Narrative ReviewIs violence a disease? Situating violence prevention in public health policy and practice
Introduction
In the wake of the mass school shooting at Sandy Hook on 14th December 2012, and the release of the Report of the State's Attorney on the Shootings at Sandy Hook Elementary School1 renewed attention has focused on how adopting a Public Health perspective may prevent, or at least reduce the frequency and deadliness, of such events.2, 3 However, such high profile and tragic mass shootings account for relatively few deaths when compared to the daily toll of gun violence in the US4, 5 let alone elsewhere in the world.6 Furthermore, gun violence itself is only one cause of homicide, with a total global estimated burden of intentional injuries attributable to violence (not self-inflicted or war and conflict) of around 600,000 per year.7 However, such fatalities represent the tip of the iceberg, and non-fatal violence is much more common. Such violence is associated with potentially devastating long-term consequences not only resulting from the direct injuries sustained but also indirectly as a risk factor for a broad range of physical and mental health outcomes among perpetrators, victims, families, communities, and wider society.8 Despite this, violence it is often underreported or even deliberately hidden by the victims.
Not only does violence pose a considerable burden as a major cause of mortality and morbidity7 it has been predicted to rise over the coming years.9 Despite some fantastic work by early pioneers10, 11, 12 violence has only relatively recently been acknowledged as a major concern for Public Health at the 49th World Health Assembly in 1996, which was re-emphasised at the 67th World Health Assembly in 2014. What is more, it was only in 2002 that the public health approach to violence was formalised by the World Health Organization (WHO) in the World Report on Violence and Health14 (hereafter referred to as World Report) which offered what is considered one of the broadest definitions of violence15 emphasising the intentionality of the act and a broad range of outcomes:
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, psychological harm, maldevelopment or deprivation (p. 5).8
Whilst violence has been recognised as a public health problem, it has not achieved widespread acceptance. One reason for this is that it may be still viewed as the purview of the criminal justice system. Additionally, it could be that violence does not fit easily into the public health classification system which has been traditionally concerned with communicable and non-communicable disease. Given the centrality of classification to public health, difficulties with classification may impact how violence prevention is situated in public health policy and practice.
This paper will briefly cover some of the thoughts, ideas, and opinions that pervade the public health literature concerning how to classify or conceptualise violence. It will begin with a consideration of the traditional classification system of communicable and non-communicable disease. This will then be followed by the consideration of the sibling issue of unintentional injury and injury control, before highlighting the social determinants perspective.
Section snippets
The scope of public health
Much of the early work in Public Health concentrated on sanitation and communicable diseases.16 Public Health has, however, been adept at adapting to society's emerging problems. Despite this, Hanlon et al.17 note that public health is now facing a number of emerging crises revolving around epidemics of obesity, drug and alcohol misuse, increased rates of depression and anxiety, reductions in general well-being, and widening global health inequalities. Moreover, it is acknowledged that while
The violence epidemic(?)
Increased academic interest and media coverage have led the peoples to believe that they live in violent times, perhaps the most violent in history. While the burden of violence is predicted to rise over the coming years relative to other conditions/outcomes,9 following a detailed analysis of violence across the centuries Pinker concluded that ‘we may be living in the most peaceable era in our species existence’ (p.xxi). Nonetheless, violence, in all its manifestations (self-directed,
Violence as a disease
Violent injury has been described as the ‘neglected disease’.33 The causation and transmission of a disease is explained through the host-agent-environment paradigm, which is also the basis for public health interventions (e.g. the Haddon Matrix34). While this paradigm has traditionally applied to communicable disease, in the second half of the 20th century the paradigm was expanded to account for non-communicable disease.35 However, as early as 1970, Haddon34, 36, 37 applied the paradigm
Violence as a communicable disease
The epidemic of ‘The disease called violence’ (p.6) has been largely attributed to the apparent contagious nature of violence,43 which shows the three main characteristics of a communicable disease in a population: clustering, spread, and transmission.46 In public health, the term contagious refers to ‘a condition that is highly infectious, usually severe’ and transmitted by direct contact.30 The concept of contagion has also been applied at a macro-level in the form of behavioural contagion47,
Violence as a non-communicable disease/condition
Violence is openly referred to as a non-communicable condition by the World Health Organization.58 Non-communicable disease is defined as ‘A descriptive term for common and important conditions of public health importance that are not caused by infectious pathogens’30 and appears to serve as a somewhat ‘catch-all’ term. Kirch29 adds to the definition further by stating that they ‘usually derive from genetic predisposition and/or certain lifestyle characteristics’ (p.993).29 Moreover,
Violence and injury
Classification is a fundamental process within public health. When considering the classification of violence, one cannot divorce the issue from that of its sibling, (unintentional) injury. In the past, injury has been attributed to ‘fate, chance or unexpectedness’ (p.377) inferring an unfortunate and unavoidable set of events not amenable to prevention.37 In fact, despite injury being among the oldest health problems encountered by humans, it has, until recently, been treated as a peripheral
Violence prevention
Perhaps the authors are, however, being premature in worrying how to classify violence. After all they still have to win wide-spread acceptance that it is a public health issue at all. Historically, violence has tended to be seen as the purview of criminal justice authorities rather than a legitimate focus for public health.70 While criminal justice is familiar with the concept of ‘risk factors’ or ‘root causes’71 the very fact that legal sanction was historically seen not only as a remedy but
The wider perspective
Some of the most vulnerable people across the globe languish in prisons, in morgues, or fear for their lives as they step outside their homes. Violence is very much an affliction of the socially deprived, with rates of perpetration and victimization at their highest across every society in the most deprived communities.77 What is more, not only is there a social gradient within and across societies - ‘the lower the ranking in society the higher the risk’(p.6)78 - there is evidence to suggest
The 4th public health revolution
Whilst definitions of public health abound30, 85, 86 what is common is ‘a sense of general public interest, a focus on the broader determinants of health, and a desire to improve the health of the entire population’ (p.16, italics added).18 Health, according to the WHO ‘is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’ (p.2).87 While Morgan88 has criticised this static, broad, idealised, and potentially unattainable goal, it does
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Funding
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Competing interests
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