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7
Context and Place
The environment in which violence occurs affects the impact of and
response to such violence. The ability to mobilize resources, support victims,
address social norms, and recognize the role of early intervention differs
across contexts and places. The presence of resiliency or other strong protec-
tive factors can mean less damaging impact and faster rebuilding. On the
other hand, localities that are already fragile and under strain see more devas-
tating effects of violence and often are trapped in repeated cycles of violence.
The first paper explores the role of social context in violence, particu-
larly how certain communities are at risk of chronic violence. It defines
concepts in a more general sense and is applicable in a number of settings.
The next three papers explore specific types of violence in specific
settings. The second paper explores the impact of youth violence in con-
flict settings, particularly in Sierra Leone, and the reintegration of such
youth post-conflict. The third paper examines the costs of intimate partner
violence in three locations—Bangladesh, Morocco, and Uganda—and the
similarities and differences between these settings. The final paper examines
the intersection of youth violence and narcotics-related violence in Jamaica.
SOCIAL CONTEXTS AND VIOLENCE
Mindy Thompson Fullilove, M.D., and Rodrick Wallace, Ph.D.
New York State Psychiatric Institute at Columbia University
Abe Lincoln may have freed all men, but Sam Colt made them equal.
—Slogan of Colt Manufacturing
84
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CONTEXT AND PLACE
Violence is part of human relationships. Several lines of inquiry link
violence to social context. Structural violence describes the ways in which
standing forms of social organization limit opportunity for some members
of society. Structural violence, because it is part of the social order and
standing law, is often considered “right” or “natural.” Criminal violence
describes the harms that are done in violation of societal laws. Because this
violence breaks the laws, it is hidden from view and punished on discovery.
All societies suffer from some level of both of these kinds of violence, and
the efforts at collective well-being are directed at exposing and correcting
the harms that are hidden from view.
Epidemic violence refers to outbreaks of violence that are substantially
in excess of the usual rates; epidemic violence might be either structural
(state-sponsored genocide, for example) or criminal (as in an outbreak of
drug-related violence). It is this third type, epidemic violence, that becomes
problematic to the survival of society especially if the rates are elevated
over long periods of time. The 2011 World Development Report puts these
issues into stark relief. The report analyzed the problems of countries that
are plagued by high levels of violence persisting over many years. It noted
(World Bank, 2011):
No low-income fragile or conflict-affected country has yet achieved a
single [UN Millennium Development Goal]. People in fragile and conflict-
affected states are more than twice as likely to be undernourished as those
in other developing countries, more than three times as likely to be unable
to send their children to school, twice as likely to see their children die
before age five, and more than twice as likely to lack clean water. On aver-
age, a country that experienced major violence over the period from 1981
to 2005 has a poverty rate 21 percentage points higher than a country
that saw no violence.
The report also emphasized that problems in conflict-affected countries af-
fect other parts of the country, lowering their productivity and destabilizing
their social organization. Thus, the problem of chronic violence poses a
serious threat to the survival of people and their societies. It emphasizes that
“insecurity … has become a primary development challenge of our time”
(World Bank, 2011). Yet overcoming chronic violence is difficult and takes,
optimistically, a generation to accomplish. What has happened in social
contexts that leads to such chronic violence and makes recovery so difficult?
Transformation of State
A modest paper by phenomenologist Eva-Maria Simms of Duquesne
University in Pittsburgh, Pennsylvania, offers a useful insight into this
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86 SOCIAL AND ECONOMIC COSTS OF VIOLENCE
problem. Simms interviewed 12 people who grew up in the Hill District,
an African-American working class neighborhood in Pittsburgh. She was
struck by the differences in the accounts of childhood that were presented
by the interviewees. She divided the responses into three eras. The first,
which spanned 1930-1960, was characterized by tight social relationships
in which all the adults collaboratively raised all of the children, who
themselves were collaboratively engaged in exploring the many opportuni-
ties and dangers of the neighborhood. Urban renewal implemented in the
late 1950s destroyed the major commercial section of the neighborhood,
which had served as a connector to Pittsburgh’s downtown. This caused
the destruction of many homes and businesses and dispersed many of the
area residents. People growing up in the Hill between 1960 and 1980 were
raised in smaller, though still substantial, networks. They had less sense
of security. During that period, deindustrialization eliminated many of the
employment opportunities for Hill residents (Simms, 2008).
Those growing up or raising children between 1980 and 2004 described
living in a very fragmented place. The networks had shrunk, often only a
single mother overseeing the care of children. The young people confronted
violence and danger in the neighborhood, what one respondent called “un-
expectancy.” The lack of predictability dictated self-protective behaviors for
anyone needing to travel outside the home. This state of vigilance and self-
reliance was in stark contrast to the earlier descriptions of interdependence
and reliability (Simms, 2008).
The changes in social organization, interpersonal relationships, and
views of the environment indicate a change of state in the place. Deborah
Wallace, in discussing findings on low birth weight in another destabilized
African-American community, noted (Wallace, 2011):
Ecosystem resilience theory can help interpret the results.... Holling articu-
lated this theory in 1973 to explain how ecosystems deal with impacts and
why they suddenly without warning may shift into an entirely different
structure and function … impacts become amplified … and eventually
cause a “domain shift.” (Holling’s term)
The change of state, or domain shift, appears to be accompanied by a
shift in the behavioral repertoire of the inhabitants of the place. Acker
examined the incursion of crack cocaine into the Hill district. She argued
that losses of business and population due to urban renewal and dein-
dustrialization devastated the Hill. The twin attractions of a new form
of cocaine and a new source of money triggered the kind of epidemic of
drug use that had been seen in other cities. The attractions for young men,
in particular, to affirm their identities by selling crack, were irresistible
for many. Following the logic of Bourgois (1995), who studied Puerto
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CONTEXT AND PLACE
Rican crack dealers in New York, Acker asserted, “In this world of deal-
ing with its imperative of violence, these young men enacted a masculine
identity that was denied them in the world of legitimate employment”
(Acker, 2010).
Other researchers, observing the violence epidemic that accompanied
the crack cocaine epidemic, reaching a peak between 1985 and 1995,
found that the violence was used to define and protect territory and ensure
reliability in black market transactions. The violence pervaded community
life and was part and parcel of an emerging ethos of hyperindividualism in
sharp contrast to earlier communitarian values.
Rodrick Wallace and colleagues, observing the violence epidemic at its
peak, were struck, as Acker, Bourgois, and others had been, by the “im-
perative of violence.” He used mathematical models to examine the idea
that violence, despite its high risk, was part of an emerging “language”
that was effective under the conditions of social disintegration caused by
deindustrialization and displacement (Wallace and Fullilove, 2008). Don-
aldson, a journalist studying minority neighborhoods in New York at that
time, was able to document the “language” of violence that was being used
(Donaldson, 1993).
Wallace and colleagues noted (1996):
The use of guns in the course of violent displays is a behavior that ap-
pears to conform to traditional norms. However, the lethality of guns
increases the harm that will occur and undermines the possibility that
the encounter will bring men together. For example, the gun, which has
been called the “great equalizer,” enhances the power of the individual
wielding it, without regard for the social norms for conferring power. A
teenager with a gun becomes more powerful than an older man without
one. The widespread adoption of guns by teenagers in inner-city communi-
ties, rather than conforming to established rules for displays of violence,
has reconfigured them around gun-related dynamics. Young teenagers are
clear that without a gun they feel exposed. The rate of weapon carrying
has risen precipitously. As more and more young people are armed, more
feel the need to be armed. With the rise of lethal weapons has come an
inevitable rise in injuries and deaths.
Wallace et al. (1996) also noted, “There are, of course, possible applica-
tions to many regions of the world where ‘cycles of violence’ seem to have
become established.” In particular, the article suggests that change of social
state—a domain shift—from interdependence to hyperindividualism in-
cludes a shift toward the use of violence as an essential tool of communica-
tion and social control. This, in turn, creates a negative feedback loop that
further undermines the social organization through exacerbating violence,
causing injury and death, and preventing social progress.
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88 SOCIAL AND ECONOMIC COSTS OF VIOLENCE
Exiting Chronic Violence
Marginalization, inequality, and lack of economic opportunity are
highlighted by the authors cited here as triggering and sustaining violence.
Exiting from the feedback loop of chronic violence requires restoring con-
fidence in collective organizations and creating opportunity for social and
economic engagement with the larger society. The World Bank emphasizes
two facts about this: (1) the World Bank has observed societies that have
exited from chronic violence; (2) it notes that succeeding in such a process
requires an array of social, justice, and financial interventions over a sus-
tained period of time (World Bank, 2011).
Such progress is constantly threatened by economic, social, and en-
vironmental perturbations that disturb the social ecology of a recovering
place. Drought, recession, and social disorder can undo progress, but con-
certed policies of serial forced displacement, as described for the United
States by Wallace and Fullilove (2008), will be particularly effective in
precluding community reknitting and recovery from the cycle of violence.
Despite the fragility of the situation, a broad consensus about the di-
rection for the future will help people remain focused on the road to peace
through difficult times. Sam Colt’s gun is one way of equalizing human
populations: we can choose another way.
THE IMPACT OF WAR ON
CHILD DEVELOPMENT AND MENTAL HEALTH:
A LONGITUDINAL STUDY OF RISK AND RESILIENCE
AMONG FORMER CHILD SOLDIERS IN SIERRA LEONE
Theresa S. Betancourt, Sc.D., M.A.
François-Xavier Bagnoud Center for Health and Human Rights,
Harvard School of Public Health
Abstract
This paper concentrates on the psychosocial and developmental conse-
quences of war experiences for child development and mental health using
examples from a longitudinal study in Sierra Leone, West Africa. In war-
affected countries, there is often an overlap of several forms of adversity
commonly characterizing large proportions of developing children and
their caregivers. As opposed to a simplistic view of children and violence
that ascribes their long-term well-being as mainly linked to traumatic ex-
posures or individual characteristics, a developmental and ecological lens is
used to consider the many ways in which mental health and well-being are
shaped by the interplay between individual, family, community, and societal
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CONTEXT AND PLACE
factors. The paper concludes with a series of recommendations illustrating
the interplay between building the evidence base, increasing political will
to make change, and improving the implementation of high-quality and sus-
tainable services for children, youth, and families.
Understanding Children’s Experience of War
The mental health of young people affected by war-related violence
and loss is a topic of increasing relevance to global public health (Jacob
et al., 2007; Lancet Global Mental Health Group et al., 2007; Patel et al.,
2007a,b; Prince et al., 2007; Saraceno et al., 2007; Saxena et al., 2007). To-
day, more than 1 billion children worldwide live in areas affected by armed
conflict. Of these children, 30 percent are below the age of 5 (UNICEF,
2009). Situations such as armed conflict had contributed to the displace-
ment of an estimated 18 million children as of 2006, including 5.8 million
child refugees and 8.8 million children internally displaced within their
own countries (UNICEF, 2008, 2009). Additionally, conflicts over the past
decade have caused an estimated 2 million child deaths and left another
6 million children disabled (UNICEF, 2006). It is estimated that 1 million
children over the last decade have been orphaned or separated from their
families (UNICEF, 2007a). Since 1990, an estimated 90 percent of global
conflict-related deaths have been civilians, with women and children ac-
counting for four out of five of these deaths (Otunnu, 2002). In countries
recently affected by conflict, the median adjusted maternal mortality was
1,000 out of 100,000 births compared to 690 out of 100,000 in countries
without recent conflict (O’Hare and Southall, 2007). The toxic influence of
armed conflict on child well-being is undeniable. Out of the 10 countries
with the highest rates of under-5 deaths, seven are affected by armed con-
flict (UNICEF, 2007a).
War-Related Violence Damages the Social Environment
War dramatically undermines the many layers of the social ecology that
normally support healthy child development and growth. War often heralds
increased levels of poverty, weakened community structures, insufficient
social services, economic devastation, and declines in health infrastructure
(Guha-Sapir et al., 2005). Because of its broad impact on many other
domains of human health and well-being, armed conflict is often viewed
as a rate-limiting step in development progress. For example, of the 20
lowest-achieving countries across all the Millennium Development Goals,
nearly half were affected by armed conflict (UNICEF, 2009). In particular,
opportunities and services for children were dramatically more limited in
areas affected by armed conflict; more than two-thirds of malnourished
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90 SOCIAL AND ECONOMIC COSTS OF VIOLENCE
children under age 5 live in war-affected countries (Southall and O’Hare,
2002; UNICEF, 2009).
Involvement with Armed Groups Has Profound Effects on Psychosocial
Adjustment
Much attention has been paid to the involvement of children in armed
conflict. Recently, it was estimated that approximately 300,000 boys and
girls under the age of 18 were involved in 17 active armed conflicts around
the world (Coalition to Stop the Use of Child Soldiers, 2008; UNICEF,
2007a). Children associated with armed forces and armed groups bear
witness to violence and may take part in committing atrocities. Their
connections to family and support networks are severed, leaving them to
develop in unsafe and frightening environments. Studies have shown that
children involved with armed forces and armed groups exhibit high rates
of mental health problems and that their ability to navigate reintegration
in post-conflict settings is limited by community stigma and difficulties in
interpersonal relationships (Bayer et al., 2007; Betancourt et al., 2010a;
Derluyn et al., 2004; Kohrt et al., 2008). In 2007, the Paris Principles: Prin-
ciples and Guidelines on Children Associated with Armed Forces or Armed
Conflict laid out comprehensive guidelines for preventing the engagement
of children in armed conflict and for facilitating their reintegration in post-
conflict settings (UNICEF, 2007b).
Of the studies conducted on these populations, several speak specifi-
cally to the psychosocial consequences of involvement with armed groups
and outline the need for more integrated, robust community services for
these young people. The longitudinal study presented in this paper under-
scores the complexities of post-conflict reintegration for war-affected youth.
The Value of an Ecological-Developmental Perspective
An intergenerational and ecological perspective is important for under-
standing the risk and protective factors that shape developmental and psy-
chosocial trajectories of war-affected youth (Bronfenbrenner, 1979). Among
war-affected youth, resilience—defined as the ability to thrive and do well
in spite of hardship—has most often been studied with a view toward in-
dividual qualities (Apfel and Simon, 1996). However, without considering
the multiple layers of family, peer, and social influence that shape any one
child’s mental health and well-being, these studies often take children out
of context (Betancourt, 2011). A social-ecological view of resilience applies
a broader perspective, looking to interactions between individual strengths,
the social ecology, and resources in a child’s larger environment.
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CONTEXT AND PLACE
Overview of the Social Ecology
The work of Bronfenbrenner (1979) and later writings by Elbedour
et al. (1993) and Betancourt and Kahn (2008) provide a foundation for
considering the social ecology of child development in the context of com-
pounded war-related violence and loss. Bronfenbrenner’s theory views indi-
vidual aspects of the developing child, such as age, gender, temperament, or
intelligence, as nested within a number of systems, including the “microsys-
tem,” “mesosytem,” “exosystem,” and “macrosystem.” The microsystem
encompasses different contexts (home, school, neighborhood) in which the
child interacts with his or her immediate environment. The mesosystem
is a larger system made up of more immediate microsystems and is impli-
cated when two or more settings of relevance interact. This could include
interactions between the child’s family and the school setting, such as the
parent’s communication with the school, or between the child’s family and
the extended social network, such as neighbor-to-neighbor interactions. Of-
ten, mesosystem interactions force children and adolescents to take on new
roles and responsibilities; for example, a child may withdraw from school
to care for younger siblings when the family is threatened by poverty or
illness (Betancourt and Khan, 2008; Elbedour et al., 1993).
The exosystem is an extension of the mesosystem and includes soci-
etal structures, both formal and informal (e.g., religious and tribal bodies,
government, major economic and cultural societal institutions). The exo-
system pertains indirectly to the individual. For children facing adversity
due to war-related violence, the exosystem may refer to the major actors
who contribute to determining the conditions of aid and global economic
development.
Finally, the macrosystem, or the larger cultural context including be-
liefs, customs, and the historical and political aspects of the social ecology,
also has an important role to play. The macrosystem touches all other as-
pects of the social ecology and affects how different layers interact.
Applying the Social Ecology to Consider War-Affected Youth
For youth in settings of war or conflict, the importance of interac-
tions across systems cannot be ignored. In these contexts, macrosystem-
level issues such as governance and social investments take on particular
importance. When applied appropriately, strong governance can exert
influence on the functioning of community exosystems, including the ser-
vices (e.g., schools) and protections (e.g., police) needed to enable positive
child development (Aguilar and Retamal, 1998; Ungar et al., 2007). In
turn, these community dynamics can bolster the family microsystems and
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92 SOCIAL AND ECONOMIC COSTS OF VIOLENCE
enable parents to best care for their children (Betancourt and Khan, 2008;
Bronfenbrenner, 1979; Hobfoll et al., 1991).
Responses to the Situation of Children Affected by War
United Nations Convention on the Rights of the Child
The United Nations (UN) Convention on the Rights of the Child (CRC)
provides protection at the macro level and may be applied to strengthen-
ing exo-, meso-, and microsystems. The CRC speaks to the child’s right to
protection from all forms of violence (Article 19) and exploitation (Articles
34-36), to life and maximum survival and development (Article 6), to an
adequate standard of living (Article 27), and to health and education (Arti-
cles 24 and 28). The CRC also contains a series of special protection articles
(Articles 19, 35, and 36) that address needed protections from physical
or mental violence, injury, abuse or neglect, and exploitation (including
sexual abuse), abduction, and trafficking. Specific to war, there are articles
referring to the rights to protection for children who are refugees (Article
22), as well as those otherwise affected by armed conflict (Article 38) and a
child’s right to physical and psychological recovery and social reintegration
(Article 39). Similar protections are upheld in the African Charter on the
Rights of the Child. Recent policy initiatives, such as the optional protocol
to the UN Convention on the Rights of the Child, have called on member
states to end the recruitment of children under age 18 into military forces
(United Nations, 1989).
Reconciling Psychosocial and Clinical Responses
True realization of the CRC’s mandates, and Article 39 in particu-
lar, has been challenged by disagreement among humanitarian responders
concerning appropriate treatment approaches to psychosocial and mental
health issues in war-affected youth. Betancourt and Williams (2008) previ-
ously described the existence of two main approaches—psychosocial and
psychiatric or clinical responses. Psychosocial approaches tend to focus on
restoring the social and physical environment by reinvigorating indigenous
coping mechanisms and implementing peer- and community-based activi-
ties. These interventions target a broad sample of beneficiaries rather than
a population selected according to narrower diagnostic criteria. In contrast,
psychiatric interventions aim to identify individuals who meet criteria for
diagnosable mental disorders; these individuals are then given specific treat-
ments targeted at reducing symptoms.
These two paradigms dominate the field but are often inappropriately
set at odds with one another. In fact, population-level (psychosocial) and
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CONTEXT AND PLACE
individual-level (clinical) interventions can be viewed as complementary. As
a first line of defense, psychosocial approaches to normalizing environment
and day-to-day routines promote stability during crises and may be inte-
grated with other exosystem health, social, and economic programs; clinical
interventions then provide a second line of response to help individuals who
demonstrate mental illness or profiles of risk. In an environment stabilized
by psychosocial activities, these clinical practices can be better supported
and more widely accepted by the community. This manner of operation
is also reflective of an emerging science of prevention as underscored by a
previous Institute of Medicine report (IOM, 1994).
Case Study: War-Affected Youth in Sierra Leone
The following case study examines these critical issues further. It pre-
sents a research project designed to examine how different layers of the
social ecology affect child mental health and adjustment. Unique in its lon-
gitudinal design, this study followed youth across three time points as they
adjusted to mesosystem interactions and macrosystem factors in a post-
conflict setting. In considering the historical and political context of Sierra
Leone, as well as more concrete factors that may be leveraged to improve
opportunities open to youth, this study has important implications for de-
signing holistic interventions for this and other war-affected populations.
Background: Sierra Leone
Sierra Leone’s 11-year civil conflict (1991-2002) involved a number of
warring groups, including the Revolutionary United Front (RUF), the Sierra
Leonean Armed Forces Revolutionary Council (AFRC), the Sierra Leone
Army (SLA), and other local groups such as the Civil Defense Forces (CDF).
During this period, tens of thousands of civilians were killed and roughly
75 percent of the population was displaced (Medeiros, 2007; Williamson
and Cripe, 2002). A wide range of human rights abuses were documented,
including mass mutilations and pervasive use of children in armed conflict.
Estimates are that as many as 28,000 children were conscripted into fight-
ing forces, some as young as 7 years of age (Coalition to Stop the Use of
Child Soldiers, 2008; Mazurana and Carlson, 2006; World Revolution,
2001). While many were abducted into their role as child soldiers, other
children chose to become involved, in part due to an extremely limited set
of opportunities resulting from a breakdown in family and community
systems as well as insufficient economic and educational opportunities
(Ashby, 2002). As a result of their involvement with armed forces and
groups, many youth witnessed and even perpetrated acts of intense physi-
cal and sexual violence, including executions, death squad killings, torture,
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94 SOCIAL AND ECONOMIC COSTS OF VIOLENCE
rape, detention, bombings, forced displacement, destruction of homes, and
massacres. Throughout this time, these children were continually deprived
of their rights to the protection of their families and were denied education
and many basic physical needs, such as food, water, clothing, and shelter.
A Longitudinal Mixed-Methods Study (2002, 2004, 2008)
In 2002, this author launched a collaboration with the International
Rescue Committee (IRC) to conduct a three-wave (T1, T2, T3) longitudinal
study of former child soldiers and other war-affected youth in Sierra Leone
(Betancourt, 2010; Betancourt et al., 2008, 2010a,b,c, 2011). The overall
aim of the study was to examine how social reintegration and psychosocial
adjustment in these youth were shaped by risk and protective factors. In line
with its ecological-developmental view, the study examined issues such as
age of involvement, experiences of loss and violence, family relationships,
social support, and societal stigma (Betancourt and Khan, 2008). Other
macro level factors included the challenges and successes that war-affected
youth experienced in securing a livelihood, completing school, avoiding
high-risk behavior, and contributing to civil society.
The study used a mixed-methods design, integrating both quantitative
and qualitative methods over several periods of data collection. Qualita-
tive data on local constructs of importance informed the development and
selection of core constructs of interest for the quantitative survey. In T2 and
T3, additional items were included to obtain more in-depth information on
economic self-sufficiency, interpersonal relationships, intimate partner re-
lationships and violence, child rearing and parenting, social capital, stigma
and discrimination, HIV-risk behavior, drug and alcohol use, civic partici-
pation, and post-conflict hardships.
The sample cohort for the survey contained three main subgroups. The
core sample comprised young people first surveyed as children formerly
involved with the RUF that had been referred to the IRC’s Disarmament,
Demobilization, and Reintegration (DDR) program in Sierra Leone’s Kono
District for resettlement. The sample was drawn from a master list of IRC
registries of all youth assisted by their Interim Care Center (ICC), which
served five districts during the most active period of demobilization (June
2001 to February 2002). A list of 309 youth was reviewed to identify
those who were aged 10 to 17 at time of release and for whom contact
information was available. This yielded 259 youth (11 percent female) and
their caregivers who were invited and agreed to participate in the baseline
assessment. At that time, the team also conducted a random door-to-door
sample of 10- to 18-year-olds not served by ICCs in the Kono district where
the IRC center was based. A comparison group of children (n 5 136, 29
percent female) who claimed to have not been involved with the RUF was
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102 SOCIAL AND ECONOMIC COSTS OF VIOLENCE
Conclusion
The direct and indirect costs of intimate partner violence are high for
women, their families, communities, and nations. The cost findings from
this study are especially alarming given the low rate at which women use
formal, more costly services related to violence.
These findings also do not include the high costs of violence beyond im-
mediate physical injuries. Physical and sexual violence increase women’s risk
for a host of other serious conditions, including chronic pain, reproductive
health problems, miscarriages, depression, and sexually transmitted diseases
such as HIV. Intimate partner violence is also linked to maternal mortality
and murders of women, as well as poor child health and mortality. These
costs to society in terms of the global burden of ill health (measured by
disability-adjusted life-years [DALYs]) and human development are enor-
mous. These immediate and sustained costs and impacts of violence against
women are significant impediments to the achievement of Millennium Devel-
opment Goals; thus, its elimination must be a key development goal in itself.
Initiatives such as Bangladesh’s Multisectoral Program on Violence
Against Women, Morocco’s recent national plan to address violence against
women, and Uganda’s pending Domestic Violence Bill are a good start. Still
more is needed. National governments and donors should provide support
services for survivors of violence. Moreover, they should invest in informal
dispute resolution mechanisms for women, including additional research to
assess the effectiveness of these systems and ensure that they work for women.
Finally, in moving forward, potential areas of research include a more in-
depth exploration of the nonmonetary impacts of intimate partner violence
and the help-seeking behavior of women. It is also important that research is
expanded to examine the cost-effectiveness of violence prevention programs.
YOUTH VIOLENCE IN KINGSTON, JAMAICA
Elizabeth Ward, M.B.B.S., M.Sc.
Institute of Criminal Justice and Security, and
Violence Prevention Alliance Jamaica
Damian Hutchinson, M.Sc.
Peace Management Initiative
Horace Levy, M.A.
Institute of Criminal Justice and Security
Deanna Ashley, M.B.B.S., D.M. (Paeds)
University of the West Indies at Mona
In recent years the Caribbean islands have been faced with rising ho-
micide rates. In the Caribbean, Jamaica has the highest homicide rate at 53
per 100,000, followed by Belize at 42 per 100,000 and St. Kitts at 40 per
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CONTEXT AND PLACE
100,000. Trinidad’s homicide rate has risen to 36 per 100,000, five times
the level it was in 1999. As violent deaths reach 5 percent of all deaths in
the Caribbean, the effect on these small island states is enormous and has
had a major impact on the health status of its youth. While resources are
being focused on crime control, the role of prevention of violence needs to
be brought to the forefront (Crime in the Caribbean, 2011).
In Jamaica, the impact of criminal violence on all facets of national life
has been large-scale, and the country’s 2009 interim Millennium Develop-
ment Goals report cites violence as a cross-cutting barrier preventing the
achievement of the goals. The national response to violence still is focused
on crime control, with a lackluster prevention response from all sectors.
This paper addresses the impact of the epidemic of violence in Jamaica on
its youth population, who bears the burden, and the costs of violence versus
the benefits of investing in prevention.
Young people in Jamaica’s marginalized communities have fallen
through the cracks. Local and international administrations, faced with
budgetary constraints, have focused on the macroeconomic issues and
neglected to protect them. Young people aged 15-24 years make up 17
percent of the population, or around half a million persons. These young
people experience high rates of unemployment and teenage pregnancy and
are often either victims of or major perpetrators of crime. In 2009, more
than 50 percent of males arrested for major crimes were in the 15-24 age
group, as were 11 percent of the victims (Planning Institute of Jamaica,
2010). Homicide is the leading cause of death among these males.
The Problem
While the focus of successive political administrations in Jamaica has
been to equip young people with the requisite technical and vocational
training and provide them with a protective environment to make the tran-
sition needed to adulthood, a wide gap exists between those needing and
those accessing the services. Inner-city youth are born into, grow up in, and
contribute to violence. They are easily sucked into gang and turf wars sim-
ply because they are from a particular area or linked with a certain group.
This violence dominates the communities. Surveys among adolescents have
shown that 5 out of every 10 adolescents (47.6 percent) had seen a dead
body other than at a funeral (Samms-Vaughan et al., 2005). Survival in
violent neighborhoods is important, and by age 15, 18 percent of school
children reported carrying a weapon to school (Fox and Gordon-Strachan,
2007).
In addition to community violence, family violence is widespread. Prior
to age 15, nearly one of five (18 percent) Jamaicans witnessed physical
abuse between their parents and two-thirds (60 percent) experienced pa-
rental physical abuse. Women are disproportionately affected by intimate
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104 SOCIAL AND ECONOMIC COSTS OF VIOLENCE
partner violence (IPV) with one of five women (17 percent) reported as
being victims of IPV, 15 percent of verbal abuse, 7 percent of physical
violence, and 3 percent of forced sex with an intimate partner. Corporal
punishment continues to be the dominant form of discipline in homes, as
well as in schools (National Family Planning Board, 2010).
Educational attainment in this group is dismal, with 27 percent not
completing more than grade 9 (Ministry of Education, 2010). Young people
who fail to progress in school or drop out often are those who have been
either suspended or expelled. Such disciplinary actions are the common
methods of dealing with student drug use, gang membership, and fight-
ing. The majority of gang members have a history of being suspended or
expelled from school.
The majority of young people associated with gang activities are ex- ex-
posed to poor parenting, often with harsh, erratic discipline. Frequently,
they are school dropouts—therefore functionally illiterate, with limited
ability to reason—and turn readily to gun violence. As early entrants into
the ranks of the unemployed except for menial tasks, they are excluded
from mainstream life and see themselves as rejected by society. As “failures”
and “losers” and in the absence of any meaningful program, they often
develop a gangster lifestyle.
While national unemployment levels were 11.6 percent in October
2010, unemployment for young males and females was 22.5 percent and
33 percent, respectively (Planning Institute of Jamaica, 2010). As such,
Jamaica has more than 127,000 young people described as unattached.
“Unattached” describes a person who falls within the age group 15-24, is
unemployed or outside the labor force, and is not in school or in training
(Fox, 2003; HEART Trust-National Training Agency, 2009). Within this
group are high-risk young people who are involved in crime, violence, and
other negative gang-related activities; this group usually makes up 5 percent
of the total youth population (Scott, 1998).
Unattached youth experience many problems. Studies of this popula-
tion have identified that more than 76 percent had no academic qualifica-
tions and probably needed remedial education (HEART Trust-National
Training Agency, 2009). Most of them come from low-income families in
which basic necessities, fathers, a caring supportive person, and especially
love are often in short supply. They look outside the family, like most young
people anywhere, to peer groups for support (Levy, 2001; Moser and van
Bronkhorst, 1999).
The Cycle: Youth Violence, Wounded Community, Battered Nation
The most pressing problem in Jamaica today is the high incidence of
crime, violence, and moral breakdown, which, although a country-wide
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CONTEXT AND PLACE
problem, is particularly concentrated in inner-city areas. Hopelessness
is pervasive among inner-city adolescents and youth. Their participa-
tion in the cycle of violence is often in gang and criminal activities for
young men and various forms of prostitution for young women. In the
case of young women, sex for financial gain, protection, and survival
tends to result in wanted or unwanted pregnancies. As such, the cycle
begins anew and is further perpetuated (Levy, 2001; Moser and van
Bronkhorst, 1999).
The Role of Prevention
Not all young people growing up in inner-city Jamaica become involved
in violence. In examining behavior in a Jamaican urban cohort, Samms-
Vaughn et al. (2005) found that aggressive and delinquent behaviors were
associated with underachievement, in addition to others factors; children
displaying prosocial behavior came from stable family units that displayed
affection and participated in organized activities. Looking at risk and pro-
pro-
tective factors, Fox and Wilks found similar results where exposure to car-
car-
ing relationships with responsible adults; high expectations; and meaningful
participation in the home, schools, or the community prevented adolescents
and youth from becoming involved in violent or delinquent behavior (Fox,
2003; Wilks et al., 2007).
Foundation for Prevention
Youth programs need to be built on a solid early childhood foundation.
Throughout the world, parenting interventions, including home visitation
for young children and interventions in preschool to reduce aggressive be-
havior, have been shown to be a cost-effective means of preventing violent
behaviour (Hawkins, 2007).
Interventions that included weekly home visits by trained community
health aides, with play sessions where praise was encouraged and physi-
cal punishment discouraged, showed that adults who had received these
home visits as children reported less involvement in fights or more serious
violent behavior (e.g., injuring someone with a weapon, gun use, gang
membership) and had higher educational attainment (McGuire, 2008;
Walker, 2011).
For the 10- to 14-year age group, school-based interventions are a
method of reaching the 82 percent who attend school (Planning Insti- Insti-
tute of Jamaica, 2010). An active program for school retention is needed
throughout the educational system to reduce the level of school dropouts
by offering alternative educational and behavioral strategies along with
financial support.
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106 SOCIAL AND ECONOMIC COSTS OF VIOLENCE
Youth Transition for High Risk Youths
Key components for transition for high-risk youths are
• High-risk youth transition programs,
• Foundation (parenting, life skills, literacy, relevant education),
• National Youth Club Movement,
• Consolidated youth programs,
• Youth empowerment officers (community based),
• Mentorship,
• Youth employment,
• Budget, and
• The will to bridge the gap.
Youth Empowerment Officers (YEOs) and PMI Program Implementers
should be assigned, one to each community being targeted. YEOs are
highly training to engage with youth directly. In marginalized Jamaican
communities, young people are at high risk for violence and need tangible
on-the-ground support to drive the transition process. The need for YEOs
varies within individual communities: some communities may require more
than one officer, or there may be a need to address a smaller number of
communities or for groups of communities to receive shared services to
achieve the desired change.
The PMI program implementer role would be to stabilize the high-
risk youth communities by resolving disputes and mediating conflict. They
would be in charge of the program for the high-risk unattached youth
outlined in Figure 7-1. The PMI Zone Officers and Program Implementers
would work with high-risk youth in collaboration with the YEOs, focusing
on conflict mediation and monitoring the case files of at-risk youth.
The YEO would be community based but also linked to youth infor-
mation centers. The YEO should have database information on the names
and addresses of the youth in the community that are unemployed and
unengaged, the number of youth who have dropped out of school, teen-
age mothers (Planning Institute of Jamaica, 2009) in the community, and
so on. YEOs should have all the information needed to drive young peo-
ple out of their current high-risk situation and into positive mainstream
activity. They should be qualified to deal with young people affected by
substance abuse, gangs, unemployment, peer pressure, broken homes,
poor family environment, and ignorance, as well as being sufficiently
aware of all the positive interventions available to young people affected
by these issues.
Consolidate Youth-Oriented Institutions. The YEO would work with the
consolidated youth institutions and would have to collaborate with the
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CONTEXT AND PLACE
FIGURE 7-1 Youth transition model.
SOURCE: Ward et al., 2011.
representatives of other government and nongovernmental agencies such as
Figure 7-1
the Social Development Commission, Jamaica Social Investment Fund, Citi-
zen Security and Justice Program,R02080
Community Security Initiative, Dispute
Resolute Foundation,bitmapped uneditable image Restorative Justice
Peace Management Initiative, the
program of the Ministry of Justice, Violence Prevention Alliance, Peace and
Love in Communities, among others. The several state agencies responsible
for public services, such as electricity and water, should also be included in
the interventions as needed.
Similarly, all parenting programs backed by a national policy on par-
enting should be coordinated with the YEO’s work. Budgetary and policy
support is necessary for proven programs that can be scaled up to have an
impact on the entire population.
Mentorship Program. This program focuses on unattached Jamaicans
who fall in the 15-25-year age group and are from marginalized com-
munities. Mentoring sessions will focus on (1) building quality relation-
ships, (2) conflict resolution skills, (3) building leadership capabilities,
(4) career or entrepreneurial exploration, and (5) promoting healthy
lifestyle behaviors.
Components of these programs are already in existence, but they have
to be refocused and revitalised. The size of the gap to meet the needs of the
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108 SOCIAL AND ECONOMIC COSTS OF VIOLENCE
BOX 7-2
Cost-Effectiveness of Interventions
Greenwood and others (1996) compare interventions to reduce youth crime in
the United States and find that providing high school students with incentives to
graduate, which costs $14,000 per program participant, is the most cost-effective
intervention, resulting in an estimated 256 serious crimes prevented per $US 1
million spent. Parent training prevents an estimated 157 serious crimes per $US
1 million, compared with 72 for delinquent supervision programs and 11 for home
visits and day care. All of these interventions (excluding home visits) are more
cost-effective that California’s “three strikes” law, which incarcerates for life those
individuals convicted of three serious crimes (Rosenberg et al., 2006).
youth population and the cost of programs for national, parish, and com-
munity levels are outlined in Box 7-2.
Guiding the Way Forward
Moser and Spergel identified an increasing recognition that programs
that focus on single issues have not been very successful in changing the
lives of adolescents or reducing the overall levels of delinquency (Moser and
van Bronkhorst, 1999; Spergel, 1995). These programs treat only the symp-
. symp-
toms, not the underlying problems. Interventions need to be comprehensive
and not run as vertical programs. Youth programs need to help adolescents
out of high-risk environments and align them with positive mainstream
activity. The programs must be guided by creative and effective planning
delivered by highly respected and committed individuals with unrelenting
dedication, based in the communities, who are truly and fiercely committed
to this arduous, on-the-ground task.
Youth violence is a complex social phenomenon, but it is also a major
development problem. In making the recommendations for developing
interventions, it must be understand what works and what doesn’t work
for youth violence prevention. Youth programs must be built on a firm
foundation (parenting, life skills, literacy, and relevant education). These
programs must be supported by the required budgetary allocation and,
more importantly, the will to bridge the gap.
Conclusion
Young people represent a tremendous untapped potential in Jamaican
society. Revamping youth development interventions to meet the challenges
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109
CONTEXT AND PLACE
of this group will provide a driving force for Jamaica toward sustainable
development and economic prosperity. This will require the commitment
of all segments of the society to focus on community prevention in order
to effect the changes needed.
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