders so much violence and our lack of action as we professionally, personally, and societally witness its consequences when we know what can be done to prevent it.