Medical Matters: ". . . Many who live with violence day in and day out assume it is an intrinsic part of the human condition. But this is not so. Violence can be prevented. Violent cultures can be turned around . . ." - Nelson Mandela
We treasure good health. It enables us to get the most from our lives. But what is "health"? The World Health Organisation's (WHO) view of health is "the extent to which an individual or group is able to satisfy needs, to realise aspirations, to change or cope with their environment".
Public health is concerned with the health and wellbeing of populations as a whole. Violence poses a major burden on that well-being. It is a universal scourge that tears at the fabric of communities and threatens life, health and happiness. No country or community is untouched by violence. Accounts of violence pervade the media; it is on our streets and in our homes, schools and workplaces.
According to the WHO's World Report on Violence and Health (Geneva 2002), more than 1.6 million people worldwide lose their lives to violence each year. Violence is among the leading causes of death for people aged between 15 and 44, accounting for 14 per cent of deaths among males and 7 per cent among females. An even larger number of people survive acts of violence. Violence can have profound health and psychological implications for victims, perpetrators and witnesses.
In Ireland in 2005, 1,461 people - 1,039 men and 422 women - died as a result of external causes or violence. Some 45 per cent of these were 15-44 years of age. Violence or external causes accounted for 5.3 per cent of all deaths in all age groups, but an alarming 46 per cent of all deaths in the 15-44 age group.
The cost of the consequences of violence is enormous. In addition to the financial costs to healthcare systems, it has larger indirect and human costs that result in untold damage to the economic and social fabric of our community.
The human cost in grief and pain cannot be calculated. Much of it is almost invisible. While satellite technology has made certain types of violence - terrorism, wars, riots and civil unrest - visible to television audiences on a daily basis, more violence occurs out of sight in our homes, workplaces and institutions.
Many of the victims are too young, old, weak or ill to protect themselves. Others are forced by social conventions or pressures to keep silent.
Because it is seen to be so pervasive, violence is often seen as an inevitable part of the human condition - a fact of life to respond to rather than prevent. It is commonly considered a "law and order" issue in which health is limited to dealing with the consequences.
A substantial proportion of the costs of violence result from its impact on victims' health and the burden it places on health systems. This gives the health sector a special interest in prevention and a key role to play.
In recognition of this, the 49th World Health Assembly passed resolution WHA 49.25, which declared violence a leading worldwide public health problem. It urged member states to assess the problem of violence in their own territory.
The WHO was requested to prepare a plan of action for the prevention of violence and for a science-based public health approach to this.
A complicated web of factors at individual, family, community and societal levels contributes to violence. Some factors include harsh discipline, poor parenting, witnessing violence, drug trafficking, alcohol and substance misuse, inequalities in gender and income, and norms that support violence as a way of resolving conflicts. There is increasing evidence that interventions can prevent violence and are cost effective.
Violence is preventable - it is not an intractable social problem or an inevitable part of the human condition. The wide variation in violence among and within nations over time suggests that it is the product of complex, yet modifiable social and environmental factors.
It can be prevented and its impact reduced in the same way that public health efforts have prevented and reduced pregnancy-related complications, workplace injuries, infectious diseases and illness resulting from contaminated food and water in many parts of the world. However, we also need to challenge notions of what is acceptable and comfortable, notions that acts of violence are simply matters of family privacy, individual choice or inevitable facets of life.
Although there are major gaps in knowledge and information, experience to date has taught some important lessons about preventing violence and mitigating the consequences.
These include:
- Violence is often predictable and preventable.
- Upstream investment brings downstream results.
- Resources should be focused on the most vulnerable groups.
- Political commitment to tackling violence is vital.
The multifaceted nature of violence reflects the need for multisectoral and collaborative approaches to tackle it. There is a need to create, implement and monitor a national plan for violence prevention.
Dr Elizabeth Keane is a consultant in public health medicine and director of public health, Health Service Executive - South.
The fifth population health summer school, "Violence: a Public Health Issue", takes place at University College Cork on September 7th and 8th. Full programme details are available at www.ucc.ie/acad/pubh/events.htm