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

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1 Introduction Violence is among the leading causes of death and disability worldwide for people aged 15-59. In fact, suicidal behavior and interpersonal violence together rank as the third leading cause of death and disability adjusted life years in this age group. In 2000, violence claimed the lives of an estimated 1.6 million people (WHO, 2002a). That number was equal to one-half the deaths from HIV/AIDS and 1.5 times the number of deaths from malaria (WHO, 2002b). Also, while deaths constitute the easiest measure of violence, the devastating impact of violence extends far beyond immediate death—with resultant injuries that are often lifelong, hospitalizations, political instability, and stagnation of economic growth for families, communities, and nations. Violence has also been linked to myriad non-injury health consequences including alcohol and substance abuse, smoking, and high-risk sexual behav- ior. In turn, these high-risk behaviors contribute to other chronic health con- ditions with high rates of morbidity and mortality: cardiovascular disease, cancer, depression, and HIV/AIDS. Furthermore, each year, violence costs the world many billions of U.S. dollars in health care, lost productivity and investment, and criminal justice system costs (WHO, 2002a). Although violence is not always isolated and containable, it over- whelmingly and disproportionately affects low- and middle-income coun- tries. Less than 10 percent of violence-related deaths occur in high-income countries. Low- and middle-income countries often lack the resources to invest in prevention and to respond to the consequences of violence, which are far more severe and pervasive than in developed countries—hindering economic growth, security, and social development. The modern world is permeated by violence; as Nelson Mandela said, “No country, no city, no  

 VIOLENCE PREVENTION IN LOW- AND MIDDLE-INCOME COUNTRIES community is immune.” We are not, however, Mandela goes on to say, “powerless against it” (WHO, 2002a, p. ix). Eleven years ago, the World Health Assembly (WHA) adopted Resolution 49.25, which declared vio- lence to constitute a major, escalating public health crisis. In identifying violence as a public health concern, the WHA said several things about the nature of violence—most importantly, that violence is not an inevitable part of the human condition to which the world must be resigned, but rather that it is a preventable phenomenon (WHO, 2002a). While no country may be immune to violence, several of the workshop presentations identi- fied rationales for developed countries, which are also political powers of the world, to be more invested in global violence prevention. Of the more than $70 billion invested annually toward global public health research, less than 10 percent is devoted to research into the health problems that account for 90 percent of the global disease burden. This phenomenon is known as the “10/90” gap and violence has been identified as one of those health problems constituting the 90 percent burden (see Appendix C, M ­ atzopoulos et al., 2007). Beyond the moral imperative is the recognition that economic strength and stability of nations are tied to a global economy. Data were presented at the workshop indentifying economic stagnation and the wealth of a nation as examples of predictive factors for future conflict. In addition to affecting economies, violence can also play a role in the devastation of societal infrastructure including food and water supply systems; public health services and health care facilities; transportation, power, and communication systems; and ultimately national leadership and governance (see Appendix C, Sidel and Levy, 2007). Destruction of this infrastructure can lead to decreased quality of life, increased ­mortality and morbidity, disruption of people’s lives, and displacement of people to other nations—­possibility across the globe—that do not always have the capacity to absorb the needs of those displaced or affected. A public health approach to violence prevention necessitates collective and collaborative action, drawing upon fields as diverse as epidemiology, medicine, nursing, psychology, sociology, anthropology, criminology, policy analysis, education, and economics. As identified in several presentations and the commissioned papers that propose and describe frameworks for applying the public health approach to violence prevention (see Appendix C), the input and inclusion of providers for violence prevention and recov- ery are critical partners in this approach. Primary strategies for prevention in “Preventing Violence in Developing Countries: A Framework for Action” include addressing behavioral and social drivers of violence, emphasizing building capacity for criminal justice and social welfare systems; as well as specific strategies for secondary and tertiary prevention such as engaging professionals from the health sector in efforts to monitor, identify, treat, and intervene in cases of interpersonal and self-directed violence; building and enhancing capacity for provision of social and health services to ­ victims; 

INTRODUCTION  improving emergency responses to violence; and reducing recidivism among perpetrators. The “Logical Framework for Preventing Interpersonal and Self-Directed Violence in Developing Countries” also include these pro- viders and activities in several of the domains for violence prevention activities. The details of the public health approach are discussed in greater detail in Chapter 2, but a brief description of the role and importance of epidemiology is important. Studying the distribution of a disease within given or similar populations (i.e., within similarly economically developed countries), public health looks to identify risk factors and high-risk groups within the community, which can then direct preventive efforts toward those most likely to benefit, thereby achieving its principal goal—primary prevention. Building upon the results of these evaluations, epidemiology looks to establish a foundation for public policy and regulatory decision making regarding a disease (Gordis, 2000). The steps of this public health approach that utilize epidemiology are proactive rather than reactive and are aimed not at punishing perpetrators and treating victims, but rather at preventing the consequences of violence altogether. There is a heterogene- ity with respect to both the types (operationally defined by the planning committee—see Box 1-1) and the prevalence of violence. These differ- ences imply that, like an infectious disease, violence is a product of the i ­nteractions between people and the world around them. Thus applying an interdisciplinary, science-based, public health approach offers the prospect of successfully intervening before violence can ravage a community’s physi- cal, mental, social, and economic well-being. In 2002, the World Health Organisation (WHO) published the World Report on Violence and Health (WHO, 2002a), which has been heralded as the first comprehensive review of violence on a global scale. That report looked to define violence, identify those it affects, and explore the ways in which public health can offer solutions. Despite the findings and recom- mendations of both the WHA and the WHO however, violence preven- tion, especially in developing countries, is just beginning to take hold as a global issue. Previous studies and reports of the Institute of Medi- cine (IOM) have focused primarily on the domestic context of different types of violence in a number of different settings and among a variety of populations—interpersonal and self-directed violence, violence in society at large and in urban settings, violence in the family, and violence against women and children, among others. To build on its previous work and on the concepts presented in the World Report, the IOM hosted a two-day Select report titles include Understanding and Preventing Violence, Volumes 1-4 (NRC, 1993, 1994); Understanding Violence Against Women (NRC, 1996); Understanding Child Abuse and Neglect (NRC, 1993); and Violence in Families: Assessing Prevention and Treat- ment Programs (NRC-IOM, 1998). These reports and others are available at www.nap.edu. 

10 VIOLENCE PREVENTION IN LOW- AND MIDDLE-INCOME COUNTRIES BOX 1-1 Defining and Classifying Violence Violence: 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. Classified by three general types (WHO, 2002a): 1. Interpersonal Violence: • Child maltreatment: any act or series of acts of commission or omission by a parent or other caregiver (i.e., in the context of a relationship of responsibility, trust, or power) that results in harm, potential for harm, or threat of harm to a child’s health, survival, development, or dignity. This definition encompasses physical, emotional, and sexual abuse; neglect or negligent treatment; and commercial or other forms of exploitation (adapted from WHO, 1999, and CDC, 2007). • Youth violence: the intentional use of physical force or power, threatened or actual, against another person, group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, mal­ development, or deprivation in which the perpetrator or victim is between 10 and 29 years of age (adapted from WHO, 2002a). • Intimate partner violence: the intentional use of physical force or power, threatened or actual, against an intimate partner (e.g., spouse, ­ cohabitating partner, date) that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation. This defi­ nition ­ encompasses physical, sexual, and emotional or psychological abuse (adapted from WHO, 2002a). workshop in Washington, D.C., on June 26-27, 2007. The task to the plan- ning committee was to plan a workshop that would promote discussion of the unmet need for high-income countries to invest in violence prevention in developing nations; to articulate feasible strategies and opportunities in both public and private sectors to increase U.S. interest and support for vio- lence prevention in developing countries; and to review the state of science and explore the issue of elevating violence prevention on the global public health agenda. The sessions were organized to review data to identify and describe the costs of violence; how and why violence is preventable; what is known to be effective in developing countries and what might be translated from effective intervention in developed countries; the gaps in research, funding, and programmatic agendas that need to be addressed to scale up 

INTRODUCTION 11 • Sexual violence: nonconsensual completed or attempted sexual contact, nonconsensual non-contact acts of a sexual nature such as voyeurism and verbal or behavioral sexual harassment, or acts of sexual trafficking commit­ ted against someone who is unable to consent or refuse (adapted from CDC, 2002). • Elder abuse: intentional actions that cause harm or create a serious risk of harm (whether or not harm is intended) to a vulnerable elder by a caregiver or other person who stands in a trust relationship to the elder, or failure by a care­ giver to satisfy the elder’s basic needs or to protect the elder from harm. This definition includes the following types of elder abuse: physical abuse, psycho­ logical abuse, sexual assault, material exploitation, and neglect (adapted from NRC, 2002). 2. Self-Directed Violence: fatal or non-fatal self-inflicted destructive acts that include both those with an explicit or inferred intent to die (e.g., suicide, suicide attempts) and those that cause self-harm, but without conscious suicidal intent (e.g., self-mutilation) (adapted from IOM, 2002). 3. Collective Violence: the instrumental use of violence by people who identify themselves as members of a group—whether this group is transitory or has a more permanent identity—against another group or set of individuals, in order to achieve political, economic, ideological, or social objectives. Collective vio­ lence includes armed conflict or social objectives. Collective violence includes armed conflict (e.g., war, genocide), state-sponsored violence (e.g., genocide, repression, disappearances, torture), and organized violent crimes (e.g., gang warfare, banditry) (WHO 2002a). violence prevention; and how the public and private sectors in the United States might support global violence prevention with increased financial, human resources, and technical assistance investments. Although presentations were made or data presented about the seven different types of violence defined in Box 1-1, an important objective of the workshop was to dialogue about how these types of violence can be exam- ined in the context of the three categories that are globally recognized in violence prevention—interpersonal violence, self-directed violence, and col- lective violence. More importantly, the examination and discussions empha- sized their shared risk factors and consequences to victims and societies; suggesting that greater and more timely progress can be made if there were a transition to cross-cutting research and interventions focused on multiple 

12 VIOLENCE PREVENTION IN LOW- AND MIDDLE-INCOME COUNTRIES risk factors. As a result, there would potentially be simultaneous and col- lateral positive effects on several types of violence; as was demonstrated in research on self-directed violence with the United States Air Force. Overall, the presentations effectively achieved this objective to foster dialogue about cross-cutting research and intervention design. With the escalating monetary, human, and political costs associated with violence; researchers, clinicians, policymakers, advocates, and others from many disciplines have been discussing and attempting to use different methodologies to address the prevention of violence and the mitigation of its consequences. One of the consistent suggestions made during the work- shop was the need for a common framework, language, tools, and agenda for violence prevention around which a multidisciplinary and international coalition could be built to elevate violence prevention on the global agendas of public health and possibly, the corporate sector and official economic development agencies or initiatives. Organization of the Report This report summarizes the major themes and data discussed at the workshop. The nine chapters of this report correspond to the organiza- tional themes and resulting sessions of the workshop. This first chapter briefly describes the magnitude of global violence; some of its consequences for the physical, social, and economic health of the people it affects; and how a public health approach might yield substantive returns on invest- ing in violence prevention. Chapter 2 sets the contextual stage for the research findings and presentations during the course of the workshop. Chapter 3 explores violence from health, criminal justice, economic, and human development perspectives. Chapter 4 identifies the intersections between violence and health by examining the impact of violence on varied health conditions. Chapter 5 examines existing interventions around the globe that are proving to be effective in preventing violence in developing countries and identifies other potentially effective interventions for these countries. Chapter 6 details suggestions for developing relationships with the media and linkages with nongovernmental organizations. Chapter 7 identifies the steps needed for international scale-up of violence prevention activities. Chapter 8 explores the challenges and opportunities that exist for U.S. agencies and other organizations that are involved in global violence The themes have been shaped to produce a readable narrative and do not necessarily follow the order of presentations at the workshop. With the exception of brief background state- ments, this summary is limited to what was discussed at the meeting, the PowerPoint presenta- tions used by speakers, and the background papers commissioned for this report. 

INTRODUCTION 13 prevention. Chapter 9, the final chapter, provides participants’ suggestions and ideas for the next steps in global violence prevention. The appendixes of the report contain the workshop agenda (A); a list of workshop partici- pants (B); commissioned background papers (C); and planning committee and workshop speaker biographies (D).