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

Senior Associate, Johns Hopkins University Bloomberg School of Public Health

April 08, 2015

Wonderful blog! It is important to remember that even as we are advancing on some important development indicators, countries facing high levels of violence often find it hard to progress. Even in countries who are doing well overall, there are lagging subnational areas where violence is very entrenched, and that are not keeping pace with the rest of the country. There is a lot we can do to help our clients break the cycles of violence and poverty.

Emre S Ozaltin
April 08, 2015

Patricio, thank you for a great read. I think the answer to the title of the blog is an emphatic “yes” and I suggest some ways in which public health can engage on IPV:
1) Engaging in Risk Factors that lie in the domain of public health: e.g. mental health; alcohol; targeting at-risk populations with appropriate programs.
2) Improving related Services: e.g. emergency services (including innovative response technologies such as gunshot detection systems); linking hospitals and law enforcement in domestic abuse cases; ensuring continuity of services in conflict settings.
3) Measurement & Research: e.g. strengthening national systems to correctly record causes of death; surveys; innovative approaches, including social media monitoring, to map and track violence-related events/mortality/morbidity; further understanding causes & consequences.
4) Advocacy: as appropriate, to strengthen national legislation and enforcement, and internationally, particularly related to control of small arms.

April 08, 2015

Dr. Rodrigo Guerrero wins Roux Prize for using data to address violence as a public health crisis in Cali, Colombia. See:…

Sarah Lengio
April 14, 2015

Interesting post! It's troublesome to consider the lack of information into this area of public health even though as noted it is a top cause of premature death and health problems, in order to address this complex problem it will be key to put some real effort into research into the major causes of violence in communities across the globe and into what kind of interventions are effective. I think the major problem with this is that violence is so widespread and diverse and different for every community. Research and information gathering is definitely key along with programs targeting risk factors.

Oscar Echeverri
May 30, 2015

Is Violence a Public Health Problem?
Yes, violence is a public health problem. But, how can it be controlled or reduced to “acceptable levels”? The recurrent answer usually is “multisectoral policies, strategies and interventions based on sound epidemiological assessments”. But I would propose a different approach on such assessments. Instead of assessing social determinants, I propose that human behavior assessments and inequality measurements can be a better focus for understanding and controlling violence.
Tracing back interpersonal violence, the bible narrates that, because of his envy, Cain killed his brother Abel; also, the God of most religions is punitive, denying heaven and threatening with hell to those who do not follow his (her?) mandates. Since then, the history of humankind has been marked by continuous interpersonal violence, and recurring collective violence – gang violence, violent social conflicts, wars-. Skipping some monotonous periods, it is worthwhile to briefly examine how human behavior and inequality remain linked to violence through history.
During the golden Greek era, Herodotus wrote that in a democracy, equality before law is the most splendid of virtues, but at the same time, Aristoteles argued that the law is deficient when it does not consider unequal conditions among citizens, and it requires equity to correct injustice – a form of violence. Some centuries after, during renaissance, Machiavelli endorsed evil and immoral behavior by rulers (the Prince) driving to governance under violence and inequality. Few centuries after, the philosophers of “enlightenment” addressed inequality as the source of interpersonal violence. Hobbes, in his Leviathan stated that all humans are by nature equal in faculties of body and mind, and from this equality and other causes in human nature, everyone is naturally willing to fight one another leading to a life "solitary, poor, nasty, brutish, and short". Rousseau, on his part, affirmed in his outstanding “Discourse on inequality” that at the beginning, the untamed man did not know each other enough to come into conflict, but later, society and the environment changed him more for bad than for good. Inequality was established “from the moment one man began to stand in need of the help of another; from the moment it appeared advantageous to any one man to have enough provisions for two, equality disappeared, (and) property was introduced…” Since then, human beings aware of inequality and property, began to feel “the thirst of raising their respective fortunes, not so much from real want as from the desire to surpass others,(and) inspired all men with a vile propensity to injure one another”.
Wilkinson and Pickett in a remarkable book “The spirit level: Why greater equality makes societies stronger”, reveal that violence is most common in more unequal societies, and that one of the most common causes of violence is degradation and humiliation people feel when they are despised and disrespected. Precisely, by middle XX century, a growing trend in the western culture is the loss of interpersonal respect and loss of respect for others (not present) in daily life. Lucinda Holdforth in her lucid book “Why manners matter” calls for a civilized world in a barbarous world. Richard Sennet addressed the relation between respect and inequality, in his book "Respect in a World of Inequality" and pointed out that modern society lacks positive expressions of respect and recognition for others to the point that a scarcity of respect has been established.
Tony Blair, in the inauguration of the Respect Action Plan said: … “But there are still intractable problems with the behavior of some individuals and families, behavior which can make life a misery for others, particularly in the most disadvantaged communities. What lies at the heart of this behavior is a lack of respect for values that almost everyone in this country shares…”
It is true that homicide is the gravest outcome of interpersonal violence, but it is far less frequent than other manifestations of violence caused by interpersonal disrespect which make life miserable and prone to much aggression and serious non-lethal violence, thus becoming more important than homicide in daily life. For instance, interpersonal disrespect is at the root of many violent manifestations: at home, as domestic violence – violence against women, child abuse, disregard for elders, etc.-; at school, as bullying; at work, as “boss harassment”; at public spaces, antisocial behavior by gangs such as Kelling´s "broken windows", destruction of city equipment, etc. In other words, life today has become "solitary, poor, nasty, brutish, and short" for many people due to loss of interpersonal respect . Our present way of life has become marked by less interpersonal respect than ever before, and with it, marked with more interpersonal violence and collective violence. Perhaps, the increased world population density in cities is reaching critical levels, making us more disrespectful and aggressive as we become closer to each other.
Much more can be said about violence as a public health problem, but I should stop here and propose: Let us work, as John Rawls tells us, for a more equitable society where Justice should protect the more disadvantaged from unfair inequality. And let us work for recovering interpersonal respect and respect for others as a signal of a more civilized world as I propose in my book El respeto, clave en la solución (Oscar Echeverri, 2012).
Oscar Echeverri, World Bank retiree