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7
Scaling Up International Support for Violence Prevention

As a precursor of, but relevant to, this session, Mark Rosenberg provided a context for the focus of the second day’s presentations—the critical step of resource mobilization. He provided an overview of the workshop’s three main messages: violence is preventable, but questions remain about the application of what is known to be effective in developing countries; demonstrating effectiveness in developing countries is the first step in widespread implementation of this important approach; and the mobilization of resources to lay the groundwork for this demonstration capacity in developing countries is necessary for its eventual widespread dissemination and implementation. He referenced the papers of Zaro et al. (2007) and Mercy et al. (2007) (see Appendix C) as complementary conceptual frameworks that can be used to think about implementing violence prevention in developing countries. He also noted that they can also be useful for addressing many other public health problems. Mercy et al. (see Appendix C) identified five key elements for building strong, national foundations for violence prevention: (1) developing a national action plan and identifying a lead agency; (2) enhancing the capacity for data collection; (3) increasing collaboration and exchange of information; (4) implementing and evaluating specific actions to prevent violence; and (5) strengthening care and support systems for victims. They further identified strategies for primary, secondary, and tertiary prevention and suggested types of interventions for these strategies that might be appropriate to implement in developing countries. Zaro et al. (see Appendix C) attempted to put all of the ideas together in the action plan and identified five different domains in which activities are necessary (leadership, research and data collection, capacity building



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7 Scaling Up International Support for Violence Prevention As a precursor of, but relevant to, this session, Mark Rosenberg pro- vided a context for the focus of the second day’s presentations—the critical step of resource mobilization. He provided an overview of the workshop’s three main messages: violence is preventable, but questions remain about the application of what is known to be effective in developing countries; demonstrating effectiveness in developing countries is the first step in wide- spread implementation of this important approach; and the mobilization of resources to lay the groundwork for this demonstration capacity in devel- oping countries is necessary for its eventual widespread dissemination and implementation. He referenced the papers of Zaro et al. (2007) and Mercy et al. (2007) (see Appendix C) as complementary conceptual frameworks that can be used to think about implementing violence prevention in devel- oping countries. He also noted that they can also be useful for addressing many other public health problems. Mercy et al. (see Appendix C) identi- fied five key elements for building strong, national foundations for violence prevention: (1) developing a national action plan and identifying a lead agency; (2) enhancing the capacity for data collection; (3) increasing col- laboration and exchange of information; (4) implementing and evaluating specific actions to prevent violence; and (5) strengthening care and support systems for victims. They further identified strategies for primary, second- ary, and tertiary prevention and suggested types of interventions for these strategies that might be appropriate to implement in developing countries. Zaro et al. (see Appendix C) attempted to put all of the ideas together in the action plan and identified five different domains in which activities are necessary (leadership, research and data collection, capacity building 72

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7 SCALING UP INTERNATIONAL SUPPORT FOR VIOLENCE PREVENTION and dissemination, intervention development, and victim services), as well as the inputs for desired impacts and outcomes, with the ultimate goal of preventing violence to promote health and well-being in developing coun- tries. In his concluding remarks before introducing the moderator of the panel that would address resource mobilization, Rosenberg stressed the need for strong and effective collaborations and partnerships. Discussions at the networking dinner following the first day’s presentations revealed that it took 24 months to build the partnerships in the Intervention with Microfinance for AIDS and Gender Equity (IMAGE) study and even longer, sometimes years, for other partnerships to be built for long-term interven- tions. Rosenberg also noted that these collaborations often need strategies, management, structure, and investments to get things accomplished. Rodney Hammond moderated this session and explained that the speakers were asked to organize their presentations around the themes of identifying the groundwork they are laying to internationally expand and scale up the public health approach, identifying what more needs to be done to support effective efforts, and providing examples of the investments and activities that suggest a strategy for widespread adoption of effective methods to prevent violence.  INTERNATIONAL DEVELOPMENT ASSISTANCE AND VIOLENCE PREVENTION Collective, interpersonal, or self-directed violence has extensive and per- vasive long-term implications for development and health. Moreover, these effects are themselves multi-layered and can undermine development at indi- vidual, communal, and national levels. Although the different paths by which violence exerts such economic strains remain unclear, the Millennium Devel- opment Plan is a useful framework for examining the wide-ranging impacts of violence on different sectors and systems. Violence and underdevelopment may be linked in a vicious circle where each perpetuates the other. There is also a vicious cycle between poverty and violence. On the one hand it is well established that poverty, particularly in the context of economic inequality and especially when geographically concentrated, contributes to high levels of violence by weakening intergenerational family and community ties, con- trol of peer groups, and participation in community organizations. In turn, evidence from the World Bank indicates that high rates of violence in a com- munity reduce property values and undermine the growth and development of business, thus contributing to the very inequalities and concentrations of poverty that play a role in causing violence (see Appendix C, Matzopoulos et al., 2007). Alexander Butchart acknowledged various bilateral efforts of the United States in South Africa and Jamaica, the United Kingdom in South Africa,

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7 VIOLENCE PREVENTION IN LOW- AND MIDDLE-INCOME COUNTRIES and the German Technical Cooperation Department in various Central American countries that have been instrumental in supporting violence prevention in these countries. He focused his remarks on the Violence Prevention Alliance, starting with a brief background of the organization, which is a loose network formed in 2004 of countries that share a similar vision about using science to prevent violence in developing countries. Its secretariat is housed at the World Health Organisation (WHO) and includes development agencies, governments, foundations, and nongov- ernmental organizations. Its objectives are to strengthen the support for science-based violence prevention, to increase collaboration and exchange of information on violence prevention, and to facilitate implementation of the recommendations of the World Report on Violence and Health. The government of Belgium hosted a Violence Prevention Alliance strategy meeting in 2006, where it was agreed to form a working group that would advocate with official development aid agencies for their increased support of science-based violence prevention programming. The working group included government representatives, development agencies, national agen- cies, centers, and councils—for example, the Centers for Disease Control and Prevention (CDC), the South African Medical Research Council, and nongovernmental organizations, one of which was in Denmark. The group decided to use a practical approach within the official development agen- cies agenda, which is driven by the Millennium Development Goals, and human rights- and human security-based approaches. The working group developed a discussion document (forthcoming, with the working title of Reducing the Impact of Violence on Health, Security, and Growth: How Development Agencies Can Help) representing a coherent Violence Preven- tion Alliance viewpoint to make the case for increased attention to violence prevention, to assess the gaps in programming and the way the discourse of official development agencies is engaging the problem, to suggest an agenda of action, and to stimulate ongoing dialogue among official development agencies on violence prevention. To determine what is needed for further action, the Violence Pre- vention Alliance conducted a content analysis of 22 official development agency websites to discern the visibility and level of priority given to the seven types of violence defined in the workshop’s materials. Data showed that collective violence, intimate partner and sexual violence, and violence against children received considerable but insufficient attention. Youth violence (especially male-on-male violence, which is a leading contributor to homicide death and to severe physical injuries) received little attention, as did elder abuse and self-directed violence. With a few exceptions, they generally found policy and program guidance to be very weak, with little focus on upstream or primary prevention—as if there were no existing evidence base for violence prevention. Guidance for fundamental processes

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7 SCALING UP INTERNATIONAL SUPPORT FOR VIOLENCE PREVENTION and systems—information systems, leadership, and national plans—was found to be lacking in many of the sites. Crosscutting strategies for preven- tion and care were largely absent, with people looking at different types of violence in isolation from one another. As for what needs strengthening or increased attention, Butchart identi- fied an inadequate focus on high-risk groups that are not defined in terms of human rights and Millennium Development Goals. In addition to the lack of support for fundamental processes, there is also a great need to address piecemeal prevention approaches and to present better arguments for approaches that deal with different types of violence and shared under- lying risk factors. The Violence Prevention Alliance made a number of international and national recommendations for strengthening the official development agencies’ agenda on violence prevention, some of which were similar to the frameworks mentioned by Rosenberg. These include foun- dation building, specific violence prevention activities, and an approach to using the science and evidence base in their efforts. The international recommendations include developing common criteria between different agencies and different United Nations groups for upstream violence preven- tion programming, recognizing and using the evidence base in developing an official development agencies’ agenda which includes violence preven- tion and expanding the sectoral entry points for violence prevention, so that health, education, employment, and welfare can be included as important partners. They also recommended the inclusion of violence prevention indicators in routine poverty and development surveys. The national recom- mendations were similar to the international and will be partially informed by the preparations for and proceedings of this workshop. Lastly, the Violence Prevention Alliance has proposed an array of violence prevention interventions according to what is known about their effectiveness; com- ments about the difficulties, challenges, and opportunities of implementing them; and descriptions of crosscutting interventions that are likely to deal with multiple types of violence simultaneously. LESSONS LEARNED FROM LONG-TERM FUNDING COMMITMENTS Gary Yates provided some considerations for lessons learned from a $70 million, 10-year, public health-based initiative to prevent gun violence, injury, and death of youth, funded by the California Wellness Founda- tion. The initiative was prompted in response to epidemiological data that showed handgun violence as the leading cause of death for young people in California in the early 1990s. Yates stated that the initiative, which was really aimed at reducing the lethality of violence, was thought to be a comprehensive approach combining research, policy advocacy, media advo-

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7 VIOLENCE PREVENTION IN LOW- AND MIDDLE-INCOME COUNTRIES cacy, community programs, and leadership development and recognition programs—wrapped in a multimillion-dollar public education campaign. He identified a few outcomes from the initiative. In a state that had never been able to even get a bill out of committee to regulate handguns, by 2003 California had the toughest gun control legislation in the country. The foundation’s investment of $7 million a year was actually larger than the state’s investment of $5 million a year for youth violence prevention, but by 2003, the state was investing nearly $400 million a year in youth vio- lence prevention. Most importantly, by 2003, the number of young people dying from gun violence in California had been reduced nearly by half. He was quick to acknowledge that the foundation certainly was not the only contributing factor to all of those things, but it was a contributing factor to what happened in California over that decade. As for the lessons learned, Yates identified eight from the initiative. The first, convening stakeholders, was an extremely important part of promot- ing the partnerships and networking that Dr. Rosenberg mentioned earlier. He identified this as one of the reasons the foundation funds the World Health Organisation and continues to help fund its annual conference on global violence prevention. The annual conference model is now applied to all of the Wellness Foundation’s health initiatives, but it began with the violence prevention initiative’s annual conferences. Next, persistence and patience are extremely important. He noted that this is true for legislation and policy efforts, as well as for the provision of funding and leveraging of resources. After seven years of that grant making program, not a single bill had been signed into law to regulate firearms in California. By the eighth year however, five legislative bills had been signed into law, including ban- ning the sale and manufacture of Saturday night specials. Every year since, additional gun control measures have been passed in California. The eighth or ninth year reflected substantial, annual, state-budgeted financial invest- ments made to the level described previously. Third lesson, research and advocacy are both necessary. Yates stated, “data is important, but data in and of itself will not move policy. Passion is important, but passion in and of itself will not move policy.” When the two are combined, there is much greater potential to have an effect not only on policy makers, but on opin- ion leaders, who tend to have an effect on policy makers, as was mentioned by David Gartner. The fourth lesson is consistency of message matters over time. When the foundation first launched the Violence Prevention Initiative in 1993, the concept of violence being a public health issue was not well understood, even in public health circles in California, and only one health department had a public health program in violence prevention. When the foundation was preparing to send out requests for proposal for research or for community work, very few programs were self-identified as focusing on

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77 SCALING UP INTERNATIONAL SUPPORT FOR VIOLENCE PREVENTION violence prevention. So the fact that violence might be able to be prevented was an important message over time. The other important message was that handguns were the number-one killer of young people in California, and a conservative state attorney general incorporated that message in a public speech during the fifth year of the initiative. Next, a multidisciplinary approach that includes law enforcement and community residents in local community programming is critical for effectiveness. For at least one- third of the 18 community sites funded that were above the bar in terms of effect, in every case, community residents were very much involved. Other disciplines, including law enforcement, public health, academia, and social work, were also involved. The sixth lesson focused on leadership programs, which can have a very powerful long-term effect. The Wellness Foundation’s leadership programs were two-year academic fellowships and two-year community fellowships, as well as a leader recognition program. Over the decade that the initiative was in place, approximately 300 indi- viduals went through one or more of those programs. Today, Yates noted, many of the people who participated in these leadership programs are still active in violence prevention, some as national and California state policy- makers. He viewed this as a ripple effect for more than just the development program in and of itself. Seventh, is that human behavior doesn’t take place in a laboratory, especially in society. He suggested that “researchers can’t control all the variables they would like to control to prove to a p-value” that the intervention being used had an effect. However, he noted that there is value in common sense and an ability to observe. “If the numbers go down the way they went down in California, you don’t really have to worry about the p-value. There are thousands of lives saved over that period of time.” The final lesson:  it is really important for organized philanthropy and government to continue funding and to continue implementing the programs when true positive effects are seen. He explained that there is a tendency for money to go elsewhere and programs to go away when things get better. He suggested that this is the worst thing to do, especially when the effort is beginning to have an effect on something. The Wellness Foun- dation continues to invest in violence prevention with $5 million a year, and the State of California, even during really serious budget deficits, kept that violence prevention amount at the $400 million level. Additionally, Yates stated that “the real credit goes to the advocates that put together a very powerful movement and network in California. They didn’t back off once the numbers got better—they kept pushing. That is extremely important.” Additional information about the evaluation of the Wellness Foundation’s violence initiative and lessons learned is available at www.tcwf.org.

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7 VIOLENCE PREVENTION IN LOW- AND MIDDLE-INCOME COUNTRIES THE UNITED KINGDOM’S EFFORTS IN ARMED VIOLENCE PREVENTION Kate Joseph’s presentation focused on discussing the rationale for the involvement of the Department for International Development (DFID), which has a budget of nearly $12 billion, in violence prevention. She also addressed strategies for elevating the issue onto the agenda of the inter- national donor community.  She reminded the group that many donors, perhaps most donors, base their interventions or their programs around the Millennium Development Goals, which cover a range of different things—eradicating extreme poverty, achieving universal primary educa- tion, maternal health, child mortality, HIV/AIDS, tuberculosis, malaria, and others. She pointed out that the framework from which her department has to operate does not make a single reference to violence, conflict, or even governance. This reinforced her rationale that careful thought and attention should be paid to how the work that DFID does impacts those indicators because they drive the donor community. She observed that DFID has a history of working on conflict prevention, post-conflict recovery, security, and justice. Due to the multifaceted nature of the work, her department often collaborates with the UK’s Foreign Office and the Ministry of Defense. She stated that the UK experience in Iraq and Afghanistan has very much “colored our engagement in conflict prevention and post-conflict recovery.” Mistakes in the post-conflict period, she further explained, should facilitate careful thinking about how this kind of work is done in the future and the order in which things are done to prevent a relapse into conflict and, perhaps more importantly and more seriously, to prevent the post-conflict environment from turning into an environment of lawlessness, chaos, disorder, and violent crime. However, she acknowl- edged that  the United Kingdom does have more positive experiences in conflict resolution and social reconstruction in Sierra Leone. The efforts on security and justice essentially started as a set of projects about build- ing the capacity of the military to ensure state security. It quickly realized that state security wasn’t particularly important for development; rather, individual and personal security was important so that people could feel safe to go about their daily lives and therefore engage in economic activity that would drive development. Providing that security was only one-half of the coin, the other half being access to fair and speedy justice. Joseph stated that this work on security and justice was just as much about involving the community in deciding what it needed for its own security. Lastly, DFID has been doing a lot of work on small arms or gun control. Originally, the small arms control efforts were very much about con- trolling the supply of weapons—controls on exports and imports, controls on arms brokers. DFID realized that these types of control don’t really

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7 SCALING UP INTERNATIONAL SUPPORT FOR VIOLENCE PREVENTION have much impact or benefit unless they are accompanied by a whole set of measures that address the context in which weapons are used—why people feel the need to acquire weapons and why they feel the need to use them. This is now essentially the focus of DFID’s work and the dialogue in which it is trying to engage others. Also, while it has legal requirements to spend 90 percent of the money in low-income countries, a lot of the coun- tries that have very high rates of gun violence—Brazil, for example—are middle-income countries. There is a close relationship between high levels of violence and extreme poverty in those countries, and her department is struggling to resolve this dilemma. She explained that the primary purpose of all this aid is poverty reduc- tion, not violence prevention or conflict reduction. Her department’s skepti- cism about diverting its resources into this area mirrors that of the donor community and national governments in what they perceive to be the “secu- ritization” of aid—spending aid on security objectives with the extreme end of that spectrum being spending on counterterrorism. In 2005, DFID attempted to recast a lot its work on security in terms that would resonate with the development community, which she stated may also facilitate its ability to meet the target of putting 0.7 percent of the gross domestic product (GDP) into development. Ms. Joseph explained that violence was reclassified to be consistent with DFID’s particular focus on service delivery by stating that security is a basic service to which everybody, especially the poor, has a right—just the same as a right to health, education, and food. Evidentiary Needs for the Development Agenda Joseph observed that many donor agencies or development actors treat violence as a “kind of external shock” with which they have to deal or cope, likely by working around it, but not actually addressing it. It is nec- essary to help donors and development agencies understand that there is something that can and should be done and—if it is done—will actually make a huge difference in the success of development interventions.  She emphasized the need for evidence that violence impedes development and that violence prevention is effective in order to elevate it to the development agenda, and she hailed public health, and criminal justice to a lesser degree, for providing some of the best evidence to date. Improved monitoring and evaluation of this area with the inclusion of economic indicators are essential to be able to explain this issue in eco- nomic terms. Joseph stated that it is not enough to say that intervention X is actually reducing the level of violence; rather, go the extra mile to say that a reduced level of violence is creating economic opportunities and that economic indicators are going up. Consistent with Butchart, Mercy et al., and Zaro et al., she also identified the need to build a capacity for

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0 VIOLENCE PREVENTION IN LOW- AND MIDDLE-INCOME COUNTRIES systematic data collection in developing countries, including having govern- ments build the kinds of datasets that underlie the United Nations Develop- ment Programme’s Human Development Index or the World Bank’s World Development Index. These data help donors assess whether countries are meeting the Millennium Development Goals. She said that many successes in this area are community-based or local and queried how they can be scaled up to the national level. She also cautioned that donors have a lot of pressure to obligate and allocate money quickly, and that it can most easily and preferably be done through governments, usually central government. The seemingly counterintuitive challenge, she stated, is to figure out how donors can fund larger, longer-term programs—spend more money, not less. Joseph identified analytical tools, models, programming ideas, and good practice as areas that need strengthening. Although she recognized that there is no one-size-fits-all approach or a true model, she identified the need to facilitate better understanding of the types of interventions that are being talking about. Ms. Joseph acknowledged a trade-off between integrating violence pre- vention into existing work and developing stand-alone initiatives by query- ing whether it is really a matter of putting a violence prevention lens on the development work that is already being done or whether it is something else.  Almost all donors have committed to the principle of country-level development defined in the Paris Declaration on Aid Effectiveness—this means letting a country decide its own priorities for action. So, donor action is rightly and increasingly led by a country’s priorities, with donor support for the budget as a whole or for a particular sector. Simply stated, violence prevention also has to be a priority for developing country gov- ernments who will then request funding for it. If countries don’t prioritize violence and continue instead to concentrate on universal primary educa- tion or other issues, it is difficult for donors to suggest elevating the issue on the country-identified agenda. She observed that decision making for countries to prioritize violence prevention may be affected by political influences, which can contribute to differences in “outsider” and “insider” perspectives. To outsiders, the violence may seem chaotic, but to insiders, not only may there be vested interests in perpetuating violence, but also it may be quite organized. Lastly, to address many of the necessary, but miss- ing, elements to elevate violence prevention on the development agenda, DFID is working within the Organisation for Economic Cooperation and Development’s Development Assistance Committee to develop guidance for donors on programming for prevention of armed violence. As a result of the workshop, she also identified a potential collaboration with the WHO-led Violence Prevention Alliance in this regard.

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 SCALING UP INTERNATIONAL SUPPORT FOR VIOLENCE PREVENTION UNICEF AND PREVENTION OF VIOLENCE AGAINST CHILDREN Alan Court described the United Nations Children’s Fund (UNICEF) programs for children up to the age of 18 years and stressed that while violence prevention is a multisectoral issue, child protection also involves health, nutrition, education about HIV/AIDS, and employment opportu- nity. He explained that violence against children is neither a minor nor a small-scale issue. It is diverse and covers harmful traditional practices such as genital mutilation and cutting of 100 million to 140 million women and girls worldwide; armed conflict and armed violence, which are responsible for 200,000 deaths and 53,000 homicides annually; physical punishment in schools and other institutions; and sexual exploitation and trafficking of an estimated 1.2 million children annually—but as Ms. Joseph mentioned, it is something that can actually be described to enable an agency to mobilize the resources to be able to address it. In UNICEF, they talk about the protective environment for children and are dealing with a whole range of issues from government commitment to life skills development of children themselves, how parents get involved, and community awareness. He identified community awareness as really important since the political and legal environments in countries can influ- ence the age of criminality. For example, the pressure from the public in Central America is to lower the age of criminal responsibility—in contrast to Amnesty International, which advocates a change in 100-year-old Iranian law to raise the age of criminality to 18 years, no longer permitting children (girls at age 8 and boys at age 12 years) to be executed for crimes. UNICEF proposed a range of solutions to address violence against children, including dealing with legislative frameworks and justice systems; expanding the knowledge base to understand what is going on, as several speakers have spoken about data collection at national, regional, and global levels; supporting national assessments and national plans of action to address issues; strengthening social welfare and service delivery systems, which are chronically weak in both low- and middle-income countries; emphasizing coordination and partnerships; and leveraging the resources needed for children. He discussed the World Report on Violence Against Children,1 inde- pendently commissioned by the UN Secretary-General, that has received the widespread endorsement of countries around the world—developing countries, industrialized countries, middle-income countries—and will guide some of the future work of the organization. In the United States, he mentioned Washington was very much involved in discussions, prior to its launch, about the content of the report, which provided the first 1 Available at http://www.violencestudy.org or http://www.unicef.org.

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2 VIOLENCE PREVENTION IN LOW- AND MIDDLE-INCOME COUNTRIES comprehensive global picture of violence in five different settings—home and family; schools and educational settings; care and justice institutions; places of work; and the community. The study concluded that violence against children occurs everywhere—in every single country, in one way or another—and suggested that violence in the home and family, especially here in the United States, could be more problematic to address than the others. However, for appropriate interventions, in his view it is important to differentiate not only the type of violence, but also where it occurs. The report also stated, “No violence against children is justifiable, and all vio- lence is preventable.” So the questions he posed were whether we recognize it, whether we are willing to address it, and whether we are willing to make it a societal concern rather than an individual concern. For female genital mutilation, for example, UNICEF found that this is an issue that can only be addressed by society as a whole, not by individuals or individual families, and the most effective thing is to provide data and information to commu- nities who are much more likely to make their own decisions to drop the practice as evidenced in Senegal. He also noted that the World Economic Forum in Amman actually concluded that issues of high unemployment are linked to violence among youth and the tendency toward greater violence among young people because of the inability of the educational systems throughout the Middle East to provide the necessary education to produce the labor force that is necessary throughout the country. Court mentioned that upcoming UNICEF programs on the prevention of violence and responding to violence against children will be based on the findings of the World Report on Violence Against Children. A finding of particular importance is the need to systematically collect and synthe- size information. Although there are data and evidence, he stated that they are by no means sufficient or of sufficient quality to actually build up programs. One major UNICEF activity under way is a review of the Graça Machel study of children in armed conflict that was started in 1996. The goals of the review are to understand the changing nature of conflict in the past decade, to review systemic-level developments, to assess policy frameworks of the United Nations and others, and to develop recom- mendations to define a platform for next decade. This review will be presented in October 2007 by the Secretary-General’s special envoy for children in armed conflict. Additionally, UNICEF is undertaking research on the direct and indirect impacts of small weapons and light arms on children. Related to human security, he noted that Japan, along with other countries, is examining how post-conflict, social reconstruction might be something different in terms of a way for people to get back together that will sow the seeds of peace. Often something as simple as reintegrating refugees can, in fact, cause future conflict between them and those who never left.

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 SCALING UP INTERNATIONAL SUPPORT FOR VIOLENCE PREVENTION Another area he emphasized for minimizing violence against children is legislation and advocacy, with UNICEF work already under way. In 2006, various international standards, laws, and amendments on violence against women and children that do exist were adopted by 15 countries. UNICEF and the French government cosponsored a February 2007 meeting in which the Paris Commitment (different from the one on aid effectiveness) was codified and adopted by 59 countries. This declaration is a commitment on freeing children from armed conflict as victims of and participants in conflict. He stated that Lebanon’s and Israel’s recent use of cluster muni- tions has increased the international impetus to reduce or ban the use of this type of munitions, while noting that many countries including the United States and the United Kingdom have still not banned the use of cluster munitions. Mr. Court identified other UNICEF efforts including strengthening institutional capacity, especially where there are weak social assistance or social welfare programs, in 64 countries around the world. Included in this capacity-building effort is the examination of tracing systems, reintegration programs in emergency settings, and what is set up in post-conflict coun- tries. UNICEF’s collaborative partnerships have produced and disseminated handbooks on child protection, child trafficking, violence in general, and reducing gun violence. UNICEF has a multisectoral child survival strategy, which examines and considers indirect and direct causes of childhood death, including communicable disease and malnutrition. UNICEF is also examining recent evidence from the University of the West Indies and others on the problems relating to young child development and preschool, as well as research that examines the effect of events and activities dur- ing pregnancy and postpregnancy that may have a direct influence on the development of children. When asked about organizational resources that would be needed to address the many components he described, Court stated UNICEF esti- mates, based on a five-year follow-up to the UN study on violence against children, would total $25 million annually. Fiscal resources for follow-up of the steps needed to address female genital mutilation and cutting were estimated through the year 2015 and totaled $240 million. He stated that he thought these estimates to be eminently reachable. He noted, however, that improved collaboration, not a continuation of “individual work on individual strands of the problem,” would move violence prevention for- ward as a collective action on multiple agendas. GENDER-BASED VIOLENCE IN THE CARIBBEAN Elsie LeFranc reiterated that violence is a major health problem in the Caribbean, being one of the top three contributors to years of life lost, with

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 VIOLENCE PREVENTION IN LOW- AND MIDDLE-INCOME COUNTRIES the heaviest toll among young people. She stated that it is now clear that the health and economic burden of violence and injury should no longer be measured only in terms of the effects of death and injury on the immedi- ate victims. Of great importance also, she stated, are the likely short- and longer-term consequences—including the hindrance that these kinds of problems are likely to be to the economic development of these countries. She hypothesized that these factors likely persuaded the Wellcome Trust of the importance of investing in basic research to examine and better under- stand the socioeconomic determinants of the problem to assist in develop- ment of the kinds of preventive efforts that need pursuit. In her research, she described use of the Conflict Tactics Scale to measure levels of interpersonal violence by examining a number of social variables that include migration, social networks, family structures, psycho- social factors, demographics, and the usual socioeconomic variables. She highlighted a few findings from the study. First, she and her colleagues were struck by the fact that there were roughly equivalent levels of physical vio- lence on men and on women. Secondly, men were more at risk of physical abuse by strangers, while women were more at risk of abuse from persons known to them. Thirdly, there was more reported sexual abuse of women than of men, but it should be noted that sexual abuse of men by women can be high. Of the things that stood out, she pointed to the lack of any serious gender differential in the levels of exposure and the magnitude of the problem, especially between partners. When looking at some of the data on the perpetration of violence within partnerships, she stated that while there is probably some female overreporting or male underreporting, it is nonetheless interesting to see that fewer men were perpetrators of physical violence. She also noted that there were no statistical gender differences in sexual coercion. These findings queried the attitudes of violence that would be found in this kind of environment. LeFranc and colleagues also utilized qualitative data in their study suggesting that violent attitudes and the pref- erence for violent conflict resolution tactics may not only be widespread, but also begin at very early ages. She also discussed the findings from a UNICEF-supported study on violence against children in Dominica. LeFranc and her colleagues were sur- prised by the preponderance of violence-oriented responses perpetrated by children for seemingly mundane, nonviolent offenses such as being pushed in the schoolyard or peers ruining homework papers—which garnered responses such as cutting, stabbing, choking, hitting, beating, and sexual assault in retaliation. The data also indicated that the punishment strate- gies at home and at school could be harsh and violent. Certainly, where an average of only 14 percent of the children in the discussions had never been hit by a teacher and only 15 percent had never been hit at home, violent corporal punishment is widespread, possibly indiscriminate, and probably

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 SCALING UP INTERNATIONAL SUPPORT FOR VIOLENCE PREVENTION encouraging the high tolerance levels they found. The data also identified the type of instruments used for punishment including scissors, stones, screwdrivers, needles, blades, cutlasses, brooms, bottles, forks, galvanizing, or being burned at least once by a candle, hot iron, or cigarette. A study in Jamaica reinforced high rates of verbal aggression or physical violence in the home (97 percent) and schools (87 percent), while another UNICEF review of the region conducted within the last year yielded similar findings. From these findings, LeFranc hypothesized that many of the traditional explanations of interpersonal violence and their associated interventions may not be as helpful as previously hoped. Most of the explanations, she stated, assume that a social pathology perpetrated by a small percentage of the population needed to be addressed. Within that conceptual framework, many studies look for social problems and dysfunction that could help explain those deviant behaviors and also search for linkages with other deviant, delinquent, and criminal behaviors. However, she explained that the data showing the commonality of the phenomenon among peers and between parents, children, and teachers really suggests a culture of violence and adversarial relationships—a culture in which violent and even aggres- sive behaviors appear to be a fairly normal and even valued means of social intercourse and negotiation. It may then be, as suggested by one study they did in Barbados and another done by other researchers in the United States, that violence is deemed necessary to maintain a workable relationship and even a “normal and deserved response to a spot of bother.” In terms of the debate about whether people are inherently violent or pacific, this conclu- sion would support the view that violence may be inherently inevitable and is only held in abeyance. If this assumption were true, it would imply that preventive approaches at the most scaled-up levels possible are certainly critical. LeFranc cau- tioned, however, that very careful thought must be given to the types and variety of entry points utilized. She advocated for interventions to target early childhood development when children begin to appreciate another person’s point of view, as well as behavior and value modification with emphasis on finding necessary structural and institutional supports for sus- tainability. Early analysis of their data has so far indicated the importance of focusing on social capital types of variables. However, the picture is not at all straightforward. She stated there is also some evidence from other studies indicating that those involved in intimate partner violence are not necessarily involved in violence outside the domestic context. From her study, the data indicated that more attention needs to be given to the types of social institutional structures and arrangements that seem to encourage violent forms of social dialogue, as well as to parenting practices, punish- ment strategies, the dynamics and tactics of relationship management, and dispute resolution strategies.

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 VIOLENCE PREVENTION IN LOW- AND MIDDLE-INCOME COUNTRIES In terms of what more is needed, Dr. LeFranc stated that a great deal more work is necessary to sort out the precise pathways for action in dif- ferent countries. Male battery, she noted, needs to be recognized and under- stood for inclusion in violence prevention efforts since its predictors may differ from those for female battery. Lastly, in accordance with the remarks of Dr. Garbarino, she advocated for increased differentiation in measures according to social contexts for a better understanding of the different types or arenas of violence and therefore the different risk factors in those social contexts in which the violence and aggression are being perpetrated. NATIONAL AND INTERNATIONAL PERSPECTIVES OF SCALING UP PREVENTION PROGRAMS Carl Bell explored lessons learned about suicide prevention from the Institute of Medicine (IOM, 2002) report Reducing Suicide: A National Imperative,2 as well as his research on HIV prevention in Africa. He reviewed a variety of risk and protective factors (biological, psychological, social, and environmental) and urged that an integrated understanding of both is needed, emphasizing that risk factors are not always predic- tive because of the moderating effect of protective factors. The extensive literature on protective factors, which he described as “being all over the place,” does identify some universal concepts (social fabric, social skills, monitoring children, and minimizing trauma) that could benefit from syn- ergistic, science-based approaches to maximize resources and outcomes. His current violence and HIV prevention work is based on a previous collaboration with Brian Flay and Flay’s triadic theory of influence, which includes all of the theories that focus on health behavior change used in the last two decades. In his simplified version of this complex biopsycho- social model, Dr. Bell identified several things needed for intervention—a social fabric that connects people together, access to modern technology to monitor behavior in the population and to create an “adult protective field” for children, self-esteem, social skills, and strategies to minimize the effects of trauma. Prior collaboration with former U.S. Surgeon General David Satcher and Bell’s current work have identified necessary elements for successful interventions and for constructing social fabric, many of which were reiterated in the lessons presented by Gary Yates—bringing all of the stakeholders together, the need to collect data and evidence to create synergistic and integrated systems, the importance of leadership to develop a common language and vision, and sustaining funding and programs after positive effects are noted. 2Available at http://books.nap.edu/catalog.php?record_id=10398.

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7 SCALING UP INTERNATIONAL SUPPORT FOR VIOLENCE PREVENTION His violence prevention work informed his HIV prevention work domes- tically and in Durban, South Africa. By working at the individual, family, and community levels, this work has had positive effects with multiple family and group interventions in terms of neighborhood social control and organization, increased primary and secondary social networking, and improved communication between youth and their parents. In South Africa, Bell focuses on social skills, teaching parents how to parent children—how to bond, how to attach, how to supervise, and how to monitor children’s behavior. He noted that creating self-esteem, a sense of power, a sense of uniqueness, a sense of model, a sense of being connected—all of these things seemed to decrease the need to engage in risky behaviors. The adult protec- tive shield in terms of monitoring children is very important. He noted that when you have neighbors monitoring other neighbors in terms of domestic violence, people modify their behavior and there are improvements in terms of punitive parenting. Bell’s HIV prevention work was also found to be effec- tive in reducing the stigma of HIV for both children and adults. From research in the Chicago Public Schools it has been shown that when children, teachers, and parents are connected and attached; the find- ings indicate less violence, less suicide, delayed sexual debut, and fewer other disruptive behaviors among children, which appears to be consistent with Hawkins’ findings with social bonding. Bell’s research on bonding and attachment dynamics in the same school system, using Aban-Aya’s Afrocentric risk behavior prevention curriculum, focused on teaching refusal skills for social or peer pressures and skills for assertiveness, nego- tiation, and conflict resolution. The study provides youth the opportunity to practice these skills to aid in their ability to avoid high-risk health behav- iors. These social skills are taught in the context of also teaching decision making (Stop, Think and Act) and problem solving skills. Bell’s work also promoted opportunities for children to become attached to their schools by creating an environmental structure during the school year and summer months, with academic and recreational activities and serving meals. Dr. Bell’s research to address child abuse and neglect domestically reduced significantly the numbers of African American children who were being removed from their homes in McLean County, Illinois. At the start of the study, 35 children per 1,000 were being removed and at the end of their initiative, the number was reduced to 14 per 1,000 children, higher than children of other races and ethnicity. He reiterated that exposure to child abuse and neglect, along with other adverse experiences such as wit- nessing violence against one’s mother, living with household members who are substance abusers, living with household members who are mentally ill or suicidal, or living with ex-offender household members are major drivers of adult mental and physical health problems. Bell also stated that various studies have shown a range of people who experience trauma, from

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 VIOLENCE PREVENTION IN LOW- AND MIDDLE-INCOME COUNTRIES 52 to 78 percent—evidence of its ubiquitous nature. His research in South Africa has indicated that minimizing the effect of trauma as part of violence prevention efforts can reduce physical illness in the country’s population, and he suggested that we need more research to understand how protective factors may promote resilience to posttraumatic stress disorder and other stress-related disorders. In summation, Bell reiterated the need for more research to build the knowledge and evidence base and the need for public will to address vio- lence prevention. He also advocated for the discontinuation of programs that have been shown to be ineffective. For youth violence prevention, he strongly encouraged participants to read Surgeon General Satcher’s report3 for guidance in moving forward. QUESTIONS AND ANSWERS A number of issues were raised during this period, but the one that prompted the most discussion was how to bring all of the perspectives that have been discussed, including public health, human rights, and develop- mental issues together to support violence prevention in low- and middle- income countries. The panelists’ responses addressed the importance of evidence gathering and dissemination of findings on the determinants, magnitude, and consequences of violence as critical to this synthesis; pro- viding data on the costs and benefits of violence prevention; and building and strengthening capacity for design, implementation, and research. Other important elements identified included repetition of the message; convening and engaging key stakeholders; persistence in engagement; identifying pro- visional or proximal indicators that can be measured as part of a review or assessment of long-term initiatives for midcourse corrections if necessary; advocacy with the national governments in countries to get them to priori- tize violence prevention in health and development investment; and greater dissemination of the success of long-term violence prevention initiatives such as that of the California Wellness Foundation, which does not treat its investment like a pilot project. Further remarks suggested examining the promising and innovative work that is already being conducted in low- and middle-income countries such as Brazil and others for strategic decision making for evaluation efforts; acknowledging and using the positive effects of advocacy for international conventions, especially for children’s issues; examining issues that affect the credibility of governments and donors to advocate with a human rights-based approach; and being inclusive when creating coalitions and multisectoral collaborations. 3Available at http://www.surgeongeneral.gov/library/youthviolence/youvioreport.htm.