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Is Violence a Public Health Problem?

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Reading Nobel Laureate Gabriel Garcia Marquez’s masterpiece “One Hundred Years of Solitude,” one is confronted with an unsettling reality: In the mythical town of Macondo, violence is an accepted mechanism used by successive generations to deal with individual and social conflicts.   It also inflicts enduring pain on the town’s people long after disputes are settled with blood.

While “magic realism” is at the core of Garcia Marquez’s novel, let’s not forget that its depiction of violence and its after-effects was shaped by real historical events in Latin America--events that continue today to illustrate the inexorable reality of violence and its negative impact on families and communities everywhere.

Since violence in its many forms—interpersonal, self-directed and collective—often leads to physical and mental impairment, disability, and premature death, it should be seen as a major public health issue that requires sound epidemiological assessment of its causes, as well as multisectoral policies and strategies, including public health interventions.  Let me make the case.

The relative importance of violence as a public health issue is clearly illustrated by the results of the 2013 Global Burden of Disease Study, which shows that interpersonal violence and self-harm are among the top 25 causes of global years of life lost. And a recent report by the World Health Organization (WHO) estimated that about 500,000 deaths occurred worldwide in 2012 as a result of homicide alone.

Interpersonal violence, which is violence that occurs between family members, intimate partners, friends, acquaintances and strangers, and includes child maltreatment, youth violence, intimate partner violence, sexual violence, and elder abuse, is particularly endemic is Latin America and the Caribbean, where it is ranked among the top five causes of years of life lost in 15 countries of the region. 

Indeed, WHO data indicate that low- and middle-income countries in the Americas have the highest estimated rate of homicide in the world (28.5 per 100,000 population), followed by the Africa region (10.9 per 100,000 population).

By contrast, the rate in high-income countries has declined over the 2000-2012 period to a low of 3.8 per 100,000 population. 

In some of countries in Latin America, the problem is severe:  young adults in El Salvador have the highest probability of death from interpersonal violence in the world, and people in Central America, more than any other region, are most at risk of being killed violently.

Key risk factors for interpersonal violence are strongly associated with weak governance, poor rule of law, cultural, social and gender norms, limited educational and employment opportunities, and social inequality.  Also, ease of access to weapons and alcohol abuse and drug use contribute to multiple types of violence.   

In turn, non-fatal physical, sexual and psychological abuse contribute to lifelong ill health and premature death due to  diseases such as heart disease, stroke, cancer and HIV/AIDS that result from unhealthy behaviors (smoking, alcohol and drug misuse, and unsafe sex) that victims of violence often adopt to cope.

In spite of the severity of the problem, the WHO report indicates that lack or limited data on homicides from civil or vital registration sources is common in a vast array of surveyed countries, hindering the design, implementation and monitoring of prevention efforts. 

Besides calling for strengthened data collection to better understand the true extent of the problem, the report also advocates for enhanced governmental action to address key risk factors for violence through cross-sectoral policies and institutional measures. These could include improving the enforcement of existing laws to deter crime and violence and making medical, social, and legal services available to identify, refer, protect and support victims of violence. 

Good practices serve to illustrate that interpersonal violence and negative social consequences can be prevented and mitigated if the roots of the problem are known. 

One such practice can be found in Cali, Colombia. By investigating and collecting data and information, the Cali municipal government, with the support of a university center, the police and the judicial system, determined that most homicides occurred on weekends, holidays, and Friday nights coinciding with payday; that about 30% of the victims were intoxicated; and that 80% of all the victims were killed by firearms. 

Guided by this knowledge, the city established Desepaz, a violence prevention program, to address the key risk factors for homicide—alcohol and firearms—by adopting measures such as limiting the hours that alcohol could be sold on weekdays and weekends, and gun bans in the city. 

Building upon the Cali experience, the municipal government of Bogota, Colombia’s capital, adopted similar measures which contributed to reducing the homicide rate from 80 per 100,000 population in 1993 to 16 in 2012. Other countries in Latin America and the Caribbean are also starting now to standardize and share data on crime and violence under an Inter-American Development Bank-supported initiative to tackle these phenomena.

While violence prevention is a complex challenge, given its broad social determinants, Colombia’s experience shows that effective solutions are possible.

Political commitment and coordinated multisectoral action should be informed by systematic collection and utilization of data and information. If this is not done, countries are destined to live perhaps not “100 years in solitude” but to be fragile and vulnerable. Their development prospects may well  continue to be undermined by high human capital and economic losses, as well as by the erosion of  social capital due to fear among the population that perhaps the next victim of violence will be a loved one.
Follow the World Bank health team on Twitter: @WBG_Health

The Global Burden of Disease: Generating Evidence, Guiding Policy

Global, regional, and national age–sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013

WHO Global Status Report on Violence Prevention 2014


Patricio V. Marquez

Former World Bank Group (WBG) Lead Public Health Specialist

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