Violence Prevention in Low- and Middle-Income Countries Finding a Place on the Global Agenda: Workshop Summary (2008) / Chapter Skim
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Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart
Violence, Health, and Development--Richard Matzopoulos, Brett Bowman, Alexander Butchart
Pages 201-246
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3Alexander Butchart is the Coordinator, Prevention of Violence in the Department of Injuries and Violence Prevention of the World Health Organization, Geneva, Switzerland. 4The findings and conclusions of this paper are those of the author and do not necessarily represent the views of the World Health Organization.
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• To describe what is known about the negative impacts of violence on health and human development in LMICs • To examine available information about the economic costs and impacts on economic development of violence in LMICs • To describe violence prevention policy developments within the global health and development agenda The paper includes a review of recent research on violence in LMICs around seven subtypes of violence: (1) child abuse and neglect, (2)
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Self-Directed Violence Suicide was the leading cause of death due to violence in LMICs in 2002, although it accounted for a smaller percentage of all deaths due to violence in LMICs than in HICs. Collective Violence Collective violence is an endemic and enduring feature of many LMICs.
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Violence is also projected to increase in rank from the 15th to the 13th leading cause of death between 2002 and 2030 with middle-income countries likely to bear most of this burden. The Burden of Violence on Other Causes of Ill Health The impact of violence on other health outcomes is clearly reflected in comparative risk assessment studies, which show that standard burden of disease measures underrepresent the impact of interpersonal violence by at least 26 percent for deaths and 30 percent for disability-adjusted life-years (DALYs)
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The Emergence of Violence Prevention as Part of the Health and Development Agenda There are clear indications that violence prevention is an emerging priority in the global health and development agenda, particularly in LMICs. Since the publication of the World Report on Violence and Health, there have been two World Health Assembly resolutions calling on countries to invest in violence prevention, and by 2006 three out of six WHO regional committees (Africa, the Americas, and Europe)
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. Although the effects of violence on other health outcomes are less well documented, some highly prevalent forms, such as child maltreatment, IPV, and abuse of the elderly, have been shown to have numerous noninjury health consequences.
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Figure C-1 • To describe what is known about the negative impacts of violence on health and human development in LMICs • To examine available information about the economic costs and impacts on economic development of violence in LMICs • To describe violence prevention policy developments within the global health and development agenda Scope and Limitations of This Paper The review of literature is limited primarily to English language publications and the authors welcome suggestions regarding additional texts and resources that may be relevant.
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Similarly, the collective violence of war and civil unrest may be precipitated by overwhelming levels of severe interpersonal violence; and some effects of collective violence, such as increased access to firearms and erosion of nonviolent value systems, increase the risk of interpersonal violence. Crosscutting these causal links between the different subtypes of violence are shared risk factors -- such as alcohol and substance misuse, parental loss, crime, household poverty, and social and economic inequalities -- that underlie most of the subtypes.
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Another South African study, this time among secondary school students in the Limpopo Province, reported a prevalence rate of 54 percent of the total sample reporting contact sexual abuse before the age of 18 years with similar rates for males and females (Madu and Pelzer, 2001)
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. Youth Violence Age and sex are important risk factors for interpersonal violence, with males in particular being more likely to engage in physical violence during adolescence and young adulthood.
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. The Latin American, Caribbean, and African regions have a large population under the age of 25, many of whom are raised in poverty, and rates of interpersonal violence are among the highest in the world (see Figures C-2 and C-3)
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Therefore sound educational and macro-economic policies applied at a societal and structural level to address the existential needs and long-term prospects of vulnerable youth and young adults may have important violence prevention effects. Intimate Partner Violence Among the numerous risk factors associated with a man's likelihood of abusing a female intimate partner are young age, heavy drinking, depression, personality disorders, low academic achievement, low income, marital conflict, marital instability, male dominance in the family, economic stress, and poor family functioning.
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. Another South African study in Cape Town reported that 32 percent of pregnant adolescents and 18 percent of matched controls had been forced into their first sexual experience (Jewkes et al., 2001)
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. Another South A frican study found that the elderly are frequently the victims of physical, psychological, and sexual violence in townships on the periphery of Cape Town (Keikelame and Ferreira, 2000)
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Nevertheless, there is growing concern about suicide as a public health priority in the region. Collective Violence Following the World Report on Violence and Health, collective violence is defined as "the instrumental use of violence by people who identify themselves as members of a group -- whether this group is transitory or has a more permanent identity -- against another group or set of individuals, in order to achieve political, economic or social objectives" (Zwi et al., 2002)
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There are indications that the incidence of interpersonal violence has increased, as sampled households have attributed fewer and fewer deaths to coalition forces as the war has continued. Between June 2005 and June 2006, over 74 percent of all violent deaths were attributed to sources other than the coalition forces.
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Collective violence in Iraq has thus produced collective health effects by driving increases in overall mortality and morbidity due to other forms of violence and communicable diseases. This is exacer bated by a systematic deterioration at all levels of health care services.
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and suicide rates, the uncommonly high rates in LMICs are apparent in the mortality rates cited by health (Figure C-1) and criminal justice agencies (Figure C-2)
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Among LMICs, there was considerable regional variation with regard to the type of violence. Mortality rates due to injuries arising from interpersonal violence were highest in the Americas followed by the African and the European regions, whereas suicide rates were highest in the European and Western Pacific regions.
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This type of research attempts to systematically evaluate changes in population health which may result from changing the distribution of exposure to specific risk factors or a group of risk factors. Preliminary data from a recent South African study estimated that although interpersonal violence accounted for 5.3 percent of deaths as an underlying cause of death, as a risk factor it accounted for 6.7 percent of deaths when its contribution to other health outcomes resulting from child sexual abuse and IPV were included (Table C-2)
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DALYs DALYs 1 Unipolar depressive disorders 8.8 1 Lower respiratory infections 6.8 2 Ischemic heart disease 6.7 2 Perinatal conditions 6.7 3 Alcohol use disorders 5.4 3 HIV/AIDS 6.6 4 Cerebrovascular disease 4.9 4 Meningitis 4.6 5 Alzheimer and other dementias 4.3 5 Diarrheal diseases 4.6 6 Road traffic injuries 3.1 6 Unipolar depressive disorders 4.0 7 Trachea, bronchus, lung cancers 3.0 7 Ischemic heart disease 3.5 8 Osteoarthritis 2.7 8 Malaria 3.0 9 Chronic obstructive pulmonary disease 2.5 9 Cerebrovascular disease 2.9 10 Hearing loss, adult onset 2.5 10 Road traffic injuries 2.8 12 Self-inflicted injuries 2.0 19 Self-inflicted injuries 1.2 31 Interpersonal violence 0.7 21 Interpersonal violence 1.1 88 War 0.0 31 War 0.8 NOTE: Bold, italic figures highlight deaths or disability due to violence. SOURCE: Reprinted from the World Report on Violence and Health (2002)
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222 TABLE C-2 Deaths Attributable to Selected Risk Factors Compared with the Underlying Causes of Death in South Africa, 2000 Rank Risk Factor % Total Deaths Rank Disease or Injury % Total Deaths 1 Unsafe sex/STIs 26.3 1 HIV/AIDS 25.5 2 High blood pressure 9.0 2 Ischemic heart disease 6.6 3 Tobacco 8.5 3 Stroke 6.5 4 Alcohol harm 7.1 4 Tuberculosis 5.5 5 High BMI 7.0 5 Interpersonal violence 5.3 6 Interpersonal violence 6.7 6 Lower respiratory infections 4.4 7 High cholesterol 4.6 7 Hypertensive disease 3.2 8 Diabetes 4.3 8 Diarrheal diseases 3.1 9 Physical inactivity 3.3 9 Road traffic accidents 3.1 10 Low fruit and vegetable intake 3.2 10 Diabetes mellitus 2.6 11 Unsafe water, sanitation, hygiene 2.6 11 Chronic obstructive pulmonary disease 2.5 12 Child, maternal underweight 2.3 12 Low birth weight 2.2 13 Urban air pollution 0.9 13 Asthma 1.3 14 Vitamin A deficiency 0.6 14 Trachea/bronchi/lung cancer 1.3 15 Indoor smoke 0.5 15 Nephritis/nephrosis 1.3 16 Iron deficiency anemia 0.4 16 Septicemia 1.2 17 Lead exposure 0.3 17 Oesophageal cancer 1.1 NOTE: Bold, italic figures highlight deaths or disability due to violence. SOURCE: Norman et al.
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WHO's study on the Comparative Quantification of Health Risks estimated the lifetime impact of child sexual abuse taking into account a wide range of disease outcomes including depression, panic disorder, posttraumatic stress disorder (PTSD) , alcohol and drug abuse/dependence and suicide attempts.
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Data on the economic costs of interpersonal violence in LMICs are scarce (Bowman and Stevens, 2004)
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. Similarly, studies in the United States have established that the direct medical costs associated with the treatment of a gunshot wound amount to only 13 percent of the total costs related to the injury (Peden and Van der Spuy, 1998)
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. At the more local level of individual cities and hospitals, a number of South African studies again highlight the high economic costs of violence.
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. Studies of the health effects of interpersonal violence have shown that different degrees of violence can result in a number of acute and chronic health conditions that in turn imply negative influences on produc
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found a strong negative correlation between homicide rates and average monthly income, with higher h omicide rates in the districts whose inhabitants had the lowest incomes. In a study of the association between SES and overall mortality in Moscow, Russia, Chenet, Leon, and Mckee (1998)
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According to recent research undertaken in six African countries, between 16 percent and just under 50 percent of girls in primary and secondary schools report sexual abuse or harassment at the hands of either male students or teachers. In a recent study in Zimbabwe, 40 percent of girls aged between 12 and 14 indicated that they had been the victims of sexual violence (Leach et al., 2000)
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Second, violence seems to be a characteristic of school life in developing countries, further hampering strategies aimed at achieving universal education at least at the primary level. MDG3: Promoting Gender Equality and Empowering Women The WHO Multi-country Study on Women's Health and Domestic Violence against Women suggests that this problem is pronounced in a range of
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. MDG4: Reducing Child Mortality According to the World Report on Violence Against Children (Pinheiro, 2006)
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. Collective violence more than interpersonal violence fragments health care systems, as health care professionals flee war-torn areas.
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A broader interpretation of "environmental sustainability" includes social paradigms linked with the production of human capital and the orderly operations of government. Interpersonal violence erodes both of these prerequisites.
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The evidence base for research and, as will become more evident in the sections that follow, rigorous and accurate surveillance systems for violence data are primarily based in HICs. Truly global partnerships must necessarily acknowledge the significant deleterious effects of violence on the potential development of LMICs and adjust resources invested in violence prevention in LMICs accordingly.
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The Economic Impact of Violence on Development As indicated in Section 3.3, the economic costs associated with violence are significant. As well as the substantial health care expenditure that violence consumes in LMICs, there are numerous costs related to development.
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The Inter-American Development Bank estimated that GDP in Latin American countries would be 25 percent higher if rates of violence were equal to global rates (Londoño and Guerrero, 1999)
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The conference will be hosted for a third time in an LMIC in Mexico in 2008. The emergence of violence within the health and development agenda can in part be ascribed to the role played by the World Health Assembly and partner organizations in driving violence prevention and injury prevention in general, an initiative that has seen injury-related topics being the focus of two World Reports in the last 5 years: namely the World Report on Violence and Health and the World Report on Road Traffic Injury Prevention.
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Yet, despite current projections indicating that violence in LMICs (as a result of both interpersonal and collective violence) is set to become an increasingly important threat to health, vigorous and concerted violence prevention efforts can arrest this trend.
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2004. Sexual violence against intimate partners in Cape Town: prevalence and risk factors reported by men.
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2004. South African National Burden of Disease Study 2000: Esti mates of provincial mortality, Medical Research Council, Cape Town.
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South African Medical Journal 94(4)
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1994. Community violence and young South African children's involvement in aggression.
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1993. The effects of chronic violence on preschool children living in South African townships.
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1998. The economic costs of homicide to a South African city.
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2002. Violence in adolescents' romantic relationships: findings from a survey amongst school-going youth in a South African community.
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Geneva, World Health Organisation. WHO and IPSCAN (International Society for Prevention of Child Abuse and Neglect)
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