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Introduction

The costs of violence are borne by all segments of society, but their measurement and impact are difficult to quantify. Traditional approaches, consisting mostly of measuring the direct economic effects of healthcare utilization and productivity loss, vastly underestimate the additional social and developmental costs of both morbidity and mortality.

Beyond the measurable costs, violence causes pain and suffering, can lead to chronic trauma, affects child development, and can increase the risk of chronic health outcomes later in life (Repetti et al., 2002). As well, violence affects communities and societies, leading to losses in business sectors, financial divestment, and increased burden on the healthcare and justice systems. Although some methodologies exist for estimating such social or indirect costs, many are confounded by uncertainties in definitions and lack of rigorous evidence of causative factors.

Nevertheless, even initial and crude estimates of both the cost of violence and the cost of prevention show the financial benefits of early intervention. In most cases, the cost of implementing successful preventive interventions is less than the cost to individuals and society of inaction.

On April 28-29, 2011, the Institute of Medicine’s (IOM’s) Forum on Global Violence Prevention convened its second workshop to explore the social and economic costs of violence. Part of the Forum’s mandate is to engage in multisectoral, multidirectional dialogue that explores cross-cutting public health approaches to violence prevention. To that end, the workshop was designed to examine these approaches from multiple perspectives and at multiple levels of society. In particular, the workshop was focused on exploring the successes and challenges presented by calculating



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1 Introduction The costs of violence are borne by all segments of society, but their measurement and impact are difficult to quantify. Traditional approaches, consisting mostly of measuring the direct economic effects of healthcare utilization and productivity loss, vastly underestimate the additional social and developmental costs of both morbidity and mortality. Beyond the measurable costs, violence causes pain and suffering, can lead to chronic trauma, affects child development, and can increase the risk of chronic health outcomes later in life (Repetti et al., 2002). As well, vio- lence affects communities and societies, leading to losses in business sectors, financial divestment, and increased burden on the healthcare and justice systems. Although some methodologies exist for estimating such social or indirect costs, many are confounded by uncertainties in definitions and lack of rigorous evidence of causative factors. Nevertheless, even initial and crude estimates of both the cost of vio- lence and the cost of prevention show the financial benefits of early in- tervention. In most cases, the cost of implementing successful preventive interventions is less than the cost to individuals and society of inaction. On April 28-29, 2011, the Institute of Medicine’s (IOM’s) Forum on Global Violence Prevention convened its second workshop to explore the social and economic costs of violence. Part of the Forum’s mandate is to engage in multisectoral, multidirectional dialogue that explores cross- cutting public health approaches to violence prevention. To that end, the workshop was designed to examine these approaches from multiple per- spectives and at multiple levels of society. In particular, the workshop was focused on exploring the successes and challenges presented by calculating 1

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2 SOCIAL AND ECONOMIC COSTS OF VIOLENCE and categorizing both direct and indirect costs at multiple levels of society, as well as the potential cost-effectiveness of intervention. Speakers were invited to share the progress and outcomes of their work and to engage in dialogue exploring gaps and opportunities in the field. The workshop was planned by a formally appointed committee of the IOM, whose members created an agenda and identified relevant speakers. Because the topic is large and the field is broad, presentations at this event represent only a sample of the research currently being undertaken. Speak- ers were chosen to present a global, balanced perspective, but by no means a comprehensive one. Given time and resource constraints, the planning committee members chose speakers who could provide diverse perspectives upon which further discussion could occur. The agenda for this workshop can be found in Appendix A. ORGANIZATION OF THE REPORT This summary provides a factual account of the presentations given at the workshop. Opinions expressed within this summary are not those of the Institute of Medicine, the Forum, or its agents, but rather of the present- ers themselves. Statements are the views of the speakers and do not reflect conclusions or recommendations of a formally appointed committee. This summary was authored by a designated rapporteur based on the workshop presentations and discussions and does not represent the views of the insti- tution, nor does it constitute a full or exhaustive overview of the field. The workshop summary is organized thematically, covering the major topics that arose during the 2-day workshop, so as to provide a larger con- text for these issues in a more compelling and comprehensive way. In addi- tion, the thematic organization allows the summary to serve as an overview resource of important issues in the field. The themes were chosen as the most frequent, cross-cutting, and essential elements that arose from the workshop, but do not represent the views of the IOM or a formal consensus process. The first part of this report consists of four chapters, which provide the summary of the workshop; the second part consists of submitted papers and commentary from speakers regarding the substance of the work they presented at the workshop. These papers were solicited from speakers to provide further information about their work, though not all speakers con- tributed papers. The appendix contains additional information regarding the agenda and participants. DEFINITIONS AND CONTEXT Violence is defined by the World Health Organization (WHO) as “the intentional use of physical force or power, threatened or actual, against

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3 INTRODUCTION 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” (WHO, 2002). WHO further categorizes violence into seven types: child and elder abuse, sexual and intimate part- ner violence, youth and collective violence, and self-directed violence. This workshop examined all seven types of violence, as well as the underlying common risk factors and common outcomes. The workshop explored both social and economic costs—the latter more easily quantifiable than the former—at four ecological levels: indi- vidual, family, community, and societal. While costs, benefits, outcomes, and measurement indicators can be defined differently, all workshop par- ticipants provided the context of their presentations and attempted to relate their content to a common framework. Speakers endeavored to enumerate costs and benefits where possible and to describe other potential costs where no suitable accounting methodology exists. Costs included not just the im- mediate and direct, but also the longer-term, widespread, and indirect. The next four chapters examine the four major themes that arose from participants’ presentations and discussions: approaches to measurement and costing methodology (Chapter 2), challenges in calculating cost (Chap- ter 3), the creation of a bigger picture of the costs of violence (Chapter 4), and the promise of investing in violence prevention (Chapter 5). The three chapters in Part II include the submitted papers, organized as direct and indirect costs (Chapter 6), context and place (Chapter 7), and investing in prevention (Chapter 8). Finally, the appendixes consist of the agenda (A), the speakers’ biogra- phies (B), the planning committee members’ biographies (C), and the Forum on Global Violence Prevention members’ biographies (D). ACKNOWLEDGMENTS The Forum on Global Violence Prevention was established to address a need to develop multisectoral collaboration among stakeholders. Violence prevention is a cross-disciplinary field that could benefit from increased dialogue among researchers, policy makers, funders, and practitioners. As awareness of the insidious and pervasive nature of violence grows, so too does the imperative to mitigate and prevent it. A number of individuals contributed to the successful development of this workshop and report. These include IOM staff: Rosemary Chalk, Angela Christian, Patrick Kelley, Elena Nightingale, Julie Wiltshire, and Jordan Wyndelts. The Forum staff, including Deepali Patel, Megan Perez, Rachel Pittluck, and Rachel Taylor, also put forth considerable effort to ensure this workshop’s success. The staff at the Kaiser Family Foundation’s Barbara Jordan Conference Center provided excellent support for the event.

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4 SOCIAL AND ECONOMIC COSTS OF VIOLENCE The planning committee contributed several hours of service to de- velop and execute the agenda, with the guidance of Forum membership. Reviewers also provided thoughtful remarks in reading the draft manu- script. These efforts would not be possible without the work of the Forum membership itself, an esteemed body of individuals dedicated to the concept that violence is preventable. Their names and biographies can be found in Appendix D. The overall successful functioning of the Forum and its activities rests on the foundation of its sponsorship. Financial support for the Forum on Global Violence Prevention is provided by the Department of Health and Human Services: Administration on Aging, Administration on Children, Youth, and Families, Office on Women’s Health; Anheuser-Busch InBev; Avon Foundation for Women; BD (Becton, Dickinson and Company); Catholic Health Initiatives; Centers for Disease Control and Prevention; Eli Lilly and Company; Department of Education: Office of Safe and Drug-Free Schools; Department of Justice: National Institute of Justice; Fetzer Insti- tute; F. Felix Foundation; Foundation to Promote Open Society; The Joyce Foundation; Kaiser Permanente; National Institutes of Health: National Institute on Alcoholism and Alcohol Abuse, National Institute on Drug Abuse, Office of Research on Women’s Health, John E. Fogarty Interna- tional Center; Robert Wood Johnson Foundation; and the Substance Abuse and Mental Health Services Administration. REFERENCES Repetti, R. L., S. E. Taylor, and T. E. Seeman. 2002. Risky families: Family social environ- ments and the mental and physical health of offspring. Psychological Bulletin 128(2): 330-366. WHO (World Health Organization). 2002. World report on violence and health. Geneva.