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

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2 Setting the Stage WELCOMING REMARKS To open the workshop, Dr. Patrick Kelley noted that, as the subtitle of the workshop suggests, the problem of violence has not yet obtained its proper place on the global public health agenda. The Institute of Medicine (IOM) seeks to establish a firm scientific foundation for policy delibera- tions and holds many events that bring together the most expert minds in the world. In this instance, the workshop provided a unique opportunity for researchers and practitioners from multiple disciplines, working to pre- vent all types of violence (child abuse, elder abuse, self-directed violence, intimate partner violence, violence against sexual partners, and collective violence) to come together in one forum to present the most up-to-date research and engage in dialogue to identify common, crosscutting risk f ­ actors and synergistic approaches to prevention. Dr. Kelley also noted that in his own travels to Peru, he has observed firsthand the very violence represented by the statistics in the World Health Organization (WHO, 2005) Multi-Country Study on Women’s Health and Domestic Violence Against Women. That study identified an Andean prov- ince in Peru as having one of the highest rates of violence against women, with approximately 70 percent reporting the experience of physical or sexual violence or both in their lifetimes by intimate partners. Lower rates for these types of violence were reported in other countries in the study: the rates were 46 percent lower in Brazil and 76 percent lower in a city in Japan (WHO, 2005). He noted that using public health science to help understand the variance in these rates can lead to risk identification and prevention in 14 

SETTING THE STAGE 15 much the same way as public health has exploited such variations in cancer and other diseases to identify prevention strategies. He also noted that the interrelationship between sexual violence and sexually transmitted diseases, coupled with approximately 5 million new cases of HIV reported each year, dramatically highlights the important interconnection between HIV and violence prevention. As director of the IOM Board on Global Health, Dr. Kelley expanded on the board’s growing awareness that global health, and America’s vital interest in it, must be seen in a larger context than infectious disease preven- tion and management. The consequences of violence are transnational and transgenerational; they emphasize the need for America’s increased interest in and support for alleviating the burdensome toll and costs that pervasive violence disproportionately exacts on developing countries and their people. These consequences affect the political and economic stability of societies and their institutions; the ability of children to grow into productive adults capable of community and family leadership; and the ability of women to protect themselves from HIV/AIDS and other reproductive health problems. In conclusion, he identified the important role for workshop participants to disseminate its messages to those who can use the tools of public health and policy making, not only to elevate violence prevention to the center of the global public health agenda, but also to help identify how the U.S. government and other leaders with resources can more effectively support violence prevention programming. THE PUBLIC HEALTH APPROACH TO VIOLENCE PREVENTION Dr. Mark Rosenberg, the chair of the workshop planning committee, focused his opening remarks on differentiating the public health approach from that of health care; providing a brief, selective history of violence and public health; explaining the tenets of a public health approach; and lastly, exploring the relationships among different types of violence to help lay the foundation for the ensuing discussions. To begin, the major differ- ence between approaches is that health care is focused on providing help to those who present to its facilities, while public health is focused on the health of everyone—regardless of whether they are known to us, where they may live, the families to whom they belong, or whether they have yet to be born. The public health focus also takes into account what the 90 percent of people who bear the burden of interpersonal and self-directed violence in developing countries have faced for their survival and what they may face in the future. While many recognize the importance of treating the major epidemics that are ravaging the world to facilitate economic and social development, more must come to believe that these efforts must include violence prevention. 

16 VIOLENCE PREVENTION IN LOW- AND MIDDLE-INCOME COUNTRIES The history of violence and public health begins with the domestic violence movement started by women in the United States 35 years ago. Lessons from this movement taught that women in wealthy countries were also affected by violence and that partnerships with the victims affected by violence, their advocates, law enforcement, social services, public policy experts, psychologists, and experts from other sectors needed to be estab- lished as part of prevention efforts. Today, these partnerships must be with our neighbors to the global south and those from developing coun- tries. Around 1982, the director of the U.S. Centers for Disease Control (CDC; now the Centers for Disease Control and Prevention) realized that the burden of disease, disability, and injury in this country was no longer dominantly attributable to infectious diseases and that the organization’s programming needed reorientation. In its exploration of the causes of the burden of disease and disability, the CDC decided that violence would somehow have to be addressed. Thus the CDC Violence Epidemiology Branch was formed and, as a result, developed the public health approach. The three tenets of the approach were (1) a focus on prevention; (2) a focus on scientific methodology that would enable identifying the risk factors and patterns, and answering the questions of where violence occurred, who it affected and how, what could be done to prevent it, and how prevention efforts could be implemented; and (3) a focus on multisectoral collabora- tion in which public health would be only one of many partners. When the statement is made that violence is a public health problem, it is not one of sole ownership, but rather one that indicates that public health must be part of the solution by bringing to bear all of its tools and knowledge. Subsequently, in Dr. Rosenberg’s historical review, an advocate named Fran Henry, working to prevent child sexual abuse, approached the CDC and asked whether the newly developed public health approach could be used to prevent such abuse. At that time, she stated that the country’s method to address the issue was to intervene after the abuse had occurred and then put the child in therapy and incarcerate the perpetrators. She tested the public health approach by applying it to the work of an organization she started, Stop It Now! Its collaborative success changed the paradigm of addressing child sexual abuse by “going upstream” and identifying those at risk for perpetration and offering services to prevent the abuse. Next in the historic evolution, Etienne Krug, a young medical officer working in Angola and in Latin and Central America, in the course of his daily work, witnessed   As early as 1979, the U.S. Surgeon General issued a report Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention, in which injury control and violence were identified as a priority to improve the nation’s health, despite the Surgeon General’s recognition that health programs did not generally address the lifestyle and social risk factors associated with increasing rates of intentional injury (DHEW, 1979). 

SETTING THE STAGE 17 countless bodies of the victims of violence. He was also spurred to action by the thoughts of going upstream to focus on preventing the violence— staunching the rivers of bloodshed from violence and reducing the numbers of its victims. He arrived at the CDC to study the public health approach for several years and later went on to apply it on an international level by spearheading the violence and injury prevention work at the World Health Organization (WHO). In 2002, he and several international colleagues authored the World Report on Violence and Health, which presented data to examine the magnitude of the problem, provided definitions for the dif- ferent types of violence, and made recommendations for multisectoral and collaborative action to address the multifaceted nature of violence. “While individual initiative and leadership are invaluable in overcoming apathy and resistance, a key requirement for tackling violence in a comprehensive manner is for people to work together in partnerships of all kinds, and at all levels, to develop effective responses” (WHO, 2002a, pp. 1-2). In 2006, the Disease Control Priorities Project published its second edition of Disease Control Priorities in Developing Countries (DCP2). For the first time, a chapter was focused on interpersonal violence and how a public health approach can be used for its prevention. The last event in this time line is this workshop in 2007 to acceler- ate the prevention of self-directed (suicide) and interpersonal violence in low- and middle-income countries (LMICs) by advocating the described public health approach from discovery to delivery. The focus is on these types of violence because they are the ones about which we know the most. However, collective violence and armed violence cannot be ignored in their importance, but Dr. Rosenberg pointed out that the relationship among them requires further study. For example, child soldiers can return from war and often wreak havoc in their families via intimate partner violence and child abuse, while some forms of interpersonal and self-directed vio- The Disease Control Priorities Project is “an alliance of organizations designed to review, generate, and disseminate information on how to improve population health in developing countries.” The project also produced a number of major publications. Each product “mar- ries economic approaches with those of epidemiology, public health, and clinical medicine” (Jamison et al., 2006, p. xvii). The first edition of Disease Control Priorities in Developing Countries or DCP1 (Jamison et al., 1993), published in 1993, “aimed to provide systematic guidance on the selection of interventions to achieve rapid health improvements in an environment of highly constrained public sector budgets through the use of costs-effectiveness analysis.” It was a result of the World Bank’s review of priorities for the control of specific diseases as inputs for compara- tive cost-effectiveness estimates and analyses of intervention to address the conditions most important in developing countries. The second edition sought to “update and improve guid- ance on the ‘what to do’ questions in DCP1 and to address the institutional, organizational, financial, and research capacities essential for health systems to deliver the right interventions” (Jamison et al., 2006, p. xvii). 

18 VIOLENCE PREVENTION IN LOW- AND MIDDLE-INCOME COUNTRIES lence create instability that can increase the likelihood of war and conflict. Armed conflict in our discussions is different from collective violence and will be referred to as violence in which some sort of weapon is used. This has important implications for other types of violence—namely, youth, intimate partner, and self-directed violence—since an important interven- tion for common risk factors is reducing access to lethal weapons, weapons which increase the risk of fatal outcomes for all those types of violence. There are also dividends to investing in early childhood interventions, espe- cially if very, very young children are given the social, cognitive, emotional, and intellectual skills to help them fend off violence either as a perpetrator or as a victim later in life. To conclude, Dr. Rosenberg detailed the organizational thought pro- cesses of the planning committee and familiarized participants with the resultant materials for the workshop. Lastly, Dr. Rosenberg introduced the workshop’s keynote speaker, Mr. Stephen Lewis, former United Nations Special Envoy for HIV/AIDS in Africa, who would help participants see the faces of those whose lives may be improved through violence preven- tion efforts. KEYNOTE ADDRESS BY STEPHEN LEWIS Mr. Lewis began his remarks by acknowledging how much the defini- tion of violence encompasses and how difficult a subject it is to address. Violence as a result of conflict, he observed, is palpable and insistent in the modern world and leads to horrendous, but often repetitive, consequences that are captured by the media. His initial experience in the 1990s with armed conflict involved the coordination of a two-year global study led by Graça Machel for the United Nations, to examine the impact of armed conflict on children, which he found “desperately upsetting because of the extraordinary violations of children on every front—physical, sexual, emotional, and physiological—unbearable violations of their tiny and vul- nerable personae.” Everywhere there were armed conflicts—from Burundi to Cambodia to Colombia—the study recommended the appointment of a special representative of the Secretary-General for the United Nations to deal precisely, and in an ongoing fashion, with the prevention of these destructive instincts of others toward children. Lewis’s experience working with a two-year panel appointed by the Organization of African Unity to investigate the genocide in Rwanda was “one of the most eviscerating emotional experiences possible,” which he stated had a tremendous impact on the way in which he viewed these issues and the world around them. Gathered in a small, community-based clinic that provided networking and support for women who were victims and survivors of violent attacks and sexual assault, seven investigators were 

SETTING THE STAGE 19 asked if they would be willing to meet with three women to hear their personal stories. Three of the investigators met with these women in an abominably hot, very tiny room with three metal cots and a tin roof. The women, who occupied the cots, ranged in age from the late teens or early twenties to the forties. Although they differed in age, their experiences were similarly horrific—being raped and assaulted—sometimes repeat- edly, sometimes with blunt and sharp instruments to inflict more pain. All were left without hope. At least one contracted HIV and died two years later. One asked why women are constantly “asked to forgive and forget” when their perpetrators are allowed to remain free and unpun- ished; another stated that she would never be able to rid herself of the ever-present olfactory memories associated with being tied to a bed for three months and used as a “perpetual raping machine.” If the definition of violence were expanded to include intimate partner violence—whether sexual, physical, psychological, or emotional—the victims mount to huge numbers, which most societies and countries in the developed world are reluctant to acknowledge according to Mr. Lewis. The WHO study of women’s health and domestic violence [2005] and a study conducted by the non­governmental organization ActionAid indicate that large numbers of women around the world report experiencing violence during their first sexual encounter. From other data, the Ministry of Health in South Africa reported more than 50,000 rapes in 2005, and extrapolations of non­reported cases would produce numbers that are “hallucinatory.” Sexual violence against women, child sexual abuse, and elder abuse meet in an intersection of alarming new trends in some areas of Kenya. In these areas, staggering numbers of rapes are being reported monthly, and in April 2006, 46 rapes were reported. Half of the victims were under the age of 18 years, and half of these were under the age of 12. In this same intersection, the newest pattern to emerge from the statistics—young men brutally raping women between the ages of 65 and 80 years—the rapists were confident they would be protecting themselves from contracting HIV. Manifestation of this pervasive violence against women in every country partially defines the “madness that grips the world,” as it surely “destroys the soul and certainly the women.” Mr. Lewis emphasized that the direct relationships between sexual violence and HIV/AIDS and our inability to address violence prevention—the desperation “to find a microbicide or vaccine as a preventive technology that can do what behavior change has not been able to do”—is underscored. The cascading effects of this rela- tionship play a role in redefining the human family in parts of the world, as elderly grandmothers struggle in their attempts to parent their orphaned grandchildren; as pregnant mothers in Africa are unable to access drugs to prevent mother-to-child transmission of HIV; and as children infected with HIV have little access to lifesaving drugs and treatment. 

20 VIOLENCE PREVENTION IN LOW- AND MIDDLE-INCOME COUNTRIES His travels through Rwanda, Uganda, and Sierra Leone would have him bear witness to the effects of genocide and other forms of collective violence on children by viewing pages and pages of their startlingly similar art therapy drawings—men holding machetes and blood dripping down the pages; through his meetings with children in Uganda who had been abducted to become soldiers or sex slaves; and remembrance of the muti- lation of 20,000 children made amputees by the Radical Force “in order to cow the population into subservience.” The physical and mental effects of this kind of violence on the functional development of these children, if they indeed survived the ordeal at all, were visibly present in the scars that marred and mutilated their bodies, the anger in their eyes and faces, and the trauma-induced ­mutism that prevented them from even describing their ordeals. He also posited that ignoring epidemics of preventable illness in children can be seen as a form of maltreatment of children, citing data from a Save the Children publication that 28,000 children die each day and 10 million each year from preventable illness. Mr. Lewis suggested that these data contribute to the complex explanation of the declines of many of the hard-won gains in child survival around the world since the 1980s. The horror in the slaughtering of 800,000 people in Rwanda in 1994, without international intervention, is relived now in Darfur where, within four years, there have been a quarter of a million deaths and unparalleled campaigns of sexual violence and rape. Still, in his observation, the 13-year- old promises of the international community for vigilance to prevent recur- rences of such “human depravity and dementia” are unmet. He queried whether there is a “subterranean racism at work in all of this” that regards the peoples of Africa who, in his experience, have such generous spirit, intelligence, sophistication, and decency, as so “profoundly expendable over such a long period of time.” Lewis stated that in many parts of the moder- ate and low-income world, societies feel under siege—as if coming apart at the seams with the imminent possibility of disintegration. An underlying part of much of the violence, Stephen Lewis stated, is acute and overwhelming poverty, where nearly 2.5 billion people globally subsist on anywhere from less than $1 per day to $750 per year. Violence can be seen in the context of economic development. He pointed out that the first Millennium Development Goal of the United Nations, which seeks to reduce poverty and hunger by 50 percent by the year 2015, speaks directly to the resultant consequences of their relationship. He also reviewed how international financial aid policies of the last 20-30 years, including condi- tions that reduce access to health care and education, may have contributed to the disintegration of the fabric of many different societal sectors and directly or indirectly induced individual and broader society violence. In conclusion, he enumerated a number of items that he felt are signifi- cant for elevating the issue on the global agenda. The first was the need for 

SETTING THE STAGE 21 political leadership and increased financial support from the United States and the rest of the Group of 8 (G8) countries, which must be held account- able to keep their promises, whether for foreign aid or trade, to ameliorate the human condition. Betrayal of these promises, he stated, “compels much of the world to live in a constant environment of violence.” Attention must be given to addressing the relationships between poverty, violence, and disease—as much, in his opinion, as the amount of attention and resources that go to supporting wars in the Middle East. The second item is support of the recommendation for a full, international agency as part of the United Nations, with an Under-Secretary-General and reasonable fiscal resources, that would give women activists the capacity to have an impact and would diminish the violence against women. The third item calls for organizational leadership, particularly from the United Nation’s Children’s Fund, to use its power on the ground and in relationships with governments to engage in the work that will prevent the violence inherent in situations in which so many children live and are found. The final item highlights the need for engaged advocacy, on all fronts, to make these issues come alive in a real and consistent way for the public, elected officials, and the media—thereby transforming them into an international movement.   The Group of Eight (G8) is an international forum for the governments of Canada, France, Germany, Italy, Japan, Russia, the United Kingdom, and the United States. Together, these countries represent about 65 percent of the world economy and the majority of global mili- tary power (7 of the top 8 positions for military expenditure, and almost all of the world’s active nuclear weapons). The group’s activities include year-round conferences and policy research, culminating with an annual summit meeting attended by the heads of government of the member states. The European Commission is also represented at the meetings. Source: http://en.wikipedia.org/wiki/G8.