Violence and Intentional Injuries: Criminal Justice and Public Health Perspectives on an Urgent National Problem

Mark H. Moore Deborah Prothrow-Stith Bernard Guyer and Howard Spivak

INTRODUCTION

When one person attacks another, and an injury occurs, most citizens view the event as a violent crime. By definition, such crimes inflict physical harms on the victims. But the important social consequences of these attacks go well beyond the immediate trauma to the victim (see Cohen et al., in this volume). The victim suffers psychological damage as well as physical pain. Others in the society may be frightened by the experience of the victim and become concerned that they, too, are vulnerable.

In the past (and, for the most part, still) society has relied primarily on the criminal justice system to respond to such incidents. Part of the reason is a deeply held conviction that such attacks are morally wrong as well as simply harmful, and that those who commit such offenses should be held accountable for their misconduct. In this view, justice demands judgment and punishment for such acts, regardless of the practical effect of punishment on future criminal offending (von Hirsch, 1976).

Yet reliance on the criminal justice system also reflects a practical

Mark Moore is at the Kennedy School of Government, Harvard University; Deborah Prothrow-Stith and Howard Spivak are at the School of Public Health, Harvard University; and Bernard Guyer is at the Department of Maternal and Child Health, Johns Hopkins University.



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Understanding and Preventing Violence: Volume 4 - Consequences and Control Violence and Intentional Injuries: Criminal Justice and Public Health Perspectives on an Urgent National Problem Mark H. Moore Deborah Prothrow-Stith Bernard Guyer and Howard Spivak INTRODUCTION When one person attacks another, and an injury occurs, most citizens view the event as a violent crime. By definition, such crimes inflict physical harms on the victims. But the important social consequences of these attacks go well beyond the immediate trauma to the victim (see Cohen et al., in this volume). The victim suffers psychological damage as well as physical pain. Others in the society may be frightened by the experience of the victim and become concerned that they, too, are vulnerable. In the past (and, for the most part, still) society has relied primarily on the criminal justice system to respond to such incidents. Part of the reason is a deeply held conviction that such attacks are morally wrong as well as simply harmful, and that those who commit such offenses should be held accountable for their misconduct. In this view, justice demands judgment and punishment for such acts, regardless of the practical effect of punishment on future criminal offending (von Hirsch, 1976). Yet reliance on the criminal justice system also reflects a practical Mark Moore is at the Kennedy School of Government, Harvard University; Deborah Prothrow-Stith and Howard Spivak are at the School of Public Health, Harvard University; and Bernard Guyer is at the Department of Maternal and Child Health, Johns Hopkins University.

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Understanding and Preventing Violence: Volume 4 - Consequences and Control judgment about the best ways of preventing and controlling violent crime. In this view, violent crime is best controlled by relying on arrests and incarcerations to deter, incapacitate, and rehabilitate criminal offenders. It is these responses that the agencies of the criminal justice system are designed to produce (for a discussion of their effectiveness, see Blumstein et al., 1986). Recently, however, interpersonal attacks have drawn the attention of public health practitioners as well as criminal justice officials (e.g., see Mercy and O'Carroll, 1988; Health Resources and Services Administration, 1986). The reason is that injuries have emerged as one of the principal threats to the nation's health. Moreover, "intentional injuries" (which includes suicides, homicides, and aggravated assaults among other violent episodes) account for a surprisingly large proportion of all injuries (National Committee for Injury Prevention and Control, 1989). Indeed, among all citizens in the United States, suicides and homicides have become the eleventh leading cause of death. Among citizens aged 15-34, homicides are now the third leading cause of death, and among black males aged 15-34, homicide is now the leading cause of death. Moreover, because intentional injuries occur disproportionately among younger Americans, they account for an unexpectedly large proportion of the total "years of potential life lost" in the United States each year (National Committee for Injury Prevention and Control, 1989:192). Behind the statistics on homicides and suicides lies a much larger but less well documented number of less severe injuries that degrade the health of the victims and make substantial claims on the nation's hard-pressed public hospitals (see Cohen et al., in this volume). In short, the health consequences of criminal violence are now large enough to show up as a significant component of the nation's overall health problems. Criminal violence exacts a particularly large toll from the health of those who are least advantaged in the society. These simple facts make violence a concern for the public health community as well as the criminal justice community. However, there are other reasons for the public health community to become involved in efforts to control criminal violence. Over the years, in controlling epidemics of cholera, smallpox, and polio, and in dealing with other kinds of injuries such as auto fatalities, public health researchers and practitioners have developed analytical and operational approaches that can usefully complement the approaches now being taken by criminal justice researchers and practitioners to control criminal violence (for a discussion of these techniques and approaches, see Friedman, 1987).

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Understanding and Preventing Violence: Volume 4 - Consequences and Control For example, public health researchers and practitioners have traditionally concentrated on preventing incidents of violence rather than dealing with their consequences after the fact. That is arguably a useful complement to the criminal justice system's predominantly reactive stance. Similarly, the public health community uses epidemiological techniques to identify specific "risk factors" that increase the risk of violence and then designs programs to eliminate or reduce their effect. This is a useful complement to the criminal justice system's primary focus on the deterrence and control of criminal offenders. Public health researchers and practitioners are instinctively multidisciplinary and seek to mobilize many different individuals, community groups, and agencies in making an attack on criminal violence. This seems a useful complement to the apparent tendency of the criminal justice system to focus principally on its own internal operations. In short, criminal violence may usefully be seen as a public health problem not only because the consequences of violent attacks constitute an important health problem, but also because public health methods may expand society's current capacities for dealing with the problem. That is the primary purpose of this paper: to show how the criminal justice system's traditional vision and response to violent crime may be usefully complemented by the public health community's approach to the problem. Of course, their approaches overlap to a great degree, and these overlaps reveal their commitment to a common cause. However, the areas in which their approaches diverge are both interesting and valuable. Although the differences in approach sometimes create tensions between the two communities, it is precisely in these areas that the most useful contributions are made by the public health community, for it is in those areas that the public health community usefully challenges criminal justice thinking and operationally complements criminal justice capabilities. Indeed, by synthesizing the somewhat different images of the problem and the solution, society may develop a more accurate and complete picture of violence and be able to fashion a more effective response than is now possible. That, at least, is what our experience of working together has taught us. In searching for a synthetic view of violence and an effective public response, we have found it useful to compare and contrast public health and criminal justice system approaches to violence in five separate domains:

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Understanding and Preventing Violence: Volume 4 - Consequences and Control how each community tends to see and define the problem of violence; the analytic frameworks (and implicit assumptions about causation) that each community uses to identify the principal causes; the entering presumptions and biases, rooted in long professional experience and empirical research, that guide each community's search for effective methods of intervention; the principal political and organizational resources that each community can mobilize to deal with the problem; and finally the principal values that each community believes are the most important ones to be advanced and protected in organizing society's response to violence. From this dialogue, we have seen the possibility of a new conception of violence, and new opportunities for society to deal effectively with it. No doubt, as the dialogue between these two communities develops, we will all learn a great deal more about how to synthesize the complementary views. Still, even at this preliminary stage, a new view of violence and its effective control is worth sketching. Violent crime is a threat to the nation's health and safety as well as to public security. It must be seen and responded to as both a health problem and a crime problem. In reckoning the social consequences of criminal attacks resulting in injury, it is important to consider not only the magnitude of the physical injury, but also the psychological damage and fear that are stimulated by criminal violence. It is important to see that violence that occurs in the context of ongoing relationships (such as within families) is particularly damaging and particularly hard for the criminal justice program to identify or manage. Consequently, it is in these areas that the public health and medical communities have particularly important roles to play. Acts of violence that will be properly labeled by society as criminal attacks emerge from a complex causal system that includes, but is not limited to, the intentions of the offender. Other factors influencing individual incidents and aggregate levels of violence include such things as (a) the availability and use of criminogenic commodities (such as guns, drugs, and alcohol); (b) the density of criminogenic situations (such as ongoing unresolved

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Understanding and Preventing Violence: Volume 4 - Consequences and Control conflicts); and (c) a variety of cultural factors that help to justify and encourage violence. It follows as a corollary, then, that there are important opportunities to prevent criminal violence beyond those ordinarily relied on by the criminal justice system. Although it is both just and effective to hold offenders accountable for violent attacks, it may also be possible to prevent such attacks or reduce their seriousness by altering the "risk factors" that lead to criminal violence. In all likelihood, society's main line of attack on criminal violence will continue to come from the nation's criminal justice agencies. They are the ones who have the troops and the most familiar paradigm for defining and attacking the problem. Their efforts can usefully be aided, however, by a partnership with those in public health. Members of the public health community can enhance the significance of the criminal justice community's efforts by emphasizing that health, as well as security, is at stake. They can widen the perspective of the criminal justice community about the possible causes of violence and the possible lines of attack, and they can mobilize support for antiviolence programs from constituencies that have not previously been involved in dealing with these issues. How we arrived at such views is described below. Before presenting our analysis, however, two cautionary notes are in order. First, the analysis uses the literary device of referring to perspectives and views held by the "criminal justice community" and the "public health community." We understand that individuals in these ''communities" do not all hold the same views. Indeed, we suspect that the differences in perspective within these communities are at least as great as those between the two communities. Even worse, our analysis attributes to these communities particular views that are sharply drawn caricatures of the actual views held by members of the communities. Thus, we risk alienating the two communities from our discussion and from one another. Despite the hazards, we think this device serves our purposes. We believe that each community does have a somewhat distinctive approach and that there is much to be learned by taking the particular gestalts seriously, developing their implications, and seeing how each complements the other. In short, we think that at this stage of intellectual development, we are likely to learn

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Understanding and Preventing Violence: Volume 4 - Consequences and Control more of we work to sharpen the distinctive perspectives and see how they challenge one another, than if we blur the distinctions in easy agreements. Second, we make a sharp distinction between the views of the "criminal justice practitioner community" and the "criminal justice research community." One could make a similar distinction for the public health community, but making this distinction seems less important for the latter. The intellectual and professional gulf between practitioners and researchers seems much less in the public health community than in the criminal justice community. In fact, in important respects, the criminal justice research community has more in common with the public health research and practitioner community than with the criminal justice practitioner community. What unites them is their common interest and commitment to "behavioral sciences." Most criminal justice practitioners are not "behavioral scientists." They have not been trained to be social science researchers or social engineers. They mete out justice through the operations of the criminal justice system. They work in close contact with the moral sentiments of local communities and with individual cases rather than aggregate phenomena. Their home disciplines are philosophy, law, and the professional arts of police and correctional administration rather than social science. In making these distinctions, we are not apologizing for the views of criminal justice practitioners. We think that their value commitments and perspectives are important to honor in dealing with criminal violence. Justice is a value society means to preserve in making its response to violence. We simply note that on some important questions (such as the causes of violence or effective methods of prevention), the view of criminal justice practitioners will be somewhat different from those of both criminal justice researchers, on the one hand, and the public health community, on the other. Third, throughout the discussion, we distinguish between "traditional" and "stereotypical" criminal justice responses to violent crime, and emerging criminal justice practices which have a more preventive focus. We do so to acknowledge that criminal justice practitioners have long been interested in prevention, and that the interest in new forms of prevention is now increasing; but also to recognize that the principal focus of the criminal justice system has been on arresting and punishing offenders once a crime has occurred.

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Understanding and Preventing Violence: Volume 4 - Consequences and Control "CRIMINAL VIOLENCE" AND "INTENTIONAL INJURIES": DIFFERENT PERCEPTIONS OF A SHARED CONCERN In today's hard-pressed communities, a world of trouble awaits attention by public agencies. Precious few resources are available to respond. Thus, common sense dictates that public agencies stay focused on the problems that are central to their responsibilities; they should not stray into new areas. Thus, it is natural to think that criminal justice agencies should remain focused on crime control, and public health agencies on traditional public health concerns. THE COMMON CONCERN: INTERPERSONAL VIOLENCE What this view overlooks, however, is that public health and criminal justice agencies share a common concern that is at the center of their respective responsibilities. Each community, consistent with its own responsibilities, must be intensely concerned about attacks by one citizen against another that produce physical injury (i.e., homicides, rapes, and aggravated assaults). The criminal justice community must be concerned because these crimes are among the most important for the criminal justice system to address. The public health community must be concerned about such events because they damage the health status of the least advantaged in society. SIGNIFICANT ASPECTS OF INTERPERSONAL VIOLENCE Both public health and criminal justice communities initially concern themselves with the nature and magnitude of the injury that results from interpersonal violence. To a degree, the criminal justice community is directed to consider the magnitude of the injury by the provisions of criminal law. If a person dies as a result of a criminal attack, the offender is charged with homicide, murder, or manslaughter rather than aggravated assault. Where the differences are not reflected in law, they are often reflected in formal administrative rules. New sentencing guidelines, for example, typically require judges to consider the extent of injury to the victims in deciding on an appropriate sentence for a given criminal offense (Nagel, 1990). Where the differences are not reflected in either law or formal procedures, they nonetheless appear in informal practices. Prosecutors, for example, commonly rely on the "seven-stitch rule" to

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Understanding and Preventing Violence: Volume 4 - Consequences and Control distinguish aggravated assault from simple assault; unless an injury requires more than seven stitches to close, the incident will be treated as a simple rather than an aggravated assault. In these respects, then, the criminal justice community gives attention to the seriousness of the injury to the victim. Criminal Justice Emphasis on the Offender What is surprising to public health professionals, however, is how quickly the attention of criminal justice officials shifts from the victim and his injuries, on the one hand, to concerns about the offender, on the other. Once some injury has been established, and some indication of who the offender is has been obtained, criminal justice officials begin to lose interest in the victim as a victim. The victim remains important as a witness in a criminal proceeding against the offender, but the victim as someone who needs continuing attention recedes into the background (for criminal justice neglect of victims, see President's Task Force on Victims of Crime, 1982; Bureau of Justice Statistics, 1983). Instead, attention begins to focus on the offender. To criminal justice officials, the seriousness of an offense is judged as much on characteristics of the offender as injury to the victim. Indeed, in judging the seriousness of an incident of interpersonal violence, three characteristics of the offender become important. The first is the intention of the offender in the instant case: the more deliberate and calculating the attack, the more serious is the crime. The second is the "dangerousness" of the conduct that led to the injury. For example, the criminal justice system often treats mere threats from gun-toting offenders more seriously than actual injuries inflicted by offenders armed only with their fists. This reflects the view that the exact nature of the injury emerging from a criminal attack is largely fortuitous. What is morally relevant (and therefore important to criminal prosecution) is the dangerousness of the conduct of the offender. The third is the offender's prior record of offending. This is important for two slightly different reasons. On the one hand, the offender's prior record is often seen as predictive of future acts of violence: the more violence there is in an offender's past and the more serious it is, the greater is the risk for the future (Chaiken and Chaiken, 1982; Greenwood, 1982). On the other, the past record of offending is often used by investigators (if not judges and juries) to gauge the intention of

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Understanding and Preventing Violence: Volume 4 - Consequences and Control the offender in the instant case: the longer the prior record, the less likely it seems that an offense was committed by accident (Moore, 1986). These concerns about the offender's intent, conduct, and prior record all distract attention from the victim and the magnitude of the injury inflicted. Yet, from the perspective of criminal justice officials, these issues are essential. What is important for the cause of justice is being clear about the heinousness of the crime: care for the victim is less significant. Public Health Focus on the Victim In contrast, in looking at instances of criminal violence, members of the public health community initially focused more attention on the victim. Because they were interested in health consequences, it mattered whether a knife wound was deeply penetrating and life threatening, or bloody but easily sutured. They were also concerned with what continuing kinds of care would be required to restore the victim to his or her previous condition. They were particularly concerned, if the victimization involved an on-going relationship, how that continuing relationship would be structured in the future. In short, their medical orientation and preventive concerns kept their attention focused on the victim rather than the offender. More recently, however, the public health community has begun to share the criminal justice system's interest in the offender. The difference in its orientation to the offender is that, like many in the criminal justice community, it is interested in preventing the emergence of people who are prone to committing violence. PROBLEMS RELATED TO INTERPERSONAL VIOLENCE The differing concerns of the two communities also affect each community's perception of what other specific problems are related to the core problem of interpersonal violence, and are therefore part of its responsibilities, and which are not. At the outset, it seems that there ought to be a fairly clear line of demarcation between the concerns of the two communities. The criminal justice community's terrain is marked out by behavior that is proscribed by criminal statutes. Presumably, the gradients of concern are determined by the seriousness of the criminal offense. The public health community's terrain is marked out by

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Understanding and Preventing Violence: Volume 4 - Consequences and Control FIGURE 1 Overlapping perspectives of public health, criminal justice, and behavioral science. SOURCE: Adapted from National Committee for Injury Prevention and Control (1989:193). the occurrence of physical trauma. The gradients of concern involve the seriousness of the injury. As noted above, these concerns produce an important overlap, but it also seems true that clear boundaries exist. Figure 1 makes this point graphically by using a Venn diagram to show the areas of overlap and of difference. In practice, however, the clear distinctions begin to blur. The sharp edges that define the concerns of one community begin to shade into the concerns of the other. As a result, the area of overlap becomes much larger. The reasons for this are the following. Violence and "Nonviolent" Crimes The concerns of the criminal justice community embrace all criminal offenses—including those offenses that do not necessarily

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Understanding and Preventing Violence: Volume 4 - Consequences and Control produce violence or physical trauma. Burglary, larceny from the person, even robberies that do not result in injury are all considered important crimes (Bureau of Justice Statistics, 1984). Yet they do not involve violence—at least not in the narrow, literal sense. Public health practitioners, focused principally on controlling violence, might be less interested in these offenses. They might be concerned about them as citizens, but as public health practitioners they might feel less responsible for them because the offenses do not involve injuries per se. In trying to account for the criminal justice community's interests in such offenses, they might reasonably assume that its concern reflected a concern for protecting property rather than life and safety. To a degree, the public health practitioner would be correct in these views. The criminal justice community is concerned about protecting property as well as protecting life and safety. Yet, in an important sense, the criminal justice community's concerns about these "property offenses" can be seen as deriving from concerns about controlling violence and its consequences as much as from concerns about protecting property. To the extent that this is true, the public health community might be interested in these offenses as well as the more obviously violent crimes. One reason is that any crime, including property crime, has the potential for creating real violence. The clearest example occurs when household burglaries become robberies because an unanticipated homeowner appears on the scene. However, this example illustrates a far broader point. When any crime is committed, a potential for violence is created simply because a powerful social norm has been violated. Those who have been wronged (and all their family, friends, and relatives) feel angry and vengeful. In defending themselves against attack, in apprehending the offender, sometimes even in punishing the offender, real violence may occur (Cook, 1981). The point is simply that it is not just literal violence that begets violence, it is the more metaphorical violence to the social order that begets violence. In the language of public health, any crime—even property crimes—can be a risk factor for violence. The second reason for the criminal justice community's concern about property offenses is closely related to the first. Precisely because crimes have the potential to escalate into violence, even nonviolent crimes produce a significant amount of fear. Fear is an important problem in its own right. Indeed, it is one of the most important reasons to be concerned about violent crime (Moore

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Understanding and Preventing Violence: Volume 4 - Consequences and Control state intervention and control. Viewed from this perspective, the two should be seen as complementary, rather than as competitive approaches to the same problem. Sometimes it may be wise for the criminal justice community to seek to widen the effective force of criminal laws by supplementing these laws with educational programs (as we are now doing in the domain of drug abuse). In other cases, it may be wise for the public health community to strengthen its ability to control risk-taking behavior by adding the weight of the criminal law to its educational efforts (as has been done in the domain of drunk driving). TOWARD A SYNTHESIS In sum, the criminal justice and public health communities bring different professional intuitions to discussions about what methods might best be used to tackle the problem of interpersonal violence. The criminal justice community brings a preference for a largely reactive, individual case-based focus, whereas the public health community brings a broader, preventive approach to the problem. Although there are some preventive aspects to the ordinary criminal justice system processing of cases, these are not the primary concern of the criminal justice community. To the extent that the criminal justice community is concerned with primary and secondary prevention, it tends to focus on changing the processes of development that produce sustained criminal offenders. In addition, the criminal justice community has sought to control some commodities that it views as criminogenic—principally drugs, but also alcohol and guns. Finally, there have been some efforts to analyze and control criminogenic environments and situations. The public health community has brought a strong commitment to prevention to discussions about the control of interpersonal violence—not only secondary prevention, but also primary. In the secondary domain, it has alerted the criminal justice community to a set of problems involving violence in ongoing relationships that was largely invisible to ordinary criminal justice system operations, and it has joined the criminal justice community in seeking out effective approaches to reducing the incidence of such offenses. Its members have also brought to the control of interpersonal violence innovative methods that use hospitals as points of contact and seek to alter local attitudes among children about violence. Finally, they have brought renewed interest to efforts to control guns and perhaps alcohol as well. In the domain of primary prevention, they have resurrected

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Understanding and Preventing Violence: Volume 4 - Consequences and Control concerns about the impact of poverty and racial discrimination on offending and victimization, and have brought new concerns about factors that are shaping the culture within which violence can occur. They have also reminded the criminal justice community of the virtue of relying on education as well as laws in seeking to regulate behavior on a large scale. All of this has stimulated the imagination of the criminal justice community about new opportunities to prevent violence and intentional injury. RESOURCES: TROOPS, ANALYSTS, AND COMMUNITY LEADERS One of the important questions a criminal justice practitioner might ask when the public health community offers to join the fight against criminal violence is what additional resources the public health community can bring to the problem, beyond a new appreciation of its significance and a new methodology for exploring causes and lines of attack. As Hitler is reputed to have asked, ''How many divisions does the Pope have?" WHO HAS THE TROOPS? At first blush, the answer seems to be relatively few. A public health department rarely has an organization focused on "intentional injuries." Indeed, only about two states now have special units in their public health departments. Those that exist are largely analytic and advisory rather than operational. This is broadly consistent with past public health tradition. Public health has always worked in interdisciplinary settings, using the resources of other agencies to make contributions to the solution of health problems. One can imagine, in the future, larger and more powerful public health offices working on the prevention of "intentional violence," but for now, the effort is small. As a result, in the minds of hard-pressed criminal justice officials who are struggling to deal with overwhelming operational problems and are accustomed to measuring resources in terms of the number of troops commanded, there is a real question about what public health can concretely contribute to efforts to deal with intentional injury. However, this is a quite myopic view for the criminal justice community to take. The public health community is quite clear that it is dependent on the operational capacity of the police and

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Understanding and Preventing Violence: Volume 4 - Consequences and Control the criminal justice system to accomplish its goals; they provide the muscle and the troops in dealing with violent crime. They are also important in dealing with other items on the public health agenda such as traffic accidents, and they are often called in to support public health initiatives in other areas such as environmental health and safety or the control of some health epidemics. So there is a long history of mutual dependence and cooperation between the criminal justice and the public health communities. That history has largely been forgotten or ignored by the criminal justice community, and to a lesser degree even by the public health community. This is a loss—particularly in a world seeking to cope with AIDS, in which this collaboration may once more be very important. Indeed, it would not be too much to say that the police are an important health-producing as well as law enforcement agency. The worry in the public health community is that if its dependence on the criminal justice system is fully acknowledged and if it does not bring powerful operational resources to the table, the criminal justice system will simply ignore the interests and the potential contributions that the public health community represents. As we have seen, its interests are in promoting health and safety, and in doing so through preventive efforts. The question is what kind of resources it brings to this enterprise, if not operational troops. PUBLIC HEALTH CONTRIBUTIONS TO THE FIGHT The answer to this question is that the public health community brings two key resources to the criminal justice community's attack on violence. The first resource is improved analytical capabilities. The second is a new political constituency for violence prevention and control. An enlightened criminal justice community should acknowledge the great value of both contributions. Analytically, the public health community is relatively far advanced compared to the usual practice in criminal justice agencies. The traditions and training of the former are much stronger. Most of its practitioners have advanced degrees. They know how to gather and analyze data about problems. They know how to design multidisciplinary programs to deal with specific problems. Although these skills also exist in the criminal justice research and practitioner community, they are less common and less commonly deployed than they are in public health.

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Understanding and Preventing Violence: Volume 4 - Consequences and Control Politically, the public health community bring two key assets. First, it brings new values that can be attached to criminal justice efforts. In the past, society was opposed to criminal violence because it was wrong and concentrated unfairly among poor people. What the public health community reveals to citizens is that criminal violence is a major threat to the nation's health as well, which changes the seriousness of the problem. It also changes who pays attention to the problem, which is the second great political contribution that the public health community's interest in violence makes to the criminal justice community. Once violence is seen as a health problem, a different group of people begins paying attention. As long as crime was viewed as a moral evil to be handled through enforcement and punishment, only a limited constituency was mobilized. The people who paid most attention were those in the criminal justice practitioner community. They were backed principally by those who were concerned with getting crime under control. The dialogue was mostly about the extent to which deterrence, incapacitation, and rehabilitation could be expected to work. Many in the minority community and those employed in "helping" professions, such as educators, psychologists, and social workers, felt excluded from the discussion. Once the problem becomes a health problem, a much different constituency is mobilized. The minority community, which is most often the victim of criminal offending, finds it much easier to talk about the problem as a health problem than as a crime problem. The health profession, educators, and social workers also find the public health formulation of the problem easier to understand and use. Thus, a new constituency interested in controlling violence is created. This new constituency for attention to violence is important because the new constituency is visible, articulate, and activist. Its interest will provide a basis for passing new laws, raising additional funds, mobilizing volunteer efforts, and inventing new approaches. In sum, although the public health community does not necessarily command many troops, like the Pope it does have the power of moral suasion and a large following. That is a valuable asset indeed to bring to the table. KEY VALUES: JUSTICE VERSUS HEALTH In the background of much of the technical issues that have been discussed so far is a larger issue—the question of what values

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Understanding and Preventing Violence: Volume 4 - Consequences and Control society ought to have in mind as it approaches a particular problem. As noted in the introduction, the predominant approach in dealing with interpersonal violence has been one guided by concepts of justice—what people properly owe one another and what should be done in instances where people fail to live up to their responsibilities. Many view the questions of blame and punishment as primitive ideas of social organization—almost indistinguishable from concepts of vengeance and retaliation. This ignores the fact, however, that victims and citizens are angered not simply because they have been injured but because an injustice occurred. They want reassurances that the social order will be restored and that their expectations about what they are entitled to will also be restored. The ceremonies that recreate expectations and norms are an important part of society's response to interpersonal violence and are performed well by the criminal justice system. To ignore the values associated with doing justice is to miss the key element that distinguishes intentional injury from unintentional injury. On the other hand, as the public health community consistently reminds us, it is best not to rely too much on blame. It attracts too much emotional heat and blots out reasoning or analysis. Imposing it is not always just, and it will not do all the practical work that it is supposed to do. The public health approach redirects our attention to care for the victims. It encourages us to see the causes of violence in different places and therefore to resist the natural tendency to want a scapegoat when something bad happens even if that is not always just, and it encourages other lines of attack. It emphasizes persuasion and education over coercion, reason over emotion, analysis over the mobilization of overwhelming force. In these broad ways, the public health community may make its largest and most important contribution to society's understanding of, and attack on, the intertwining problems of criminal violence and intentional injury. NOTE 1.   There is some confusion within the public health community about how these terms should be defined. We are following the definitions offered by Last (1980).

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Understanding and Preventing Violence: Volume 4 - Consequences and Control REFERENCES Aaronson, D.E., C.T. Dienes, and M.C. Musheno 1982 Decriminalization of Public Drunkenness: Tracing the Implementation of Public Policy. Washington, D.C.: National Institute of Justice. Bard, M. 1969 Family intervention: Police teams as a community mental health resource. Journal of Criminal Law, Criminology and Police Science 60(2):247-250. Bard, M., and J. Zacker 1976 The Police and Interpersonal Conflict: Third-Party Intervention Approaches. Washington, D.C.: Police Foundation. Berk, R.A., D.R. Loseke, S.F. Berk, and D. Rauma 1980 Bringing the cops back in: A study of efforts to make the criminal justice system more responsive to incidents of family violence. Social Science Research 9:193-215. 1982 Throwing the cops back out: The decline of local program to make criminal justice system more responsive to incidents of domestic violence . Social Science Research 11:245-279. Blake, P.A., and R.A. Feldman 1986 Typhoid fever. Pp. 238-240 in J.M. Last, ed., Public Health and Preventive Medicine, 12th ed. New York: Appleton-Century-Crofts. Blumstein, A., J. Cohen, and D. Nagin, eds. 1978 Deterrence and Incapacitation: Estimating the Effects of Criminal Sanctions on Crime Rates. Washington, D.C.: National Academy Press Blumstein, A., J. Cohen, J.A. Roth, and C.A. Visher, eds. 1986 Criminal Careers and "Career Criminals." Washington, D.C.: National Academy Press. Bureau of Justice Assistance 1988 An Invitation to Project DARE: Drug Abuse Resistance Education: Program Brief. Washington, D.C.: U.S. Department of Justice. Bureau of Justice Statistics 1983 Victim and witness assistance: New state laws and the systems response. Bureau of Justice Statistics Bulletin (May). Washington, D.C.: U.S. Department of Justice. 1984 The severity of crime. Bureau of Justice Statistics Bulletin (January). Washington, D.C.: U.S. Department of Justice. Bureau of Justice Statistics and Federal Bureau of Investigation 1985 Blueprint for the Future of the Uniform Crime Reporting Program: Final Report of the UCR Study. Washington, D.C.: U.S. Department of Justice.

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