Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 14
3
Challenges in
Calculating Costs
As a companion to the discussions of various approaches to calculat-
ing costs, speakers offered cautions and considerations in utilizing existing
methodologies. Most of the challenges are not specific to cost calculation,
but plague other aspects of violence prevention research and implementa-
tion as well. Some challenges were evident in health economics and the
costing of other public health problems. These challenges in both arenas
increased the difficulty in enumerating costs and placing appropriate value
on various preventive interventions.
The major challenge, reiterated by many speakers, was the difficulty in
placing a value on nontangible, social costs. In particular, pain and suffering
were two outcomes speakers cited as being unquantifiable. Some speakers
suggested these costs could be indirectly measured by assessing psychologi-
cal costs, but no accurate and direct assessment of them could currently
be made. Speakers also felt that this was indicative of other quality-of-life
issues. Thus, in placing a dollar value on some costs but not others, the true
impact of violence is not being captured.
The field of violence prevention suffers from a few issues that add
difficulty to estimating costs. Speaker Phaedra Corso of the University of
Georgia emphasized that generating the evidence base for violence preven-
tion is hampered by imprecise definitions and underreporting of events.
Lacking clear definitions of what constitutes violence and violent events
makes determining both prevalence and incidence difficult, both of which
are essential to assessing true cost. Also, underreporting of events obscures
true incidence and prevalence. Dr. Corso and other speakers proposed that
relying on medical records and claims requires accurate coding of causes of
injury, which does not always occur because universal screening is not in
14
OCR for page 15
15
CHALLENGES IN CALCULATING COSTS
place for violence. Speaker Deborah Prothrow-Stith of Spencer Stuart also
highlighted the importance of definitions and their cultural context; what
constitutes violence in one setting might not translate to another setting and
therefore might not be captured in data analysis. Speaker Mindy Fullilove
of Columbia University noted that structural violence, or violence that is
institutionalized but not criminalized, is difficult to define and measure,
correlates with other inequities, and is often missed when considering the
cost of overt violence.
Dr. Corso, speaker Philip Cook from Duke University, and speaker and
Forum member David Hemenway from Harvard University also empha-
sized the difficulty and importance of determining attributable risk, particu-
larly for longer-term outcomes. Dr. Corso observed the lack of a good risk
model, and Drs. Cook and Hemenway discussed the difficulty of attributing
violence to specific risk factors. This provides a challenge in assessing how
costs are allocated to risk factors or types of violence, making it difficult to
assess how well preventive interventions are truly working.
Dr. Corso also identified general issues with the availability and gener-
alizability of data; typically, a disparity in both the comprehensiveness and
the quality of data from high-income countries and low-income countries
exists. Thus, the assessment of costs in one context may not be applicable
anywhere else. Dr. Waters emphasized this issue, citing that values placed
on specific components do not take into account differences in cost-of-living
standards across different countries. For example, productivity measured
by loss of wages is markedly different in high-income and low- or middle-
income countries, where average wages can differ by orders of magnitude.
This human capital approach also takes into account life expectancy and
age, which have other health implications and result in different values be-
ing placed on both employment and human life based on a country’s eco-
nomic development status. Speaker and Forum member Michael Phillips of
the Shanghai Jiao Tong University School of Medicine highlighted another
downside to the human capital approach—specific types of violence pose
different relative financial burdens in relation to others and thus receive
lower priority than others, despite being a potentially greater social burden.
Dr. Hemenway added to the previous comments of speakers on the
availability and generalizability of data by pointing out that not only is
violence underreported, but also active data collection is often limited to ar-
eas of higher income or socioeconomic status. Receiving data from diverse
populations is difficult when less effort is made to collect such data. Forum
member Evelyn Tomaszewski made a similar statement in commenting on
undercurrents of violence and effects of violence in society, such as undiag-
nosed psychological illness or trauma, and the impossibility of enumerat-
ing such costs. In addition, the data are often inaccurate—Dr. Hemenway
stated that a recent review of the National Violent Death Reporting System
OCR for page 16
16 SOCIAL AND ECONOMIC COSTS OF VIOLENCE
(NVDRS) indicates that reporting of mortality due to firearms has overesti-
mated the age of victims; such victims are actually younger than previously
estimated. This can have a profound effect in calculating long-term costs
(especially productivity and social losses).
A few issues on the actual accounting of costs were also raised. Dr.
Corso asked how pain and suffering are quantified. Ms. Tomaszewski sug-
gested that including community costs, not just aggregated individual costs,
is important as well. Dr. Waters pointed out that aggregating numbers can
often yield huge ranges, because each individual cost is often displayed as
a range. He also noted, and was echoed by speaker and Forum member
Rodrigo Guerrero of Cali, Colombia, that these large ranges are not always
helpful to policy makers. Likewise, traditional economic approaches to
measuring costs can result in confusion, such as the determination of the
discount rate—the deduction applied to the future value of money so as to
make comparisons to current value. The discount rate can vary by region,
year, time line of projection, and economic model, yielding large intervals in
value. The mathematical models often used for calculating costs rely heavily
on theoretical assumptions that might not always be valid—for example,
models incorporating counterfactual worlds in which violence does not ex-
ist can never be assessed for accuracy.
Speakers also questioned the presentation of cost data. Often such
numbers are presented in terms of dollars lost or as a percentage of the
gross domestic product (GDP). The first has the disadvantage of providing
less meaningful comparison across countries, and the second is often con-
fusing to those outside of economics. The importance of context-specific
denominators for such numbers is essential in showing true impact but can
hamper generalizability and comparison.
Both Ms. Tomaszewski and Dr. Prothrow-Stith commented on mea-
suring externalities such as historical trauma and discrimination. Dr.
Prothrow-Stith also questioned the possibility of measuring fear and its ef-
fect on behavior, which could have enormous implications for longer-term
outcomes such as chronic health effects and future perpetration of violence.
Dr. Betancourt mentioned the impact of collective violence on non-state ac-
tors and infrastructure, causing widespread damage that often takes years
to address. Such impact can serve as a risk factor for future violence, again
bringing forth the question of measuring the cost of future violence.
Finally, some speakers questioned the negative costs of some measures
of prevention that are deemed effective. In particular, Dr. Phillips and Dr.
Hemenway pointed out that access to dangerous weapons is a risk factor
that can be addressed by legislation, but has implications of restricting
freedom in the U.S. political climate. If costs can be calculated based on
what society is willing to pay to prevent such violence, certain preventive
interventions will always be deemed as having too high a cost.
