Elsevier

Public Health

Volume 128, Issue 11, November 2014, Pages 960-967
Public Health

Narrative Review
Is violence a disease? Situating violence prevention in public health policy and practice

https://doi.org/10.1016/j.puhe.2014.09.010Get rights and content

Highlights

  • Violence poses a considerable public health problem through its direct and indirect effects on health.

  • Classification of violence as a disease falls short of capturing the complexity the problem.

  • A change of scope in public health is required to prevent violence through policy and practice.

  • Governments should be held accountable for the violence endemic in societies across the globe.

Abstract

The paper provides a review of some of the thoughts, ideas, and opinions that pervade the public health literature concerning how to classify or conceptualise violence. It is argued that violence transcends classic distinctions between communicable and non-communicable diseases, distinguishes itself from the discipline of injury control, and is influenced by wider, social determinants. Through a discussion of these varied perspectives it is concluded that a fourth revolution in public health is needed – a ‘change in scope’ revolution – that recognizes the influence of social justice, economics, and globalization in the aetiology of premature death and ill health, into which violence fits. However, rather than be shackled by debates of definition or classification, it is important that public health acknowledges the role it can play in preventing violence through policy and practice, and takes unified action.

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

Ethical approval

Not required.

Funding

None.

Competing interests

None declared.

References (92)

  • M. Marmot

    Health in an unequal world

    Lancet

    (2006)
  • E.D. Acheson

    On the state of the public health [The fourth Duncan lecture]

    Public Health

    (1988)
  • P. Hanlon et al.

    Making the case for a ‘fifth wave’ in public Health

    Public health

    (2011)
  • Sedensky SDI. Report of the state's Attorney for the judicial district of Danbury on the shootings at Sandy Hook...
  • A.L. Kellermann et al.

    Silencing the science on gun research

    J Am Med Assoc

    (2013)
  • D. Hemenway

    Private guns. Public health

    (2007)
  • Nocera J. The gun report. The New York Times website:...
  • The Graduate Institute G

    Small arms survey 2012: moving targets

    (2012)
  • WHO

    The global burden of disease: 2004 update

    (2008)
  • L. Dahlberg et al.

    Violence: a global public health problem

  • WHO

    World health statistics: 2008

    (2008)
  • L. Cohen et al.

    A public health approach to the violence epidemic in the United States

    Environ Urbanization

    (1993)
  • J.A. Mercy et al.

    Public health policy for preventing violence

    Health Aff

    (1993)
  • J.A. Mercy et al.

    New directions in violence prevention: the public health arena

    Violence Vict

    (1988)
  • P.H. Tolan

    Understanding violence

  • G. Rosen

    A history of public health

    (1993)
  • P. Hanlon et al.

    A perspective on the future public health: an integrative and ecological framework

    Perspect Public Health

    (2012)
  • T.H. Tulchinsky et al.

    The role of schools of public health in capacity building

    J Public Health

    (2012)
  • J. Olsen et al.

    Global response to non-communicable diseases—the role of epidemiologists

    Int J Epidemiol

    (2012)
  • S.L. Marrero et al.

    Noncommunicable diseases: a global health crisis in a new world order

    J Am Med Assoc

    (2012)
  • L. Potvin et al.

    Modernity, public health, and health promotion: a reflexive discourse

  • M. Terris

    The complex tasks of the second epidemiologic revolution: the Joseph W. Mountin lecture

    J Public Health Policy

    (1983)
  • K.K. Christoffel

    Firearm injuries: epidemic then, endemic now

    Am J Public Health

    (2007)
  • J. Gilligan

    Violence: reflections on our deadliest epidemic

    (2000)
  • J.O. Mason

    The dimensions of an epidemic of violence

    Public Health Reports

    (1993)
  • M. Kingma

    Workplace violence in the health sector: a problem of epidemic proportion

    Int Nurs Rev

    (2001)
  • J.M. Last

    A dictionary of public health

    (2007)
  • H.A. McDavid et al.

    Is criminal violence a non-communicable disease? Exploring the epidemiology of violence in Jamaica

    West Indian Med J

    (2011)
  • J. Fagan et al.

    Social contagion of violence

  • R.W. Sattin et al.

    The epidemiology and costs of unintentional and violent injuries

  • W. Haddon

    On the escape of tigers: an ecologic note

    Am J Public Health

    (1970)
  • T.H. Tulchinsky et al.

    The new public health

    (2009)
  • W. Haddon

    Advances in the epidemiology of injuries as a basis for public policy

    Public Health Reports

    (1980)
  • S.P. Baker et al.

    Reducing injuries and their results: the scientific approach

    Milbank Meml Fund Q Health Soc

    (1974)
  • Cited by (0)

    View full text