4

Toward a Bigger Picture of the Costs of Violence

Despite difficulties in creating a universal framework that could comprehensively capture the total costs of violence, many workshop speakers considered some utility in enumerating some of the direct costs of violence and describing the potential impact of other types of costs, namely indirect and social costs. In particular, such an exercise serves to show an emerging picture of the larger costs of violence, beyond the immediate and obvious (see Boxes 4-1 and 4-2).

The division between direct and indirect costs was rough at best, in part due to differences in definitions and methodologies for calculation. However, speakers attempted to make such distinctions, expressing dollar values where such existed and exploring potential impact where numbers did not exist, even when values sometimes seemed contradictory. This chapter distinguishes roughly between enumerated and estimated costs for the purpose of organization, while recognizing that the distinction is often artificial and can obscure the fuller picture.

ENUMERATED COSTS

One of the most comprehensive overviews of the costs of interpersonal violence was presented by Dr. Hugh Waters of the RAND Corporation, who drew from a World Health Organization (WHO)–sponsored study exploring the costs of violence across multiple countries. The study reviewed more than 100 studies and determined that studies that included indirect costs yielded significantly higher numbers than those that looked only at direct costs. Dr. Waters further broke down the various categories of



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4 Toward a Bigger Picture of the Costs of Violence Despite difficulties in creating a universal framework that could com- prehensively capture the total costs of violence, many workshop speakers considered some utility in enumerating some of the direct costs of violence and describing the potential impact of other types of costs, namely indirect and social costs. In particular, such an exercise serves to show an emerging picture of the larger costs of violence, beyond the immediate and obvious (see Boxes 4-1 and 4-2). The division between direct and indirect costs was rough at best, in part due to differences in definitions and methodologies for calculation. However, speakers attempted to make such distinctions, expressing dollar values where such existed and exploring potential impact where numbers did not exist, even when values sometimes seemed contradictory. This chapter distinguishes roughly between enumerated and estimated costs for the purpose of organization, while recognizing that the distinction is often artificial and can obscure the fuller picture. ENUMERATED COSTS One of the most comprehensive overviews of the costs of interpersonal violence was presented by Dr. Hugh Waters of the RAND Corporation, who drew from a World Health Organization (WHO)–sponsored study exploring the costs of violence across multiple countries. The study re- viewed more than 100 studies and determined that studies that included indirect costs yielded significantly higher numbers than those that looked only at direct costs. Dr. Waters further broke down the various categories of 17

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18 SOCIAL AND ECONOMIC COSTS OF VIOLENCE BOX 4-1 A Bigger Picture of the Cost of Violence: The Case of Lily Lily was a patient from Hot Springs, Arkansas, who moved to Chicago to care for her 16-year-old grandson because her daughter, his sole caregiver, was incarcerated. Lily suffered from a number of medical problems, with arthritis and diabetes as her most prominent complaints. Because of the severity of her arthri- tis pain, she was eventually prescribed a medication called Dilaudid, which is a hydromorphone that is stronger than morphine. Dilaudid comes in both pills and a sublingual form that can dissolve rapidly without entering the gastrointestinal (GI) tract. In Chicago, Lily obtained employment in the mailroom of an office. About 3 months after her second visit to her physician, she complained that her pain seemed to be getting worse. As it turned out, her grandson had been taking her medication and selling it on the street (Dilaudid in the sublingual form, such as the one she had been taking, has fairly high street value because it provides a rapid “high” and has no GI side effects). Her grandson was performing poorly in school and experiencing difficul- ties with other youth. He also tried to steal money from Lily for drugs and other illicit uses. Because Lily’s pain was not well-controlled, she began to experience difficulty at work, arousing the suspicion of her supervisors that she was falsifying claims of pain in order to obtain disability. She also began to experience harassment in the workplace and worried that she would be fired with no recourse available. One day there was a fire drill in the building, requiring everyone to take the stairs. In the stairwell, someone pushed Lily and she fell, and she broke her hip. She had a complicated intratrochanteric fracture that took her to the hospital, where she underwent a difficult surgery. She experienced excess bleeding and a skin infection and developed pneumonia. Both her cognitive abilities as well as her physical function deteriorated rapidly, and she was admitted to a long-term care facility. Because Lily was no longer at home, child protective services was called and her grandson was placed in foster care. Since she was no longer able to work, she could not pay her medical bills and had to sell her house and stay in the nurs- ing home. About a year later, she passed away from a complicated pulmonary embolism, a clot from her legs that went to her lungs. SOURCE: Vignette presented by XinQi Dong, Rush University Medical Center. costs, details of which can be found in Chapter 6. Overall, he noted that in 2000, the total cost of interpersonal violence was $37 billion in the United States, a number that speaker Phaedra Corso of the University of Georgia also referenced (Corso et al., 2007). This total included medical costs and productivity costs only. The same study also stated that suicide and self- directed violence accounted for $33 billion in productivity loss and medical

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19 TOWARD A BIGGER PICTURE BOX 4-2 A Bigger Picture of the Cost of Violence: The Case of Vi and Alex Vi was a 36-year-old member of the school board, mother of an 8-year-old and wife to a state trooper, Alex, in Pulaski, Tennessee. She was shot by her husband under uncertain circumstances, which Alex initially stated were accidental. The bullet of the .357 magnum severed her spine, and left her a quadriplegic and unable to breathe without a ventilator. Following the shooting, evidence began to emerge that Vi and Alex had been experiencing domestic disputes and financial insecurity. Alex was reportedly unhappy about Vi’s standing in the community as a member of the school board and was potentially abusing alcohol. When Vi decided to take steps to end the marriage, Alex allegedly sent their young child, Little Alex, outside to play and shot his wife. Vi suffered tremendously from the injury, experiencing multiple infections, cerebral spinal leak, and severe psychological trauma. Her stay in the hospital required constant watch, and she was plagued by nightmares about dying. She also experienced psychological distress when her husband visited, torn between wanting to see him and being unable to come to terms with what he had done. When Vi left the hospital, she and her son went to stay with her sister, who was a nurse. Her sister undertook the complicated care required for Vi, as well as her son. Little Alex suffered from nightmares regarding his father and faced diminish- ing achievement at school. Vi’s husband, Alex, was tried for the attempted murder, but was acquitted. Vi filed a civil suit, and a jury awarded her several million dollars. She was unable to attend the trial, but resolved to be in court for the civil case, riding in the back of a moving van in her wheelchair from Chicago to Tennessee. For the rest of her life, Vi experienced a number of costly medical problems as a quadriplegic and often received substandard care. Her ex-husband, Alex, continued to abuse alcohol, smoke excessively, and died several years later. Her son experienced pain and guilt for much of his adult life, often finding himself in unhealthy or violent relationships. Vi spent the last part of her life in a long-term care facility, where she died in her sleep. She was buried next to her brother, also a victim of a violent shooting, in the town in which she was born. SOURCE: Vignette presented by Mark Rosenberg, Task Force for Global Health. costs. Dr. Waters indicated that specific risk factors, or what he termed “facilitators,” accounted disproportionately for costs. For example, alcohol accounts for 8.3 percent of costs of violent crimes, and drug-related violent crime accounts for some $6 billion to $10 billion annually. Speaker Kevin Sabet of the White House Office of National Drug Control Policy also highlighted the impact of drugs as a risk factor for violence, stating that its pathway is triple: violence is related to pharmacologic changes, economic

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20 SOCIAL AND ECONOMIC COSTS OF VIOLENCE motivation to procure further drugs, and illegal “turf” wars, suggesting that the costs can be much higher than simple calculations can specify. Dr. Waters said that the costs of violence are borne by the public sec- tor; in the United States, up to 80 percent of such costs are absorbed as unpaid or specifically covered by public financing. Speaker christie cunning- ham noted that the National Institute for Occupational Safety and Health (NIOSH) has estimated that workplace violence in the United States costs approximately $121 billion. Speaker and Forum member Michael Phillips stated that in terms of disability-adjusted life-years (DALYs), the global burden of violence equals at least that of diabetes, suggesting the impact of both are equally concerning. Dr. Corso shared evidence that violence can have an effect on the next generation, citing a study in which children of mothers experiencing intimate partner violence utilize health care at higher rates through the rest of their lives, regardless of whether the abuse occurred before or after the children were born (Rivara et al., 2007). In a similar vein, speaker and Forum member XinQi Dong of the Rush Medical Center noted that elder abuse is linked to greater utilization of emergency services, which is far more expensive to both the victim and the community (see Box 4-1). These costs extend beyond the United States to other countries, where the burden of violence is more significant. Speaker and Forum member Arturo Cervantes of the Mexican Ministry of Health noted that the cost of violence in Mexico was estimated between $83 billion and $112 bil- lion, depending on the cost calculation for “intangibles,” or indirect costs that are difficult to measure. He also pointed out that the estimated cost of combating violence—for public and private security, private bribes, and other individual measures—was $815 per person, 10 percent of gross do- mestic product (GDP) per capita in Mexico. Speaker and Forum member Elizabeth Ward of the Jamaican Violence Prevention Alliance indicated that the cost of violence to Jamaica equaled 5 percent of GDP. In one particular instance, the extradition of a narcotics trafficker in 2010, which resulted in increased unrest and instability, was estimated to have cost (Jamaican) $23 billion; the majority of this loss was in the tourism sector, Jamaica’s largest industry. Forum member Rodrigo Guerrero noted that violence in Colombia costs the equivalent of 15 percent of GDP. Speaker Aslihan Kes of the International Center for Research on Women stated that intimate partner violence poses significant costs to so- ciety. Costs calculated in Uganda included the criminal justice, health, and political sectors and equaled about $5 per case. In Morocco, transportation costs were also included, resulting in $157 per case. Ms. Kes also noted that while these numbers may seem low, in relation to relative gross national product (GNP)—$350 in Uganda and $2,000 in Morocco—the costs are

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21 TOWARD A BIGGER PICTURE significant and account for only one particular form of violence. For further information, see Chapter 7. The Small Arms Survey’s Global Burden of Violence 2008 estimates that the cost of nonconflict violence in 90 countries is about $95 billion, but may reach up to 0.14 percent of global GDP, as a measure of lost pro- ductivity. “Insecurity” related to armed conflict is estimated at an annual burden of $400 billion. The cost of lost productivity due to violence-related mortality varies from 0.74 percent of GDP in Latin America and the Carib- bean to 0.02 percent in Southeast Asia (using a 5 percent discount rate). On the other hand, gains in life expectancy and productivity if violence had not occurred can be enormous, particularly in Latin America. Also, rebuilding institutions in the aftermath of violence, which is essential to preventing fu- ture violence, can yield additional economic benefit in measures of national productivity (Geneva Declaration Secretariat, 2008). In a related area, Dr. Waters noted that research into the cost- effectiveness of interventions has shown promising results. For example, the Violence Against Women Act has been estimated to have saved more than $16 billion since its enactment, the majority of which has been in averted victims’ costs. Dr. Waters also referenced other interventions that target juvenile offenders and yield economic benefits orders of magnitude beyond the costs that accrue to violence (and the investment in such interventions) and mentioned a gun registration law in Canada that saved almost $5 bil- lion annually. ESTIMATED COSTS By far, speakers felt that those costs that are not easily enumerated in terms of financial cost, but whose impact are readily seen, constituted the bulk of the cost of violence. Such costs generally fall within the realm of social costs but can also include economic costs, which are difficult to measure, or social costs, which result in financial loss indirectly. Social costs include outcomes such as future violence or loss of social cohesion. Economic costs that are difficult to measure can include community divest- ment or loss of infrastructure, and indirect financial costs can be accrued by indirect victims who are affected by a violent environment without being directly victimized by violence. Such costs often cause a “domino effect” and result in other costs down the line. As speaker David Hemenway stated: “The cost of gun crime in the inner city is not just that somebody is dying and somebody has a traumatic brain injury … but it’s the whole destruction of the entire city…. Gun violence today has a real cost because it increases the likelihood of gun violence a year from now.” Dr. Cervantes concurred, stating that violence causes a loss of trust among the citizenry in law enforcement and political leaders. Such a loss

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22 SOCIAL AND ECONOMIC COSTS OF VIOLENCE of trust means an inability to use social services in the public sector, such as emergency services and the judicial system. This leads to a loss of social cohesion and distrust within the community itself and also places citizens at higher risk for being victimized by violence and for responding to vio- lence outside the legal confines of society. Speaker Michael Phillips noted that self-directed violence correlates highly to loss of social cohesion, par- ticularly in cultures where family and community ties are strong. He said that the indirect victims of suicide—the family members—often experience longer-term adverse outcomes such as trauma and trauma-related issues. Speakers also described a set of costs in terms of missed opportunities, or diverted costs (in economic terms, opportunity costs). Such costs include those that are used to address violence, either the prevention before or the response after, which are diverted from other necessary programs or people. As an example, Dr. Waters pointed out that hospital operating costs such as infrastructure or salary, which are paid regularly, could be used to ad- dress other diseases instead of violence. This is particularly important in resource-constrained settings. Speaker Gary Milante from the World Bank agreed, noting that “fragile states” that are prone to social and economic distress often choose between addressing chronic violence or other obstacles to development, such as poverty, insecurity, or lack of healthcare infrastruc- ture. The inability to address stressors because of lack of resources puts these same fragile states at risk of future violence. Arturo Cervantes of the Mexican Ministry of Health made a similar statement, pointing out that in Ciudad Juàrez, funds could be used to strengthen social development, but instead are needed to combat narcotics- and firearms-related violence. In a similar vein, a number of speakers highlighted the impact of violence on the Millennium Development Goals (MDGs). Speakers Juma Assiago and Elizabeth Ward mentioned that violence is impeding the achievement of MDGs, while Forum chair Jacquelyn Campbell and speaker Aslihan Kes specifically mentioned that intimate partner violence is an obstacle to the achievement of MDGs 3 (gender equality and women’s empowerment) and 5 (maternal health). Ms. Kes also addressed this issue of opportunity costs, particularly in light of the burden on women and the difficulty of enumerating the cost of violence against women. Because women tend to perform household or intermittent work, it is difficult to measure lost productivity. However, the cost of seeking care, addressing injuries, and other outcomes of intimate partner violence can be quite significant in terms of lost household produc- tivity. Also, if a woman is the sole earner in the home, the costs are even more significant when she cannot work. Speaker Michael Wells of the U.S. Department of Education’s Office of Safe and Drug-Free Schools shared similar concerns about opportunity costs related to school violence. Edu- cational systems often have to divert costs to dealing with violence, such as

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23 TOWARD A BIGGER PICTURE fixing damage and covering increased insurance costs. In turn, this means that fewer funds are allocated toward educational essentials (counselors, textbooks, or other needs) and high-quality staff is more difficult to retain. In addition, indicators of educational achievement fall, as students are dis- tracted from studying or fear attending school. Dr. Hemenway also referenced another category of estimated costs— avoidance or protection costs. He listed a number of examples, including changing work and going-out habits, not allowing children to play outside, moving businesses to safer neighborhoods, and utilizing “target hardening” measures, such as metal detectors in schools or the individual purchase of concealed firearms (which can increase the fragility of a community). These costs have further implications for neighborhood deterioration: businesses and wealthier individuals flee for safer neighborhoods, often in suburbs; loss of social capital, as young men are incarcerated; and increased unem- ployment, as businesses fail to invest (see Chapter 6 for more information). Dr. Cervantes highlighted an excellent example of this, stating that Juàrez, Mexico, has the highest perception of insecurity in the world: 90 percent of residents, as citizens, lack trust in the social institutions designed to protect them. Speaker Juma Assiago of UN Habitat reiterated this, pointing out that violence often stigmatizes neighborhoods, creates silos within cities, particularly in the development of “gated” neighborhoods, and increases extrajudicial response. Speakers also discussed the impact of immediate and long-term costs on the community. Speaker Rachel Davis of the Prevention Institute noted that fear of violence affected behavior because people are afraid to go outside or let their children play outside. Businesses, such as grocery stores, fail to invest in violent neighborhoods, denying residents access to healthy food. Such an environment creates unhealthy eating and exercise habits, resulting in future costs down the line as residents are at high risk of diet- and activity-related health outcomes. Dr. Milante stated that violence has a persistent and often multiplying effect, disrupting social and economic development and continuing downward spirals. Evidence in fragile states points to an enormously high burden on vulnerable populations such as children, who are two times as likely to be under- nourished and three times as likely to not attend school than children in stable states. NEUROBIOLOGICAL EFFECTS AND LONG-TERM OUTCOMES OF VIOLENCE Several speakers discussed the neurobiology of violence and its long- term physical and mental effects. Speakers noted that emerging evidence from the field of neuroscience suggests that violence, with its associated

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24 SOCIAL AND ECONOMIC COSTS OF VIOLENCE trauma and toxic stress, changes the physiology and response mechanisms of the brain and body. Speaker and Forum member Rowell Huesmann explored this concept in discussing the contagious nature of violence, or how violence can spread from person-to-person or community-to-community. He noted that indi- viduals living in violent environments are socialized toward violence as a “normal” response, changing social structures and interpersonal relation- ships. Violence also increases aggression and aggressive behavior, which reinforces itself in a positive feedback loop, a concept both Drs. Milante and Hemenway identified at the community and societal levels as well. In particular, Dr. Huesmann referenced a longitudinal study from Columbia County, New York, which has been ongoing since 1960, and shows evi- dence of increased aggression in later life in children exposed to violence (particularly television violence). Dr. Huesmann also referenced his work in Israel and Palestine on aggressive behavior of youth in both places; the experience of living in a violence environment shows impact on aggression toward peers in each group. Further details can be found in Chapter 6. Dr. Shonkoff explored some of the evidence of the neurobiological transformation that occurs as a result of violence (see Chapter 6 for more details). He described the natural physiological response to stress as evo- lutionary adaptation. For example, increased heart rate, shorter breathing pattern, high alert to external stimuli, and other processes are a result of the activation of the sympathetic nervous system to the perception of hazard in the external environment. When a person is exposed to high levels of stress for extended periods of time in childhood, the body learns to adapt and accepts the high level of arousal as typical. Over time, this becomes detrimental because the body wants to maintain these high arousal levels when they are no longer necessary. This biological embedding results in individuals who are more likely to aggress or to see aggression where there is none, to respond to nonstressful situations with violence or anger, and to experience adverse outcomes of chronic stress throughout life. In short, cu- mulative well-being for such individuals is less (Figure 4-1). As Dr. Shonkoff stated, “What was biologically adaptive becomes socially maladaptive.” Dr. Shonkoff also noted two pathways that may occur simultaneously and can result in adverse health outcomes later in life—the first is that adversity in childhood can have behavioral effects that result in risk taking, and the second is that such adversity also has physiological effects that result in psychological disruption. Dr. Shonkoff cited two studies showing long-term physiological effects related to child maltreatment. The first, the Adverse Childhood Experiences (ACE) study, is an ongoing study of a large cohort who self-reported abuse and neglect in childhood, which correlates to chronic health outcomes experienced in adulthood (Felitti et al., 1998). The second is a study from

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25 TOWARD A BIGGER PICTURE C UMULATIVE WELL-BEING ADVERSE TRAJECTORY EVENT OF W ELL-BEING LIFESPAN FIGURE 4-1 The effect of an adverse event on cumulative well-being over the life span. Dunedin, New Zealand, which takesigure 4-1.eps F a life-course perspective on childhood events and later impact in life. One particular outcome, measurement of revised C-reactive protein, an inflammatory marker of heart disease, is increased in R02080 study participants who report child maltreatment earlier in life (Danese et al., 2007). This indicates the potential for inappropriate activation of the stress response to cause physiological changes in the body that can have effects decades later. REFERENCES Corso, P., J. Mercy, T. Simon, E. Finkelstein, and T. Miller. 2007. Medical costs and productiv- ity losses due to interpersonal and self-directed violence in the United States. American Journal of Preventive Medicine 32(6):474-482. Danese, A., C. M. Pariante, A. Caspi, A. Taylor, and R. Poulton. 2007. Childhood maltreat- ment predicts adult inflammation in a life-course study. Proceedings of the National Academy of Sciences 104(4):1319-1324. Felitti, V. J., R. F. Anda, D. Nordenberg, D. F. Williamson, A. M. Spitz, V. Edwards, M. P. Koss, and J. S. Marks. 1998. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults—The Adverse Childhood Experiences (ACE) study. American Journal of Preventive Medicine 14(4):245-258. Geneva Declaration Secretariat. 2008. The global burden of armed violence. Rivara, F. P., M. L. Anderson, P. Fishman, A. E. Bonomi, R. J. Reid, D. Carrell, and R. S. Thompson. 2007. Intimate partner violence and health care costs and utilization for children living in the home. Pediatrics 120(6):1270-1277.