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 protective factors can mean less damaging impact and faster rebuilding. On the other hand, localities that are already fragile and under strain see more devastating effects of violence and often are trapped in repeated cycles of violence.

The first paper explores the role of social context in violence, particularly 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 conflict 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



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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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85 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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87 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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89 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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91 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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93 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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103 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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105 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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107 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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