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4
The Intersection of Violence and Health

The definition of violence encompasses a wide range of actions and possible deleterious health and developmental outcomes. The most common and direct ways of measuring its impact directly are in terms of the numbers and rates of deaths and injuries it causes. Although they are less easy to measure, violence also has important impacts on a range of mental and physical health problems. The paucity of accurate and detailed data, however, makes it difficult to fully measure all of these impacts in low- and middle-income countries (LMICs). Furthermore, because many of the impacts of violence present within the health sector as major risk factors for and causes of a range of other health conditions and outcomes, it could be said that violence foments a vicious cycle. For example, the adverse impacts of violence on quality of life may lead to the deterioration of mental health and well-being, which may in turn impose a direct (and measurable) burden on the health system, while at the same time driving rates of violence even higher within afflicted communities (see Appendix C, Matzopoulos et al., 2007).

This session explored how violence can worsen many health conditions and examined the impacts of violence beyond the apparent and immediate physical injuries, as well as the role of violence as a consequence of other forms of violence. Jacquelyn Campbell moderated this session and also closed with a presentation on the intersection of violence and women’s health with a focus on HIV/AIDS. Presentations about collective violence and its impact on disease burden, self-directed violence and the crosscutting issues it shares with other types of violence, and the scale and consequences of child abuse and maltreatment for chronic diseases in adulthood were made by Richard Garfield, Eric Caine, and James Mercy, respectively.



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4 The Intersection of Violence and Health The definition of violence encompasses a wide range of actions and possible deleterious health and developmental outcomes. The most common and direct ways of measuring its impact directly are in terms of the numbers and rates of deaths and injuries it causes. Although they are less easy to mea- sure, violence also has important impacts on a range of mental and physical health problems. The paucity of accurate and detailed data, however, makes it difficult to fully measure all of these impacts in low- and middle-income countries (LMICs). Furthermore, because many of the impacts of violence present within the health sector as major risk factors for and causes of a range of other health conditions and outcomes, it could be said that violence foments a vicious cycle. For example, the adverse impacts of violence on quality of life may lead to the deterioration of mental health and well-being, which may in turn impose a direct (and measurable) burden on the health system, while at the same time driving rates of violence even higher within afflicted communities (see Appendix C, Matzopoulos et al., 2007). This session explored how violence can worsen many health conditions and examined the impacts of violence beyond the apparent and immediate physical injuries, as well as the role of violence as a consequence of other forms of violence. Jacquelyn Campbell moderated this session and also closed with a presentation on the intersection of violence and women’s health with a focus on HIV/AIDS. Presentations about collective violence and its impact on disease burden, self-directed violence and the crosscutting issues it shares with other types of violence, and the scale and consequences of child abuse and maltreatment for chronic diseases in adulthood were made by Richard Garfield, Eric Caine, and James Mercy, respectively. 

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7 THE INTERSECTION OF VIOLENCE AND HEALTH COLLECTIVE VIOLENCE Collective violence, especially in the form of armed conflict, accounts for more death and disability than many major diseases worldwide. Collec- tive violence destroys families, communities, and sometimes entire cultures. It directs scarce resources away from promotion and protection of health, medical care, and other health and social services. It destroys that health- supporting infrastructure of society. It limits human rights and contributes to social injustice. It leads individuals and nations to believe that violence is the only way to resolve conflicts. It contributes to destruction of the physical environment and the overuse of nonrenewable resources. In sum, collective violence threatens much of the fabric of our civilization (see Appendix C, Sidel and Levy, 2007). Self-directed violence, interpersonal violence, and collective violence in some ways overlap. Those involved in collective vio- lence may engage in self-directed violence as a symptom of posttraumatic stress syndrome or as a result of self-hatred because of acts committed in war. Collective violence may also be associated with interpersonal violence. For example, individuals and groups engaged in collective violence may commit interpersonal violence, sometimes fueled by ethnic tensions or by conflict with superior officers or with fellow service members in the midst of war. Soldiers may return from war with a battlefield mind-set in which they commit violence to address interpersonal conflicts that could have been addressed in nonviolent ways. Children raised in the midst of war may come to believe that violence is an appropriate way to settle interpersonal conflicts (see Appendix C, Sidel and Levy, 2007). Richard Garfield opened his presentation by providing a common operational definition of conflict, which was that at least 1,000 deaths would occur in a period of conflict, which is usually a multiyear period. The good news, he noted, is that the trend has been a long-term decline in global conflict as he defined it since the end of World War II, a short-term increase at the end of the Cold War, followed by a continued decline. Since fewer people are engaged in conflict, the resultant deaths are the lowest at any time during the last 150 years. For the first time, the prevalence of organized political violence between states or in a military fashion within states is so low that it is has become almost an exception to the political engagement between groups—a message that seldom gets out to the media or to those who work in violence prevention. These data may be indica- tive of two of the strategic primary prevention foci outlined by Mercy (see Appendix C, Mercy et al., 2007)—the importance of changing social norms to promote nonviolence for conflict resolution and possibly reducing the social distance between conflicting groups. The exception, Garfield noted, is Africa where most conflicts are concentrated, are often within borders, and do not come to international attention. Even here, research findings indicate

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 VIOLENCE PREVENTION IN LOW- AND MIDDLE-INCOME COUNTRIES that although the number of deaths as outlined by the definition is high, the proportion of the entire population in these areas is small. Far more important is what Garfield termed the “carry-on effects” of conflict—where for every death there are likely to be 10 people injured and 100 people displaced. While there is variability in this unofficial measure, it is seen as a “rule of thumb” that the data report in terms of consistency. The context of the changing circumstances due to the disruption of people’s lives during conflict affects these data since people choose one of two com- mon coping responses to conflict. The first, he stated, is to “hunker down” and stay in the area. The other is to leave the area, which he noted is a more sincere measure internationally to understand how people are doing in areas where there is conflict. The problem he identified with these data is that once someone is registered as a displaced person or refugee, the person might have that status for 40-60 years even though his or her life circumstances may improve and the true life status may not be consistent with what is implied by those terms. As noted in discussions of earlier pre- sentations, new forms of violence or nonpeaceful activities may occur when people return to their countries and communities, even after political peace has been attained or restored. In his opinion, changes in the life status and life chances of people are what need to be studied and measured to better understand the issues and develop appropriate interventions for aid. From his work in post-conflict Sudan, he found that in the 2.5 years of peace that followed three decades of conflict, some types of violence have increased slightly, while others have decreased. Much of the violence now happens between neighbors versus organized, armed groups; with one in five house- holds reporting a death since peace occurred. Despite this, the Sudanese perceive their situation as much improved—neighbors now have reduced access to weapons (another strategic primary prevention focus posited by Mercy [see Appendix C, Mercy et al., 2007]) and worry less about starva- tion since they can now work their fields. He observed that new measurements are emerging in the field, and his own research is examining multiple threats to well-being because violence is often associated with disasters, either preceding or following them, and geographically tends to occur in similar places and at similar times. When using these new measures, he argued, we obtain a different picture of areas of major instability in the world than when we examine death and displace- ment among conflicts. He stated that advocates are also moving away from the traditional use and measure of conflict deaths and are instead examin- ing the proportion of the population whose life circumstances are radically changed for the worse in a given period. As a result, the most important lesson learned to date is that there are usually multiple ways in which a life is altered, not merely one event.

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 THE INTERSECTION OF VIOLENCE AND HEALTH Effects of Collective Violence on Health Conflict has significant effects on morbidity and mortality beyond the direct deaths that occur. Along with the direct impacts of war and other military activities on health, collective violence may also cause serious health consequences through its impact on the physical, economic, social, and biological environments in which people live. The environmental dam- age may affect people not only in nations directly engaged in collective violence but in all nations. Much of the morbidity and mortality during war, especially among civilians, has been the result of devastation of soci- etal infrastructure, including destruction of food and water supply systems, healthcare facilities and public health services, sewage disposal systems, power plants and electrical grids, and transportation and communication systems. Destruction of infrastructure has led to food shortages and resul- tant malnutrition, contamination of food and drinking water and resultant foodborne and waterborne illness, and deficiencies in health care and public health and resultant disease (see Appendix C, Sidel and Levy, 2007). On a global scale, the areas with conflict tend to have the highest mortality rates among children. In Garfield’s opinion, the two statistically strong predictors of conflict are high rates of infant mortality that do not decline and economic stagnation. Of the ten countries with the highest under-5 child mortality rates, seven have experienced recent civil conflict. In terms of economic impact, his research indicates that in low-income and middle-income countries, there are different epidemiologic conditions and solutions for the patterns of injury that are occurring, which he attributed to the continued decrease in economic growth in low-income countries as well as many forms of social decline. According to Sidel and Levy (see Appendix C), World Bank data demonstrate a striking relationship between the wealth of a nation and its chances of having a civil war. For example, a country with a gross domestic product (GDP) income per capita of U.S. $250 has a 15 percent probability of war in the next five years, and this probability drops by approximately half for a country with a GDP of $600 per person. In contrast, countries with a per capita income of more than U.S. $5,000 have less than a 1 percent chance of having a civil conflict, all else being equal. In addition to poverty, risk factors for armed conflict may be associated with poor health and poor access to quality medical care, low status of women, large gaps between the rich and the poor, weak development of a civil society within a country, people’s not having the right to vote or otherwise participate in decisions that affect their lives, limited education and employment opportunities, increased access to small arms and light weapons, and failure to meet the basic needs of civilians. While other researchers might point to health conditions such as tuberculosis and infant mortality as causal factors for conflict, Garfield sees a strong

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0 VIOLENCE PREVENTION IN LOW- AND MIDDLE-INCOME COUNTRIES and important association with poorer quality of life, which may lead to or play a role in the emergence of instability and affect the life chances or circumstances of people in the area. Garfield has identified gaps in research and data collection that need to be addressed, including measuring the deaths that occur in relationship to conflict—not just the numbers, but also the dynamics, which are poorly understood. This is the area in which he stated there can be a reduction in mortality using a public health approach, but it is the area in which we know the least. His studies in Guatemala show that when there are excess deaths in an area, the reporting becomes worse and essentially stops. Counting numbers is not the only issue of concern; the lack of healthcare workers leads to an inability to respond to the health needs of the injured and also contributes to excess mortality, especially in Africa. These worker shortages can be due to either the explosion in mortality of local healthcare workers who work for international organizations or the reduced presence of international organizations. As for development and humanitarian assistance, the amount of aid is increasing around the world. Yet in Garfield’s estimation, only 50 percent of the Millennium Development Goals have been achieved (see Appendix C, Matzopoulos et al., 2007, for their perspective on the impact of violence in relation to the Millennium Development Goals). Garfield stated that while $10 billion of international aid per year goes for humanitarian assis- tance, “we are not getting much bang for this buck” because it really costs nearly three times this amount to conduct health programs in areas that are insecure. In his estimate, the more that the insecurity associated with armed conflict can be reduced, the easier it will be to address other forms of insecurity (e.g., nutritional, economic) and prevent neighboring countries from becoming less stable. SELF-DIRECTED VIOLENCE Eric Caine began by detailing the central importance of a public health approach to multidisciplinary and multiorganizational suicide (self-directed violence) prevention efforts so they become more proactive and less reactive, as well as better target the high-risk people that they are missing. Many of the data he discussed were from the United States because more data are available there, but he noted that what is true in the United States is amplified greatly around the rest of the world. The interrelationship of suicide and other adverse outcomes is based on risk factors for a variety of adverse outcomes such as intimate partner violence including homicide and accidental death. The morbidity, he stated, is the suicide attempt, whereas the mortality is the suicide itself. Cultural forces, age, gender, and ethnic differences are important risk factors for understanding the epidemiology

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 THE INTERSECTION OF VIOLENCE AND HEALTH of suicide; we have little understanding of the protective cultural factors that are used to negate risk factors. Based on data from the World Health Organisation (WHO), some places around the world have more suicides and others less, and some places do not report these statistics—which he stated may be due to lack of reporting capacity or to the strong cultural prohibition and stigmatization of the act. What is clear from these data is that suicide is underreported throughout the world—and the reported statistics of more than 50 percent of violent deaths resulting from suicide, or about 800,000 deaths annu- ally, indicate that suicide is a major problem. In terms of years of life lost, suicide exceeds homicide and HIV/AIDS in the United States. While rates of suicide rise with age in the United States, especially for white males, the suicides accounting for the majority of years of life lost occur between the ages of 20 and 55 years—a productive workforce-related age group. These people are typically parents, have families, are employed, and are relation- ship filled—not “the psychiatric patient.” Risk Factors for Suicide Many of the data about risk factors come from psychological autopsy data and are generally not helpful in setting up prevention programs, and there are cross-national variations as well. In children and young adults, these factors include but are not limited to major psychopathology, per- sonal or family turmoil, exposure to violence, legal problems, poor school performance, and prior suicide attempts or a family history of suicide. Factors in adulthood include comorbid depression and alcohol use or dependence; interpersonal disruptions and social isolation; poor work per- formance and unemployment; violence and legal problems; variable impact of marital and parental status; and prior attempts and family history of suicide. In elders, they include late-onset, comorbid depression and general medical conditions, often associated with pain and role function decline; social dependence or isolation; widowhood; inflexible personality; alcohol and prescription substance abuse; and frequent contact with primary care providers. While their identification is important to understanding suicide, Caine suggested that what is needed is identification of risk factors as they unfold over the course of life that will enable clinicians to effectively address them in a variety of settings that relate to personal ecology and social status. He states that there is also a critical need for a developmental context, especially for people who are high risk and for whom some broad public health approaches may provide less leverage. He noted the importance of this because of the influences of socially driven policies that do not actu- ally target the populations most in need. In the United States, most of the

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2 VIOLENCE PREVENTION IN LOW- AND MIDDLE-INCOME COUNTRIES resources for prevention are spent on high school students. Ironically, the suicide rates in this country begin to accelerate between 18 and 22 years, where there are young people who are school dropouts, incarcerated, or subject to other circumstances that might exacerbate the risk factors. There is also a lot of attention on university students, but most suicides do not occur in this setting. Suicide Is Preventable Caine’s research with the U.S. Air Force showed that not only is suicide preventable, with a dose-response effect even across major commands (the intervention reduced suicide by one-third), but its prevention can also significantly reduce other forms of violence, with a 50 percent reduction in homicide rates, as well as substantial reductions in accidental deaths and moderate to severe family violence. What became very clear from the findings was that prevention is achievable, but that it is a violence pre- vention intervention, not just suicide prevention. He also acknowledged that addressing the symptoms of psychopathology is necessary to facilitate further efforts to address other important risk factors, but it alone is not sufficient to prevent suicide in the longer term. As an example, he briefly explored a layered, developmental context for suicide prevention for men aged 25-54 years in which the people in this range often, but not always, have 10 to 20 years’ worth of what he termed ascending alcohol abuse, ascending family turmoil, partner violence, and eventual unemployment. By and large, the typical scenario in a man’s life is a dramatic life event three to six weeks before he kills himself. The turmoil- filled life situations that exacerbate psychiatric distress must be addressed for successful suicide prevention. He also noted that women in the United States attempt suicide more, but succeed less. They are less lethal in their attempts, but their attempt level far exceeds that of men. Certainly women who drink or use drugs move into another category and their statistics look much worse than their female peers and, at times, worse than their male peers. As a cascade effect of suicide among men, however, women may often become victims of homicide before the men commit suicide. In his research in China over the past nine years, Caine has observed that the suicide rates are decreasing. Even though these rates are estimates, China still has the highest number of suicides in the world because it has the largest population. One of the cross-national differences he alluded to earlier is that young women in rural China exceed young men in actual suicides. The rates of attempt by women or men, he noted, may not neces- sarily be higher than in the United States—they may in fact be lower—but the methods are more lethal, such as ingestion of pesticides (58 percent). Similar to the United States, he and his colleagues noted the context of life

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 THE INTERSECTION OF VIOLENCE AND HEALTH turmoil or regular, chronic stressors that may have lasted 1-12 months prior to the time of death, even though 63 percent had a mental illness at the time of death. Nevertheless, people in rural China describe less overall stress, likely due to economic assistance from the millions of migrant workers who are sending money home. Other examples he presented underscored the linkages between alcohol use or dependence, economic stressors, and other indicators of social tur- moil, including high rates of HIV/AIDS and intimate partner violence, as drivers of suicide in Russia after the dissolution of the Soviet Union. This is another example of how these issues are linked, with common problems and risk factors at the base, but result in different adverse outcomes. Data also indicated an increase in male suicides in Hong Kong after its economic slump in the late 1990s with high rates of unemployment. Current research shows that suicide rates in Hong Kong are decreasing as the economy improves. These linkages among risk factors and outcomes are the current topic of discussion with colleagues in China to adapt interventions that may have been successful in other countries. CHILD MALTREATMENT AND ITS HEALTH CONSEQUENCES James Mercy opened his presentation with his bottom line—we pay a huge price for our failure to prevent child maltreatment and we are blind to that price. By inference, the data show that the inability to address child maltreatment is a barrier to the social and economic progress of developing countries. The data on the magnitude of child maltreatment in develop- ing countries are not robust, but we do have information that is useful in understanding the magnitude of the problem since important scientific find- ings that document and validate the mechanisms that lead from exposure to child maltreatment and important health outcomes have emerged in the past 30 years (see Figure 4-1). So that we would all be talking and thinking about the same thing, he provided the following operational definition: Any act, or series of acts, of commission or omission by a parent or other caregiver that results in harm, the potential for harm, or threat of harm to a child’s health, survival, development, or dignity. This definition en- compasses physical abuse, sexual abuse, neglect or negligent treatment, abandonment, emotional or psychological abuse, and commercial or other forms of exploitation, like sexual trafficking of children. Magnitude of the Problem Homicide data from around the world shows that homicides among 0-4 year olds are primarily committed by parents and caretakers and are,

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 VIOLENCE PREVENTION IN LOW- AND MIDDLE-INCOME COUNTRIES Early Death Death Disease, Disability, and Social Problems Adoption of Health-Risk Behaviors Social, Emotional, and Cognitive Impairment Child Maltreatment Birth FIGURE 4-1 The influence of child maltreatment throughout life. SOURCE: Mercy (2007). fig 4-1 therefore, a good proxy for child maltreatment homicides. These homicide rates are highest in Africa and also, interestingly in North America, and represent only a small proportion of the problem. Mercy cautioned that these data were problematic because it is very difficult to get reliable esti- mates of child homicides, which often get buried in other causes of death, such as unintentional injury or sudden infant death syndrome in the United States. In regard to data on nonfatal child maltreatment, even though the available research uses different definitions and methodologies, a consistent picture of the seriousness of child maltreatment across nations of the world emerges. In Egypt, 37 percent of children report being beaten or tied up by parents. In Romania, nearly half the parents admit to regularly beating their children. In Ethiopia, 21 percent of urban and 65 percent of rural schoolchildren report bruises and swellings as a result of parental beat- ings. In Iran, in the Kurdistan province, almost 39 percent of adolescents report mild to severe injury from physical violence at home. These studies

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 THE INTERSECTION OF VIOLENCE AND HEALTH all examine physical abuse, which is highly associated with the issue of corporal punishment by parents and caretakers. The WorldSafe study provides more reliable and comparable measures of non-fatal child maltreatment from several countries. In this study, mothers were interviewed and asked about their use of harsh physical punishments during the past 6 months. In Egypt, rural India, and the Philippines, rela- tively higher proportions of children were punished by being hit with an object (not on the buttocks) and by being kicked. He acknowledged this as another source that demonstrates that in many developing countries, harsh physical punishment is a day-to-day reality. He presented data from a meta-analysis conducted by the World Health Organisation (WHO) in 2004 to estimate the fractional burden that child sexual abuse contributes to mental health problems. WHO used avail- able studies from different regions of the world to derive estimates of the proportion of children who experience sexual abuse. He pointed out that while we must remember that the studies underlying these estimates have significant methodological weaknesses, they nevertheless show that there is a substantial prevalence of child sexual abuse across the world. Among the poorest countries of the world, the prevalence among female children varied from a low of 13 percent in Latin American/Caribbean countries to a high of 68 percent in Southeast Asian countries. With the exception of those countries in the Latin American and Caribbean region, the prevalence was consistently higher for females the males. In addition, data from this study yielded global fractional estimates of the burden of mental disorders and suicidal behavior attributable to child sexual abuse, disaggregated by sex (see Table 4-1). TABLE 4-1 Fractional Estimates of Mental Disorders and Suicidal Behavior Attributable to Child Sexual Abuse, by Sex Behavior Female (%) Male (%) Depression 7-8 4-5 Alcohol use or dependence 7-8 4-5 Drug use or dependence 7-8 4-5 Panic disorder 13 7 PTSD 33 21 Suicide attempts 11 6 NOTE: PTSD = posttraumatic stress disorder. SOURCE: Mercy (2007).

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 VIOLENCE PREVENTION IN LOW- AND MIDDLE-INCOME COUNTRIES The study also found that based on WHO data, these estimates were greater in the poorest countries in Africa and Southeast Asia because the prevalence of child sexual abuse was also greater. What Science Tells Us The science that has emerged in the past 30 years—from neuroscience, developmental psychology, social sciences, and epidemiology—is showing a pattern that child maltreatment contributes to social, emotional, and cogni- tive impairments, and the adoption of health risk behaviors, which in turn lead to disease, disability, social problems, and then premature mortality (see Figure 4-1). Mercy stated that support for these findings comes from a variety of sources, many of which are documented in the NRC-IOM report From Neurons to Neighborhoods (NRC-IOM, 2000). Another source he mentioned was the body of research and publications from the MacArthur Research Network on early experience in brain development. There are over 50 publications on this topic from the MacArthur Research Network that are available on their website at http://www.macbrain.org/publications. htm. Translational efforts from research to policy and practice are now under way by the National Scientific Council on the Developing Child. He also pointed out a strong scientific basis that combines animal research with human research to support the kind of progression he explained in terms of the impact of child maltreatment. One of the mechanisms being identified as contributing to this link is the damage to the brain architecture in the form of toxic stress. One critical form of toxic stress, clearly, in childhood, is exposure to child maltreatment in its various forms—which often happens repeatedly and can be severe. One example of how the brain is damaged is an altered stress-response system. He proposed an analogy between the stress-response system and a thermometer in the heating system in a house, which has a set point. If the temperature within the house goes below that set point, the heat comes on. Similarly in our brains, there are set points for the stress-response system. We inevitably deal with stress daily and our bodies have neurochemical and other responses that are activated when we experience severe stress. In many children exposed to maltreatment, however, that thermometer is damaged—such that the set point is altered. For example, it can be lowered so that the stress-response system repeatedly or constantly kicks in—as if the thermometer in the house were set at a lower point. If the heater were to kick in more frequently, it would probably burn out earlier. In the human body, this burnout could lead to premature aging. He acknowledged that there are literally hundreds of research studies linking child maltreatment to many different types of health outcomes, specifically identifying health risk behaviors that are documented to be

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7 THE INTERSECTION OF VIOLENCE AND HEALTH associated with child maltreatment—from alcohol and substance abuse to smoking, behavioral problems, and mental and social problems, including depression and anxiety. He noted that maltreatment also has an impact on cognitive development. Thus it can have a long-term impact on the develop- ment of human capital in societies with high rates of child maltreatment. These, in turn, are related to disease and injury outcomes. Going back to the analogy of the lower set point on a thermometer, he provided an example of a child who might cope with the stress by self-medicating by smoking cigarettes. Smoking, in turn, leads to cancer, heart disease, or other problems seen in our clinics and hospitals. This is the inferential mecha- nism and causal link that may occur in terms of child maltreatment and its relationship to health. There are also strong epidemiological data that link child maltreatment and health—the U.S. study called the Adverse Childhood Exposure (ACE) study. Mercy provided an overview of the collaborative study between the U.S. Centers for Disease Control and Prevention (CDC) and the Kaiser Permanente Health Maintenance Organization (HMO) in California. They interviewed a sample of the participants in this HMO and asked them about their childhood exposures to maltreatment and other adverse expo- sures. They were also asked about their health status, their health experi- ences, and the health problems they have experienced in their lives. In terms of the prevalence of the different types of adverse exposures, 28 percent reported being exposed to physical abuse as a child, along with reports of exposure to other adverse outcomes such as mental ill- ness, parental incarceration, emotional and sexual abuse, intimate partner violence in the home, household substance abuse, and parental separation or divorce. The other point here, he noted, is that many of these adverse exposures often co-occur, so it is not always easy to look at them separately. Based on the previous review of data from developing countries, we can imagine other types of adverse exposures of children beyond just child maltreatment. In the ACE study, researchers added those adverse exposures and each person received a score from 0 to 4+, based on the number of individual adverse exposures experienced as a child. Then they related the scores to various types of health outcomes. For example, the more adverse expo- sures they had experienced, the more likely were they to engage in early smoking initiation. The same trend was observed with chronic obstruc- tive pulmonary disease, which was not as consistent, but still indicated a greater likelihood of having that disease based on the more of these adverse childhood exposures they had experienced. Examination of teen sexual behaviors (intercourse by age 15, teen pregnancy in females, teen pater- nity in males) revealed the same pattern of greater likelihood of engaging in these behaviors correlated with more adverse exposures. For HIV risk

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 VIOLENCE PREVENTION IN LOW- AND MIDDLE-INCOME COUNTRIES exposure—ever injected drugs, had 50 or more intercourse partners, or ever had a sexually transmitted disease—the same pattern holds. He also pointed out that these patterns held up when controlling for demographic factors and socioeconomic status. In conclusion, Mercy stated that by all available measures—not just the studies he had described—other studies and anecdotal experience indicate that • Child maltreatment is highly prevalent in many developing countries. • Child maltreatment has been demonstrated by science to have a powerful influence on health and human capital, through its influence on brain architecture. • Child maltreatment creates an enormous drag on the socioeconomic progress of developing countries; and though we may not be able to put an economic figure on the effect of this or intimate partner violence on other health outcomes, due to the paucity of economic analyses estimating the relationship of GDP to violence, these problems probably add a much greater cost than is seen in the available figures. However, according to Mercy, it is safe to say that interventions that are effective for preventing child maltreatment in developing countries will have enormous long-term economic benefits. A lot of work is under way in the United States in terms of making investments in early childhood education because of data that show a relationship among early exposure to toxic stress, other adverse exposures, cognitive development, and an individual’s ability later to contribute in economically productive ways to society. VIOLENCE AGAINST WOMEN AND WOMEN’S HEALTH Violence against women can take on many forms including sexual vio- lence that occurs during times of conflict. Although men are also victims of violence, women in low- and middle-income countries are most frequently the victims of intimate partner violence and therefore are most affected by this intersection. In the United States, approximately 1.3 million women are physically assaulted by an intimate partner compared to 835,000 men (NIJ-CDC, 2006). According to the 2005 U.S. National Violence Against Women Survey, 64 percent of the women who reported being raped, physi- cally assaulted, or stalked since age 18 were victimized by a current or former husband, cohabitating partner, boyfriend, or date. In addition, one in six women has experienced an attempted or completed rape—defined as a forced or threatened vaginal, oral, or anal penetration—in her lifetime;

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 THE INTERSECTION OF VIOLENCE AND HEALTH and many are raped at an early age (NIJ-CDC 2006). Of the 18 percent of all women surveyed who said they had been the victim of a completed or attempted rape at some time in their lives, 22 percent were younger than age 12 when they were first raped, and 32 percent were ages 12 to 17 years (NIJ-CDC 2006). For a global perspective of violence against women, Jacquelyn Campbell acknowledged the value of WHO’s (2005) Multi-Country Study on Domestic Violence and Women’s Health1 in providing reliable, comparable data about violence against women in developing and some industrialized coun- tries, along with the ethical protocols that make the study the gold standard in terms of addressing sensitive issues of safety and confidentiality when studying interpersonal violence. In the majority of settings in the WHO study, more than 75 percent of women who had been physically or sexu- ally abused since the age of 15 reported abuse by a partner (WHO, 2005). Lifetime prevalence estimates of physical violence by partners ranged from 13 percent in a Japanese city to 61 percent in an Andean province in Peru, with African countries such as Namibia and Tanzania reporting estimates of 31 and 47 percent, respectively. The range of reported lifetime preva- lence of sexual violence by partners was between 6 percent (cities in Japan, Serbia, and Montenegro) and 59 percent (Ethiopian province). Namibia and Tanzania had lifetime sexual violence estimates of 17 and 31 percent, respectively. The Japanese sample consistently reported the lowest preva- lence of all forms of violence, whereas provinces in Bangladesh, Ethiopia, Peru, Tanzania, and Namibia reported the highest estimates (WHO, 2005). Lifetime prevalence estimates of forced sex by an intimate partner varied from 4 percent in Serbia and Montenegro to 46 percent in Bangladesh and Ethiopian provinces (WHO, 2005). The high rates of forced sex are particularly alarming in light of the HIV/AIDS epidemic and the difficulty that women often face in protecting themselves from HIV infection. These data, she pointed out, showed a common, high prevalence of physical part- ner violence, and of sexual assault as part of intimate partner violence. In some countries, sexual assault is more common than physical violence for some women. Nearly half of the 40 million people living with HIV/AIDS worldwide are women; and women make up the fastest growing group of persons newly infected with HIV. In sub-Saharan Africa, women represent the majority of those infected and the majority of those dying. A critical aspect of this trend is the intersection of HIV/AIDS and violence against women, which has been recognized and documented with persuasive and rigorous research. As critical as it is to address this pandemic, the issues of intimate 1This study is available at www.who.int/gener/violence/who_multicountry_study/en/index. html.

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0 VIOLENCE PREVENTION IN LOW- AND MIDDLE-INCOME COUNTRIES partner violence and gender inequality remain inadequately addressed by most policy, research, and prevention and intervention initiatives in the United States and globally (see Appendix C, Campbell et al., 2007). Other Health Effects of Violence Against Women Other documented physical health effects include chronic pain (which may be related to previous injuries, but also has important neurological implications), mental health problems, chronic irritable bowel, smoking (which we have already heard leads to other problems), effects on stress- response systems (possible links to exacerbating hypertension in African American women), gynecological problems, sexually transmitted infections and the diseases they cause, and effects on the immune system. The latter may be linked to increased risk of STDs and HIV and may contribute to rapid reductions in Cluster of Differentiation 4 (CD4) counts in women, resulting in quicker progression to AIDS and rapid death. Another important aspect of the health effects identified by Campbell is related to reproductive health, especially the amount of abuse during pregnancy, which exhibits cross-national variations. For now, we know that intimate partner violence around the world is significantly associated with unintended pregnancy. Other maternal health correlates mirror those identified by Mercy in his examination of child maltreatment—depression, substance abuse, low social support, smoking—with the addition of spon- taneous abortion and risk of homicide. Women who are abused during pregnancy are at increased risk of being killed by their partner—if not during the pregnancy (maternal mortality), then later in that abusive rela- tionship. Campbell identified the issue of maternal mortality as one that needs greater attention for better data collection. Anecdotal studies from India, Mozambique, and Bangladesh are beginning to consider the issue as part of their examination of intimate partner violence and homicide. In one state in India, it has been reported that 16 percent of all deaths during pregnancy were due to intimate partner violence. She noted that in India, as we also see in the United States, these deaths are often incorrectly categorized or recorded. In the United States, data from fatality reviews of intimate partner homicide cases reveal that homicide is the leading cause of maternal mortality. The CDC is initiating an approach for improved data collection by linking homicide and maternal mortality databases to improve our understanding of the magnitude of this outcome. Related to infant outcomes, data from meta-analyses conducted by Campbell showed that infant birth weights are likely to be lower for women who are abused during pregnancy and who live in industrialized countries—which may occur through connections to smoking, substance abuse, and stress. Also, among women abused during pregnancy, there is

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 THE INTERSECTION OF VIOLENCE AND HEALTH more likely to be child abuse when the infant is born—a painful example of the interconnectedness of various types of violence. New Research and Promising Prevention Programs New research is being conducted in the United States to examine the comorbidity of posttraumatic stress disorder (PTSD) and depression in women, which may have different effects on the immune system, causing a proinflammatory response that may be associated with either chronic pain or immune suppression. Similarly to the pathways described by Dr. Garbarino earlier in the day, these need to be examined not only to help understand why some women are affected the way they are, but also to guide both prevention and treatment efforts. More proactive intimate partner violence prevention messages should be included in women’s health campaigns, such as the Safer Motherhood Campaign. Campbell also stated that we need to increase health provider education and awareness about violence against women, as well as clini- cal initiatives for systematic, confidential, and safe assessments of intimate partner violence; appropriate referrals must be made that link health- care systems around the world with community-based nongovernmental organizations. Promising Prevention Programs The Intervention with Microfinance for AIDS and Gender Equity (IMAGE) study, which used a microcredit finance mechanism to address intimate partner violence, as well as programs that promote safe dating and prevention of date rape, were offered as examples of successful com- munity partnerships. Nurse home visitation programs have been effective in the United States, and although they may be cost-prohibitive in developing countries, she queried whether elements of the intervention for families at risk could be translated, transported, and tested in developing countries. Treatment for PTSD in adults (especially those involved in collective vio- lence), as recommended by two previous Institute of Medicine studies, may prevent intimate partner violence and child abuse (IOM 2006, IOM-NRC, 2007). Campbell identified what she called “some good changing-the- norms kinds of campaigns” from around the world, including the “White Ribbon Campaign” that originated in Canada; “Raising Voices” in Uganda that has helped change the community norms around gender and intimate partner violence; training of new recruits in the military; and the Family Violence Prevention Fund’s initiative of coaching boys into men and get- ting men involved in the prevention of intimate partner violence, which has translated into an international effort. While all of these efforts are

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2 VIOLENCE PREVENTION IN LOW- AND MIDDLE-INCOME COUNTRIES promising and should be implemented on larger scales, she reinforced the need to rigorously evaluate the interventions and programs to document and facilitate the proactive translation of effective outcomes into global policy and practice. QUESTIONS AND ANSWERS Key issues raised in response to questions from the audience included the need to increase the focus on resiliency of individuals, communities, societies, and systems (and the cultural and historical factors that influence resiliency) to understand their possible roles as protective factors against the types of violence and the adverse outcomes described in the presentations. Awareness of the issue of the historical trauma of oppression by colonists through time and around the globe, as well as the healing role of restor- ative justice programs, was also raised as worthy of consideration in global violence prevention efforts.