- Email: [email protected]
Violence as a public health issue
H o r a c e G. O g d e n
Violence as a Public Health Issue Horace G. Ogden is director of the Center for Health Promotion and Education at the Center for Disease Control in Atlanta, Ga. From 1974 to 1980, he zoas director of the Bureau of Health Education at CDC. Previously, he occupied a number of positions in education and communications with the Public Health Service in Washington, D.C.
'd like to sketch the rapid and rather dramatic changes that are taking place in the public health m o v e m e n t - - c h a n g e s which, among many other beneficial things, are bringing belated attention to violence as a public health issue which can and must be addressed by the public health forces of the nation. It is hardly newsworthy that the health problems facing the United States in the last quarter of the 20th century are strikingly different, in magnitude and relative importance, from those which faced previous generations of public health professionals. Thanks in very large part to dramatic successes in dealing with the infectious diseases and to advances in medical treatment, many of the principal killers and disablers of the past have declined and, in some cases, have fallen off the charts. In their place are the chronic diseases, like heart disease and cancer, and a constellation of problems that are not really "diseases" at all in the traditional sense of the w o r d - - a c c i d e n t s of many kinds, and violence, including homicide and suicide. Beginning about a decade ago and accelerating rapidly in the last five years, there has been a strong resurgence of interest in the concept of prevention, adapted to meet changing needs. Prominence has also been given to the relatively n e w concept of health promotion, in recognition of the fact that public health should n o w be concerned, not only with the prevention of unnecessary death and disability but with enhancing the quality of life. The publication in 1979 of the book significantly titled
I
Healthy People: The Surgeon General's Report on Health Promotion and Disease
40
P u b l i c H e a l t h Ismue
Prevention, signaled what has been called "the new revolution in public health."
Healthy People was the product of three years of intensive work by a very wide range of experts both within and outside the federal health establishment. It was followed a year later by Promoting Health and Preventing Disease: Objectives for the Nation, which charts a detailed course of action for both public and private sector health forces in the decade of the '80s. It also specifies more than 200 measurable objectives which, in the judgment of the many scientists who put it together, are achievable by 1990 and represent a reasonable set of expectations. Healthy People describes priority health problems opportunities by age groups of the population, from infancy to old age. Objectives for tlle Nation groups its specific objectives under three broad categories--preventive health services, health protection, and health promotion, Permeating both is the theme that individual lifestyle choices and environmental problems are the predominant causes of today's principal health challenges, and thus the environment and personal choice behavior related to health offer the most promising avenues for progress,:, The stage is now set to look at ~,iolence as a public health issue. Obviously, violence is a direct product of personal behavior conditioned in many ways by environmental factors. Like most modern health problems it has multiple causes. It is not susceptible to simple cure. But if is susceptible to definition and measurement. It can be analyzed as a disease can, in terms of victim, agent, circumstances. Based on these assessments, relative risks can be estimated, populations at special hazard defined, common factors of environment or relationship identified. In short, it is a fit subject for the science that has been public health's most powerful tool in earlier triumphs, epidemiology. And once this is done, it is reasonable to hope that intervention strategies can be designed to alter the circumstances most likely to produce violent behavior, to reduce risks, ultimately to reduce unnecessary and preventable death and disability caused by violent behavior. By way of illustration, let us look for a few minutes at the specific problem of homicide, viewed from the public health perspective. Lest anyone doubt that we are dealing with a public health problem of the first magnitude, homicide now ranks among the top five causes of death for every age group in the U.S. population from ages 1 through 44. It accounts for more than 10 percent of all deaths among adolescents and young a d u l t s - - a b o u t seven percent for whites but more than 30 percent for blacks in this age group. (At this juncture let me add an important parenthetical note. Many of these statistics will show this striking disparity between homicide rates according to race. The disparity is there and cannot be ignored. But the fact is that we do not know what it means. Sources of homicide data m gathered both from health statistics and from crime reportsmindicate the race of the victim. They rarely if ever indicate a measure of socio-economic status. One of the many things we need to learn is the degree to which 41
Public Relations Review homicide risk is a function of economic level, of educational level, of living environment, and so on.) Homicide is of special concern to the United States. The American homicide rate is very much greater than that of most other industrialized nations. Our rate of 10.2 per 100,000 people in 1974 is more than 10 times greater than that of Great Britain, France and Sweden, and more than nine times greater than that of Japan. The homicide rate in the last decade was the highest in the century. The trend is true for all races and for both males and females. While levels for blacks have stabilized in the years 1974-78, the rates for whites continue to rise. As I have already indicated, the incidence of homicide varies with race and sex. However for all races and both sexes, the greatest incidence occurs during the economically most productive period of life. In 1979 alone, more than 630,000 work years were lost to homicide. From 1978-79, more than 57 percent of homicide incidents involved family members or acquaintances. Family members clearly predominate where the victim is a young child. Examined in another way, more than 75 percent of homicides did not occur during the perpetration of some other felony. These findings are true for all victim ages, but are most pronounced for the years of childhood. .The weapons used in homicide vary with the age of the victim. Firearms, followed by knives, are the major weapons involved in the homicide of adults. The Surgeon General's report indicates that in 1977 63 percent of all murders involved firearms, and 18 percent involved knives. This is less true for younger victim ages. The same overall proportions hold true when sex and race of the victim are included in the analysis, whether or not the incident involves family or acquaintances. It is interesting to note that during the period of most rapid increase in homicide rates, the decade 1968-78, the proportion of deaths because of various weapons did not change. In summary, then, homicide is a massive public health problem in the United States. It is a growing problem. It is a problem in which our national record is shockingly worse than that of other industrialized n a t i o n s - nations whose vital statistics are closely comparable with ours in most other respects. Moreover, its cost to the nation is not measured solely by death rates. Unlike cardiovascular disease and cancer, for example, whose greatest toll is among older people, homicide deaths are heavily concentrated among youth, multiplying the cost in terms of excess years of life lost, productivity wasted, potential unrealized. In a very preliminary look, it is evident that the majority of homicides are not the products of other felonious crimes, but rather, they involve family members and acquaintances. The majority of these types of homicides involve firearms, but there has been an increase in homicides associated with other weapons as well.
42
Publle Health Issue Where do we go from here? The Objectives for 1990 to which I referred earlier lists a few specific goals related to violence. Under "Improved Health Status" appear the following three: "a. By 1990, the death rate from homicide among black males ages 15 to 24 should be reduced to below 60 per 100,000. (In 1978 the rate for this group was 72.5 per 100,000.) "b. By 1990, injuries and deaths of children inflicted by abusing parents should be reduced by at least 25 percent. (Reliable baseline data unavailable--estimates vary from 200,000 to 4 million cases of child abuse occurring each year.) "c. By 1990, the rate of suicide among people 15 to 24 should be below 11 per 100,000. (In 1978, the suicide rate for this age group was 12.4 per 100,000.)" At first glance, these three health status objectives may appear very modest i n d e e d - - p e r h a p s too modest. But these were deliberately drawn so as to be achievable objectives--reasonable expectations for a decade already underway. Further, they were developed in recognition of the fact that this is an extremely complex field in which public health professionals recognize that they are neophytes. If these objectives are surpassed, so much the better. To me, the most significant fact about these objectives is that they are there at all. Ten years ago, or perhaps even five, such items would not have appeared on the public health agenda. Also of great significance is the fact that our present Secretary of Health and H u m a n Services, Richard Schweiker, has stated repeatedly that prevention and health promotion are among his highest priorities. We in the Center for Health Promotion and Education of the Center for Disease Control consider the reduction of preventable death and disability because of violence to be among our most exciting challenges in the immediate future. CDC, as the principal prevention arm of the Public Health Service, has built its reputation on epidemiology and public health. Its successes have been based first on surveillance--the accurate assessment of the extent and nature of health p r o b l e m s - - a n d then on active prevention of death and disability. The process, which we believe can be applied to the problem of violence in general and homicide in particular, can be divided into three stages. The first is surveillance. Homicides currently are reported to police and vital statistics agencies. We suggest a collaboration permitting the linking and comparison of these data. We have' begun this endeavor with an examination of child homicide, growing out of an initial interest in the broader problem of child abuse. Much evidence indicates that homicide in this age group is more difficult to define than for other ages. The national Center for Health Statistics of the Public Health Service and the Federal Bureau of Investigation of the Department of Justice have assisted us by supplying their homicide data.
Public Relations Review Preliminary findings indicate that current figures may underestimate the incidence of child homicide b y as much as 25 percent. This work is ongoing and is being broadened to include surveillance of adult homicide, as well as suicide and other violent deaths. The second stage in which the public health enterprise, and specifically CDC, may be able to assist is in the epidemiologic assessment of precursors to violence. It has been suggested, among other places in the 1990 Objectives document, that the goal of stress reduction will decrease violence in our society. Thus far, the link between stress--which is variously d e f i n e d - - a n d violent behavior is preliminary at best. We urgently need large population data that relate economic status, employment, isolation, crowding, illness in the family, drug or alcohol abuse, or lifestyle to such outcomes as homicide and suicide. Examination of these issues presents an exciting epidemiologic challenge in the coming decade.
Full-time granny, part-time cop. ~'~,'~,'~
. , ~ ,.. '~ ~
~i[~o
~-'~ln~.
~ ",~//~,.~ ~ .,~v~:l,.
My ns_me'sMc(3ru ff, the Crime Dog.Ap.d that's Mimi -
Marth. She a n d h e r neighbors in H a r t f o r ~
Write to: McGrufs
~ ~ ~ ]
TAKE A BITE OUT OF
t h ~ pu~llcauon a~.dThe A(~C ~ ncll
44
th~ d~. Ho~'bout:~ou?
Crime P r e v e n t i o n Coalition,
Violence as a Public Health Issue Horace G. Ogden is director of the Center for Health Promotion and Education at the Center for Disease Control in Atlanta, Ga. From 1974 to 1980, he zoas director of the Bureau of Health Education at CDC. Previously, he occupied a number of positions in education and communications with the Public Health Service in Washington, D.C.
'd like to sketch the rapid and rather dramatic changes that are taking place in the public health m o v e m e n t - - c h a n g e s which, among many other beneficial things, are bringing belated attention to violence as a public health issue which can and must be addressed by the public health forces of the nation. It is hardly newsworthy that the health problems facing the United States in the last quarter of the 20th century are strikingly different, in magnitude and relative importance, from those which faced previous generations of public health professionals. Thanks in very large part to dramatic successes in dealing with the infectious diseases and to advances in medical treatment, many of the principal killers and disablers of the past have declined and, in some cases, have fallen off the charts. In their place are the chronic diseases, like heart disease and cancer, and a constellation of problems that are not really "diseases" at all in the traditional sense of the w o r d - - a c c i d e n t s of many kinds, and violence, including homicide and suicide. Beginning about a decade ago and accelerating rapidly in the last five years, there has been a strong resurgence of interest in the concept of prevention, adapted to meet changing needs. Prominence has also been given to the relatively n e w concept of health promotion, in recognition of the fact that public health should n o w be concerned, not only with the prevention of unnecessary death and disability but with enhancing the quality of life. The publication in 1979 of the book significantly titled
I
Healthy People: The Surgeon General's Report on Health Promotion and Disease
40
P u b l i c H e a l t h Ismue
Prevention, signaled what has been called "the new revolution in public health."
Healthy People was the product of three years of intensive work by a very wide range of experts both within and outside the federal health establishment. It was followed a year later by Promoting Health and Preventing Disease: Objectives for the Nation, which charts a detailed course of action for both public and private sector health forces in the decade of the '80s. It also specifies more than 200 measurable objectives which, in the judgment of the many scientists who put it together, are achievable by 1990 and represent a reasonable set of expectations. Healthy People describes priority health problems opportunities by age groups of the population, from infancy to old age. Objectives for tlle Nation groups its specific objectives under three broad categories--preventive health services, health protection, and health promotion, Permeating both is the theme that individual lifestyle choices and environmental problems are the predominant causes of today's principal health challenges, and thus the environment and personal choice behavior related to health offer the most promising avenues for progress,:, The stage is now set to look at ~,iolence as a public health issue. Obviously, violence is a direct product of personal behavior conditioned in many ways by environmental factors. Like most modern health problems it has multiple causes. It is not susceptible to simple cure. But if is susceptible to definition and measurement. It can be analyzed as a disease can, in terms of victim, agent, circumstances. Based on these assessments, relative risks can be estimated, populations at special hazard defined, common factors of environment or relationship identified. In short, it is a fit subject for the science that has been public health's most powerful tool in earlier triumphs, epidemiology. And once this is done, it is reasonable to hope that intervention strategies can be designed to alter the circumstances most likely to produce violent behavior, to reduce risks, ultimately to reduce unnecessary and preventable death and disability caused by violent behavior. By way of illustration, let us look for a few minutes at the specific problem of homicide, viewed from the public health perspective. Lest anyone doubt that we are dealing with a public health problem of the first magnitude, homicide now ranks among the top five causes of death for every age group in the U.S. population from ages 1 through 44. It accounts for more than 10 percent of all deaths among adolescents and young a d u l t s - - a b o u t seven percent for whites but more than 30 percent for blacks in this age group. (At this juncture let me add an important parenthetical note. Many of these statistics will show this striking disparity between homicide rates according to race. The disparity is there and cannot be ignored. But the fact is that we do not know what it means. Sources of homicide data m gathered both from health statistics and from crime reportsmindicate the race of the victim. They rarely if ever indicate a measure of socio-economic status. One of the many things we need to learn is the degree to which 41
Public Relations Review homicide risk is a function of economic level, of educational level, of living environment, and so on.) Homicide is of special concern to the United States. The American homicide rate is very much greater than that of most other industrialized nations. Our rate of 10.2 per 100,000 people in 1974 is more than 10 times greater than that of Great Britain, France and Sweden, and more than nine times greater than that of Japan. The homicide rate in the last decade was the highest in the century. The trend is true for all races and for both males and females. While levels for blacks have stabilized in the years 1974-78, the rates for whites continue to rise. As I have already indicated, the incidence of homicide varies with race and sex. However for all races and both sexes, the greatest incidence occurs during the economically most productive period of life. In 1979 alone, more than 630,000 work years were lost to homicide. From 1978-79, more than 57 percent of homicide incidents involved family members or acquaintances. Family members clearly predominate where the victim is a young child. Examined in another way, more than 75 percent of homicides did not occur during the perpetration of some other felony. These findings are true for all victim ages, but are most pronounced for the years of childhood. .The weapons used in homicide vary with the age of the victim. Firearms, followed by knives, are the major weapons involved in the homicide of adults. The Surgeon General's report indicates that in 1977 63 percent of all murders involved firearms, and 18 percent involved knives. This is less true for younger victim ages. The same overall proportions hold true when sex and race of the victim are included in the analysis, whether or not the incident involves family or acquaintances. It is interesting to note that during the period of most rapid increase in homicide rates, the decade 1968-78, the proportion of deaths because of various weapons did not change. In summary, then, homicide is a massive public health problem in the United States. It is a growing problem. It is a problem in which our national record is shockingly worse than that of other industrialized n a t i o n s - nations whose vital statistics are closely comparable with ours in most other respects. Moreover, its cost to the nation is not measured solely by death rates. Unlike cardiovascular disease and cancer, for example, whose greatest toll is among older people, homicide deaths are heavily concentrated among youth, multiplying the cost in terms of excess years of life lost, productivity wasted, potential unrealized. In a very preliminary look, it is evident that the majority of homicides are not the products of other felonious crimes, but rather, they involve family members and acquaintances. The majority of these types of homicides involve firearms, but there has been an increase in homicides associated with other weapons as well.
42
Publle Health Issue Where do we go from here? The Objectives for 1990 to which I referred earlier lists a few specific goals related to violence. Under "Improved Health Status" appear the following three: "a. By 1990, the death rate from homicide among black males ages 15 to 24 should be reduced to below 60 per 100,000. (In 1978 the rate for this group was 72.5 per 100,000.) "b. By 1990, injuries and deaths of children inflicted by abusing parents should be reduced by at least 25 percent. (Reliable baseline data unavailable--estimates vary from 200,000 to 4 million cases of child abuse occurring each year.) "c. By 1990, the rate of suicide among people 15 to 24 should be below 11 per 100,000. (In 1978, the suicide rate for this age group was 12.4 per 100,000.)" At first glance, these three health status objectives may appear very modest i n d e e d - - p e r h a p s too modest. But these were deliberately drawn so as to be achievable objectives--reasonable expectations for a decade already underway. Further, they were developed in recognition of the fact that this is an extremely complex field in which public health professionals recognize that they are neophytes. If these objectives are surpassed, so much the better. To me, the most significant fact about these objectives is that they are there at all. Ten years ago, or perhaps even five, such items would not have appeared on the public health agenda. Also of great significance is the fact that our present Secretary of Health and H u m a n Services, Richard Schweiker, has stated repeatedly that prevention and health promotion are among his highest priorities. We in the Center for Health Promotion and Education of the Center for Disease Control consider the reduction of preventable death and disability because of violence to be among our most exciting challenges in the immediate future. CDC, as the principal prevention arm of the Public Health Service, has built its reputation on epidemiology and public health. Its successes have been based first on surveillance--the accurate assessment of the extent and nature of health p r o b l e m s - - a n d then on active prevention of death and disability. The process, which we believe can be applied to the problem of violence in general and homicide in particular, can be divided into three stages. The first is surveillance. Homicides currently are reported to police and vital statistics agencies. We suggest a collaboration permitting the linking and comparison of these data. We have' begun this endeavor with an examination of child homicide, growing out of an initial interest in the broader problem of child abuse. Much evidence indicates that homicide in this age group is more difficult to define than for other ages. The national Center for Health Statistics of the Public Health Service and the Federal Bureau of Investigation of the Department of Justice have assisted us by supplying their homicide data.
Public Relations Review Preliminary findings indicate that current figures may underestimate the incidence of child homicide b y as much as 25 percent. This work is ongoing and is being broadened to include surveillance of adult homicide, as well as suicide and other violent deaths. The second stage in which the public health enterprise, and specifically CDC, may be able to assist is in the epidemiologic assessment of precursors to violence. It has been suggested, among other places in the 1990 Objectives document, that the goal of stress reduction will decrease violence in our society. Thus far, the link between stress--which is variously d e f i n e d - - a n d violent behavior is preliminary at best. We urgently need large population data that relate economic status, employment, isolation, crowding, illness in the family, drug or alcohol abuse, or lifestyle to such outcomes as homicide and suicide. Examination of these issues presents an exciting epidemiologic challenge in the coming decade.
Full-time granny, part-time cop. ~'~,'~,'~
. , ~ ,.. '~ ~
~i[~o
~-'~ln~.
~ ",~//~,.~ ~ .,~v~:l,.
My ns_me'sMc(3ru ff, the Crime Dog.Ap.d that's Mimi -
Marth. She a n d h e r neighbors in H a r t f o r ~
Write to: McGrufs
~ ~ ~ ]
TAKE A BITE OUT OF
t h ~ pu~llcauon a~.dThe A(~C ~ ncll
44
th~ d~. Ho~'bout:~ou?
Crime P r e v e n t i o n Coalition,