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VIOLENCE, HEALTH, AND DEVELOPMENT

Richard Matzopoulos1

Brett Bowman2

Alexander Butchart3,4

Executive Summary

The burden of violence-related deaths is heaviest in low- to middle-income countries (LMICs). Less than 10 percent of all violence-related deaths occur in high-income countries (HICs), and LMICs have a mortality rate due to violence that is almost two-and-a-half times greater than for high-income countries. Over and above the substantial contribution of violence as a cause of death and physical injuries, victims of violence are also more vulnerable to a range of mental and physical health problems.

1

Richard Matzopoulos is a Researcher at the the University of Cape Town School of Public Health and Family Medicine, and a Specialist Scientist at the MRC/UNISA Crime, Violence and Injury Lead Programme in South Africa.

2

Brett Bowman is a Senior Researcher in the Discipline of Psychology at the School of Human and Community Development of the University of the Witwatersrand, Johannesburg, South Africa.

3

Alexander Butchart is the Coordinator, Prevention of Violence in the Department of Injuries and Violence Prevention of the World Health Organization, Geneva, Switzerland.

4

The findings and conclusions of this paper are those of the author and do not necessarily represent the views of the World Health Organization.

Terms of reference

The following paper was prepared as a scoping document for participants of the two-day workshop hosted by the Institute of Medicine in Washington DC from 26 to 27 June 2007: Preventing Violence in Low- and Middle-Income Countries: Finding a Place on the Global Health Agenda. The contents are those of the autho(s) and do not necessarily reflect the opinions or positions of the Institute of Medicine.



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20 APPENDIX C VIOLENCE, HEALTH, AND DEVELOPMENT Richard Matzopoulos1 Brett Bowman2 Alexander Butchart3, 4 Executive Summary The burden of violence-related deaths is heaviest in low- to middle- income countries (LMICs). Less than 10 percent of all violence-related deaths occur in high-income countries (HICs), and LMICs have a mortality rate due to violence that is almost two-and-a-half times greater than for high-income countries. Over and above the substantial contribution of vio- lence as a cause of death and physical injuries, victims of violence are also more vulnerable to a range of mental and physical health problems. 1Richard Matzopoulos is a Researcher at the the University of Cape Town School of Public Health and Family Medicine, and a Specialist Scientist at the MRC/UNISA Crime, Violence and Injury Lead Programme in South Africa. 2Brett Bowman is a Senior Researcher in the Discipline of Psychology at the School of Hu- man and Community Development of the University of the Witwatersrand, Johannesburg, South Africa. 3Alexander Butchart is the Coordinator, Prevention of Violence in the Department of Injuries and Violence Prevention of the World Health Organization, Geneva, Switzerland. 4The findings and conclusions of this paper are those of the author and do not necessarily represent the views of the World Health Organization. Terms of reference The following paper was prepared as a scoping document for participants of the two-day workshop hosted by the Institute of Medicine in Washington DC from 26 to 27 June 2007: Preventing Violence in Low- and Middle-Income Countries: Finding a Place on the Global Health Agenda. The contents are those of the autho(s) and do not necessarily reflect the opin- ions or positions of the Institute of Medicine.

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202 APPENDIX C Although the effects of violence on other health outcomes are less well documented, some highly prevalent forms, such as child maltreatment, inti- mate partner violence (IPV), and abuse of the elderly, have been shown to have numerous noninjury health consequences. These consequences include high-risk behaviors such as alcohol and substance misuse, smoking, unsafe sex, eating disorders, and the perpetration of violence. These behaviors in turn contribute to such leading causes of death as cardiovascular disorders, cancers, depression, diabetes, and HIV/AIDS. The social toll of violence is further exacerbated by economic costs that represent formidable threats to fiscal growth and development. Several studies describe the deleterious impact of different types of vio- lence on a range of health outcomes, but no review has yet been undertaken that presents a composite overview of the current state of knowledge. This paper aims to review the scientific literature describing the nature, magni- tude, and impact of violence on health and development in LMICs. It has the following specific objectives: • To review the literature on violence in LMICs according to the typology commonly used by international agencies such as the World Health Organisation (WHO) • To describe what is known about the negative impacts of violence on health and human development in LMICs • To examine available information about the economic costs and impacts on economic development of violence in LMICs • To describe violence prevention policy developments within the global health and development agenda The paper includes a review of recent research on violence in LMICs around seven subtypes of violence: (1) child abuse and neglect, (2) youth vio- lence, (3) intimate partner violence (IPV), (4) sexual violence, (5) abuse of the elderly, (6) self-directed violence, and (7) collective violence, and discusses its broader implications and macro-level impacts on health and development. Child Maltreatment and Other Violence Directed at Children Homicide rates are considerably higher in LMICs than in HICs among older children: 2.6 times higher among boys aged 5 to 9 years, 3.6 times higher among girls aged 5 to 9, and more than 4 times higher among chil- dren aged 10 to 14 for both sexes. Sexual and physical abuse experienced during childhood are just some of the numerous psychological and behav- ioral factors endemic in many LMIC settings that may predispose children and young adults to display violent and aggressive behavior later in life and have been shown to have substantial long-term effects on health.

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20 APPENDIX C Youth Violence Countries with the highest adolescent homicide rates are either develop- ing countries or those experiencing rapid social changes. Among children aged 15 to 17 years male homicide rates in LMICs were three times higher than in HICs, and female rates in LMICs more than double those in HICs. There is an increased risk of violence in populations where adolescents and young adults are overrepresented and, as is the case in LMICs, may include a large percentage of “marginalized youth” with poor prospects of educa- tion and employment. Intimate Partner Violence Many of the risks associated with a man’s likelihood of abusing a female intimate partner are prevalent in low-income settings and some of the highest rates of IPV have been recorded in LMICs. Sexual Violence The true extent of sexual violence is difficult to gauge within HICs as well as in LMICs, as statistics on rape and indecent assaults are typically underreported. Nevertheless, there are indications that rates of sexual vio- lence in LMICs are substantial. Abuse of the Elderly Most research on violence against the elderly has been conducted in HICs. While more descriptive work in the area is required, there is growing evidence to suggest that the elderly are also frequently victims of violence in LMICs. Self-Directed Violence Suicide was the leading cause of death due to violence in LMICs in 2002, although it accounted for a smaller percentage of all deaths due to violence in LMICs than in HICs. Collective Violence Collective violence is an endemic and enduring feature of many LMICs. The hallmark of countries that have been at war is a combination of poverty, strained economic and social infrastructure, and severely eroded health services. Collective violence is restricted almost entirely to LMICs,

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20 APPENDIX C with particularly high rates experienced in Africa followed by the Eastern Mediterranean and LMICs in the European region. The Impact of Violence on Health Violence has numerous impacts on health and these can be measured in a variety of ways. The most common and direct ways of measuring its impact are in terms of the numbers and rates of deaths and injuries it causes. Although less easy to measure, violence also has important impacts on a range of mental and physical health problems. It is important and use- ful to quantify these various impacts in both health and economic terms. The Burden of Injury Estimated mortality rates compiled by WHO for 2002 suggested that overall mortality rates due to violence in LMICs were on average more than double those of HICs. Violence is also projected to increase in rank from the 15th to the 13th leading cause of death between 2002 and 2030 with middle-income countries likely to bear most of this burden. The Burden of Violence on Other Causes of Ill Health The impact of violence on other health outcomes is clearly reflected in comparative risk assessment studies, which show that standard burden of disease measures underrepresent the impact of interpersonal violence by at least 26 percent for deaths and 30 percent for disability-adjusted life-years (DALYs) when its contribution to other health outcomes resulting from child sexual abuse and IPV are taken into account. The Economic Impact of Violence on Health The direct costs (or impacts) of violence include the medical costs related to the treatment of the victims of violence and nonmedical costs associated with prevention. Indirect costs include those that are tangible such as the impact of violence on the broader macro economy and those that are intangible such as those relating to quality of life. Based on exist- ing estimates primarily calculated in South Africa, the Caribbean, and Latin America, it is clear that the costs of violence are enormous in LMICs. Overall, WHO reports that health care expenditure related to violence consumes a significant portion of gross domestic product (GDP) in LMICs. These direct health expenditures represent just a fraction of violence-related costs and impacts.

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20 APPENDIX C The Impact of Violence on Development Collective, interpersonal, and self-directed violence all have extensive and pervasive long-term implications for development as well as health. These effects are themselves multilayered and can therefore undermine devel- opment at individual, communal, or national levels. This paper describes the impact of violence in relation to all eight goals of the Millennium Development Plan. The impact of violence on the Millennium Development Goals (MDGs) must also be read alongside growing evidence that demon- strates the negative, enduring effects of exposure to violence in childhood. The Economic Impact of Violence on Development Violence in whatever form absorbs sizeable amounts of health care expenditure that could be better used to prevent other forms of health threat. Although data are limited, health economic research on violence has begun to demonstrate the substantial economic impacts of violence in LMICs. National spending on collective violence in the form of “defense” budgetary allocations and investment in postconflict recovery have been shown to lead to drastic reductions in national investment in health care services. The Emergence of Violence Prevention as Part of the Health and Development Agenda There are clear indications that violence prevention is an emerging pri- ority in the global health and development agenda, particularly in LMICs. Since the publication of the World Report on Violence and Health, there have been two World Health Assembly resolutions calling on countries to invest in violence prevention, and by 2006 three out of six WHO regional committees (Africa, the Americas, and Europe) had adopted simi- lar resolutions. Conclusion Violence is a pressing global health concern and is inextricably linked with a range of other health indicators. Yet despite the fact that early pro- jections indicate that violence is on the increase, vigorous and concerted violence prevention efforts can turn this trend around. International devel- opment partners may have an important role to play in providing financial and technical support for intersectoral collaboration, multilateral research cooperation, and the development of research capacity in LMICs.

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20 APPENDIX C Background and Overview Violence is a global problem. In 2002, violence claimed approximately 1.6 million human lives and caused at least another 16 million injuries severe enough to warrant medical attention. These consequences burden health systems, cripple communities, and are responsible for immeasur- able human suffering. The burden of violence-related deaths is heaviest in LMICs. Less than 10 percent of all violence-related deaths occur in HICs (Krug et al., 2002; Mathers et al., 2002), and LMICs have a mortality rate due to violence that is almost two-and-a-half times greater than for HICs (see Figure C-1). Over and above the substantial contribution of violence as a cause of death and physical injuries, victims of violence are also more vulnerable to a range of mental and physical health problems. The size of the violence problem can be better appreciated when it is compared to other major health threats. The estimated 1.6 million deaths due to violence in 2002 was around half the number of deaths due to HIV/ AIDS, roughly equal to deaths due to tuberculosis, greater than the number of road traffic deaths, and 1.5 times the number of deaths due to malaria. Suicide was the leading cause, accounting for 870,000 or 54 percent of violent deaths; homicide accounted for 560,000 deaths (35 percent) and the remaining 170,000 deaths (11 percent) were the direct result of war (Krug et al., 2002). Although the effects of violence on other health outcomes are less well documented, some highly prevalent forms, such as child maltreatment, IPV, and abuse of the elderly, have been shown to have numerous noninjury health consequences. These consequences include high-risk behaviors such as alcohol and substance misuse, smoking, unsafe sex, eating disorders, and the perpetration of violence. These behaviors in turn contribute to such leading causes of death as cardiovascular disorders, cancers, depression, diabetes, and HIV/AIDS. The social toll of violence is further exacerbated by economic costs that represent formidable threats to fiscal growth and development (Krug et al., 2002; Felitti et al., 1998; Waters et al., 2005). Aim and Objectives Because a composite review of the literature on the relationships between various types of violence and health and development in LMICs has not yet been undertaken, this paper aims to review the scientific litera- ture dealing with the magnitude and impact on health and development of violence in LMICs, and has the following specific objectives: • To review the literature on violence in LMICs according to the typology commonly used by international agencies such as WHO

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207 APPENDIX C 32.1 All violence 14.4 10.1 Homicide 2.9 15.5 Suicide 11.4 6.2 War 0 High-income countries Low- and middle-income countries FIGURE C-1 Estimated mortality rate per 100,000 population from violence by income level, 2000. SOURCE: Mathers et al., 2002. Figure C-1 • To describe what is known about the negative impacts of violence on health and human development in LMICs • To examine available information about the economic costs and impacts on economic development of violence in LMICs • To describe violence prevention policy developments within the global health and development agenda Scope and Limitations of This Paper The review of literature is limited primarily to English language publi- cations and the authors welcome suggestions regarding additional texts and resources that may be relevant.

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20 APPENDIX C The Nature of Violence in LMICs The World Report on Violence and Health (Krug et al., 2002, p. 5) defines violence as The intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation. The following subsections review recent research on violence in LMICs according to seven subtypes of violence also identified in the World Report on Violence and Health, namely (1) child abuse and neglect, (2) youth vio- lence, (3) IPV, (4) sexual violence, (5) abuse of the elderly, (6) self-directed violence, and (7) collective violence. The broader implications of violence and its macro-level impacts on health and development are discussed in Sections 3 and 4. It is noted that while this categorization is useful for describing violence and identifying prevention opportunities, the different subcategories are not mutually exclusive and there are strong links between different types of violence. For example, child maltreatment victims are more likely than nonvictims to experience IPV, sexual violence, and youth violence, while perpetrators of homicide where the victim is another family member are at substantially increased risk of later committing suicide. Similarly, the collec- tive violence of war and civil unrest may be precipitated by overwhelming levels of severe interpersonal violence; and some effects of collective violence, such as increased access to firearms and erosion of nonviolent value systems, increase the risk of interpersonal violence. Crosscutting these causal links between the different subtypes of violence are shared risk factors—such as alcohol and substance misuse, parental loss, crime, household poverty, and social and economic inequalities—that underlie most of the subtypes. Child Maltreatment and Other Violence Directed at Children Among children younger than 4 years of age, death rates due to vio- lence in LMICs are comparable with rates in HICs, although closer analysis shows that, whereas rates of homicide among boys in this age category are 10 percent lower in LMICs, the homicide rate among girls is 20 percent higher. There are also distinct regional differences, with homicide rates among African children more than double the global average for both boys and girls (Krug et al., 2002, p. 357). However, homicide rates are consider- ably higher in LMICs than in HICs among older children: 2.6 times higher among boys aged 5 to 9 years, 3.6 times higher among girls aged 5 to 9, and more than 4 times higher among children aged 10 to 14 for both sexes.

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20 APPENDIX C Data on nonfatal child maltreatment in LMICs are, unfortunately, limited, as they are derived from studies that use different definitions and assessment methods. Nevertheless, there is growing consensus on the definition of child maltreatment (Leeb et al., 2007; WHO and ISPCAN, 2006) and the development of recent surveillance guidelines for child mal- treatment should ensure better comparability between future studies (Leeb et al., 2007). Despite the current methodological challenges, what we can deduce from the available data is that child maltreatment is indeed a widespread and serious problem. Physical child maltreatment often associated with punishment by parents or other caregivers has been examined in a number of LMICs. In a study of students aged 11 to 18 in the Kurdistan Province of the Islamic Republic of Iran, 38.5 percent reported experiencing mild to severe physical injuries from abuse at home (Stephenson et al., 2006). In a survey of households in Romania 4.6 percent of children reported suffering severe and frequent abuse and nearly half of Romanian parents admitted to beating their children regularly (Browne et al., 2002). In Ethiopia 21 per- cent of urban and 64 percent of rural school children reported bruises or swellings on their bodies from being physically punished by their parents (Ketsela and Kedebe, 1997). Among younger children, serious injuries most frequently arise as a consequence of head injuries or injuries to the internal organs, often at the hand of a caregiver. Shaken infant or shaken impact syndrome is a potentially devastating form of child abuse. The physical, medical, and emotional neglect of children is also an important dimension of child maltreatment. In many countries it is the most frequently reported form of maltreatment. In Kenya, for example, the forms of abuse most commonly cited by adults in selected communities were abandonment and neglect (African Network for the Prevention and Protection Against Child Abuse and Neglect, 2000). Young children and infants may also be the victims of sexual abuse, but findings from descriptive studies point to the increased risk of sexual abuse among girls with the onset of adolescence, whereas among boys this vulnerable period is marked by a much increased likelihood of engaging in physical violence. Data from a children’s hospital in Cape Town, South Africa, for example, show that whereas boys accounted for a greater per- centage of cases presenting for violence-related injuries (63 percent), sexual assaults were the cause of injury among 48 percent of girls compared to only 3 percent of boys (Matzopoulos and Bowman, 2006). However, such findings cannot be generalized. Another South African study, this time among secondary school students in the Limpopo Province, reported a prevalence rate of 54 percent of the total sample reporting con- tact sexual abuse before the age of 18 years with similar rates for males and females (Madu and Pelzer, 2001). Lalor (2004) points to rapid social

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20 APPENDIX C change, the patriarchal nature of society, and HIV/AIDS as both a cause and consequence of sexual exploitation of children in sub-Saharan Africa. In other LMIC settings many studies reveal lower rates. For example, in a study across three Latin American countries (El Salvador, Guatemala, and Honduras), the percentage of women reporting being sexually assaulted before the age of 15 years ranged from 4.6 to 7.8 percent (Speizer et al., n.d.). However, the intimate nature of child sexual abuse, which often involves close family members and acquaintances as victims and perpetra- tors, along with cultural norms and taboos that may discourage disclo- sure, compromises the collection and comparison of data across different settings. Sexual and physical abuse experienced during childhood are just some of the numerous psychological and behavioral factors endemic in many LMIC settings that may predispose youths and young adults to display violent and aggressive behavior later in life (Karr-Morse and Wiley, 1997), and have been shown to have substantial long-term effects on health (see Section 3.2). In addition to these impacts of direct victimization, children exposed to violence as witnesses and bystanders may also be psychologi- cally traumatized. In South Africa, for example, a study of Xhosa-speaking youth in a township with high levels of community violence showed that all of the 60 respondents had been exposed to community violence, while 56 percent had been victims and 45 percent had witnessed at least one murder. The psychological imprint of these experiences manifested in 22 percent of these children fitting the diagnosis for posttraumatic stress disorder, 32 percent for dysthymia, and 7 percent for major depression (Ensink et al., 1997). Domestic violence also has direct effects on children, with one study suggesting that a substantial proportion of unintentional injuries in young children may have occurred in the course of their being used as “shields” by women attempting to protect themselves from physical attack by their male partners (Fieggen et al., 2004). Youth Violence Age and sex are important risk factors for interpersonal violence, with males in particular being more likely to engage in physical violence during adolescence and young adulthood. Consequently there is a sharp increase in the rate of aggressive behavior and victimization from the age of about 15 years. In LMICs this is compounded by underresourced educational systems and the fragility of traditional family and community structures that create an enabling environment for violence within homes and commu- nities. Invariably, the countries with the highest adolescent homicide rates are either developing countries or those experiencing rapid social changes (Pinheiro, 2006, p. 287).

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2 APPENDIX C Among children aged 15 to 17 years, male homicide rates in LMICs were three times higher than in HICs, and female rates in LMICs more than double those in HICs. In every region homicide rates among children aged 15 to 17 compared to those aged 10 to 14 are at least three times greater among males and nearly double among female children (Pinheiro, 2006, p. 287). Nevertheless, there are sharp regional differences, with Africa recording the highest rates among girls across all age categories and among boys aged 10 to 14 years, whereas the highest fatality rates among boys aged 15 to 17 were recorded in the Latin American and Caribbean regions, followed closely by Africa (Pinheiro, 2006, p. 357). The Latin American, Caribbean, and African regions have a large population under the age of 25, many of whom are raised in poverty, and rates of interpersonal violence are among the highest in the world (see Figures C-2 and C-3). Living off the informal economy and without family structures there is little hope of these children being integrated into formal society (Maddaleno et al., 2006). It is estimated that adolescents from 10 to 19 years of age comprise a third of all homicides in the Americas (PAHO, 2003) and globally rates of fatal violence are higher among 15- to 19-year- olds than in other 4-year age groups (Pinheiro, 2006, p. 287). In South Africa, a cross-sectional study revealed that more than 50 per- cent of all boys and girls had experienced violence, either as victims or perpetrators (Swart et al., 2002). In the Lavender Hill and Steenberg areas in Cape Town, over 70 percent of a sample of primary school children Caribbean 30 Southern and West Africa 29 South Africa 26 East and Southeast Asia 22 Central America 22 Eastern Europe 17 Central Asia 9 East Africa 8 North America 7 South Asia 4 Southeast Europe 3 Oceania 3 West and Central Europe 2 North Africa 1 Middle East and Southwest Africa 1 0 5 10 15 20 25 30 35 FIGURE C-2 Murder rates by region of the world. SOURCE: UN Crime Trends Survey and Interpol, 2002. C-2

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2 APPENDIX C hospitals, and social development. Significantly, military spending as a per- centage of GDP is associated with economic slowdowns across countries. This is alarming as many researchers have pointed to the changing nature of insecurity over the last couple of decades. Human security threats no longer take traditional cross-border forms but are predominantly within nations (Jolly, 2004). In Africa, war and conflict have been shown to consume a startlingly significant portion of GDP (Table C-5). In 2005, spending on the military amounted to US$ 7.2 billion in sub-Saharan Africa in 2005 (Omitoogun, 2001). However, military expenditure does not paint a complete picture of total war costs. For example, a case study of the war in Sri Lanka showed that military spending accounted for just over half of the total costs of the war. Studies in both Jamaica and South Africa have demonstrated that vio- lence (in the form of violent crime) represents a substantial cost to business (NEDCOR Project, 1996; Francis et al., 2003). Global estimates suggest that crime and violence together cost approximately 14 percent of GDP in LMICs. This is almost three times more than the 0.5 percent of GDP calculated as the cost of violence in HICs (Pfizer, 2001). The multiplier effects of this disparity are significant. The Inter-American Development Bank estimated that GDP in Latin American countries would be 25 percent higher if rates of violence were equal to global rates (Londoño and Guerrero, 1999). TABLE C-5 The Burden of Military Expenditure as a Share of GDP in 10 Countries with the Highest Milex: GDP Ratio in Africa 1991-1999 Countries 1991 1992 1993 1994 1995 1996 1997 1998 1999 Algeria 1.2 2.2 2.6 3.2 3.0 3.3 3.7 4.0 3.8 Angola 6.8 12.0 12.5 19.8 17.6 19.5 22.3 11.4 23.5 Botswana 4.4 4.3 4.5 3.9 3.5 2.9 3.1 3.7 3.4 Burundi 3.8 3.6 3.7 3.9 4.2 5.7 6.3 5.9 6.1 Djibouti 5.9 6.1 5.6 5.4 5.1 4.2 4.5 4.4 No data Eritrea No data No data 21.4 13.0 19.9 22.8 13.5 29.0 22.9 Ethiopia 2.0 2.7 2.9 2.4 2.0 1.9 3.4 5.1 9.0 Morocco 4.1 4.3 4.4 4.9 4.7 3.9 No data No data No data Rwanda 5.5 4.4 4.6 3.4 3.9 5.2 4.1 4.3 4.2 Zimbabwe 3.8 3.7 3.4 3.3 3.6 3.2 3.4 2.7 3.4 SOURCE: Omitoogun (2001).

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27 APPENDIX C The Emergence of Violence Prevention as Part of the Health and Development Agenda Despite the numerous and substantial impacts as a direct and indirect result of violence, it has received limited attention on the global health agenda. Violence is mentioned only once in the World Bank’s seminal publi- cation, The Millennium Development Goals for Health: Rising to the Chal- lenges, despite its extensive influence on all eight of the millennium goals, as described in Section 3 of this paper. However, there are indications of an increasing awareness among policy makers of the role that violence plays in undermining international health and development, and the potential of violence prevention as a means of reducing these destructive effects. Two recent World Bank reports consistently highlight violence as a fundamental threat to human development. A World Bank publication focused on using participatory methods to foreground the perceptions, needs, and experi- ences of the poor. The report emphasizes violence as a much-cited every- day reality and constant threat to the potential development of the poor (Narayan, 1999). The 2007 World Bank report on Human Development cites numerous examples of the way that violence compromises individual development (World Bank, 2006). Many LMICs have lobbied for violence prevention to receive increased prioritization and are favorably disposed to the recommendations emanat- ing from violence prevention agencies. South Africa, emerging from decades of apartheid rule, was initially at the forefront of the movement tabling res- olution 94.5 at the end of its tenure in chairing the World Health Assembly in 1994. More recently the African Union adopted the recommendations of the World Report on Violence and Health in declaring 2005 the “African year of violence prevention.” LMICs have also played host to two World Conferences on Injury Prevention and Safety Promotion, in India in 2000 and in South Africa in 2006. The conference will be hosted for a third time in an LMIC in Mexico in 2008. The emergence of violence within the health and development agenda can in part be ascribed to the role played by the World Health Assembly and partner organizations in driving violence prevention and injury preven- tion in general, an initiative that has seen injury-related topics being the focus of two World Reports in the last 5 years: namely the World Report on Violence and Health and the World Report on Road Traffic Injury Pre- vention. Since the publication of the World Report on Violence and Health there has been a World Health Assembly resolution (WHA49.25) calling on countries to invest in violence prevention, and by 2006 three out of six WHO regional committees (Africa, the Americas, and Europe) had adopted similar resolutions.

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2 APPENDIX C The inclusion of violence prevention on the agenda of other multilateral agencies is also a useful indication of its emergence as a global priority. The World Bank’s Disease Control Priorities, for example, includes a single chapter on all of injuries and violence in its first edition in 1993, whereas the second in 2006 had an entire chapter dedicated to interpersonal violence alongside another entire chapter that addressed unintentional injuries and a third chapter on trauma care. The United Nations General Assembly has also reviewed special reports on violence against children and violence against women, which have resulted in resolutions calling for greater invest- ment in multisectoral efforts to address these forms of violence. Conclusion This paper has demonstrated that violence is a global health issue of especial concern to LMICs, and that violence is inextricably linked with a range of other health indicators. Yet, despite current projections indicating that violence in LMICs (as a result of both interpersonal and collective vio- lence) is set to become an increasingly important threat to health, vigorous and concerted violence prevention efforts can arrest this trend. While there are indications that violence prevention is also gaining more prominence in LMICs, it will need to be integrated and institutional- ized within government ministries if it is to be successfully implemented. An important first step would be for the improvement of data systems and research on the economic and other social costs of violence in LMICs so that violence can be better framed and understood as an issue well beyond social order and “law enforcement.” Ongoing support of intersectoral collaborative forums is one of sev- eral areas that could benefit from development aid and the involvement of international development partners, as this is an area where many LMIC governments are underskilled. Also, much of the research and evidence relating to violence prevention arises from a small number of HICs. This imbalance needs to be addressed as LMICs may require a different set of interventions. This could be facilitated by the availability of more funding and the development of mechanisms to support and sustain equitable multi- lateral research cooperation. Another key requirement is the development of research capacity within research organizations and among implementing agencies in the criminal justice, policing, and social development sectors, which may require the establishment of a program or fund for research, capacity development, and exchanges and/or placements. A fund could also be established to support the education of public-sector managers in LMICs in fields related to violence prevention (public health, psychology, sociology, criminology, biostatistics, and other related disciplines) with conditions to ensure their

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2 APPENDIX C continuing work in the public sector for a suitable period following comple- tion of their studies. There are certainly other important areas of synergy to explore to help shape and fast-track this agenda, such as those existing between the public health and rights-based approaches to violence prevention. It may also be worthwhile to document the recent developments in the policy and prevention environments together with some of its current challenges more comprehensively. In addition, there is a pressing need to explore opportunities to provide technical support and assistance to and within such environments, with a view to replicating some of the key studies that have successfully raised the profile of violence prevention in HICs. In the interim, efforts to consolidate and share information on key developments and successes in violence prevention research, policy, and practice in LMICs should be encouraged. References Aalund, O., L. Danielsen, E. Katz, and P. Mazza. 1989. Injuries due to deliberate violence in areas of Argentina. I. The extent of violence. Copenhagen Study Group. Forensic Science International 42:151-163. Abrahams, N., R. Jewkes, M. Hoffman, and R. Laubscher. 2004. Sexual violence against intimate partners in Cape Town: prevalence and risk factors reported by men. Bulletin of the World Health Organisation. Geneva, Switzerland: World Health Organisation, 82:330-337. Abromowitz, S. 2005. The poor have become rich and the rich have become poor: Collective trauma in the Guinean languette, Social Science and Medicine 61: 2106-2118. African Network for the Prevention and Protection Against Child Abuse and Neglect. 2000. Awareness and views regarding child abuse and child rights in selected communities in Kenya. Nairobi, Kenya. Allard, D., and V. Burch. 2005. The cost of treating serious abdominal firearm-related injuries in South Africa. South African Medical Journal 95(8):591-594. Andrews, G., J. Corry, T. Slade, C. Issakidis, and H. Swanston. 2004. Child sexual abuse. In Comparative quantification of health risks: Global and regional burden of disease attributable to selected major risk factors. Vol. 1, edited by M. Ezzati, A. D. Lopez, A. Rodgers, and C. Murray. Geneva: World Health Organisation. Archer, J. 2006. Cross-cultural differences in physical aggression between partners: a social- role analysis. Personality and Social Psychology Review 10(2):133-153. Bangdiwala, S. I., L. Ramiro, L. S. Sadowski, I. A. S. Bordin, W. Hunter, and V. Shankar. 2004. Intimate partner violence and the role of socioeconomic indicators in WorldSAFE communities in Chile, Egypt, India and the Phillipines. Injury Control and Safety Promo- tion 11:101-109. Barbarin, O. A., L. Richter, and T. deWet. 2001. Exposure to violence, coping resources, and psychological adjustment of South African children. American Journal of Ortho- psychiatry 71:16-25. Bennis, P., and K. Lever. 2005. The Iraq quagmire: The mounting costs of war and the case for bringing home the troops. Institute for Policy Studies and Foreign Policy in Focus. Washington: IPS.

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