Violence Prevention in Low- and Middle-Income Countries: Finding a Place on the Global Agenda: Workshop Summary (2008)

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Summary INTRODUCTION In June of 2007, the Institute of Medicine, in collaboration with Global Violence Prevention Advocacy and with support from the F Felix Founda- tion, held a workshop in Washington, D.C., on violence prevention in low- and middle-income countries (for definition, see Appendix C, Sidel and Levy, 2007, p. 173). Many of the participants were domestic and international researchers, clinicians, and advocacy organizations from dif- ferent disciplines focusing on violence prevention. Other participants in the workshop included those with a wide array of expertise in fields related to health, criminal justice, and economic development, as well as representa- tives from U.S. government agencies, private philanthropic foundations, nonprofit organizations in the private sector, the U.S. Department of State, and bilateral and multilateral organizations. The overarching goals of the two-day workshop were to illuminate the issue of global violence prevention and to articulate specific opportu- nities for the U.S. government and other leaders with resources to more effectively support programming for prevention of the many forms of violence. While this workshop report does not contain formal recommen- dations from the Institute of Medicine, several important messages and participants’ suggestions emerged that could help facilitate new dialogue The planning committee’s role was limited to planning the workshop, and the workshop summary has been prepared by the workshop rapporteur as a factual summary of what o ­ ccurred at the workshop.  

 VIOLENCE PREVENTION IN LOW- AND MIDDLE-INCOME COUNTRIES among those who will play critical roles in elevating violence as a priority issue for increased global attention. Increased support for global violence prevention could have far-reaching impact since violence occurs in differ- ent settings and affects different populations, with many of the different types of violence often sharing underlying risk factors and occurring in similar contexts. There is scant scientific literature available that comprehensively reviews the harmful impact of different types of violence on a range of health outcomes in developed or developing countries. The first report to successfully attempt this was the 2002 World Health Organization (WHO) Report on Violence and Health. Despite this pioneering effort by WHO and the synergism between violence and other factors that hinder the health and well-being of populations, violence prevention has lagged behind other issues on global agendas for public health, economic development, politics, and governance in terms of the priority and resources it receives. For example, statistics show that collective violence and armed conflicts represent approximately 11 percent of deaths due to violence globally, compared to the nearly 54 percent attributed to suicide (WHO, 2002a); yet collective violence often receives a disproportionate level of attention, especially from the media. WORKSHOP MESSAGES One of the overarching messages from the workshop is that violence is costly in both human and monetary costs. In 2000, more than 1.5 mil- lion deaths globally were attributed to violence compared to other public health priorities. Of those deaths, more than half were due to suicide (about 800,000 deaths annually); 35 percent to interpersonal violence; and 11 per- cent to collective violence, which can include organized violence, forms of war, and gang violence (WHO, 2002a). The global distribution of deaths due to violence shows that 91 percent of this burden is disproportionately shouldered by low- and middle-income countries, compared to 9 percent by developed countries: • The overall economic direct and indirect costs associated with the short and the long-term consequences of violence (other than physical injury and death) are difficult to assess accurately. There is a paucity of studies on the economic costs of interpersonal and other types of violence, especially in low- and middle-income countries (WHO, 2004). Innovative research, advocacy, and policy analyses are beginning to examine the criti- cal issue of costing and economic effects to define areas in need of greater research and programmatic focus or needed advances or changes in health, public, and economic policy. It was also suggested that the inclusion of eco- 

SUMMARY  nomic indicators and cost-effectiveness in intervention design and outcome evaluations of interventions may help bridge the gap between the official economic development community and the public health community. • There is an increasingly recognized and documented intersection of violence with other health conditions, such as linkages to longer-term health conditions and disability and the synergism of violence and increased HIV/ AIDS exposure and infection, especially for women. Child maltreatment has been shown to contribute to high-risk behaviors in adulthood such as alcohol and substance use—making an argument for increased investment and urgent focus on its prevention for lifelong benefits. THE VALUE OF VIOLENCE PREVENTION Violence also has collateral effects on education and schooling, com- merce and business, criminal justice and law enforcement, the environ- ment, leadership and capacity for governance, and societal productivity and cohesion in general. The second workshop message is that emerging evidence shows that many types of violence are not only predictable but also preventable. Heightened interest and investment in prevention would confer beneficial returns not only to the places and people most affected by violence but also the world in general—by saving lives, improving health outcomes, and facilitating economic growth that could encourage foreign investments. This in turn may contribute to political, civil, and economic stability in low- and middle-income countries. Various players in violence prevention are using different ­methodologies to address violence and the mitigation of its consequences. However, disci- plines beyond those traditionally associated with health and health care are also advocating for an increased use of science-based approaches to better understand the patterns of violence, its risk and protective factors, and the needs of its victims, as well as to build evidence and apply best practices to pathways for intervention. It was also acknowledged that using public health science to help understand the variance in rates and types of violence can lead to risk identification and prevention in much the same way public health has exploited such variations in cancer and other diseases to identify prevention strategies. A public health approach would also include multi- sectoral and multidisciplinary collaboration in which public health would be only one of many partners. THE PROMISE OF RESEARCH The phenomenon known as the “10/90 gap” states that less than 10 percent of funds invested in global health research ($73 billion annu- ally) is devoted to the health problems that account for 90 percent of the 

 VIOLENCE PREVENTION IN LOW- AND MIDDLE-INCOME COUNTRIES global disease burden (see Appendix C, Matzopoulos et al., 2007). Growing evidence points to violence being a part of that 90 percent burden. Despite limited funding however, the current state of science in violence prevention reveals progress, promise, and a number of remaining challenges. Most of what is known about effective violence prevention comes from ­studies in developed countries but improved integration and collaboration could accelerate application of what is known to developing countries for appro- priate adaptation. Promising, effective interventions are currently being implemented in and by developing countries, but they have not been rigor- ously evaluated for scaling up to regional and national levels. This is where it was thought contributions from private and corporate philanthropy could effectively bridge science with practice. Historical and emerging pathways to violence have been identified, suggesting that greater understanding of them will provide critical input for programmatic and methodological design. Some examples include efforts to improve social, emotional, and behavioral competencies, to improve family functioning and parenting practices to affect and change social norms, and to reduce access to lethal means. WHAT PARTICANTS THINK IS NEEDED TO MOVE VIOLENCE PREVENTION FORWARD Participants highlighted the need for the timely development of an integrated, science-based approach and agenda to support research, clinical practice, program development, policy analysis, and advocacy for violence prevention. It was suggested that the agenda be based on realistic estimates of the resources and funding necessary for effectiveness—not simply what is believed “reasonable” in order to garner short-term political or financial support. Other suggestions for progressive action steps included • learning from and linking to other economic development or health initiatives (such as HIV/AIDS or maternal and child health) as platforms from which the nascent violence prevention efforts can be launched, but continuing to build a coalition to promote widespread formal financial and programmatic support for violence prevention; • developing collaborative relationships with reporters to influence how violence is covered in local and global news to examine the root causes of violence and pathways of prevention versus coverage of the consequences; • conveying the critical message to organized philanthropy and government to continue funding and program implementation when true positive effects are seen. Educating funders about the time required for successful relationship building for community participatory research or collaborations to maximize comparative advantage might help explain why 

SUMMARY  multiyear funding requests are not only reasonable and appropriate, but also more likely in the future; • developing a national plan and lead agency; enhancing capacity for data collection; increasing collaboration and exchange of informa- tion; implementing and evaluating specific actions to prevent violence, and strengthening care and support systems for victims were identified for building a strong, national foundation for violence prevention. These func- tional elements could provide governments with increased knowledge and confidence in workable interventions, while having alternatives to policing and public security to address violence; and • building collaborative relationships via international initiatives to attempt breaking the cycles of interdependence between violence and underdevelopment and elevating the issue of violence prevention on the agendas of official development agencies. There are also calls for an array of violence prevention interventions for country adoption according to what is known about their effectiveness, the challenges and opportunities in implementing them, and the crosscutting interventions that are likely to deal with multiple types of violence simultaneously. OPPORTUNITIES FOR GREATER INVESTMENT FROM THE UNITED STATES Presentations from representatives from U.S. government agencies and the private sector detailed their programmatic involvement in domestic and global violence prevention. Many U.S. government agencies are already involved in domestic research on pathways for violence prevention—from neurobiology to criminal justice. Of these government entities, the U.S. Centers for Disease Control and Prevention, the U.S. Agency for Interna- tional Development, and the National Institute of Mental Health, as well as the multilateral organization—the United Nations Children’s Fund—had the most extensive research and programmatic portfolios in international violence prevention, though they were often limited either by funding or scope. It was suggested that government agencies could bring additional resources and expertise to this area if they were statutorily directed to think and act globally for violence prevention. From the private sector, the InterAmerican Development Bank and the International Justice Mission face different challenges than government agencies when involved in violence prevention because they are permit- ted by their organizational charters to engage in global activities; but they share challenges that stem from a reliance on the country governments and civil societies in which they work to prioritize violence for action, provide leadership, allocate resources, or request additional assistance to increase their attention to violence prevention. 

 VIOLENCE PREVENTION IN LOW- AND MIDDLE-INCOME COUNTRIES Despite the repeated call for multidisciplinary collaborations, several presenters acknowledged that the participation of invited government agen- cies on the workshop panel represented the first time that many of them had ever been in the same room together to talk about violence prevention. While information could be exchanged and a common agenda developed among the agencies for violence prevention, it was also acknowledged that respect for differences in agencies would have to be maintained to facilitate effective collaboration. One important message from this panel was that, while additional research is necessary to build the evidence base for violence prevention, enough is currently known to adapt programs and polices in developing countries to increase gains in violence prevention. Workshop participants met in small groups to brainstorm ideas for how to move violence prevention forward, with an emphasis on increasing investment or involvement from the U.S. public and private sectors, which can be found in the last chapter. The most often cited were • integrating violence prevention with economic development and corporate interests; • using the evidence base and precise language to tailor arguments for violence prevention to potential partners; • building capacity in developing countries to contribute to the evi- dence base for violence prevention, while advocating for administrative, policy, or legislative changes that increase the ability of U.S. agencies to engage in international activities for violence prevention; and • developing strategic alliances with professional, political, and civil associations and organizations. Given the evidence presented during the workshop, an effective coales- cence among researchers, policy makers, advocacy organizations, funders, and communities around a common framework and agenda that utilizes a public health approach could transform isolated efforts into an inter­ national, violence prevention movement—a movement from which every- one on the planet could reap immediate and future benefits.