place for violence. Speaker Deborah Prothrow-Stith of Spencer Stuart also highlighted the importance of definitions and their cultural context; what constitutes violence in one setting might not translate to another setting and therefore might not be captured in data analysis. Speaker Mindy Fullilove of Columbia University noted that structural violence, or violence that is institutionalized but not criminalized, is difficult to define and measure, correlates with other inequities, and is often missed when considering the cost of overt violence.

Dr. Corso, speaker Philip Cook from Duke University, and speaker and Forum member David Hemenway from Harvard University also emphasized the difficulty and importance of determining attributable risk, particularly for longer-term outcomes. Dr. Corso observed the lack of a good risk model, and Drs. Cook and Hemenway discussed the difficulty of attributing violence to specific risk factors. This provides a challenge in assessing how costs are allocated to risk factors or types of violence, making it difficult to assess how well preventive interventions are truly working.

Dr. Corso also identified general issues with the availability and generalizability of data; typically, a disparity in both the comprehensiveness and the quality of data from high-income countries and low-income countries exists. Thus, the assessment of costs in one context may not be applicable anywhere else. Dr. Waters emphasized this issue, citing that values placed on specific components do not take into account differences in cost-of-living standards across different countries. For example, productivity measured by loss of wages is markedly different in high-income and low- or middle-income countries, where average wages can differ by orders of magnitude. This human capital approach also takes into account life expectancy and age, which have other health implications and result in different values being placed on both employment and human life based on a country’s economic development status. Speaker and Forum member Michael Phillips of the Shanghai Jiao Tong University School of Medicine highlighted another downside to the human capital approach—specific types of violence pose different relative financial burdens in relation to others and thus receive lower priority than others, despite being a potentially greater social burden.

Dr. Hemenway added to the previous comments of speakers on the availability and generalizability of data by pointing out that not only is violence underreported, but also active data collection is often limited to areas of higher income or socioeconomic status. Receiving data from diverse populations is difficult when less effort is made to collect such data. Forum member Evelyn Tomaszewski made a similar statement in commenting on undercurrents of violence and effects of violence in society, such as undiagnosed psychological illness or trauma, and the impossibility of enumerating such costs. In addition, the data are often inaccurate—Dr. Hemenway stated that a recent review of the National Violent Death Reporting System



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