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

Chapter: Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart

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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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Suggested Citation:"Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart." Institute of Medicine. 2008. Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/12016.
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APPENDIX C 201 Violence, Health, and Development Richard Matzopoulos1 Brett Bowman2 Alexander Butchart3, 4 Executive Summary The burden of violence-related deaths is heaviest in low- to middle- income countries (LMICs). Less than 10 percent of all violence-related deaths occur in high-income countries (HICs), and LMICs have a mortality rate due to violence that is almost two-and-a-half times greater than for high-income countries. Over and above the substantial contribution of vio- lence as a cause of death and physical injuries, victims of violence are also more vulnerable to a range of mental and physical health problems. 1Richard Matzopoulos is a Researcher at the the University of Cape Town School of Public Health and Family Medicine, and a Specialist Scientist at the MRC/UNISA Crime, Violence and Injury Lead Programme in South Africa. 2Brett Bowman is a Senior Researcher in the Discipline of Psychology at the School of Hu- man and Community Development of the University of the Witwatersrand, Johannesburg, South Africa. 3Alexander Butchart is the Coordinator, Prevention of Violence in the Department of Injuries and Violence Prevention of the World Health Organization, Geneva, Switzerland. 4The findings and conclusions of this paper are those of the author and do not necessarily represent the views of the World Health Organization. Terms of reference The following paper was prepared as a scoping document for participants of the two-day workshop hosted by the Institute of Medicine in Washington DC from 26 to 27 June 2007: Preventing Violence in Low- and Middle-Income Countries: Finding a Place on the Global Health Agenda. The contents are those of the autho(s) and do not necessarily reflect the opin- ions or positions of the Institute of Medicine.

202 APPENDIX C Although the effects of violence on other health outcomes are less well documented, some highly prevalent forms, such as child maltreatment, inti- mate partner violence (IPV), and abuse of the elderly, have been shown to have numerous noninjury health consequences. These consequences include high-risk behaviors such as alcohol and substance misuse, smoking, unsafe sex, eating disorders, and the perpetration of violence. These behaviors in turn contribute to such leading causes of death as cardiovascular disorders, cancers, depression, diabetes, and HIV/AIDS. The social toll of violence is further exacerbated by economic costs that represent formidable threats to fiscal growth and development. Several studies describe the deleterious impact of different types of vio- lence on a range of health outcomes, but no review has yet been undertaken that presents a composite overview of the current state of knowledge. This paper aims to review the scientific literature describing the nature, magni- tude, and impact of violence on health and development in LMICs. It has the following specific objectives: • To review the literature on violence in LMICs according to the typology commonly used by international agencies such as the World Health Organisation (WHO) • To describe what is known about the negative impacts of violence on health and human development in LMICs • To examine available information about the economic costs and impacts on economic development of violence in LMICs • To describe violence prevention policy developments within the global health and development agenda The paper includes a review of recent research on violence in LMICs around seven subtypes of violence: (1) child abuse and neglect, (2) youth vio- lence, (3) intimate partner violence (IPV), (4) sexual violence, (5) abuse of the elderly, (6) self-directed violence, and (7) collective violence, and discusses its broader implications and macro-level impacts on health and development. Child Maltreatment and Other Violence Directed at Children Homicide rates are considerably higher in LMICs than in HICs among older children: 2.6 times higher among boys aged 5 to 9 years, 3.6 times higher among girls aged 5 to 9, and more than 4 times higher among chil- dren aged 10 to 14 for both sexes. Sexual and physical abuse experienced during childhood are just some of the numerous psychological and behav- ioral factors endemic in many LMIC settings that may predispose children and young adults to display violent and aggressive behavior later in life and have been shown to have substantial long-term effects on health.

APPENDIX C 203 Youth Violence Countries with the highest adolescent homicide rates are either develop- ing countries or those experiencing rapid social changes. Among children aged 15 to 17 years male homicide rates in LMICs were three times higher than in HICs, and female rates in LMICs more than double those in HICs. There is an increased risk of violence in populations where adolescents and young adults are overrepresented and, as is the case in LMICs, may include a large percentage of “marginalized youth” with poor prospects of educa- tion and employment. Intimate Partner Violence Many of the risks associated with a man’s likelihood of abusing a female intimate partner are prevalent in low-income settings and some of the highest rates of IPV have been recorded in LMICs. Sexual Violence The true extent of sexual violence is difficult to gauge within HICs as well as in LMICs, as statistics on rape and indecent assaults are typically underreported. Nevertheless, there are indications that rates of sexual vio- lence in LMICs are substantial. Abuse of the Elderly Most research on violence against the elderly has been conducted in HICs. While more descriptive work in the area is required, there is growing evidence to suggest that the elderly are also frequently victims of violence in LMICs. Self-Directed Violence Suicide was the leading cause of death due to violence in LMICs in 2002, although it accounted for a smaller percentage of all deaths due to violence in LMICs than in HICs. Collective Violence Collective violence is an endemic and enduring feature of many LMICs. The hallmark of countries that have been at war is a combination of poverty, strained economic and social infrastructure, and severely eroded health services. Collective violence is restricted almost entirely to LMICs,

204 APPENDIX C with particularly high rates experienced in Africa followed by the Eastern Mediterranean and LMICs in the European region. The Impact of Violence on Health Violence has numerous impacts on health and these can be measured in a variety of ways. The most common and direct ways of measuring its impact are in terms of the numbers and rates of deaths and injuries it causes. Although less easy to measure, violence also has important impacts on a range of mental and physical health problems. It is important and use- ful to quantify these various impacts in both health and economic terms. The Burden of Injury Estimated mortality rates compiled by WHO for 2002 suggested that overall mortality rates due to violence in LMICs were on average more than double those of HICs. Violence is also projected to increase in rank from the 15th to the 13th leading cause of death between 2002 and 2030 with middle-income countries likely to bear most of this burden. The Burden of Violence on Other Causes of Ill Health The impact of violence on other health outcomes is clearly reflected in comparative risk assessment studies, which show that standard burden of disease measures underrepresent the impact of interpersonal violence by at least 26 percent for deaths and 30 percent for disability-adjusted life-years (DALYs) when its contribution to other health outcomes resulting from child sexual abuse and IPV are taken into account. The Economic Impact of Violence on Health The direct costs (or impacts) of violence include the medical costs related to the treatment of the victims of violence and nonmedical costs associated with prevention. Indirect costs include those that are tangible such as the impact of violence on the broader macro economy and those that are intangible such as those relating to quality of life. Based on exist- ing estimates primarily calculated in South Africa, the Caribbean, and Latin America, it is clear that the costs of violence are enormous in LMICs. Overall, WHO reports that health care expenditure related to violence consumes a significant portion of gross domestic product (GDP) in LMICs. These direct health expenditures represent just a fraction of violence-related costs and impacts.

APPENDIX C 205 The Impact of Violence on Development Collective, interpersonal, and self-directed violence all have extensive and pervasive long-term implications for development as well as health. These effects are themselves multilayered and can therefore undermine devel- opment at individual, communal, or national levels. This paper describes the impact of violence in relation to all eight goals of the ­ Millennium Development Plan. The impact of violence on the Millennium Development Goals (MDGs) must also be read alongside growing evidence that demon- strates the negative, enduring effects of exposure to violence in childhood. The Economic Impact of Violence on Development Violence in whatever form absorbs sizeable amounts of health care expenditure that could be better used to prevent other forms of health threat. Although data are limited, health economic research on violence has begun to demonstrate the substantial economic impacts of violence in LMICs. National spending on collective violence in the form of “defense” budgetary allocations and investment in postconflict recovery have been shown to lead to drastic reductions in national investment in health care services. The Emergence of Violence Prevention as Part of the Health and Development Agenda There are clear indications that violence prevention is an emerging pri- ority in the global health and development agenda, particularly in LMICs. Since the publication of the World Report on Violence and Health, there have been two World Health Assembly resolutions calling on countries to invest in violence prevention, and by 2006 three out of six WHO regional committees (Africa, the Americas, and Europe) had adopted simi- lar resolutions. Conclusion Violence is a pressing global health concern and is inextricably linked with a range of other health indicators. Yet despite the fact that early pro- jections indicate that violence is on the increase, vigorous and concerted violence prevention efforts can turn this trend around. International devel- opment partners may have an important role to play in providing financial and technical support for intersectoral collaboration, multilateral research cooperation, and the development of research capacity in LMICs.

206 APPENDIX C Background and Overview Violence is a global problem. In 2002, violence claimed approximately 1.6 million human lives and caused at least another 16 million injuries severe enough to warrant medical attention. These consequences burden health systems, cripple communities, and are responsible for immeasur- able human suffering. The burden of violence-related deaths is heaviest in LMICs. Less than 10 percent of all violence-related deaths occur in HICs (Krug et al., 2002; Mathers et al., 2002), and LMICs have a mortality rate due to violence that is almost two-and-a-half times greater than for HICs (see Figure C-1). Over and above the substantial contribution of violence as a cause of death and physical injuries, victims of violence are also more vulnerable to a range of mental and physical health problems. The size of the violence problem can be better appreciated when it is compared to other major health threats. The estimated 1.6 million deaths due to violence in 2002 was around half the number of deaths due to HIV/ AIDS, roughly equal to deaths due to tuberculosis, greater than the number of road traffic deaths, and 1.5 times the number of deaths due to malaria. Suicide was the leading cause, accounting for 870,000 or 54 percent of violent deaths; homicide accounted for 560,000 deaths (35 percent) and the remaining 170,000 deaths (11 percent) were the direct result of war (Krug et al., 2002). Although the effects of violence on other health outcomes are less well documented, some highly prevalent forms, such as child maltreatment, IPV, and abuse of the elderly, have been shown to have numerous noninjury health consequences. These consequences include high-risk behaviors such as alcohol and substance misuse, smoking, unsafe sex, eating disorders, and the perpetration of violence. These behaviors in turn contribute to such leading causes of death as cardiovascular disorders, cancers, depression, diabetes, and HIV/AIDS. The social toll of violence is further exacerbated by economic costs that represent formidable threats to fiscal growth and development (Krug et al., 2002; Felitti et al., 1998; Waters et al., 2005). Aim and Objectives Because a composite review of the literature on the relationships between various types of violence and health and development in LMICs has not yet been undertaken, this paper aims to review the scientific litera- ture dealing with the magnitude and impact on health and development of violence in LMICs, and has the following specific objectives: • To review the literature on violence in LMICs according to the typology commonly used by international agencies such as WHO

APPENDIX C 207 32.1 All violence 14.4 10.1 Homicide 2.9 15.5 Suicide 11.4 6.2 War 0 High-income countries Low- and middle-income countries FIGURE C-1  Estimated mortality rate per 100,000 population from violence by income level, 2000. SOURCE: Mathers et al., 2002. Figure C-1 • To describe what is known about the negative impacts of violence on health and human development in LMICs • To examine available information about the economic costs and impacts on economic development of violence in LMICs • To describe violence prevention policy developments within the global health and development agenda Scope and Limitations of This Paper The review of literature is limited primarily to English language publi- cations and the authors welcome suggestions regarding additional texts and resources that may be relevant.

208 APPENDIX C The Nature of Violence in LMICs The World Report on Violence and Health (Krug et al., 2002, p. 5) defines violence as 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, p ­ sychological harm, maldevelopment or deprivation. The following subsections review recent research on violence in LMICs according to seven subtypes of violence also identified in the World Report on Violence and Health, namely (1) child abuse and neglect, (2) youth vio- lence, (3) IPV, (4) sexual violence, (5) abuse of the elderly, (6) self-directed violence, and (7) collective violence. The broader implications of violence and its macro-level impacts on health and development are discussed in Sections 3 and 4. It is noted that while this categorization is useful for describing violence and identifying prevention opportunities, the different subcategories are not mutually exclusive and there are strong links between different types of violence. For example, child maltreatment victims are more likely than nonvictims to experience IPV, sexual violence, and youth violence, while perpetrators of homicide where the victim is another family member are at substantially increased risk of later committing suicide. Similarly, the collec- tive violence of war and civil unrest may be precipitated by overwhelming levels of severe interpersonal violence; and some effects of collective violence, such as increased access to firearms and erosion of nonviolent value systems, increase the risk of interpersonal violence. Crosscutting these causal links between the different subtypes of violence are shared risk factors—such as alcohol and substance misuse, parental loss, crime, household poverty, and social and economic inequalities—that underlie most of the subtypes. Child Maltreatment and Other Violence Directed at Children Among children younger than 4 years of age, death rates due to vio- lence in LMICs are comparable with rates in HICs, although closer analysis shows that, whereas rates of homicide among boys in this age category are 10 percent lower in LMICs, the homicide rate among girls is 20 percent higher. There are also distinct regional differences, with homicide rates among African children more than double the global average for both boys and girls (Krug et al., 2002, p. 357). However, homicide rates are consider- ably higher in LMICs than in HICs among older children: 2.6 times higher among boys aged 5 to 9 years, 3.6 times higher among girls aged 5 to 9, and more than 4 times higher among children aged 10 to 14 for both sexes.

APPENDIX C 209 Data on nonfatal child maltreatment in LMICs are, unfortunately, limited, as they are derived from studies that use different definitions and assessment methods. Nevertheless, there is growing consensus on the definition of child maltreatment (Leeb et al., 2007; WHO and ISPCAN, 2006) and the development of recent surveillance guidelines for child mal­ treatment should ensure better comparability between future studies (Leeb et al., 2007). Despite the current methodological challenges, what we can deduce from the available data is that child maltreatment is indeed a widespread and serious problem. Physical child maltreatment often associated with punishment by parents or other caregivers has been examined in a number of LMICs. In a study of students aged 11 to 18 in the Kurdistan Province of the Islamic Republic of Iran, 38.5 percent reported experiencing mild to severe physical injuries from abuse at home (Stephenson et al., 2006). In a survey of households in Romania 4.6 percent of children reported suffering severe and frequent abuse and nearly half of Romanian parents admitted to beating their children regularly (Browne et al., 2002). In Ethiopia 21 per- cent of urban and 64 percent of rural school children reported bruises or swellings on their bodies from being physically punished by their parents (Ketsela and Kedebe, 1997). Among younger children, serious injuries most frequently arise as a consequence of head injuries or injuries to the internal organs, often at the hand of a caregiver. Shaken infant or shaken impact syndrome is a potentially devastating form of child abuse. The physical, medical, and emotional neglect of children is also an important dimension of child maltreatment. In many countries it is the most frequently reported form of maltreatment. In Kenya, for example, the forms of abuse most commonly cited by adults in selected communities were abandonment and neglect (African Network for the Prevention and Protection Against Child Abuse and Neglect, 2000). Young children and infants may also be the victims of sexual abuse, but findings from descriptive studies point to the increased risk of sexual abuse among girls with the onset of adolescence, whereas among boys this vulnerable period is marked by a much increased likelihood of engaging in physical violence. Data from a children’s hospital in Cape Town, South Africa, for example, show that whereas boys accounted for a greater per- centage of cases presenting for violence-related injuries (63 percent), sexual assaults were the cause of injury among 48 percent of girls compared to only 3 percent of boys (Matzopoulos and Bowman, 2006). However, such findings cannot be generalized. Another South African study, this time among secondary school students in the Limpopo Province, reported a prevalence rate of 54 percent of the total sample reporting con- tact sexual abuse before the age of 18 years with similar rates for males and females (Madu and Pelzer, 2001). Lalor (2004) points to rapid social

210 APPENDIX C change, the patriarchal nature of society, and HIV/AIDS as both a cause and consequence of sexual exploitation of children in sub-Saharan Africa. In other LMIC settings many studies reveal lower rates. For example, in a study across three Latin American countries (El Salvador, Guatemala, and Honduras), the percentage of women reporting being sexually assaulted before the age of 15 years ranged from 4.6 to 7.8 percent (Speizer et al., n.d.). However, the intimate nature of child sexual abuse, which often involves close family members and acquaintances as victims and perpetra- tors, along with cultural norms and taboos that may discourage disclo- sure, compromises the collection and comparison of data across different settings. Sexual and physical abuse experienced during childhood are just some of the numerous psychological and behavioral factors endemic in many LMIC settings that may predispose youths and young adults to display violent and aggressive behavior later in life (Karr-Morse and Wiley, 1997), and have been shown to have substantial long-term effects on health (see Section 3.2). In addition to these impacts of direct victimization, children exposed to violence as witnesses and bystanders may also be psychologi- cally traumatized. In South Africa, for example, a study of Xhosa-speaking youth in a township with high levels of community violence showed that all of the 60 respondents had been exposed to community violence, while 56 percent had been victims and 45 percent had witnessed at least one murder. The psychological imprint of these experiences manifested in 22 percent of these children fitting the diagnosis for posttraumatic stress disorder, 32 percent for dysthymia, and 7 percent for major depression (Ensink et al., 1997). Domestic violence also has direct effects on children, with one study suggesting that a substantial proportion of unintentional injuries in young children may have occurred in the course of their being used as “shields” by women attempting to protect themselves from physical attack by their male partners (Fieggen et al., 2004). Youth Violence Age and sex are important risk factors for interpersonal violence, with males in particular being more likely to engage in physical violence during adolescence and young adulthood. Consequently there is a sharp increase in the rate of aggressive behavior and victimization from the age of about 15 years. In LMICs this is compounded by underresourced educational systems and the fragility of traditional family and community structures that create an enabling environment for violence within homes and commu- nities. Invariably, the countries with the highest adolescent homicide rates are either developing countries or those experiencing rapid social changes (Pinheiro, 2006, p. 287).

APPENDIX C 211 Among children aged 15 to 17 years, male homicide rates in LMICs were three times higher than in HICs, and female rates in LMICs more than double those in HICs. In every region homicide rates among children aged 15 to 17 compared to those aged 10 to 14 are at least three times greater among males and nearly double among female children (Pinheiro, 2006, p. 287). Nevertheless, there are sharp regional differences, with Africa recording the highest rates among girls across all age categories and among boys aged 10 to 14 years, whereas the highest fatality rates among boys aged 15 to 17 were recorded in the Latin American and Caribbean regions, followed closely by Africa (Pinheiro, 2006, p. 357). The Latin American, Caribbean, and African regions have a large population under the age of 25, many of whom are raised in poverty, and rates of interpersonal violence are among the highest in the world (see Figures C-2 and C-3). Living off the informal economy and without family structures there is little hope of these children being integrated into formal society (Maddaleno et al., 2006). It is estimated that adolescents from 10 to 19 years of age comprise a third of all homicides in the Americas (PAHO, 2003) and globally rates of fatal violence are higher among 15- to 19-year- olds than in other 4-year age groups (Pinheiro, 2006, p. 287). In South Africa, a cross-sectional study revealed that more than 50 per- cent of all boys and girls had experienced violence, either as victims or perpetrators (Swart et al., 2002). In the Lavender Hill and Steenberg areas in Cape Town, over 70 percent of a sample of primary school children Caribbean 30 Southern and West Africa 29 South Africa 26 East and Southeast Asia 22 Central America 22 Eastern Europe 17 Central Asia 9 East Africa 8 North America 7 South Asia 4 Southeast Europe 3 Oceania 3 West and Central Europe 2 North Africa 1 Middle East and Southwest Africa 1 0 5 10 15 20 25 30 35 FIGURE C-2  Murder rates by region of the world. SOURCE: UN Crime Trends Survey and Interpol, 2002. C-2

212 APPENDIX C African Region European Region Region of the Americas Western Pacific Region South-East Asia Region Eastern Mediterranean Region 0 10 20 30 40 50 60 70 Homicide War Suicide FIGURE C-3  Estimated mortality rates per 100,000 population from violence in LMICs by health region, 2000. SOURCE: Adapted from WHO’s World report on violence and health by Mathers et al., 2002. Figure C-3 reported exposure to violence (Van der Merwe and Dawes, 2000). A youth risk behavior study conducted among a representative sample of in-school youth revealed that approximately 17 percent of pupils carried weapons and that approximately 30 percent of pupils had been involved in a physical assault in the past 6 months (MRC, 2002). These findings suggest there is an increased risk of violence in popula- tions where adolescents and young adults are overrepresented and, as is the case in LMICs, may include a large percentage of “marginalized youth” with poor prospects of education and employment. Therefore sound edu- cational and macro-economic policies applied at a societal and structural level to address the existential needs and long-term prospects of vulnerable youth and young adults may have important violence prevention effects. Intimate Partner Violence Among the numerous risk factors associated with a man’s likelihood of abusing a female intimate partner are young age, heavy drinking, depres- sion, personality disorders, low academic achievement, low income, marital conflict, marital instability, male dominance in the family, economic stress, and poor family functioning. Some studies have shown that boys who are

APPENDIX C 213 exposed to conflict in early childhood are at increased risk to be violent as adults. Correspondingly the community and societal factors for IPV include weak community sanctions against domestic violence, poverty and low social capital (Heise and Garcia-Moreno, 2002), and, at a societal level, cultural norms and values such as those that support gender inequality are particularly important. As many of these factors are prevalent in low-income settings it is not surprising that some of the highest rates of IPV have been recorded in LMICs: 27 percent of all women who have ever had an ongoing sexual partnership in Leon, Nicaragua, and 52 percent of currently married Pales- tinian women in the West Bank and Gaza Strip reported ever having expe- riencing IPV. A WHO multicountry study on women’s health and domestic violence against women in sampled country sites found that 37 percent of respondents in Brazil, 56 percent of women in Tanzania, and 62 percent of women in Bangladesh reported having ever experienced physical or sexual violence by an intimate partner (WHO, 2005). In South Africa, women aged 14 and older were killed by an intimate partner at a rate of 8.8 per 100,000, accounting for approximately half of all women murdered in a single year, the highest recorded rate in the world (Mathews et al., 2004). Sexual Violence Sexual violence encompasses a wide range of sexually violent acts per- petrated by family members, acquaintances, strangers in the community, and, particularly in LMICs, the perpetrators of collective violence. The true extent of sexual violence is difficult to gauge within HICs as well as in LMICs, as statistics on rape and sexual assaults are typically underreported. Nevertheless, there are indications that rates of sexual violence in LMICS may be higher. For example, in an address to parliament in September 2005, the South African Minister of Safety and Security reported that dur- ing the period April 1, 2004, through March 31, 2005, 55,184 rapes were reported at a rate of more than 250 per 100,000 women compared to 80 per 100,000 in the United States for the same period (also see Section 2.3). Another South African study in Cape Town reported that 32 percent of pregnant adolescents and 18 percent of matched controls had been forced into their first sexual experience (Jewkes et al., 2001). Comparing data across countries and national reports from the inter- national crime victim survey between 1992 and 1997 indicated that LMICs in Latin America, Africa, and Eastern Europe have among the highest per- centage of women aged 16 years and older who report having been sexu- ally assaulted (United Nations, 1998). Similarly, countries in these regions accounted for some of the highest percentages of adult women reporting sexual victimization by an intimate partner and forced sexual initiation.

214 APPENDIX C Abuse of the Elderly Elder abuse encompasses acts of physical, psychological, or sexual violence or neglectful financial and material maltreatment of older persons (Wolf et al., 2002). In Africa, the extent of elder abuse remains largely unknown, although it has been linked to practices such as persecutions of women suspected of witchcraft (Wolf et al., 2002) and the ostracism of tribal elders (Lachs and Pillemer, 2004). More systematic measurement has, however, been undertaken. There is growing evidence that the elderly are becoming increasingly at risk for violence in Africa (Gorman, 2000). In South Africa, the homicide rate among men aged older than 60 years was 6.4 times higher than the global rate in 2000, whereas it was 6.9 times the global rate among women (Norman et al., 2007a). Another South A ­ frican study found that the elderly are frequently the victims of physical, psycho­logical, and sexual violence in townships on the periphery of Cape Town (Keikelame and Ferreira, 2000). In South America, elderly women represented 2 percent of the victims of violence in an Argentinean study. This figure matches estimates of violence against the elderly in Denmark (Aalund et al., 1989). A study of mortality and morbidity patterns in Brazil showed that violence resulted in a significant number of hospitalizations in the elderly (Minayo, 2003). A survey study by Bezerra-Flanders and Clark (2006) in Brazil found that psychological abuse and abandonment, followed by physical abuse, were the most cited forms of elderly abuse in the sample. A multicountry qualitative study of perceptions of elder abuse found that violence against the elderly was identified as significant problem in Kenya, India, Brazil, Lebanon, and Argentina (WHO/INPEA, 2002). In combination, these studies have begun to identify violence against the elderly as a significant problem in LMICs, although far more descriptive work is required. Self-Directed Violence Suicide was the leading cause of death due to violence in LMICs in 2002, although it accounted for a smaller percentage of all deaths due to violence than in HICs (50 versus 68 percent, respectively; WHO, n.d.). However, as self-inflicted injuries are more frequently fatal, interpersonal violence imposed a greater burden in LMICs when nonfatal outcomes such as disabilities and other long-term effects were considered, accounting for 46 percent of DALYs, compared to 40 percent for suicide (WHO, n.d.). As with the other subtypes of violence there are wide regional varia- tions, and in a substantial number of LMICs in 2000 the suicide rate was considerably higher than the global average (13.5 per 100,000 population), particularly in Eastern Europe (28.2 per 100,000 population) and China

APPENDIX C 215 (23 per 100,000 population). Whereas the suicide rate in India has been estimated at 13.6 per 100,000 (Peden et al., 2002), the rate in Sri Lanka in 1995 was estimated at 47.7 per 100,000 (Eddleston et al., 1998). In Africa, which as a region had one of the lowest estimated suicide rates at 4.3 per 100,000 population in 2000 (Peden et al., 2002), there is a paucity of data on the burden of self-inflicted violence (Bertolote and Fleischmann, 2002), which makes regional and international comparisons difficult (Kinyanda, 2006). As with certain other types of violence socio­ political and cultural factors may increase vulnerability and also inhibit the collection of comprehensive and reliable data. Nevertheless, there is grow- ing concern about suicide as a public health priority in the region. Collective Violence Following the World Report on Violence and Health, collective vio- lence is defined as “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 or social objectives” (Zwi et al., 2002). Collective violence is an endemic and enduring feature of many LMICs, which bear what Sidel (1995) described as the hallmark of countries that have been at war: poverty, destroyed economic and social infrastructure, and severely eroded health services. Collective violence is restricted almost entirely to LMICs, with particularly high rates experienced in Africa fol- lowed by the Eastern Mediterranean and LMICs in the European Regions (see Figure C-3). Muggah (in press) maintains that the health implications of collective violence for civilians in LMICs are dramatic, as conflicts are frequently characterized by multiple armed groups, the targeting of civilians, the use of rape as a weapon of war, the involvement of child soldiers, and ulti- mately state fragility and even collapse (Duffield, 2001; Kaldor, 1999). The human costs extend well beyond death, physical injuries, and disabilities, and may lead to intergenerational “collective trauma” as many civilians witness shootings, killings, rapes, and the loss of family members.1 Inter- views with 301 former child soldiers abducted by the northern Ugandan rebellion movement, the “Lord’s Resistance Army,” provide some insight. On average the children had been exposed to six different traumatic events, with 77 percent witnessing someone being killed during their abduction; 6 percent witnessing their own father, mother, brother, or sister being killed; 39 percent killing another person themselves; and 2 percent killing their 1See, for example, Abramowitz (2005), De Jong et al. (2000), Miles and Medi (1994), and Mollica (1999).

216 APPENDIX C own relatives. Most of the children (64 percent) were forced to participate in fights and 27 percent had to drink their own urine (Derluyn et al., 2004). It is estimated that 300,000 children younger than 18 years are currently serving as soldiers, guerrilla fighters, or in supporting roles in conflicts around the world (Machel, 2001). Furthermore, collective violence in LMICs fundamentally influences many of the structural factors such as migration and rapid urbanization that stress the social fabric of families and communities, which in turn fuel a range of social ills that may give rise to interpersonal and self-directed violence. Hence, unfavorable living conditions, family characteristics, and perceptions among youths that they will derive economic benefit, social rec- BOX C-3 The Economic and Health Costs of War in Iraq The cumulative economic costs of war in Iraq are staggering and the economic impacts of the war are experienced daily across the global economy. According to a comprehensive report released by the Institute for Policy Studies in 2005, total U.S. ex­ penditure amounted to $204.4 billion. In September 2006, the revised report calculated total U.S. spending at $321 billion and projected total long-term spending to be US$ 1.3 trillion (Bennis and Lever, 2005). A paper presented at the Allied Social Sciences Association Congress of 2006 reported total costs of the war in Iraq to be US$ 251 billion as of December 30, 2005, and projected a total cost in excess of US$ 1 trillion, assuming U.S. troops return by 2010 (Bilmes and Stiglitz, 2006). As astounding as these costs may appear, they are nonetheless relatively meaning­ less without some form of comparison with missed opportunity costs for global develop­ ment. Drawing on the earliest 2005 figure, war spending by the U.S. government could have cut world hunger in half and covered HIV/AIDS medicine, childhood immunization, and clean water and sanitation needs of the developing world for almost 3 years (Bennis and Lever, 2005). Although the country had not yet fully recovered from the effects of the first Gulf War of 2001, there were relatively few deaths as a result of violence prior to the 2003 inva­ sion. Burnham et al. (2006) surmise that as deaths due to violence rose sharply after coalition forces entered Iraq, all postinvasion violent deaths can be considered “excess violent deaths” as these would presumably not have occurred in the absence of the invasion. Postinvasion crude mortality rose from 5.5 to 13.2 per 1,000. Deaths due to violence accounted for approximately three-quarters of the increase and were primarily responsible for the escalating mortality toll that has resulted in approximately 600,000 Iraqi deaths. There are indications that the incidence of interpersonal violence has increased, as sampled households have attributed fewer and fewer deaths to coalition forces as the war has continued. Between June 2005 and June 2006, over 74 percent of all violent deaths were attributed to sources other than the coalition forces. The effects of the war on the social and health infrastructure of Iraq clearly illustrate

APPENDIX C 217 ognition, and easier access to drugs are among the frequently cited as risk factors for the emergence of gangs in the Americas, essentially a manifesta- tion of collective violence at a micro level (PAHO, 2002). Frequently these groups of young men, drawn together for purposes of criminal activities, companionship, or protection, develop their own social norms in the absence of traditional family or community support structures and violence is a fre- quent means of resolving conflict and acting out social justice or revenge. As a case study, the war in Iraq, which has received widespread inter- national media coverage from its onset, also provides a comprehensive yet tragic example of the social costs and consequences of sustained conflict (Box C-3). the developmental consequences of collective violence. Increases in overall mortality have strained the health system in many ways and have hampered access to health services. Access to health care in central Iraq and Baghdad in particular is constrained by constant security threats, and health services for vulnerable groups such as preg­ nant women and the elderly are severely compromised. Collective violence in Iraq has thus produced collective health effects by driving increases in overall mortality and morbidity due to other forms of violence and communicable diseases. This is exacer­ bated by a systematic deterioration at all levels of health care services. It is estimated that over one-third of the country’s doctors have emigrated since conflict erupted. There has also been no significant improvement in food and water security as well as a marked decrease in standards of sanitation, which has multiple effects on popu­ lation health. WHO (2007) reports that 80 percent of people lack effective sanitation, 70 percent lack access to regular clean water, and only 60 percent have access to the public food distribution system. Diarrhea and acute respiratory infections are worsened by these barriers to nutrition and essential health care services and so account for about two-thirds of deaths among children under age 5 years. According to the report, the chronic child malnutrition rate is estimated at 21 percent and the successes of the country’s polio immunization program in keeping Iraq polio free for some 6 years could be undermined by disruptions related to violence. It must be emphasized that the accuracy and validity of some of the research that has been conducted in Iraq can be disputed from a scientific standpoint. There are very real difficulties in conducting research and collecting accurate and representative data in countries in constant turmoil, such as Iraq and Afghanistan. As well as concerns about safety, there are also powerful forces that can restrict access to information, not only as a result of overt (or even covert) action, but also by shaping the social and political climate that enables the free flow of information. Hence there is a clear need for the development of guidelines for the collection of credible information in similar circumstances.

218 APPENDIX C The Impact of Violence on Health The definition of violence encompasses a wide range of actions and possible deleterious health and developmental outcomes (see The Impact of Violence on Other Causes of Ill Health section below). These health impacts can be measured in a variety of ways. The most common and direct ways of measuring its impact are in terms of the numbers and rates of deaths and injuries it causes. Although less easy to measure, violence also has important impacts on a range of mental and physical health problems. It is important and useful to quantify these various impacts in both health and economic terms. The paucity of accurate and detailed data, however, make it difficult to fully measure all of these impacts in LMICs. Further- more, as many of the impacts of violence present within the health sector as major risk factors and causes for a range of other health conditions and outcomes, it could be said that violence foments a vicious cycle. For example, the adverse impacts of violence on quality of life may lead to the deterioration of mental health and well-being that may in turn impose a direct (and measurable) burden on the health system, while at the same time driving rates of violence even higher within afflicted communities. Hence the impacts of violence on health and development in LMICs are addressed in separate subsections. With regard to health impacts, the bur- den of violence relating specifically to the physical effects of violence-related injuries is first described, followed by a review of how violence impacts upon other noninjury health outcomes. Available data on the direct costs of violence on the health system are then reviewed. The impact of violence on development, which mirrors the WHO/Centers for Disease Control (CDC) typology with respect to the nonmedical and many of the tangible and intangible indirect costs, is described in more detail below. The Burden of Injury The most commonly used measures to describe the health impact of violence are mortality rates to describe its direct consequences (i.e., deaths as a result of physical injuries). Typically expressed as homicide (or ­murder2) and suicide rates, the uncommonly high rates in LMICs are apparent in the mortality rates cited by health (Figure C-1) and criminal justice agencies (Figure C-2). Data from the UN Crime Trends Survey and Interpol (Figure C-1) point to a considerable variation in regional murder 2The term homicide refers to the intentional use of force resulting in the death of another person. “Murder” is a criminal justice term that may exclude certain categories of homicide where a crime is not perceived to have been committed. Although the terms refer to marginally different subsets, for the purposes of this report they are essentially interchangeable.

APPENDIX C 219 rates, but the highest rates invariably occur in LMICs, particularly in South and Central America, and South and West Africa. Estimated mortality rates compiled by the WHO for 2000 also sug- gested that overall mortality rates due to violence in LMICs were on average more than double those of HICs (Mathers et al., 2002). This was mainly attributable to higher homicide rates and deaths resulting from wars and conflict, which almost exclusively afflicted LMICs in 2000. Among LMICs, there was considerable regional variation with regard to the type of violence. Mortality rates due to injuries arising from inter- personal violence were highest in the Americas followed by the African and the European regions, whereas suicide rates were highest in the European and Western Pacific regions. At 32 per 100,000 population, injury mortal- ity rates from war and conflicts were far higher in Africa in 2000 than in any other region and almost four times higher than the next most afflicted region, the Eastern Mediterranean, with an injury mortality rate of 8.2 per 100,000 population. Violence is also projected to increase in rank from 15th to 13th position among the leading causes of death between 2002 and 2030 and middle- income countries will likely bear most of this burden. This will mainly be attributable to increases in the rate of interpersonal violence as rates of suicide are projected to decrease over the next 30 years (Mathers and Loncar, 2006). Although these data clearly show a substantial injury burden in LMICs directly attributable to violence, there are a number of reasons why they are likely to underrepresent the actual magnitude of the problem. First, injuries from violence afflict a younger population cohort than most non- communicable diseases (e.g., chronic conditions associated with diseases of lifestyle) and some infectious diseases and, consequently, account for a larger percentage of premature deaths than evinced by mortality rates. Second, as mortality rates only reflect the number of people who die from a specific cause, they ignore the often significant burden imposed on survivors living with physical disabilities or mental illnesses and their next of kin. Third, whereas the mortality rates cited above reflect only violence-related deaths, violence affects health and development broadly and may contribute to premature mortality from a range of other causes. More sophisticated methods are therefore required to better describe the impact of violence, and the burden-of-disease methodology provides   n addition to issues of definition, regional differences between the homicide rates in Fig- I ure 1 and the murder rates in Figure 2 can be ascribed to the different geographic boundaries of the defined regions as well as the methodologies underpinning the collection of the data. This topic falls outside of the scope of this paper and hence interested readers should refer to the original manuscripts for a more informed understanding of these rather complex issues.

220 APPENDIX C adjusted estimates that take into account the age of the injured and deceased through measures such as potential years of life lost (YLL) and DALYs, which includes YLL and years lived with a disability. The burden of violence in LMICs in 2000, taking these more sophisticated measures into account, is shown in Table C-1 (Mathers et al., 2002). Even DALYs underestimate the impact of violence, however, because up until this point DALYs have failed to incorporate adequate measures of the impact of nonfatal forms of violence such as child maltreatment and IPV on health. The Impact of Violence on Other Causes of Ill Health In those LMICs where more detailed data and epidemiological exper- tise are available, the burden of disease methodology can provide valuable information about the impact of violence on health outcomes other than injury. In South Africa, for example, injuries arising from violence, road traffic collisions, and other causes present part of a quadruple disease burden, along with HIV/AIDS, persistent infectious diseases, and emerging chronic conditions. Within this mix, violence is the major contributor to the high rates of injury, accounting for 12.9 percent of premature mortality in the country (Bradshaw et al., 2004). Injuries arising from interpersonal violence were the second leading cause of all DALYs after HIV/AIDS, accounting for 6.5 percent of the total 16.2 million DALYs (Norman et al., 2007a). An age-standardized homicide rate of 64.8 per 100,000 placed South Africa among the most violent countries in the world with male and female homicide rates respectively more than 8 and 5 five times higher than global averages (Norman et al., 2007c). Notwithstanding this considerable direct burden, the additional impact in South Africa of violence on other health outcomes is beginning to become apparent though comparative risk assessment studies. This type of research attempts to systematically evaluate changes in population health which may result from changing the distribution of exposure to specific risk factors or a group of risk factors. Preliminary data from a recent South African study estimated that although interpersonal violence accounted for 5.3 percent of deaths as an underlying cause of death, as a risk factor it accounted for 6.7 percent of deaths when its contribution to other health outcomes resulting from child sexual abuse and IPV were included (Table C-2). Simi- larly, for nonfatal outcomes, interpersonal violence as an underlying cause accounted for 6.5 percent of DALYs, but 8.5 percent of DALYs as a risk factor (Norman et al., 2007b). These findings imply that standard burden- of-disease measures underrepresent the impact of interpersonal violence by at least 26 percent for deaths and 30 percent for DALYs when its contribu- tion to other health outcomes resulting from child sexual abuse and IPV are taken into account.

TABLE C-1  Rankings for Violence-Related DALYs by Income Level and Their Contribution to the Burden of Disease, 2000 High-Income Countries Low-Income Countries Proportion of Proportion of total total Rank Cause (%) Rank Cause (%) DALYs DALYs  1 Unipolar depressive disorders 8.8 1 Lower respiratory infections 6.8  2 Ischemic heart disease 6.7 2 Perinatal conditions 6.7  3 Alcohol use disorders 5.4 3 HIV/AIDS 6.6  4 Cerebrovascular disease 4.9 4 Meningitis 4.6  5 Alzheimer and other dementias 4.3 5 Diarrheal diseases 4.6  6 Road traffic injuries 3.1 6 Unipolar depressive disorders 4.0  7 Trachea, bronchus, lung cancers 3.0 7 Ischemic heart disease 3.5  8 Osteoarthritis 2.7 8 Malaria 3.0  9 Chronic obstructive pulmonary disease 2.5 9 Cerebrovascular disease 2.9 10 Hearing loss, adult onset 2.5 10 Road traffic injuries 2.8 12 Self-inflicted injuries 2.0 19 Self-inflicted injuries 1.2 31 Interpersonal violence 0.7 21 Interpersonal violence 1.1 88 War 0.0 31 War 0.8 NOTE: Bold, italic figures highlight deaths or disability due to violence. SOURCE: Reprinted from the World Report on Violence and Health (2002) with permission of the World Health Organisation. 221

222 TABLE C-2  Deaths Attributable to Selected Risk Factors Compared with the Underlying Causes of Death in South Africa, 2000 Rank Risk Factor % Total Deaths Rank Disease or Injury % Total Deaths  1 Unsafe sex/STIs 26.3 1 HIV/AIDS 25.5  2 High blood pressure 9.0 2 Ischemic heart disease 6.6  3 Tobacco 8.5 3 Stroke 6.5  4 Alcohol harm 7.1 4 Tuberculosis 5.5  5 High BMI 7.0 5 Interpersonal violence 5.3  6 Interpersonal violence 6.7 6 Lower respiratory infections 4.4  7 High cholesterol 4.6 7 Hypertensive disease 3.2  8 Diabetes 4.3 8 Diarrheal diseases 3.1  9 Physical inactivity 3.3 9 Road traffic accidents 3.1 10 Low fruit and vegetable intake 3.2 10 Diabetes mellitus 2.6 11 Unsafe water, sanitation, hygiene 2.6 11 Chronic obstructive pulmonary disease 2.5 12 Child, maternal underweight 2.3 12 Low birth weight 2.2 13 Urban air pollution 0.9 13 Asthma 1.3 14 Vitamin A deficiency 0.6 14 Trachea/bronchi/lung cancer 1.3 15 Indoor smoke 0.5 15 Nephritis/nephrosis 1.3 16 Iron deficiency anemia 0.4 16 Septicemia 1.2 17 Lead exposure 0.3 17 Oesophageal cancer 1.1 NOTE: Bold, italic figures highlight deaths or disability due to violence. SOURCE: Norman et al. (2007b).

APPENDIX C 223 The severity and range of the long-term effects of violence on children were systematically measured in a study by Felitti et al. (1998). Their study found a graded relationship between childhood exposure to violence and other adverse events and outcomes such as alcoholism, drug abuse, depres- sion, suicide attempts, smoking, risky sexual practices, sexually transmitted disease, physical inactivity, and severe obesity. These in turn were related to the presence of adult diseases including ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease. Evidence from HICs suggests an association between child sexual abuse (CSA) and a range of psychiatric disorders (Andrews et al., 2004). Investing in the preven- tion of violence may therefore result in a substantial yield for improved national mental health in LMICs with a high prevalence of CSA. More generally, Pinheiro (2006) reports that children exposed to violence are at greater risk than their peers of suffering from allergies, asthma, gastroin- testinal problems, depression, and anxiety. Children exposed to violence also present with poor concentration and focus and are therefore likely to underperform at school. The effects of exposure to domestic violence are also intergenerational with boys growing up in violent homes being twice as likely to become violent, abusive adults. Additionally, girls who witness the abuse of their mothers are significantly more likely to accept violence in their married lives. Thus the impact of violence on the MDGs must be read alongside this growing evidence pool that clearly demonstrates the negative, enduring effects of exposure to violence in childhood. WHO’s study on the Comparative Quantification of Health Risks estimated the lifetime impact of child sexual abuse taking into account a wide range of disease outcomes including depression, panic disorder, post- traumatic stress disorder (PTSD), alcohol and drug abuse/dependence and suicide attempts. Consequently it was estimated that CSA accounted for approximately 6 percent of cases of depression, 6 percent of alcohol and drug abuse/dependence, 8 percent of suicide attempts, 10 percent of panic disorders, and 27 percent of PTSDs (Andrews et al., 2004). Although such detailed data are simply not available in most LMICs, it is not inconceivable that with a higher prevalence, the burden of CSA may be even greater. The first study measuring the burden of disease due to IPV in Victoria, Australia, took into account a wide range of consequences include depres- sion, suicide, anxiety, and panic disorders; alcohol, drug, and tobacco abuse; eating disorders; and high-risk sexual behavior spread throughout a person’s lifetime. The study concluded that IPV contributed 9 percent to the total disease burden among women aged 15 to 44 years and 3 percent among all Victorian women (Webster, 2004). Although not indicative of all LMICs, recent estimates from South Africa suggest that the burden is con- siderably higher, with IPV responsible for an estimated 7 percent (95 per-

224 APPENDIX C cent CI: 5-11.2 percent) of the burden of disease among South ­ African women (Norman et al., 2007c). Of course the impact of violence would be shown to be even greater if it were possible to accurately and comprehensively quantify all possible health outcomes. Important categories missing from the South African study were mental health outcomes and the impact of violence on the elderly and at the community level (Norman et al., 2007b,d). The latter would include all other health outcomes resulting from physical and sexual violence affecting adults outside the home (e.g., sexual violence perpetrated by strangers, rob- bery and assault, gang conflicts, etc.) as well as the deleterious and chronic effects that high rates of violence have on the national psyche, the general mental health of the population, and its effect on lifestyle choices, such as the use of public transport or health-seeking behavior. The Economic Impact of Violence on Health The economic cost of violence can be assessed in terms of a variety of direct and indirect costs (Table C-3). The direct costs (or impacts) include the medical costs related to the treatment of the victims of violence and nonmedical costs associated with the three levels of prevention. Indirect costs include those that are tangible such as the impact of violence on the broader macro economy and those that are intangible such as those relating to quality of life (WHO and CDC, n.d.). However, the current paucity of accurate and detailed data on even the direct costs and impacts relating to violence in LMICs makes it difficult to apply the WHO/CDC framework in its entirety. Data on the economic costs of interpersonal violence in LMICs are scarce (Bowman and Stevens, 2004). However, based on available estimates from South Africa, the Carib- bean, and Latin America, it is clear that the economic costs of violence are enormous in LMICs. Overall the WHO reports that health care expenditure related to vio- lence consumes a significant portion of GDP in LMICs. The cost of health expenditures related to violence as a percentage of GDP was 1.9 percent in Brazil, 4.3 percent in Colombia, 4.3 percent in El Salvador, 1.3 percent  �������������������������������������������������������������������������������������������� Within the public health approach are three “levels of prevention,” typically ­described as primary, secondary, and tertiary, which refer to the timing of the prevention response. Primary prevention attempts to prevent violence before it occurs and can target potential perpetrators by curbing tendencies toward violent ­ behavior, or potential victims by reducing the factors and characteristics that predispose them to victimization. Secondary prevention focuses on the immediate response to violence, such as emergency medicine including prehospital care for victims, and retribution through the criminal justice system. Tertiary prevention is aimed at mitigating the long-term effects of violence-related trauma and the rehabilitation and reinte- gration of offenders and victims (Dahlberg and Krug, 2002).

APPENDIX C 225 TABLE C-3 A  Typology for Assessing the Cost of Violence Cost Disaggregating Category Type of Cost Components Options Inpatient costs Outpatient costs Ambulance fees Medical Physician fees Drugs/lab tests Direct Counseling costs Costs of policing and incarceration Costs of legal services Non-Medical Direct perpetrator control costs Costs of foster care Private security contracts By demographic group Productivity losses (perpetrators and By type of injury victims, earnings and time) By mechanism Lost investments in social capital By intentionality Tangible Life insurance costs Indirect protection costs Macro-economic costs Indirect Health-related quality of life (pain and suffering, psychological costs) Intangible Other quality of life (reduced job opportunities, access to schools, public services, community participation) Source: Matzopolous (in press). in Mexico, 1.5 percent in Peru, and 0.3 percent in Venezuela. These direct health expenditures represented less than 30 percent of the estimated costs and impacts of violence within these countries (Buvinic et al., 1999). Simi- larly, studies in the United States have established that the direct medical costs associated with the treatment of a gunshot wound amount to only 13 percent of the total costs related to the injury (Peden and Van der Spuy, 1998) and medical treatment accounts for less than 20 percent of the life- time costs of injury in general when the loss of productivity is taken into account (Corso et al., 2006). In Columbia, for example, armed violence has been estimated to account for US$ 4 billion in lost productivity. In Brazil, lost productivity due to homicides has been calculated at US$ 10 billion or 0.5 percent of the annual GDP (Small Arms Survey, 2006).

226 APPENDIX C For example, according to pilot studies undertaken by the Small Arms Survey, the direct medical costs of treating firearm injuries in Rio de Janeiro, Bogotá, and Cali amounted to a per-patient average of US$ 4,521, 6,804, and 11,403, respectively. When national mortality and morbidity data are included to estimate loss of future earnings in the largely male population of gunshot victims, the figures climb to US$ 10 billion per year in Brazil and US$ 4 billion in Colombia. The direct medical costs of IPV were calculated at US$454,000 in Jamaica in 2001 (Waters et al., 2005). At the more local level of individual cities and hospitals, a number of South African studies again highlight the high economic costs of violence. One study at Groote Schuur Hospital in Cape Town found that the direct treatment costs for firearm-related violence amounted to ZAR 3,858,331 for a total of 969 patients (Peden and van der Spuy, 1998). In a more recent study conducted by Allard and Burch (2005) the minimum cost of treating an abdominal firearm-related injury for 21 patients at G.F. Jooste Hospital in Cape Town was estimated at ZAR 215,649. This figure represents an amount 13 times the per capita government expenditure on health in South Africa in 2001. Indirect costs of violence were included in Phillips’ (1998) study of homicide in the city of Cape Town. She calculated total costs of homicide (excluding intangibles) to be ZAR 11.8 million for that year. The lack of a costing culture within many public health systems in LMICs makes the generation of reliable violence costs difficult. In such countries rudimentary surveillance and reporting systems are still under development so costing is not viewed as a reporting priority at this time. Nevertheless, as the incidence of violence in LMICs is much higher, it f ­ ollows that the economic costs, or at least the relative economic costs, may be higher. Further empirical research is needed that takes into account the differences in treatment costs across income contexts. Moreover, the calcu- lation of the costs of other health burdens such as HIV has mobilized civil society to lobby for prevention. An accurate estimation of the costs of vio- lence in LMICs is therefore imperative to the violence prevention agenda. With respect to IPV, lost earnings and opportunity costs were extrapo- lated to US$ 1.73 billion in Chile and US$ 32.7 million in Nicaragua from pilot study results in both countries. IPV alone has been calculated to cost the economies of Nicaragua and Chile 1.6 and 2 percent of their GDPs, respectively. The GDP effects of suicide appear even more difficult to measure and are scarce in the literature. A study conducted in Alberta, Canada, showed that suicide significantly detracts from future GDP. The study calculated that suicide costs the equivalent of 0.3 percent of the pro- vincial GDP. However limited, violence costing in research has begun to clearly dem- onstrate the substantial economic impacts of violence in LMICs. Greater general investment in improving on and prioritizing this area of research is

APPENDIX C 227 imperative for generating a more accurate and comprehensive profile of the costs of violence in these contexts. More specifically, such studies should disaggregate the costs of violence according to the more specific typologies of violence listed above. This would enable the identification of relative contributions of these different types to overall costs. The Impact of Violence on Development Collective, interpersonal, and self-directed violence have extensive and pervasive long-term implications for development and health. Moreover, these effects are themselves multilayered and can undermine development at individual, communal, and national levels. Although the different paths by which violence exerts such economic strains remain unclear, the follow- ing section describes the available research findings on the consequences of violence for development, and how violence and underdevelopment may be linked in a vicious circle where each perpetuates the other. The Impact of Violence in Relation to the Millennium Development Goals In describing the wide-ranging impacts of violence on different sectors and systems, the eight goals of the Millennium Development Plan (World Bank, 2004) provide a useful organizing framework. These eight goals are at the forefront of the global development agenda, and showing how violence impacts upon them helps to highlight its importance within this agenda. MDG1: Eradicating Extreme Poverty and Hunger There is a vicious cycle between poverty and violence. On the one hand it is well established that poverty, particularly in the context of economic inequality (Nafziger, 2006; Fajnzylber et al., 1999; Unithan and Whitt, 1992), and especially when geographically concentrated, contributes to high levels of violence by weakening intergenerational family and commu- nity ties, control of peer groups, and participation in community organiza- tions (see Box C-4; Sampson and Lauritsen, 1994; Wilson, 1987). In turn, there is also evidence that high rates of violence in a community reduce property values and undermine the growth and development of business (World Bank, 2006), thus contributing to the very inequalities and concen- trations in poverty that play a role in causing violence. Low SES has been linked to risk for interpersonal violence (GHRI, 2005). Studies of the health effects of interpersonal violence have shown that different degrees of violence can result in a number of acute and chronic health conditions that in turn imply negative influences on produc-

228 APPENDIX C BOX C-4 Socioeconomic Status, Social Inequality, and Violence: Evidence from South Africa, Brazil, and Russia Associations between socioeconomic status (SES) and health have been rela­ tively well documented by researchers over the last 50 years. The general gradual relationship between these two variables is commonly referred to as the health- wealth gradient (Deaton, 2002). Although much work in this field has ­focused on the epidemiological distributions of general health outcomes by income levels (Marmot, 1994; Link and Phelan, 1995; Feinstein, 1993), there is growing evi­ dence to support the hypothesis that low levels of development, relative poverty, and income inequality predict high levels of various forms of violence. A number of studies have narrowed this general focus to assessing the rela­ tionship between development and homicide across and within nations (Unithan and Whitt, 1992; Butchart and Engström, 2002; Neapolitan, 2003). A study by Moniruzzaman and Andersson (2005) found a strong correlation between levels of homicide and economic development that was especially pronounced in LMICs. South Africa, Brazil, and Russia have been especially useful case ­ studies for i ­lluminating such relationships. In South Africa, a study of the relationship ­between local (community) inequality and crime found a strong positive correlation between rates of unemployment and murder (Demombynes and Özler, 2005) and a strong positive correlation between homicide and inequality measured by the Gini index. In Sao Paulo, Brazil, Gawryszewski and Costa (2005) found a strong negative correlation between homicide rates and average monthly income, with higher h ­ omicide rates in the districts whose inhabitants had the lowest incomes. In a study of the association between SES and overall mortality in Moscow, Russia, Chenet, Leon, and Mckee (1998) found a strong association between homicide and levels of education, with individuals who had received less education at g ­ reatest risk of being killed. Another study in Russia found that negative socio­ economic changes were positively correlated with rising homicide rates (Kim and Pridemore, 2005). tivity and labor (Plichta and Falik, 2001) and exert tremendous strains on health care systems. More generally, poor countries have higher rates of violent crime taxing already-burdened criminal justice systems. Whether cause or consequence, or both, countries with higher inequality have higher murder and robbery rates (Leggett et al., 2007). Rapid urbanization has also been associated with increases in levels of violence due in part to p ­ ockets of concentrated poverty on the outskirts of large cities. Such prob- lems have become formidable and often cripple the economic prospects of entire cities (Maninger, 2000). While scenes of urban decay have become almost synonymous with African and Asian LMICs, recent research from Russia indicates that the transition to a more pluralistic and democratic

APPENDIX C 229 system of government was accompanied by a range of social problems such as unemployment, poverty, and inequality. These are conditions associated with likely increases in rates of violence, as at a micro level individual needs and values supplant those of the community, while at a macro level gov- ernments’ ability to provide adequate social support is compromised. The results of the study indicated that in the face of these changes even regions with higher levels of social support were unable to contain the consequent increase in rates of violence. Another violence-related threat to the goal of eradicating poverty and hunger are the deleterious effects of collective violence on food security. These effects are pronounced at the level of food production with global agricultural production declining by 1.5 percent during conflict periods (Teodosijevic, 2003). Total food production is usually reduced, and in some cases collapses, leading to hunger and starvation and forcing mass migration. In some cases the per-capita-per-day calorie availability plunges by an average of 7 percent as a result of conflict. According to Messer (1998), people of at least 32 countries suffered malnutrition, poverty- related ­ inaccessibility to food stocks, and dramatic food shortages as a direct result of war in 1994. Food itself frequently becomes a weapon of war. In the Sudan, the government sold grain reserves in 1990 to help fund the war. The government and opposition forces created famine as a means to control territories and populations, and restricted access to food (Keen and Wilson, 1994). This led to widespread food poverty among the already-impoverished population (Keen, 1994). The development costs are summarized in Table C-4. MDG2: Achieving Universal Primary Education Violence impacts directly on education systems by depleting LMICs of their human capital in the form of educators, undermining access to educa- tion, and hampering attempts at providing conducive learning environments. While school shootings commonly make new headlines in HICs, school violence is common within LMICs, initiating a vicious cycle of violence and limits to development. Epidemiological data has shown that girls subjected to sexual violence at schools are more likely to leave formal education (Heise et al., 1999). Unfortunately, such subjections are frequent. According to recent research undertaken in six African countries, between 16 percent and just under 50 percent of girls in primary and secondary schools report sexual abuse or harassment at the hands of either male students or teachers. In a recent study in Zimbabwe, 40 percent of girls aged between 12 and 14 indicated that they had been the victims of sexual violence (Leach et al., 2000). A sample survey of nine Caribbean countries found that 20 percent of males carried weapons to school in the last month and that 10 percent of the

230 APPENDIX C TABLE C-4  The Development Costs of War Category of Capital Destruction of existing stock Impact on new investment Productive capital— Land mined; factories bombed. Fall in private productive plant equipment and investments—foreign and buildings. local, including farmers’ investments. Some new investment in new informal activities; and in arms production. Economic Transport and communication Decline in government infrastructure system, power, irrigation, expenditure on infrastructure. disrupted. Social infrastructure Schools, hospitals, clinics damaged. Human capital Death, migration especially Decline in public entitlements, of skilled workers; worsened reduced education in quantity nutrition and health or and quality. Reduced private workforce. sector training. Organizational capital Government institutions, banks, No resources in formal sector; agricultural extensions, science new informal organizations and technology organizations develop; NGOs take on new weakened. activities. Social capital Destruction of trust; work New forms of social capital, ethic; respect for property; through groups that develop community links. links in war, NGO activity. SOURCE: Stewart and FitzGerald (2000). sample had been knocked unconscious in a fight (Garber et al., 2003, cited in Leggett et al., 2007). In the Dominican Republic over half of a representa- tive sample of students reported violence at their schools. These figures point to the manifold effects of violence on education. First, unsafe schools deter quality educators from participating in primary education in LMICs. Second, violence seems to be a characteristic of school life in developing countries, further hampering strategies aimed at achieving universal education at least at the primary level. MDG3: Promoting Gender Equality and Empowering Women The WHO Multi-country Study on Women’s Health and Domestic Vio- lence against Women suggests that this problem is pronounced in a range of

APPENDIX C 231 LMICs. The study collected data from over 24,000 women in Bangladesh, Brazil, Ethiopia, Japan, Namibia, Peru, Samoa, Serbia and Montenegro, Thailand, and the United Republic of Tanzania. In Ethiopia 59 percent of respondents indicated that they had ever been physically assaulted by an intimate partner. In Dhaka, Bangladesh, 40 percent of ever-married women reported having ever experienced physical violence. The health, economic, and social effects of this type of violence are far-reaching. Abused women are more likely to suffer from a range of health problems including depres- sion, anxiety, psychosomatic symptoms, eating problems, sexual dysfunc- tion, and many reproductive health problems, including miscarriage and stillbirth, premature delivery, HIV, and other sexually transmitted infec- tions, leading to significantly high health care costs in those contexts in which medical institutions are consulted or available. Also, some 25 percent of women are likely to be victims of assault while pregnant, compromising the health and development of both mother and child (Heise et al., 1999). However, IPV also appears to be closely related to some development indicators. Research conducted in Chile, Egypt, India, and the Philippines showed that levels of female education and general household wealth were related to decreased levels of IPV (Bangdiwala et al., 2004). Moreover, a cross-national study by Archer (2006) found that female empowerment was associated with levels of individualism and that women were less frequently victims of violence in countries in which they were more empowered. As gender equality and individualism increased so the sex differences between victims of violence decreased. Hence there is evidence that increasing wom- en’s economic participation decreases their rate of violent victimization (Cheston and Kuhn, 2002; Shrestha, 1998). MDG4: Reducing Child Mortality According to the World Report on Violence Against Children (Pinheiro, 2006), 2.05 children between ages 0 and 4 per 100,000 were victims of homicide in LICs in 2002. In Africa this rate was 4.16. However, the child homicide rate in Africa climbs to 5.58 per 100,000 if every person below the age of 18 is included. Although constituting a relatively small propor- tion of child mortality in LMICs, the long-term developmental effects of violence against children are, as shown above, far-reaching and ultimately result in a broad range of health problems. Violence can lead to a variety of health problems for the expectant mother. These include a range of mental disorders (Patel, 2007); sexually transmitted diseases; gastrointestinal disorders; and gynecological prob- lems, including vaginal bleeding and vaginal infections, urinary tract infec- tions, and various chronic pain syndromes, including chronic pelvic pain (Ellsberg, 2006). Studies in Bangladesh and Latin America have also shown

232 APPENDIX C that IPV therefore contributes to maternal mortality (Ronsmans and Khlat, 1999; Espinoza and Camacho, 2005) in these LMICs. Maternal health also impacts the health of the child. Problems experienced in early childhood are among the numerous psychological and behavioral factors that may pre- dispose youths and young adults to display violent and aggressive behavior (Karr-Morse and Wiley, 1997) and hence the mental health of the mother is an important factor in the formative stages of a child’s life. Unwanted pregnancy, teenage motherhood, and pregnancy complications have also been shown to predict risk for violence across the lifespan of the child. MDG6: Combating HIV/AIDS, Malaria, and Other Diseases Widespread violence further undermines the capacity of health care systems to provide effective programs for dealing with a host of diseases. A study of health care workers in South Africa showed that they are especially at risk for violence. The findings indicated that over 60 percent (61.1 percent) of the 176 health care practitioners working in Cape Town had been exposed to violence in its various forms (Marais et al., 2002). In a country with high levels of HIV prevalence, such figures imply direct threats on health care capacity and productivity. In addition to this vio- lence-related effect, IPV has been shown to directly contribute to risk for HIV contraction (Dunkle et al., 2004; Petersen et al., 2005; Abrahams et al., 2004). Thus IPV needs to be addressed alongside other interventions in order to reduce HIV infection and promote safer sexual behavior (Jewkes et al., 2006). There are two examples of the apparent successes of targeting IPV in HIV interventions. A recent evaluation of the Stepping Stones HIV, communication, and relationships behavioral program, by Jewkes et al. (2006) in South Africa, showed decreased rates of reported IPV following program implementation. A recent structural intervention provides another neat demonstration of this concept and the interrelationship between vio- lence, HIV/AIDS, and empowerment of women. The intervention took the form of a microfinance program for women in Limpopo that aimed to assist in reducing poverty, income inequality, empowering participants, and hence improve health and included a gender and HIV training curriculum. Although the focus was on improving knowledge and behavior with respect to HIV/AIDS, there was a significant decrease in reported IPV among par- ticipants (Pronyk et al., 2006). Collective violence more than interpersonal violence fragments health care systems, as health care professionals flee war-torn areas. The food insecurity and poor sanitation resulting from various forms of collective violence have also been shown to contribute directly to diarrheal diseases, measles, acute respiratory infections, and malaria (Tool and Waldman,

APPENDIX C 233 1990). Areas of conflict also report higher rates of tuberculosis (Gibson et al., 1998). While some disagreement prevails as to the extent to which war-torn populations are more vulnerable to HIV, some studies have found significant evidence of such associations. Following conflict in the Ivory Coast, 90 percent of medical doctors left flashpoint areas (Betsi et al., 2006). Fleeing health care personnel along with diminishing prophylaxis stocks were all suggested to impede HIV prevention in the area. MDG7: Ensuring Environmental Sustainability The most direct effect of violence on environmental sustainability is demonstrated through several sustained conflicts in LMICs that are in large part driven by competition over the extraction of high-value resources such as minerals (e.g., diamonds), narcotics, and timber. While the root causes of such conflicts are complex, they are invariably driven by economic impera- tives in which the health of resident populations and environmental sustain- ability are marginalized. These effects may be felt long after conflicts have ceased as the means of agricultural production and basic food security is compromised. Landmines, for example, render large tracts of land unusable for agriculture, livestock, gathering firewood, and collecting water (Sethi and Krug, 2000). Consequent urbanization and increased population densi- ties in nonafflicted rural areas strain the holding capacity of the land with devastating environmental impacts. A broader interpretation of “environmental sustainability” includes social paradigms linked with the production of human capital and the orderly operations of government. Interpersonal violence erodes both of these prerequisites. In fact some commentators have argued that the ero- sion of social capital by violence is among the most significant obstacles to sustainability (Goodland, 2002). These erosions most frequently take the form of impoverishment and concentrations of high mortality in violent areas. Violence also has dramatic effects on the sectors required to maintain sustainable environments. A study of the policing sector in South Africa showed this group to be especially at risk for a range of stress-related symptoms and significant levels of suicidal ideation resulting in high suicide rates (Kopel and Friedman, 1997). High levels of stress lead to increased burnout. High levels of violence have also been shown to severely affect the productivity and efficiency of the transport (Lerer and Matzopoulos, 1996; Peltzer, 2001) and banking (Miller-Burke et al., 1999) sectors in this country. Widespread violence in many LMICs also impedes sustainable environmental development through disincentivizing direct foreign invest- ment and tourism (Bourguignon, 1999).

234 APPENDIX C MDG8: Developing a Global Partnership for Development The sum total of all of the negative impacts of violence on the achieve- ment of the above goals represents a significant obstacle to the creation of global partnerships aimed at development. As in many other sectors the 10/90 gap is particularly pressing with regard to violence preven- tion. The gap refers to the fact that, of the $73 billion invested annually toward ­public health research worldwide, less than 10 percent is devoted to research into the health problems that account for 90 percent of the global disease burden (measured in DALYs). Despite significant advances in the recognition of this discrepancy, formulating the means to its correction has been slow. The evidence base for research and, as will become more evident in the sections that follow, rigorous and accurate surveillance systems for violence data are primarily based in HICs. Truly global partnerships must necessarily acknowledge the significant deleterious effects of violence on the potential development of LMICs and adjust resources invested in violence prevention in LMICs accordingly. Other Developmental Impacts of Violence Although the MDGs provide a useful framework within which to assess the impact of violence on some aspects of development, they also have a number of limitations. For instance, the almost exclusive focus on women and children in MDGs 3 to 5 does not accommodate the fact that male victims of homicide and suicide substantially outnumber female victims. In LMICs the male-to-female ratio for homicide is more than three times higher than in HICs and males also significantly outnumber females for suicide in these contexts (Mathers et al., 2002). This enormous differential has major socioeconomic consequences as young men are often the bread- winners in LMICs. Likewise, the MDG 4 focus on reducing child mortality emphasizes a reduction in infant mortality rates and under 5 mortality rates. While violence does impact upon both of these rates, its burden is largely concentrated in early to middle life and most prevalent in the 15-to- 44-year cohort. The nonfatal health outcomes of violence have been shown to be important mediators of childhood health, with the child being defined as every human being below the age of 18 under the Convention on the Rights of the Child. Describing the impacts of violence on early childhood development is especially useful for gauging the potentially detrimental developmental effects of violence across the human lifespan. A key review by Walker et al. (2007) identified exposure to violence as a major contributing factor to compromised human development with far-reaching intergenerational effects in developing countries. In fact, exposure to violence (alongside

APPENDIX C 235 malaria, intrauterine growth restriction, maternal depression, and expo- sure to heavy metals) was identified as in urgent need of intervention. Children exposed to violence in South Africa present higher levels of PTSD ( ­ Magwaza et al., 1993), aggression (Liddel et al., 1994), attention prob- lems, and depression (Barbarin et al., 2001). The effects of violence in Eritrea and Bosnia appeared to be mediated by levels of social cohesion and caregiver mental health—both of which are further compromised in various forms across the different typologies of violence. The Economic Impact of Violence on Development As indicated in Section 3.3, the economic costs associated with violence are significant. As well as the substantial health care expenditure that vio- lence consumes in LMICs, there are numerous costs related to development. These costs represent formidable challenges to investing in sustainable development. The most widely acknowledged relate to war and conflict, and these are succinctly encapsulated in the following excerpt from Hillier and Wood (2003, p. 4): The uncontrolled proliferation and misuse of arms by government forces and armed groups takes a massive human toll in lost lives, lost livelihoods, and lost opportunities to escape poverty. An average of US$22bn a year is spent on arms by countries in Africa, Asia, the Middle East, and Latin America—a sum that would otherwise enable those same countries to be on track to meet the Millennium Development Goals4 of achieving uni- versal primary education (estimated at $10bn a year) as well as targets for reducing infant and maternal mortality (estimated at $12bn a year). Violence in whatever form absorbs sizeable amounts of health care expenditure that could be better used to prevent other forms of health threat. A seminal study by Milanovic (2005) showed that war and civil strife alone accounted for an income loss of about 40 percent over the last 20 years in the least developed countries. National spending on collective violence in the form of “defense” budgetary allocations and investment in postconflict recovery have been shown to lead to drastic reductions in national investment in health care services. In essence this type of spending “squeezes” the resources available for development. Although the top 15 military spenders are mostly HICs, many LMICs spend a greater proportion of their available resources on defense than these developed countries. Mainly attributable to the wars in Afghanistan and Iraq, the United States spent approximately 6 percent of its GDP on the military in 2003. Yet in 2001 Burundi and Ethiopia spent 8 and 6.2 percent, respectively (Jolly, 2004). These are both postconflict countries and so this high proportion of spending detracts from spending on schools,

236 APPENDIX C hospitals, and social development. Significantly, military spending as a per- centage of GDP is associated with economic slowdowns across countries. This is alarming as many researchers have pointed to the changing nature of insecurity over the last couple of decades. Human security threats no longer take traditional cross-border forms but are predominantly within nations (Jolly, 2004). In Africa, war and conflict have been shown to consume a startlingly significant portion of GDP (Table C-5). In 2005, spending on the military amounted to US$ 7.2 billion in sub-Saharan Africa in 2005 (Omitoogun, 2001). However, military expenditure does not paint a complete picture of total war costs. For example, a case study of the war in Sri Lanka showed that military spending accounted for just over half of the total costs of the war. Studies in both Jamaica and South Africa have demonstrated that vio- lence (in the form of violent crime) represents a substantial cost to business (NEDCOR Project, 1996; Francis et al., 2003). Global estimates suggest that crime and violence together cost approximately 14 percent of GDP in LMICs. This is almost three times more than the 0.5 percent of GDP calculated as the cost of violence in HICs (Pfizer, 2001). The multiplier effects of this disparity are significant. The Inter-American Development Bank estimated that GDP in Latin American countries would be 25 percent higher if rates of violence were equal to global rates (Londoño and ­Guerrero, 1999). TABLE C-5  The Burden of Military Expenditure as a Share of GDP in 10 Countries with the Highest Milex: GDP Ratio in Africa 1991-1999 Countries 1991 1992 1993 1994 1995 1996 1997 1998 1999 Algeria 1.2 2.2 2.6 3.2 3.0 3.3 3.7 4.0 3.8 Angola 6.8 12.0 12.5 19.8 17.6 19.5 22.3 11.4 23.5 Botswana 4.4 4.3 4.5 3.9 3.5 2.9 3.1 3.7 3.4 Burundi 3.8 3.6 3.7 3.9 4.2 5.7 6.3 5.9 6.1 Djibouti 5.9 6.1 5.6 5.4 5.1 4.2 4.5 4.4 No data Eritrea No data No data 21.4 13.0 19.9 22.8 13.5 29.0 22.9 Ethiopia 2.0 2.7 2.9 2.4 2.0 1.9 3.4 5.1 9.0 Morocco 4.1 4.3 4.4 4.9 4.7 3.9 No data No data No data Rwanda 5.5 4.4 4.6 3.4 3.9 5.2 4.1 4.3 4.2 Zimbabwe 3.8 3.7 3.4 3.3 3.6 3.2 3.4 2.7 3.4 SOURCE: Omitoogun (2001).

APPENDIX C 237 The Emergence of Violence Prevention as Part of the Health and Development Agenda Despite the numerous and substantial impacts as a direct and indirect result of violence, it has received limited attention on the global health agenda. Violence is mentioned only once in the World Bank’s seminal publi- cation, The Millennium Development Goals for Health: Rising to the Chal- lenges, despite its extensive influence on all eight of the millennium goals, as described in Section 3 of this paper. However, there are indications of an increasing awareness among policy makers of the role that violence plays in undermining international health and development, and the potential of violence prevention as a means of reducing these destructive effects. Two recent World Bank reports consistently highlight violence as a fundamental threat to human development. A World Bank publication focused on using participatory methods to foreground the perceptions, needs, and experi- ences of the poor. The report emphasizes violence as a much-cited every- day reality and constant threat to the potential development of the poor (Narayan, 1999). The 2007 World Bank report on Human Development cites numerous examples of the way that violence compromises individual development (World Bank, 2006). Many LMICs have lobbied for violence prevention to receive increased prioritization and are favorably disposed to the recommendations emanat- ing from violence prevention agencies. South Africa, emerging from decades of apartheid rule, was initially at the forefront of the movement tabling res- olution 94.5 at the end of its tenure in chairing the World Health Assembly in 1994. More recently the African Union adopted the recommendations of the World Report on Violence and Health in declaring 2005 the “African year of violence prevention.” LMICs have also played host to two World Conferences on Injury Prevention and Safety Promotion, in India in 2000 and in South Africa in 2006. The conference will be hosted for a third time in an LMIC in Mexico in 2008. The emergence of violence within the health and development agenda can in part be ascribed to the role played by the World Health Assembly and partner organizations in driving violence prevention and injury preven- tion in general, an initiative that has seen injury-related topics being the focus of two World Reports in the last 5 years: namely the World Report on Violence and Health and the World Report on Road Traffic Injury Pre- vention. Since the publication of the World Report on Violence and Health there has been a World Health Assembly resolution (WHA49.25) calling on countries to invest in violence prevention, and by 2006 three out of six WHO regional committees (Africa, the Americas, and Europe) had adopted similar resolutions.

238 APPENDIX C The inclusion of violence prevention on the agenda of other multilateral agencies is also a useful indication of its emergence as a global priority. The World Bank’s Disease Control Priorities, for example, includes a single chapter on all of injuries and violence in its first edition in 1993, whereas the second in 2006 had an entire chapter dedicated to interpersonal violence alongside another entire chapter that addressed unintentional injuries and a third chapter on trauma care. The United Nations General Assembly has also reviewed special reports on violence against children and violence against women, which have resulted in resolutions calling for greater invest- ment in multisectoral efforts to address these forms of violence. Conclusion This paper has demonstrated that violence is a global health issue of especial concern to LMICs, and that violence is inextricably linked with a range of other health indicators. Yet, despite current projections indicating that violence in LMICs (as a result of both interpersonal and collective vio- lence) is set to become an increasingly important threat to health, vigorous and concerted violence prevention efforts can arrest this trend. While there are indications that violence prevention is also gaining more prominence in LMICs, it will need to be integrated and institutional- ized within government ministries if it is to be successfully implemented. An important first step would be for the improvement of data systems and research on the economic and other social costs of violence in LMICs so that violence can be better framed and understood as an issue well beyond social order and “law enforcement.” Ongoing support of intersectoral collaborative forums is one of sev- eral areas that could benefit from development aid and the involvement of international development partners, as this is an area where many LMIC governments are underskilled. Also, much of the research and evidence relating to violence prevention arises from a small number of HICs. This imbalance needs to be addressed as LMICs may require a different set of interventions. This could be facilitated by the availability of more funding and the development of mechanisms to support and sustain equitable multi­ lateral research cooperation. Another key requirement is the development of research capacity within research organizations and among implementing agencies in the criminal justice, policing, and social development sectors, which may require the establishment of a program or fund for research, capacity development, and exchanges and/or placements. A fund could also be established to support the education of public-sector managers in LMICs in fields related to violence prevention (public health, psychology, sociology, criminology, biostatistics, and other related disciplines) with conditions to ensure their

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The current state of science in violence prevention reveals progress, promise, and a number of remaining challenges. In order to fully examine the issue of global violence prevention, the Institute of Medicine in collaboration with Global Violence Prevention Advocacy, convened a workshop and released the workshop summary entitled, Violence Prevention in Low-and Middle-Income Countries.

The workshop brought together participants with a wide array of expertise in fields related to health, criminal justice, public policy, and economic development, to study and articulate specific opportunities for the U.S. government and other leaders with resources to more effectively support programming for prevention of the many types of violence. Participants highlighted the need for the timely development of an integrated, science-based approach and agenda to support research, clinical practice, program development, policy analysis, and advocacy for violence prevention.

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