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

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3 Why the World Should Care About Violence Prevention The World Report on Violence and Health, published by the World Health Organisation (WHO) in 2002, postulated that the lack of a clear definition of violence has been a contributor to its being ignored as a public health issue. Violence is often defined in cultural terms, which are based on prevailing notions of acceptable or harmful behaviors that change over time. In addition, prevailing definitions of violence have typically been influenced by who is providing the definition and the purposes for which it is being used. For example, a definition used in the criminal justice sys- tem for arrests and convictions may be different from that used in a social services system. An important point is that a useful definition of violence should not be so broad as to lose its meaning, but should capture the range of acts of those who engage in violence and the subjective experiences of victims. Additionally, there must be global agreement on a definition so that data can be compared among countries to contribute to building a sound, scientific evidence base with which to address the issue (WHO, 2002a). The report (WHO, 2002a, p. 5) defines violence as 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. For the purposes of this workshop, that definition was used. To ensure that participants and presenters were using the same terminology through- out discussions, the committee provided and referred to a handout of 22 

WHY THE WORLD SHOULD CARE ABOUT VIOLENCE PREVENTION 23 w ­ orking definitions for this and the subtypes of violence that have been adapted from the most reliable scientific sources (see Box 1-1). The moderator of this session, Sir George Alleyne, M.D., opened the discussion by observing a change in the session title. The title of this chap- ter was the original title of the session, but the version of the agenda he received titled it “Why the World Should Be More Invested in Violence Prevention.” He believed that greater investment is really the thesis for dis- cussion and one of the major themes of this workshop. If the question were asked, he said that the answer would be because of the tremendous returns on such investment. Another rationale of the workshop, he stated, was to reenergize ourselves and energize those who can invest in violence preven- tion by reawakening our sensitivities and sensibilities, which he stated had been “repeatedly dulled by the pictures and images of violence coming through our living rooms.” From his own background in public health, he has come to believe that (1) health can be used as a platform or bridge to reduce some forms of violence, as we would see from the program in Bogotá, Colombia, and (2) tools of public health can be applied to address some aspects of both interpersonal and collective violence. Presentations by Etienne Krug, Irvin Waller, Bernice van Bronkhorst, and James Garbarino explored violence prevention from several different perspectives—health, criminal justice, economic development, and human development. HEALTH PERSPECTIVE Dr. Etienne Krug began by contrasting the 1.6 million annual deaths globally attributed to violence to other public health priorities. Tubercu- losis results in roughly the same number of deaths as violence, but more people die from HIV/AIDS, while fewer die from malaria. Of the 1.6 mil- lion deaths from violence, half of them are due to suicide, 35 percent to interpersonal violence, and 11 percent to collective violence, which can include organized violence, forms of war, and gang violence. He suggested that we have a counterintuitive or inverse level of attention, especially from the media, paid to collective violence when epidemiology shows us that the greater issue within types of violence is suicide. His professional experiences dealing with the consequences of collective violence, such as amputating the legs of people who have stepped on land mines, treating babies cut by machetes, and treating women who have had their breasts cut from their bodies during war, are horrific reminders of the importance of addressing collective violence, but he pointed out that other hugely important public health aspects of violence receive much less attention. In terms of the pattern of distribution of violence globally, the dispro- portionate burden of death due to violence is in low- and middle-income countries (LMICs)—91 percent compared to 9 percent in high-income or 

24 VIOLENCE PREVENTION IN LOW- AND MIDDLE-INCOME COUNTRIES developed countries. Violence is among the leading causes of death for those aged 15 to 29 years. Suicide is the fourth leading cause of death, homicide the fifth, and war-related deaths are the sixth (see Table 3-1). This has important, generational effects in LMICs, since these people are usu- ally the breadwinners in families. When they die prematurely, the economic security of entire families often plunges for more than a generation. Matzopoulos et al. 2007 (see Appendix C) propose that although mor- tality rates, especially for suicide, interpersonal violence, and war, show a substantial injury burden in LMICs, the data likely under­represent the actual magnitude of the problem. They state that mortality rates only reflect the number of people who have died from specific causes, but ignore the significant health burden imposed on survivors. They also fail to capture the broad effects of violence on health that may contribute to premature mortality from a range of other deaths. They suggest that more sophisti- cated methods that include measures such as potential years of life lost and disability-adjusted life-years (DALYs) are more appropriate to better describe the impact of violence. Though deaths from violence are impor- tant, there are other health, social, and mental consequences, some of which were mentioned earlier by Stephen Lewis. Depending on the country and studies reported, 10-70 percent of women report being victims of intimate partner violence. Dr. Krug stated that data from other studies indicate that about 10 percent of men and 20 percent of women report having been sexually abused when they were children. While these events did not result in death, there are long-term mental health consequences including depression, anxiety, stress, and insomnia; unwanted pregnancies; exposure Years of potential life lost (YPLL) is a measure of premature mortality and is presented for persons under 75 years of age because the average life expectancy in the United States is over 75 years. YPLL-75 is calculated using eight age groups. The number of deaths for each age group is multiplied by the years of life lost, calculated as the difference between age 75 years and the midpoint of the age group. YPLL is derived by summing years of life lost over all age groups (National Center for Health Statistics; available at http://www.cdc.gov/nchs/ datawh/nchsdefs/yearsofpotentiallifelost.htm; accessed on September 6, 2007). ­ Disability- adjusted life-year (DALY) is a health gap measure that extends the concept of potential years of life lost (PYLL) due to premature death to include equivalent years of “healthy” life lost by virtue of being in states of poor health or disability. The DALY combines in one measure the time lived with disability and the time lost due to premature mortality. One DALY can be thought of as one lost year of “healthy” life and the burden of disease as a measurement of the gap between current health status and an ideal situation in which everyone lives into old age free of disease and disability (World Health Organization; available at http://www.who. int/healthinfo/­boddaly/en/index.html; accessed on September 6, 2007).   By contrast, Muenning (2002) states that while the DALY is frequently used for studies in developing countries and might serve as an international standard for cost-effectiveness a ­ nalyses, it does have limitations because of the different cultural perceptions of human s ­ uffering and quality of life, which would be exaggerated when generating health-related q ­ uality-of-life scores and using them in cross-national comparisons. 

WHY THE WORLD SHOULD CARE ABOUT VIOLENCE PREVENTION 25 TABLE 3-1�  Top 10 Causes of Death, Ages 5-44 Years, Both Sexes, 2002 Rank 5-14 Years 15-29 Years 30-44 Years 1 Childhood cluster HIV/AIDS HIV/AIDS 200,139 855,406 855,406 2 Road traffic injuries Road traffic injuries Tuberculosis 118,212 354,692 368,501 3 Drowning Tuberculosis Road traffic injuries 113,614 238,021 354,692 4 Respiratory infections Self-inflicted injuries Ischemic heart disease 112,739 216,661 224,986 5 Diarrheal diseases Interpersonal violence Self-inflicted injuries   88,430 188,451 215,263 6 Malaria War injuries Interpersonal violence   76,257   95,015 146,751 7 HIV/AIDS Drowning Cerebrovascular disease   46,022   78,639 145,965 8 War injuries Respiratory infections Cirrhosis of the liver   43,671   65,153 135,072 9 Tuberculosis Poisonings Respiratory infections   36,362   61,865 102,431 10 Tropical diseases Fires Liver cancer   31,845   61,341   84,279 NOTE: Bold, italic figures highlight deaths or disability due to violence. SOURCE: Krug (2007). to sexually transmitted infections including HIV/AIDS; and engagement in high-risk behaviors such as smoking, alcohol, and substance use that are linked to chronic diseases, cancer, and cardiovascular disease. New research is providing more information about violence and its consequences beyond death and severe injury, including data about economic costs. As Krug reviewed the causes of violence, an important message was that there is not a single cause and therefore there is a need to move away from a single risk factor approach. In fact, multiple risk factors for both individuals (being male, previous experience with violence, alcohol and substance use, family environment with poor parenting, or marital conflict) and communities (high concentrations of poverty; widespread violence in society; alcohol and substance use, access to weapons; and high rates of social, justice, economic, and gender inequalities) suggest that these risk factors need to be addressed simultaneously. When different types of vio- lence such as abuse against children, the elderly, and women share multiple risk factors, this suggests that interventions to address them may result in an impact on several types of violence. These shared risk factors include parental loss, crime, alcohol and substance use, mental illness, and social isolation. 

26 VIOLENCE PREVENTION IN LOW- AND MIDDLE-INCOME COUNTRIES The World Report on Violence and Health began to look at violence prevention at the international level and from a public health perspec- tive. Before this effort, violence had been considered a domestic issue that every country had to deal with in its own way. The report has been widely distributed, with more than 30,000 copies in more than 15 languages. A global campaign was created to help mobilize different agencies in the imple- mentation of the report. A number of political bodies—the World Health Assembly (WHA), several of the WHO regional committees, the African Union, the Council of Europe, the World Medical Association, a number of personalities such as Nelson Mandela, and the ministers of several European countries and South Africa—have all endorsed the report and participated in political events to help place the report on the global agenda. The primary recommendation of the WHO report called for a focus on primary prevention at all of the levels of an ecological model—work- ing with individuals, families, communities, and societies—to address the root causes of violence versus a criminal justice focus on incarceration. Other recommendations called for countries to develop a national plan of action that emphasized increasing data collection capacity and strengthen- ing research into the costs and causes of prevention; promoting gender and social ­equality; and strengthening victim care and support services. These and other recommendations serve as a basis for the programs WHO has been implementing for several years. Because a number of countries have adopted the report and developed national action plans, WHO is now developing a series of follow-up documents to assist countries in strengthen- ing victims’ services and to assist ministries of health to increase their focus and prevention activities on the different types of violence. Krug stated that the WHO report also clearly shows that successful responses to violence require a multisectoral effort—health, justice, diplo- macy, police, employment, and others. Like Rosenberg, he emphasized that public health does not have sole responsibility for the problem but can bring specific tools and knowledge such as data collection, research, pre- vention, services, and evaluation of prevention efforts to help shape policy, improve services, and conduct the advocacy that Stephen Lewis mentioned. In summation, he pointed out that Dr. Margaret Chan, the newly appointed Director General of WHO and the acknowledged global leader in public health, stated in her opening speech that violence and injuries must be addressed as part of the global public health agenda. CRIMINAL JUSTICE PERSPECTIVE Dr. Irvin Waller reflected on the data presented by Dr. Krug as an underrepresentation of the magnitude of the problem. While he concurred that attention must be diverted from an obsession with collective violence 

WHY THE WORLD SHOULD CARE ABOUT VIOLENCE PREVENTION 27 to interventions and policies that reduce the number of people who are victimized by violence, his approach focused on the criminal justice industry (police, courts, and corrections), particularly in the United States. Here, he noted, the annual $200 billion spent on a reactive, judicial response is incongruous with public opinion, which has expressed twice as much inter- est in investing in programs for at-risk youth. Despite this public sentiment, he pointed out that the U.S. leadership has a long history of investing in corrections and is responsible for one out of five incarcerations in the world today. This effort apparently does little for the public perception of safety and security, he stated, since two out of three handgun owners in the U.S. claim they own guns to feel safe. While this “law-and-order” approach may have an economic benefit in wealthy countries by creating jobs, Waller believes that this is a “bankrupt solution” when it comes to safety and ben- efiting victims of violence by reducing the amount of harm done to them. By contrast, he noted that although similar expenditures are not affordable in LMICs for policing that is in complete chaos—complicated by issues such as corruption that affect and reduce the size of the police force due to jobs being terminated—the policing and criminal justice in these countries do need strengthening and upgrading. For additional benefit to improve services to victims and greater epi- demiological understanding of the problem (especially for sexual assault), Waller argued for the inclusion of victimization surveys as part of data collection efforts, such as those being demonstrated in Argentina. Waller proposed that lesser developed countries are better at obtaining justice for victims than more developed countries by focusing on truth and protec- tion for victims rather than resorting to the execution of criminals. Sexual assault, he noted, is seldom reported in any country. In Canada, which is considered to have one of the best police forces in terms of payment and professionalism, only 8 percent of sexual assaults are reported to the police. He challenged the group to imagine the effect that corruption and other issues of poor policing would have on the reporting rate in LMICs. He also noted that even when violence is addressed through a criminal justice perspective, there are innovative initiatives, such as the all-female police sta- tions in a province in Southern India with 16 million people that can help victims report crimes and increase cooperation with law enforcement. This is an example of the adaptation of strategies developed by other LMICs since the idea was conceived in Brazil. Waller emphasized that organizations in different sectors in the United States, the United Kingdom, South Africa, and the United Nations have endorsed the use of evidence-based approaches to crime and victimization reduction and have issued reports similar to WHO’s world report on vio- lence. Building on some of the research findings of the National Academies’ National Research Council, the United Nations Office on Drugs and Crime 

28 VIOLENCE PREVENTION IN LOW- AND MIDDLE-INCOME COUNTRIES has published similar guidelines to emphasize a science-based approach to focus on prevention and collaboration. He also noted that efforts in the private sector are significantly important, citing the international nonprofit organization Habitat, which is implementing Safer Cities—a municipal safety and crime reduction strategy—in Africa and Latin America. Evidence of the effectiveness of the public health approach in LMICs is demonstrated by the work in Bogotá, Colombia, which used mayoral leadership to diag- nose the problem, prepare a funded plan, implement the plan, evaluate its implementation and outcomes, and ensure a planning group with authority and responsibility for implementation and evaluation. Dr. Waller proposed that the real solution for addressing violence is a term he called “second re-prevention”—focusing on addressing risk factors for more immediate, significant reductions in violence, while simultane- ously addressing longer-term factors such as elimination of poverty and creating gender equity. His first recommendation called for implementa- tion of youth-oriented programs in school curricula. He reinforced the call for ­ evidence-based interventions and acknowledged that Canada and the United Kingdom have conducted randomized controlled trials of several interventions that were shown to be not only cost-effective, but also suc- cessful in reducing violent behavior in most high-risk youth. Some of these interventions focus on negotiation skills for young men in schools so they do not resort to bullying and sexual assault. This success can promote generational violence prevention by teaching young people how to become functional adults in society. His second recommendation called for an emphasis on prevention of violence against women and children, which he stated can result in reduction of a huge proportion of violence globally; it will have a generational impact on the problem by reducing violence against children, and women will become more effective contributors to their children’s well-being and increasingly productive contributors to society at large. He identified empowering local partnerships with mothers, com- munity agencies, and others as another necessary component of effective violence prevention. Strengthening the capacity of these partnerships to analyze the evidence on crime problems and focus on outcomes and results can make a difference in the levels of violence in communities. Waller closed by underscoring the need not only for public health leader­ship in multisectoral collaborations, but also for presidential or prime ministerial leadership, such as that seen in South Africa with the Mandela administration. He stated that it is essential to institutionalize political leader­ship to focus on prevention and ensure the availability of adequate funds and the existence of legislation that will drive the success of the collaborations. In South Africa, the leadership balanced effective criminal justice with social and public health interventions. He warned this is par- ticularly important because of the vulnerability of public health initiatives 

WHY THE WORLD SHOULD CARE ABOUT VIOLENCE PREVENTION 29 to address violence when leadership only criminalizes violence—enabling the police to expand their resources and power. ECONOMIC DEVELOPMENT PERSPECTIVE Ms. Bernice van Bronkhorst focused her presentation on the economic costs of violence in the Caribbean as noted in a joint report of the World Bank and the United Nations Office on Drugs and Crime (UNODC-WB, 2007). She started with an overview of the region, which she identified as the most violent subregion in the world—with average homicide rates of 30 per 100,000 people and higher rates in Jamaica and Haiti (see Figure 3-1). Crime statistics, she stated, are extremely difficult to compare inter­ nationally, but the most reliable gauge of violence in a society is its murder rate because lesser forms of violence may never come to the attention of the police. She cautioned, however, that even the murder figures can be deceptive because in countries with small populations, a small number of murders can result in very high rates. Also, murder rates are based on the number of residents, but many Caribbean countries swell to several times their normal size during the high season due to the influx of tourists. Any of these tourists could be a victim or perpetrator of murder, so the rates may appear artificially high. Finally, definitions of what constitutes murder Caribbean 30 Southern and West Africa 29 South Africa 26 East and Southeast Asia 22 Central America 22 Eastern Europe 17 Central Asia 9 East Africa 8 North America 7 South Asia 4 Southeast Europe 3 Oceania 3 West and Central Europe 2 North Africa 1 Middle East and Southwest Africa 1 0 5 10 15 20 25 30 35 FIGURE 3-1  Homicide rates per 100,000 people by world region, 2002. SOURCE: Bronkhorst (2007) and UNODC-WB (2007). fig 3-1 

30 VIOLENCE PREVENTION IN LOW- AND MIDDLE-INCOME COUNTRIES vary surprisingly from country to country. Many of the countries that we might suspect to have high murder rates simply do not report them. Even with these caveats, on the basis of this figure, she asserted, it is clear that the Caribbean has a serious problem with violence. Give the prevalence of �������������� interpersonal violence around the world, including the homicide rates in Latin America—which have been steadily rising in the late 1990s and early 2000s, she reinforced earlier comments about not losing sight of the impor- tance of interpersonal violence and not focusing extensively on collective violence. In identifying challenges for understanding what is happening in the region, Bronkhorst also underscored the issue of poor data collection and quality (particularly for sexual assault, rape, and property crimes) and reemphasized Waller’s advocacy of the use of victimization surveys. Kidnapping has emerged, particularly in Haiti, as a contributor to vio- lence in the region. Its geographical location and the region’s topography, with long shorelines that are difficult to police, also make illicit drugs and trafficking a major driver of violence and crime since the region is between drug-producing and drug-consuming countries. Drug trafficking has not only increased the quantity but also changed the type of drug used (from marijuana to cocaine). Drug trafficking promotes violence in a range of ������������������������������������������������� ways: drug markets are regulated by violence, which is used to collect debts, settle contract disputes, and defend or acquire turf. Drugs bring firearms into a country, resulting in their increased use for a variety of crimes and the increased lethality of injuries caused, which reinforces the need for reductions ����������������������������������� in lethality of and in access to means for violence.�������������������������� Perhaps more ­insidious, she stated, is the effect drugs have on corruption. The value of the drug flows through the Caribbean exceeds the values of the economies of many of its countries. This economic weight gives traffickers a tremendous amount of leverage in promoting corruption and undermining entire economies.� In discussing violence and its impact on economic development, she explained that the issue is often evaluated in terms of direct costs (e.g., health care, judicial costs) and indirect or nonmonetary, intangible costs (e.g., morbidity, mortality, stigma, reductions in social capital, pain). Cas- cading social and economic consequences of violence can include reductions in social capital and heightened fears of violence. Together, they can have a significant effect when they prevent people from either participating in social activities or engaging in activities that might facilitate a change in an individual’s socioeconomic status, such as attending night classes or work- ing a night shift that may pay a higher wage. For intimate partner violence, studies in Haiti, Peru, and Central America found that women generally earn less than non-victims, have lower productivity, have less access to neonatal services, and are more likely to be anemic. In terms of costing methodologies for crime and violence, she reiterated the use of DALYs and identified new research focusing on estimating total 

WHY THE WORLD SHOULD CARE ABOUT VIOLENCE PREVENTION 31 costs of society’s willingness to pay regardless of the methodologies used. The accounting approach—where all of the total costs in different sectors are added—is the most popular in Latin America. She mentioned that, using this approach, researchers found the cost of violence in Jamaica to be 3.7 per- cent of the gross domestic product (GDP), including business, health, and criminal justice costs, but not private security costs. The World Bank has conducted investment climate surveys showing that the business climate is constrained by crime and violence—with issues such as cost for private secu- rity including protection of personnel and property. In Jamaica, 39 percent of businessmen indicated that violence had prevented them from expanding their businesses. She emphasized that a foreign business will examine all of these costs when considering where to locate or expand its operations and, if the costs are too high, will not consider that geographical area, so violence can seriously prevent or constrain foreign direct investments. The World Bank has been attempting to estimate the effects on eco- nomic growth or “growth dividends” by using cross-country panel data in the Caribbean. This method attempts to distinguish between short-run economic costs (e.g., the cost imposed on an economy in a particular year by crime and violence) and long-term costs to the economy (e.g., tourism), particularly in terms of growth. In this region, she stated, the cost of tour- ism is a major concern and various studies have indicated that if crime and violence increase, tourism suffers. “Enclave tourism,” where people stay in one resort area, increases because people are too afraid to go to other areas of the region. In their studies, econometric modeling predicted that if the current murder rate in the Caribbean were reduced by one-third, the growth rate of the region could more than double. She postulated that this example of tremendous growth through a reduction in violence represents excellent data that can be used to persuade the region’s policy makers to make greater investments in violence prevention. She presented concrete examples—if the homicide rates of Jamaica and the Dominican Republic could be reduced to the levels in Costa Rica (which she reported as one of the safest, least violent countries in the region), there would be an annual increase in per capita growth of 5.4 percent. Furthermore, in Guyana, similar findings in reduction of the homicide rates predicted a growth of 1.8 percent per year. Over 20 years, this would equal a 43 percent increase in Guyana’s gross domestic product. These examples demonstrate that crime and violence are economic development issues and that prevention The GDP is the primary indicator used to gauge the health of a country’s economy. It represents the total dollar value of all goods and services produced over a specific period. It is often thought of as the size of the economy. Usually, GDP is expressed as a comparison to the previous quarter or year. For example, if the year-to-year GDP was up 3 percent, it means that the economy has grown by 3 percent over the last year (http://www.investopedia. com/ask/answers/199.asp). 

32 VIOLENCE PREVENTION IN LOW- AND MIDDLE-INCOME COUNTRIES is worthy of investment; yet many of the resources spent in Latin America and the United States go to the judicial system. Since we have little in the way of cost-effectiveness evidence to support prevention intervention, she advocated making systematic cost-effectiveness studies a priority. She did report that the World Bank has conducted limited cost-effectiveness studies in Brazil, where it matched a number of Brazilian crime prevention pro- grams with similar programs that have been evaluated in North America and Europe. The preliminary findings showed that in terms of the numbers of crimes averted per real (monetary unit in Brazil) spent, secondary preven- tion was by far the most cost-effective approach. In pragmatic terms and in alignment with the research findings of Irvin Waller, if one were going to spend $5 to decrease crime and violence, it should be invested in secondary prevention. Matzopoulos et al. (see Appendix C) note that the lack of a costing cul- ture within many public health systems in LMICs makes the generation of reliable violence costs difficult. In such countries, rudimentary surveillance and reporting systems are still under development so costing is not viewed as a reporting priority at this time. Further empirical research is needed that takes into account the differences in treatment costs across income con- texts. Moreover the calculation of the costs of other health burdens, such as HIV, has mobilized civil society to lobby for prevention. An accurate estimation of the costs of violence in LMICs is therefore imperative to the violence prevention agenda. With respect to intimate partner violence, they cite lost earnings and opportunity costs extrapolated to U.S. $1.73 billion in Chile and U.S. $32.7 million in Nicaragua from pilot study results in both countries. Intimate partner violence alone has been calculated to cost the economies of Nicaragua and Chile 1.6 and 2 percent of their GDPs, respectively. The effects of suicide on GDP appear even more difficult to measure, and figures are scarce in the literature. A study conducted in Alberta, Canada, showed that suicide significantly detracts from future GDP. The study calculated that suicide costs the equivalent of 0.3 percent of the provincial GDP. However limited, violence costing in research has begun to clearly dem- onstrate the substantial economic impacts of violence in LMICs. Greater general investment in improving on and prioritizing this area of research is imperative for generating a more accurate and comprehensive profile of the costs of violence in these contexts. More specifically, such studies should disaggregate the costs of violence according to the more specific typologies of violence listed above. This would enable the identification of relative contributions of these different types to overall costs (see Appendix C, Matzopoulos et al., 2007). 

WHY THE WORLD SHOULD CARE ABOUT VIOLENCE PREVENTION 33 HUMAN DEVELOPMENT PERSPECTIVE Dr. Garbarino began his presentation by explaining the ecological approach that is used in the field of human development, which concludes that there is rarely a simple cause-and-effect relationship that can be applied to everyone everywhere, but rather that development occurs contextually, which negates the universality or permanence of facts about human devel- opment. From this perspective, in terms of violence, few causal factors can be applied across the board to everyone and this creates a contextual conundrum for researchers. Of importance and promise to those working in violence prevention, he cited research from New Zealand that explains the biological vulner- ability of children to violent behavior involving the monoamine oxidase (MAO) gene that affects arousal. Garbarino explained that, in simplest terms, the gene is either turned on or turned off. Among children who are abused and had the gene turned off, nearly 85 percent developed chronic patterns of aggression with acting-out behavior and violating the rights of others—consistent with a diagnosis of conduct disorder in Version IV of the Diagnostics and Statistical Manual. Compared to abused children with the gene turned on, only 42 percent developed the same pattern of aggres- sion and antisocial violence, demonstrating that biological vulnerability doubles the likelihood of abused children developing chronic patterns of aggression. Thus a compelling case can be made for preventing child abuse to counteract children’s genetic vulnerability to violence. Gender, he stated, appears to play an important role with this gene since it is located on the X chromosome. Other data he presented suggest that community factors can influence whether antisocial behavior can blossom into chronic violent delinquency. Technology, he noted, is also a part of the changing context, with the evolution of current medical interventions (e.g., trauma care) to reduce the lethality of violence, as well as a decrease in access to firearms with changing laws and social norms. By the same token, the evolution of firearm technology has increased the lethality of injury when people do have access. Garbarino identified the philosophical question at the root of the issue that has long been debated: Are we inherently violent or pacific? If one hypothesized the former, how do we learn to be nonviolent? In his discus- sion, he pointed to socialization as it is used to set parameters for socially acceptable aggression (e.g., horseplay between fathers and sons as a pos- sible explanation of why fatherless boys have a disproportionate problem with violence). He also described promising research that focused on the processes that control whether innate dispositions to aggression become a coherent problem of antisocial violence and what processes can reduce this. The researchers proposed cognitive structuring (the ideas that are 

34 VIOLENCE PREVENTION IN LOW- AND MIDDLE-INCOME COUNTRIES received about aggression) and behavior rehearsal (experience in settings where aggression is manifested or demonstrated and thus subject to the psychological processes of reinforcement, punishment, and conditioning) as the key processes for prevention. He identified cognitive structuring case studies examining the role of television violence in instigating aggressive behavior as one of the most studied areas on the influences on violence. Some recent data, he reported, indicated that the effect of TV violence on eliciting aggressive behavior is about as strong as the effect of smoking on lung cancer. Additional, older studies found that television violence ­elicited aggressive behavior in boys as early as the 1960s, but the same effect was not reported for girls until the 1980s. Dr. Garbarino asserted that the g ­ ender equity in this phenomenon is clearly attributable to changes in cognitive structuring. He has found cognitive structuring to be particularly important because his international research around violence and families suggests that nearly every act of violence that is committed is done so with a sense of justification; he cited the research of one of his colleagues that has examined how the dynamics of shame can lead to the validation and justification of what, to an outsider, looks like “crazy, unimaginably bizarre violence.” He noted that in behavioral rehearsal, social change can affect aggres- sion. The issue of reducing the gender gap to increase gender equality (e.g., the increase in the number of girls playing sports) may have unintended negative consequences by environmentally exposing girls to increased violence, with validation and reinforcement of physical aggression. He explained that meta-analyses of the role of gender in explaining normal physical aggression show a progression in the United States over the last 30 years of decreasing relevance of gender. In the United States, where gender equality starts to become something approximating a reality, other factors are much more important than gender in producing and predicting normal aggressive behavior. Dr. Garbarino closed with some thoughts on collective violence and the potentially beneficial role that peace and reconciliation efforts and the affirmative respect of human rights may have on the mental health of children exposed to and traumatized by violence. He and his colleagues conducted research on Palestinian children, and their findings supported the notion that the context in which the trauma occurred has a lot to do with the prognosis for child development. The results of the children’s test responses fell into three categories: passive victimization, violent revenge, and a sort of prosocial revenge. Each of these groupings also has very dif- ferent mental health scores, with passive victimization being the worst and the prosocial revenge group showing the clearest absence of debilitating mental health problems. 

WHY THE WORLD SHOULD CARE ABOUT VIOLENCE PREVENTION 35 QUESTIONS AND ANSWERS Many questions were raised for the panelists, but one of note was whether there is enough evidence or scientific knowledge to move violence prevention forward. While all of the presentations focused on preven- tion as the necessary approach, they also acknowledged gaps in data and knowledge as they relate to cost and programmatic effectiveness, multiple risk factors or determinants of violence, the context of violence, and the environments in which interventions would be implemented. The panelists acknowledged that there are many examples of best practices and lessons learned that have already been scaled up to national levels in LMICs, as well as knowing what interventions they felt should be avoided (i.e., those that involve increased detention and incarceration, which only increase the economic costs of violence). They identified other foci including efforts to facilitate national planning, implementation, and evaluation that would call for and allow country governments to increase their investments in vio- lence prevention. The countries would also need technical assistance from U.S. agencies such as the Centers for Disease Control and Prevention, the National Institutes of Health, the U.S. Agency for International Develop- ment, and the Department of Justice, as well as other agencies and organi- zations from the philanthropic and corporate sectors, to support funding for these prevention efforts. It was also pointed out that the United States has invested billions of dollars to globally support HIV/AIDS prevention, treatment, and care on a much leaner evidence base than what is currently known for violence prevention. There was also lengthy discussion about the positive and negative effects and use of television programming either to incite aggressive behavior or to educate and provide population-level messages about violence prevention.