Understanding and Controlling Violence

Abstract

156 Presentation UNDERSTANDING AND CONTROLLING VIOLENCE FELTON EARLS, M.D. Professor of Child Psychiatry Harvard Medical School and the Judge Baker Children's Center; Professor of Human Behavior and Development Harvard School of Public Health 677 Huntington Avenue Boston, Massachusetts 02115 Violence is as much a public health issue for me and my successors in this country as smallpox, tuberculosis, and syphilis were for my predecessors in the last two centuries. —Former Surgeon General C. Everett Koop, M.D., August 1984 COMPLEX SOCIAL dimensions govern our understanding of and response to violence. An uneasy, yet cogent, analogy might be drawn between the current response to violent behavior and our comprehension of and reaction to infectious diseases a century ago. Without adequate knowledge, the public's response to infectious diseases then was to be fearful and to quarantine high-risk communities. In contemporary America, jails and prisons have taken the place of sanatoria and asylums. The circumstances that led us to isolate persons with tuberculosis and pellagra may not be so different from the current incapacity of the criminal justice system to contain a record number of prisoners. But while our level of understanding of violence, and our capacity to control it, is as underdeveloped and poorly informed as during our confrontation with infectious disease, the likelihood that the public health community will mobUize research and create policies to curb violence as successfully as it has curbed the spread of infectious disease is very much an open question. This paper reviews the magnitude of violence, issues surrounding organizational and scientific approaches to its control, and emerging strategies that promise to significantly advance knowledge of its causes. The discussion will Journal of Health Care for the Poor and Underserved, Vol. 2, No. 1, Summer 1991 _____________________________Earls___________________________157 largely be restricted to the acts of interpersonal violence. I prefer not to treat violence among children as a separate problem. Perhaps that needs some justification since the theme of this conference relates to children. The circumstances that lead to children becoming either perpetrators or victims of violent acts do not appear to differ from those that are linked to violence amongyoung adults.1 Indeed, the problems of child abuse, domestic violence, and assaultive behavior and homicide are known to aggregate in communities, and in families. I will argue that a major impediment to understanding is that we have evolved different systems to respond to these conditions , as if they were independent. Some of my colleagues have referred to this fragmentation as reflecting a moral partition in society. On one hand, we have the criminal justice system, which pursues the morality of blame, retribution, and punishment. Itisa system chiefly concerned about finding and isolating violent individuals from the larger society. Predatory violenœ—in which strangers and the general public are at risk—is of greatest concern. On the other side, we have the public health, medical, and social service communities, which embody a concern oriented towards human welfare. The violence that these systems address occurs among intimates: spouses, parents, and children. Estimating the magnitude of violence Three major sources of information are customarily used to gauge the magnitude of violence: mortality data showing the number of persons (including children) who are victims of homicide; survey data indicating the number of persons who report that they are victims of violent confrontations; and data from criminal justice and juvenile justice sources showing the number of persons arrested, in custody, or incarcerated for violent offenses. Hospital records constitute another source, but such data have not been aggregated uniformly to serve as a basis for estimating the magnitude of violence-inflicted injuries throughout the population. One study, the Northeastern Ohio Trauma Project2, has been widely cited for its demonstration that hospital emergency and trauma services see roughly four times the number of victims of violence than arrest data would indicate for the same population. Thus, this underutilized source of data is of great significance. Injuries sustained from physical and sexual abuse of children are also reflected in figures reported by state and local social service and child welfare agencies, but in most cases the reporting systems are not satisfactory for public health surveillance. Four types of violent crimes are recorded...