Violence is a Public Health Issue: Public Health is Essential to Understanding and Treating Violence in the U.S.

Abstract
This policy statement proposes that APHA officially deem violence a public health crisis, that public health approaches have proven effective in reducing violence, and that a comprehensive system is needed to prevent the loss of 60,000 lives and countless traumas each year. Current efforts to reduce violence have not been sufficiently effective. National data demonstrate a recent increase in violent events. In addition, there is increasing evidence of the profoundly harmful effects of violence on child development, the long-term health of affected populations, and the economic development of entire communities, especially communities of color. The current fragmented approach that leans heavily on the justice system needs to be updated to an integrated one that supports extensive cross-sectoral collaboration with an emphasis on health. This will allow all agencies to be involved and held accountable for preventing violence and its health effects. In this approach, health departments, hospitals, schools, universities, nonprofit organizations, and justice systems share data on all forms of violence, identify protocols for screenings and referrals, develop and enhance programs and policies to prevent and reduce violence, and use data to continuously increase the efficiency and effectiveness of these efforts. A unified effort that works mainly through existing infrastructure, addresses systemic and institutionalized trauma, and connects the health sector to other sectors is the most effective way to address the violence that devastates so many American communities and jeopardizes the health of the nation. This policy statement serves as an introductory statement that can be expanded upon through additional policies.

Relationship to Existing APHA Policy Statements
This policy statement is related to APHA Policy Statements 9818 (Handgun Injury Reduction) and 200914 (Building Public Health Infrastructure for Youth Violence Prevention). The existing APHA policy on gun violence illustrates strategies and policies that can be applied to other types of violence as well and social transmission of violence in neighborhoods that are known as violence hotspots. Violence prevention programs can be implemented in parallel with gun control legislation. The existing policy on youth violence was a significant step for the public health field to take toward deeming violence a threat to the health of the nation. However, that statement was specific to youths and excluded domestic violence and suicide. A focus on the interconnectedness of all forms of violence, along with a call for a system of health approaches to prevent all forms of violence in all populations, is imperative for the health of our nation.[1]

Problem Statement
The recognition of violence as a health issue is founded on an understanding of violent behavior as arising from contextual, biological, environmental, systemic, and social stressors.[2]Violence is defined as "the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, which either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation.[3] A "trauma-informed" approach suggests that violence is not symptomatic of "bad people" but, rather, is a negative health outcome resulting from exposure to numerous risk factors.[4] The public health approach to violence focuses on prevention through addressing the known factors that increase or decrease the likelihood of violence. Within the health system, every interaction is an opportunity to prevent violence directly. Thus, the public health system must play a primary role in preventing the spread of violence, with the public health workforce involved in the critical functions of training, educating, and analyzing, and there must be an explicit focus on addressing inequities and reducing racial bias in the system's institutions. This approach not only prevents harm and injustice but also saves a significant amount in funding. In Maryland, the cost of gun violence alone is estimated at $3.6 billion[5]; the overall U.S. estimate is $460 billion,[6] including $318 billion in lost productivity[7] and $93.5 billion related to suicide alone.[8]

This builds on a growing body of work, including the 2001 surgeon general's report on youth violence, showing that the health approach to violence can be effective. In this foundational document, Dr. David Satcher stated that "the key to preventing a great deal of violence is understanding where and when it occurs, determining what causes it, and scientifically documenting which of many strategies for prevention and intervention are truly effective."[9] Community members have unique insight into the local context and often have the credibility to reach those at highest risk and engage in the work of violence prevention. Several models of prevention and health care delivery have seen success through employment of "credible messengers" or community health workers, including outreach workers, prevention professionals, hospital responders, and violence interrupters. These individuals can help young people and families navigate systems, resolve differences, and choose alternative paths and can speak up for the need for more positive resources in communities. They function as an integrated team across all sectors in a community.[10] Violence is a health problem in which prevention is the key to both immediate and long-term outcomes. The issue of violent behavior is much broader and deeper than current law enforcement, firearm control, and mental health debates may suggest. If we want to reduce violence in our local and global communities, we must acknowledge that it is predictable and preventable. Violence is almost never "senseless" or "random"; rather, it is an epidemic, meaning that it spreads, clusters, and transmits through exposure. Our current system for addressing violence was born largely from a misdiagnosis of the problem. With a new scientific understanding, the health system can implement strategies to reduce and eliminate violence.[11] As a society, we desperately need a deeper understanding of individual and communal behaviors, how they arise, and how to maintain or prevent them, with public health at the center of these approaches.

More than 30 years ago, U.S. surgeon general C. Everett Koop issued a public health call to action that included the following components: "education of the public on the causes and effects of violence, education of health professionals as to better care for victims and better approaches to violence prevention, improved reporting and data-gathering, some additional research, and increased cooperation and coordination...among health and health-related professions and institutions."[12] Dr. Koop had a prescient vision for a health-centered response to violence in which the health system assumes a central role in both treatment and prevention.

This statement was echoed by the World Health Organization, particularly in regard to the use of data to inform violence prevention efforts. Many areas globally and locally lack collection mechanisms to strategize appropriately or evaluate the success of existing efforts. This has led to missed opportunities to comprehensively address violence in a sustainable manner. All forms of violence, including community or peer violence, suicide, intimate partner violence, bullying, workplace violence, elder abuse, child abuse, and sexual abuse and trafficking, must be addressed and prevented.

Every day in our nation, an average of 39 people are killed and 117 die by suicide.[13]; 180 more are shot and wounded,[14] 27,400 are hurt by a partner or significant other,[15] and 8,640 children are abused or neglected at the hands of someone they trust.[16] In the United States, homicide is the third-leading cause of death among those 1 to 45 years of age, resulting in a loss of approximately half a million years of life before the age of 65 years.[17] Violence affects all of us, with some groups impacted much more than others. For example, the homicide rate among Black male youths between 10 and 25 years old is nearly 20 times higher than the rate among White male youths.[18]

Beyond direct injury, exposure to violence increases the risk of other medical illnesses, including asthma,[15] hypertension,[19] cancer,[20] and stroke.[21] Violence also contributes to psychiatric illness, including depression and post-traumatic stress disorder.[22] In addition, those who are exposed to violence are more likely to sleep poorly,[23] to smoke,[24] and to become socially isolated,[13] all added risk factors for early death. Negative health outcomes are also seen in statistics related to HIV, maternal health, and adoption of unhealthy behaviors such as alcohol and substance abuse.[25]

It is understood that doctors, nurses, and other health workers play a key role in saving the victims of violence in trauma units and emergency departments. However, we must expand the role of health care workers to helping people and communities stay safe in the first place by preventing violence. A crucial way to do this is by treating violence as a public health problem addressed by health practitioners.[26] A violence prevention system similar to disease prevention initiatives can be incredibly effective. Just as health campaigns in the flu season encourage hand washing and vaccination, violence prevention programs should encourage conflict resolution to interrupt transmission of violence.[27] Local approaches to investing in opportunities and addressing risk factors among young people can build trust, hope, and resilience.[28] Within the health care system, health worker interactions with patients provide opportunities to screen for domestic violence, past exposure to violence, or behavioral problems that may lead to violence. Most people who have mental illnesses are not dangerous, but many people at risk for violence are at risk due to mental health issues, suicidal thoughts, or feelings of desperation. As people with mental illnesses are more likely to be victims of violent crime than members of the general population, strategies and interventions must be developed and implemented with a focus on building resilience among these individuals and providing resources and connections that address their needs.[29]

To prevent violence at home and in communities, the public health approach focuses on building healthy gender norms, healthy relationships, socially just institutions[30]; changing norms; and creating protective environments.[31]

As stated previously, violence disproportionately impacts people of color and other oppressed groups such as the lesbian, gay, transgender, queer, intersex, and asexual (LGBTQIA) population and those living below the poverty line. Communities living without adequate resources and those facing unfair treatment are more susceptible to all health issues, including violence. The factors that enhance or inhibit health also impact violence, while violence in turn affects determinants such as housing, education, transportation, and economic conditions. Thus, violence itself should be seen as a social determinant in that violence begets violence and exposure to violence is the greatest predictor of future violence.

To mitigate the various risk factors for violence, communities must address environmental factors that increase susceptibility to violence in order to both reduce communities' susceptibility and bolster their resistance.[32] Communities must work to replace negative norms that encourage use of violence with positive norms that hinder its spread.[33] Community efforts also must address environmental factors such as employment, education, housing, safe spaces, equity, and social cohesion.[34,35] Community initiatives including violence prevention programs improve quality of life through provision of accessible, high-quality health care as well as school facilities, libraries, parks, and other public amenities. Grassroots mobilization of community members is also essential for improving health, in particular by holding systems accountable and changing social norms to prevent violence rather than accept it. It is critical that members of impacted communities be deeply involved in all aspects of development, implementation, and evaluation of the components of this integrated, collaborative health system.

In combination with violence prevention strategies such as those just described, health intervention strategies can address historical and systemic inequities that allow violence to persist.[36,37] Violence prevention strategies might also increase the impact of firearm legislation on violence and the effectiveness of community policing,[38] and decrease violence among and between school-aged youths, by introducing the health approach before violence occurs.[39] Violence costs each U.S. taxpayer approximately $3,200 per year in medical expenses, court costs, lost productivity, subsequent trauma, and more. With prevention strategies showing declines in violence of upwards of 70%, the savings would be considerable. The comprehensive, integrated approach would also allow for pilots, enhancements, and dissemination of promising practices in all sectors. Given the lack of research and successful efforts in some areas of violence prevention, including efforts addressing child sexual assault, trafficking, elder abuse, and more, this innovative approach has the potential for immeasurable impact.[40]

Evidence-Based Interventions and Strategies
Rigorous evaluations of health approaches to violence prevention and intervention have shown reductions in injuries, shootings, and deaths as well as changes in attitudes and norms. Examples are outlined below.

• A Chicago program using public health methods to interrupt violence, reduce risk, and change neighborhood norms reduced homicides and shootings by up to 70% and retaliations by 100%.[41] In Baltimore, one historically violent neighborhood went more than 22 months without a homicide after implementation of the same model.[42] In New York City, the John Jay College of Criminal Justice Research and Evaluation Center released an extensive independent evaluation of the local Cure Violence program that showed a 37% to 50% reduction in gun injuries in the two communities examined, a 14% reduction in attitudes supporting violence (with no change in the control groups), and increased confidence in and willingness to contact police.[43]
• The results of an investigation of an Oakland, California, hospital-based violence intervention program (HVIP) incorporating trauma-informed care practices and case navigation showed that 98% of program clients were not reinjured and 70% were not arrested.[44]
• Positive outcomes have also been documented in studies of other HVIPs around the country. An evaluation of a program in Baltimore, for example, revealed an injury recidivism rate of 5% among participating patients (as compared with 36% among nonparticipants), creating significant savings in health care costs. Moreover, patients participating in the program were half as likely as those who did not participate to be convicted of a crime and four times less likely to be convicted of a violent crime, generating significant savings owing to reduced levels of incarceration.[45]
• Evaluations of HVIPs in Indianapolis, Chicago, and Richmond, Virginia, have also shown promising outcomes, including significant reductions in reinjury rates.[46]
• The Safe and Successful Youth Initiative in Massachusetts, which requires cities to focus on using a street outreach model to provide comprehensive services and mentoring to at-risk young men 17 to 24 years of age, has been associated with a 35% reduction in violence and a cost saving of $7 per dollar invested.[47]
• Rates of dating violence victimization were 56% to 92% lower among youths exposed to a North Carolina adolescent dating violence prevention intervention than among control group members, and the effects were sustained for 4 years.[48]
• A health-based parenting program delivered in communities of 100,000 children under 8 years of age resulted in an average of nearly 700 fewer cases of childhood maltreatment over 2 years.[49]
• A nurse-visiting program delivered among children born to high-risk unmarried teens led to 80% fewer cases of child abuse and neglect in Elmira, New York, and a program in Memphis yielded 79% fewer hospital days for child injuries relative to the comparison group total.[50]
• Suicide prevention programs focused on a wide range of interventions, populations, and settings have been evaluated with positive outcomes across numerous contributing risk and protective factors. Many of these programs have been evaluated and shared through the Suicide Prevention Resource Center. The Centers for Disease Control and Prevention (CDC) also makes the case for addressing suicide as a public health issue and provides recommendations for establishment of evidence-based programs.[51]
• In Philadelphia, system-level solutions are sought to prevent violence, in part through an innovative citywide injury review panel that engages leaders from law enforcement, medicine, psychiatry, behavioral health, child protection, legal services, and education to identify policy lessons and solutions from the experiences of injured youths.[52]
• In Los Angeles, business improvement districts demonstrated an 8% reduction in violent incidents across 30 communities.[53] Other outcomes were reductions in out-of-school time,[54] increases in dropout ages,[55] decreases in alcohol outlet density,[56] and increases in alcohol taxes.[57]
• Nationally, the Family Violence and Prevention Services Act, the Violence Against Women Act, and Department of Justice initiatives such as the National Institute of Justice Programs and Supporting Male Survivors of Violence, along with the National Forum for Violence Prevention and many CDC initiatives (e.g., Striving to Reduce Youth Violence Everywhere), have been essential to paving the way in incorporating health approaches into policy and programmatic collaborative efforts to address violence.[58–63]

The strategies just listed and many other promising practices are intentionally focusing on those at highest risk for violence. In the United States, we know that communities of color are experiencing higher rates of violence and exposure to violence. We also know that this burden impacts other oppressed groups, including women and the LGBTQIA community. If violence is reduced in these communities, inequities related to violence (e.g., inequities with respect to birth outcomes, life expectancy, and chronic disease) will decrease in turn, creating healthier, safer communities and homes so that people can reach their fullest potential.

Cities across the country are using the public health approach to address violence across all sectors. In Minneapolis, for example, this comprehensive strategy was designed by city agencies; community, civic, and business groups; and hundreds of young people. Initial findings suggest that adoption of the model in the 20 neighborhoods with the highest rates of violence correlated with a decrease of 57% in the number of individuals younger than 18 years (i.e., those involved in the intervention) arrested or suspected in violent crimes, while killings of people younger than 24 years fell by 76%.[38]

The body of knowledge and evidence supporting this approach has grown tremendously. Although much work is still needed, the health responses emphasized above have been shown to have impact. The CDC provides technical packages largely based on these findings.[64]

There is a great need for collaboration among different sectors to provide holistic assistance to those at risk of violence, to make resources from multiple sectors available, and to institutionalize a true change in our nation’s understanding of and approach to violence and its prevention. In this new framework, cooperation will occur at all levels and be facilitated through regular cross-sector meetings designed to exchange information and develop coordinated responses. Cross-sector collaboration also focuses on particular sectors that have natural linkages in their work as it relates to violence prevention, with leadership coming from health stakeholders such as local health departments, universities, and nonprofit organizations with expertise in this area. One current example of a successful cross-sector collaboration involves the Street Violence Response Team in San Francisco, which convenes weekly meetings with senior representatives from the mayor’s office, the police department, community-based organizations, the public health department, child and family services, and the district attorney’s office, among others.[4]

Opposing Arguments
Much of the resistance to the public health approach to violence revolves around our current framing of violence as an issue that is the responsibility of law enforcement and the criminal justice system.[65,66] Current approaches and dominant beliefs erroneously focus on law enforcement, public safety programs, and the criminal justice system and their emphasis on violence during or after an incident has occurred. Focusing on punishing violent actors after a violent incident has occurred fails to acknowledge the larger societal factors contributing to perpetuation of violence and the fact that violence is in fact preventable.[67] These strategies have also been shown to reduce the overall health of the communities most impacted by violence and to contribute to mass incarceration, especially among young Black men. Public health methods are inherently designed to address upstream factors to improve downstream outcomes, and these strategies have been proven to be effective in the prevention of violence.

Another argument attempting to dissuade people from adopting health approaches is that there often is a lack of funding available to address the problem. However, numerous studies show that our nation is paying extremely high costs, many of which are avoidable by investing in prevention and intervention.[68] Significant savings in multiple sectors can occur with investments in public health approaches. For example, HVIPs have been proven to be cost effective. In San Francisco, researchers found that, for approximately every 100 young adult patients served annually, the city’s program generates 24 quality-adjusted life-years and produces hospital savings of $4,100.[69] In addition, a 2014 study examining the financial burden of violent injuries on the Medicaid program showed that the newly covered patient population would result in approximately $397 million in annual costs for direct medical care of violent injuries. It has been estimated that providing HVIPs to all violently injured hospitalized patients would result in a national Medicaid savings of $69 million.[70]

Those promoting prevention strategies are often challenged to prove the role of these strategies in reducing the occurrence of violence. However, there is a long history of violence being treated as a public health issue, and the evidence that has driven these approaches is extensive.[71] Core to public health strategies is the use of data to prove effective model designs and implementations, which are significant drivers for the large shift toward these approaches being observed around the world. Well-designed studies comparing neighborhoods have controlled for such effects as gentrification and law enforcement measures and still proven that public health methods are having a significantly positive impact.[43,44] Nevertheless, there is a consistent need for dedicated funding for continued, rigorous research on the impact of primary, secondary, and tertiary prevention efforts designed to reduce the incidence and impact of violence.

Health professionals often understand the data and see the need but may be unsure how to address the issue given existing resources. With the growing understanding of the impact of violence on the nation’s health and increased acceptance of evidence-based methods, a shift in thinking and action will continue to prove that health leaders can use their powerful methods in the violence prevention arena.

Action Steps

• APHA calls on health departments to assess and analyze data on violence to provide improved health information related to violence and implementation of violence prevention models (e.g., Cure Violence). Data must be collected, analyzed, and reported at least annually by all state and county health departments and include details regarding effects on historically marginalized communities, including communities of color, women, children, youths, LGBTQIA populations, and religious groups. Health departments must see violence prevention as essential to promoting health and as falling within their sphere of influence and responsibility.
• APHA calls on entities implementing or funding community health programs, including nonprofit foundations and associations, to initiate programs to prevent violence that include detection and interruption of transmission of violence on the part of professionally trained workers and that identify and change behaviors and social norms among at-risk individuals and the community. Community health workers, nurses, patient navigators, and promotoras are often aware of potentially violent circumstances within homes and communities long before they manifest in a hospitalization or in a police or child protective services report. Linkages to mediation, child protective, or crisis management services allow providers to address the critical need for safety among their clients.[72] Providers must be equipped to deliver trauma-informed and culturally relevant services that recognize that patients may bring with them a history of traumatic experiences and a need for emotional support, and they must identify those at risk for violence in order to intervene effectively.[73,74] Specific attention must be paid to those disproportionately impacted by violence, including communities of color, women, children, youths, and LGBTQIA and religious groups. All community health programs should be able to implement violence prevention and trauma initiatives that include training of frontline staff as a core component.
• APHA calls on hospitals, societies of health professionals, and academic institutions to train health professionals, including doctors and nurses, in identifying risks,[75] detecting signs of violence and trauma, responding in a trauma-informed manner, and ensuring appropriate referrals to services and treatment. Health worker interactions with individuals provide opportunities to screen for violence, past exposure to violence, or behavioral problems that may lead to violence. These at-risk individuals can then be provided with and connected to resources that address their needs.[76] As with community health programs, all health care institutions that interact with individuals exposed to violence should be able to implement violence prevention and trauma initiatives that include training of staff as a core component.
• APHA calls on local, state, and federal government agencies to adopt, invest in, expand, and support evidence-based and promising public health approaches to violence prevention, including screening practices related to intimate partner violence, elder abuse, and abuse of vulnerable adults as detailed in the U.S. Preventive Services Task Force recommendations.[77] Local health departments play a critical role in leading impactful violence prevention work nationwide.[78] Existing funding is not sufficient to address the violence epidemic and evaluate interventions in terms of effectiveness and cost savings. Past funding has fluctuated significantly, which has proven detrimental to communities already experiencing health crises. At present, only five states are directly investing in these types of community-based violence prevention solutions.[79] Funding for research and evaluation must be included in this strategy if there is to be an understanding of all aspects of violence and its evolution among populations such as communities of color, women, children, youths, LGBTQIA populations, and religious groups. The public health approach employs research to stay relevant and credible. Evaluation of the efforts implemented will reveal ways to improve, expand, adapt, and shift in order to invest in and leverage high-impact efforts in all 50 states. Prioritization must be given to approaches that have shown an effect on multiple adverse outcomes (e.g., prevention of or decreases in violence and substance abuse).
• APHA calls on the CDC, in collaboration with local and state health departments, to establish a database or active surveillance system for monitoring violence as it occurs in communities. This will inform violence prevention organizations with real-time data in an effort to include violence in emergency preparedness activities across the United States. This effort will build off of the only existing national database on violence, CDC’s National Violent Death Reporting System, thus diverting resources to existing outbreaks. Across sectors, further methods for reporting, collecting, sharing, and using data on all forms of violence must be established in accordance with data privacy laws and Health Insurance Portability and Accountability Act restrictions to protect the privacy and safety of individuals while also strengthening use of data across all prevention programs. This information will be used to generate cost-benefit data and predictive analytics to prevent and reduce violence across communities, with a specific emphasis on identifying ways to reduce inequities related to violence. Institutions with health-based data reporting systems already in place should adapt those systems to include data on violence.[80] The proposed surveillance system must make data on violence more accessible to the public and guide violence prevention efforts moving forward.

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