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5 The Promise of Investing in Violence Prevention Estimating the costs of violence serves two purposes: demonstrating the significant burden of violence on health and development, and highlighting the importance of early investment in preventive interventions that cost less to implement. Speakers highlighted a number of cost-benefit comparisons, as well as demonstrations of the value of prevention not only in averting costs but also in providing future benefit. Interventions that prevent violence also prevent the realization of the costs of violence. Such primary interventions can be addressed to specific types or occurrences of violence, or they can strengthen prosocial behav- ior and community resiliency to prevent potential violence. Interventions can mitigate the impact of violence, prevent the recurrence of violence, or prevent long-term outcomes due to violence. These secondary and tertiary preventive interventions can yield enormous financial benefit. Interventions also have the unintended positive consequence of driving productivity and economic growth, thus providing even more benefit by increasing health and well-being. Several speakers pointed out the importance of assessing the cost- effectiveness of interventions. Speaker Phaedra Corso of the University of Georgia emphasized the need to integrate cost-effectiveness into evaluations of programs. Speaker and Forum member David Hemenway of Harvard University highlighted the importance of collecting robust data to show where investment is cost-effective and why certain interventions are nec- essary even if they are not popular. Speaker Hugh Waters of the RAND Corporation noted evidence showing that interventions that address proxi- mal factors are more cost-effective than those that address distal factors. 26
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27 THE PROMISE OF INVESTING IN VIOLENCE PREVENTION Speaker David Hawkins of the University of Washington gave an example of the State of Washington deciding to cut funding for a new prison from its budget upon reviewing cost-benefit analysis for prevention and instead putting additional funds toward violence and crime prevention. Speakers addressed the importance of interventions that emphasized prosocial behavior and resiliency as a means of providing coping mecha- nisms in the face of everyday stress, adversity, or violence. Speaker Theresa Betancourt of Harvard University discussed her ongoing work with war- affected youth in Sierra Leone (further information can be found in Chap- ter 7), noting that children formerly associated with armed groups who underwent formal reintegration adapted better to post-conflict community life. She stressed the importance of a “safe place,” a sentiment that speaker Mindy Fullilove of Columbia University also expressed. The formal demili- tarization process in Sierra Leone provided such a space via interim care centers, before youth were reunited with their families. This process was intended to help facilitate healthy reconnection with family and community members. Dr. Betancourt emphasized that one of the most critical findings of the study was that the long-term mental health of war-involved youth was influenced not only by past war experiences, but also by ongoing stress- ors in the post-conflict environment, again underscoring the importance of “place” and the larger social ecology. For instance, exposure to toxic violence (such as rape or being forced to injure/kill others) was associated with increased hostility over time and deficits in interpersonal function- ing, but these deficits were further compounded by community stigma. Furthermore, loss of a caregiver during war was associated with increases in internalizing problems (e.g., depression and anxiety) over time, but fur- ther exacerbated by family abuse and neglect and daily hardships such as food and housing insecurity. The research also identified several malleable protective factors, such as access to school, community acceptance, and adequate social support all of which have the potential to serve as key lever- age points for intervention. Again, underscoring the importance of “place,” community acceptance was observed to have beneficial effects on all mental health outcomes investigated (see Box 5-1). Speaker and Forum member Elizabeth Ward of the Violence Prevention Alliance in Jamaica also spoke to the importance of enforcing prosocial behavior and messaging. Unattached youth in Jamaica—those who are not employed, are not in school or training, and face high rates of violence— fare better and are more empowered if they have received prosocial messag- ing at home or at school than those who did not. Dr. Ward pointed out that keeping youth in school prevents them from joining gangs, and learning to read reduces aggression. The cost of after-school programs in Jamaica is ap- proximately 45,000 Jamaican dollars per year, while a specific literacy pro- gram costs about 3,000 Jamaican dollars. On the other hand, caring for a
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28 SOCIAL AND ECONOMIC COSTS OF VIOLENCE BOX 5-1 Impact of Prosocial and Resiliency Factors: The Stories of Sahr and Amina In 1991-2002, Sierra Leone experienced a civil war that displaced up to 75 percent of the population. An estimated 20,000 youth were associated with armed groups, many with the Revolutionary United Front (RUF), but only 7,000 underwent formal Disarmament, Demobilization, and Reintegration (DDR). DDR provided interim care centers that offered care and support, community sensitiza- tion, preparation for reintegration, and follow-up. Sahr was abducted by the RUF at age 7; he is now 17. For 4 years, he was forced to spy and gather information and was force-fed drug-laden food. He wit- nessed massacres, rapes, bombings, and amputations. After the war ended, Sahr lived with a foster mother for 2 years (but not through DDR) before reuniting with his grandmother, uncle, and mother, who experienced depression. He had trouble reintegrating into the community and was considered “troublesome” by his uncle. The community ridiculed and harassed him, and individuals administered beatings as discipline. Sahr had difficulty coping with everyday stress and dropped out of school. He was prone to aggression against others, sometimes threatening with a knife. His mother does not know his current whereabouts. Amina was 10 years old when abducted by the RUF; she is now 23. She served as a supply carrier and cook, was beaten frequently, and now has a deformity. She was forced to take drugs and participated in amputations. After the war, she participated formally in DDR and reunited with her mother and grandmother; she has a child but no partner. Her mother was a teacher and provided a tremendous amount of support. Amina initially had difficulty reintegrating, but her mother stood as a strong advocate. She now reports no problems within the community, suc- ceeds in school, and feels good about the future. SOURCE: Vignettes presented by Theresa Betancourt, Harvard University. gunshot wound in a hospital costs half a million Jamaican dollars; keeping a child in a foster home costs more than 1 million dollars; and the cost of incarcerating a male young person is 800,000 Jamaican dollars. Education, job training, and other skill building are relatively cheaper to implement than the cost of addressing violence after it occurs (further details can be found in Chapter 7). Such interventions also yield potential financial benefit in their own right—providing skilled workers for the workforce and driving economic growth. Speaker Ivan Juzang of MEE Productions agreed with the importance of highlighting prosocial messaging as well as developing coping strategies at both the individual and the community levels. He noted that his programs emphasize the development of a “plan,” because having goals and objectives can make a violent event seem less traumatic. Speaker and Forum member Rodrigo Guerrero also highlighted the importance of
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29 THE PROMISE OF INVESTING IN VIOLENCE PREVENTION prosocial messaging, particularly at the community and family levels. In an intervention conducted in Colombia, the use of media to display messages about parenting and interpersonal relationships showed a reduction in the rates of self-reported child maltreatment, including physical and verbal abuse. Speaker David Hawkins of the University of Washington noted the importance of empowering the community in preventing violence. He de- scribed the program Communities That Care (CTC) and explored its suc- cesses in terms of community involvement. CTC points to two important actions that ensure success. The first is assessment to determine whether a community has the motivation and resources to implement the program (and what might be needed to do so). The second is a focus on applying evidence-based intervention models that match the community’s assessed needs. Thus, the integration of community involvement and evidence-based prevention ensures more dramatic results. Dr. Hawkins shared results show- ing up to 25 percent reduction of juvenile delinquency in communities that had implemented the program. He mentioned that one factor for success was the ability to address the violence component, thereby allowing youth to focus on skill building, developing healthy relationships, and increasing educational achievement. Dr. Hawkins also shared the financial benefit of CTC, including an estimated return on investment of $5 per child (which includes reductions not just in violence but also in smoking and other risky behaviors) and an estimated benefit of $5,000 per child over 10-15 years by reducing delinquency. Further information about CTC can be found in Chapter 8. Speaker Rachel Davis highlighted several points of evidence show- ing the reduction in costs by investing in violence prevention. She cited a preschool program estimated to show a return of $16 per dollar invested; participants also had significantly fewer encounters with the legal system than nonparticipants. Ms. Davis stated that violence prevention was the single most effective way to promote economic development in communi- ties, showing a multiplier effect of prevention—averting costs and providing additional benefits. She further detailed this multiplier effect by explaining that investment in preventing violence resulted in reduction of severity not only of the targeted outcome, but also of associated outcomes. Further in- formation on assessing value in prevention can be found in Chapter 8. The importance of investment in early intervention was also highlighted by speakers who discussed the neurobiology of trauma. Speaker Jack Shonkoff of Harvard University emphasized the importance of addressing the biological embedding of the stress response to violence at sensitive peri- ods. He noted that while chronic stress can have a long-term impact, certain stages in neurodevelopment are more vulnerable to impact than others, and identifying and protecting these moments could provide resilience or reduce
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30 SOCIAL AND ECONOMIC COSTS OF VIOLENCE the longer-term impact of stress. He also pointed out that the physiological changes and psychological disruption that occurs due to violence cannot be addressed by behavior change interventions later in life without significant cost; at best, they will only have limited success. Gary Milante of the World Bank noted that this biological developmental mechanism was similar to a social developmental one, in which strong institutions in countries served as protective factors, much like a relationship or a social support system. Mindy Fullilove made a similar comparison, saying that a city affected by violence deteriorates, leading to future violence and a collective decision- making paralysis. Juma Assiago noted that this highlights the importance of framing public safety as a common good.