CRIME AND VIOLENCE PREVENTION: FROM SCIENCE TO ACTION

Cali, Colombia--June 26, 2013Mark Rosenberg—The Task Force for Global Health

1

The State of Violence Prevention: Progress and Challenges

Smallpox is the only human disease that has ever been eradicated

• 1806—Jefferson wrote to congratulate Jenner on making smallpox history, like finding the holy grail

• 1959–-WHO estimated global eradication could be achieved in 4-5 years through a massive effort but administrative problems at WHO sapped the momentum.

• 1966—Bill Foege arrived in northern Nigeria when they had several hundred outbreaks of smallpox.

• 1973—Foege was sent to India where there were 87,000 cases of smallpox and the situation quite hopeless.

Smallpox was eradicated by changing the paradigm

• From mass immunization to containment• It is the only human disease that has ever been

eradicated• Eradication protects even the poorest from a

disease or problem that would otherwise smolder among poor people in low income countries

• This accomplishment has inspired other efforts at disease eradication and elimination

We have paradigm shifts that are just as significant in the field of violence prevention

• Violence is preventable—it does not have to happen and our approach is not limited to intervening after it happens

• There is science to be applied—and more to be learned—and it comes from a broad range of disciplines

• Collaboration is an absolute neccessity. Violence does not “belong” to any one ministry or discipline or sector; no one age group or gender, no region, no nation, no community is immune, and the lessons each of us learn can benefit each other.

Violence is not “evil in the world”• “The intentional use of physical force or power,

threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation.“

• Specific categories of violence: child maltreatment, intimate partner violence, youth violence, armed violence, sexual violence, elder abuse, suicide and self-directed violence.

• For each type of violence, we apply science, ask the four questions:

CDC’sPublicHealth Model

Define the Problem

IdentifyRisk Factors

Find what Prevents

the Problem

Implement &Evaluate Programs

What’s the problem?

What are the causes?

What works?

How to do it?

Discovery Delivery

“Knowing is not enough, we must apply….”

• When we talk about our “science base” or evidence-based approach we are talking about knowledge

• We do four things with knowledge– Knowledge generation (research)– Knowledge integration– Knowledge dissemination– Knowledge application (delivery).

• The goal is to apply it, and this is going to be your job.

What’s the problem?• Burden is large and truly global—1.6M deaths each year,

more than 90% of the burden born by low- and middle-income countries.

• Deaths are a poor measure: impact far beyond the direct costs of physical injury and death. – Exposure to violence in childhood (maltreatment or witnessing) is a

risk factor for many chronic and infectious diseases through its influence on risk behaviors such as substance abuse, depression, obesity, smoking, teenage pregnancy, and high-risk sexual behavior.

• Costs will be enormous: exposing children to violence will have long-term impacts on infectious and chronic disease, and mental illness.

What are the causes?

• Risk factors and protective factors for each type of violence—many of these affect more than one type of violence: e.g. alcohol, child maltreatment, exposure to violence

• Different types of violence are connected in many ways, how a cycle of violence that begins with child neglect at birth, leads to hyper-vigilant children who are less likely to be calmed and more likely to participate in interpersonal violence, intimate partner violence, elder abuse and suicide when they get older.

What works to prevent it?

Prevention before

occurrence

Prevention of

recurrence

Prevention of

impairment

Physical abuseSexual abuseEmotional abuseNeglectExposure to IPV

Long-term outcomes

Universal Targeted

MacMillan HL, Wathen CN, Barlow J, Fergusson DM, Leventhal JM, Taussig HN. (2009). Interventions to prevent child maltreatment and associated impairment. The Lancet. 2009;373:(9659):250-266. Claire Crooks, Ph.D., C.Psych.

Associate Director, CAMH Centre for Prevention Science

A system with many points of entry:

You will hear so much more about this.

How do you do it?

• Value of collaboration among different sectors and disciplines: police and public health, instead of fighting for control collaborate effectively. No one sector “owns” this problem.

• Important advocacy groups led by survivors• Expanded from treatment only to treatment and prevention,

often working together rather than at odds.• Institutions have been strengthened: WHO, CDC, World Bank,

IADB, law enforcement, development, education have regional/national/community programs.

CDCPublicHealth Model

Define the Problem

IdentifyRisk Factors

Find what Prevents

the Problem

Implement &Evaluate Programs

What’s the problem?

What are the causes?

What works?

How to do it?

Discovery Delivery

Challenges: What’s the problem?• Fatalism: violence is an inevitable part of human life and not

preventable. • Separation of different types of violence into siloes• Violence affects the most needy, poor, and vulnerable

disproportionately and they don't set the spending priorities.• “Either/or” thinking: don't believe violence is really a public health

problem, but that it belongs to criminal justice. Or vice versa • Privacy ruse—the belief that violence is a family affair and that

what happens in the family (or country) stays in the family. IPV is seen as family business.

• Stigma and shame keep people and countries from reporting kinds of victimization like rape.

Challenges: What are the causes?• Dichotomous thinking: the cause must either be guns,

or mental illness; angry husbands or too much alcohol.• Becoming disconnected while believing we are

becoming more connected: There is a risk that increased reliance on indirect communication methods such as cellphone and email may diminish the direct personal communications and thereby make it more likely that violence will be employed against someone whose face and persona are not known.

Challenges: What works?– We lack proof of effectiveness for many interventions

in low- and middle-income countries and without the proof of effectiveness countries and donors don't want to invest in preventive interventions. Without their wanting to invest, we can't demonstrate effectiveness.

• Few interventions have been implemented in developing countries with the capacity to evaluate the outcomes and collect the data needed to measure cost-effectiveness.

• Must invest in building the capacity to take interventions that have proven effective in developed countries and systematically implement and evaluate them in developing countries (WHO, 2008).

Challenges: How do you do it?• Lack of political will• Lack of resources• Scepticism about the feasibility of delivering complex social

interventions in resource-poor setting, • Time-lag between prevention program delivery and reduced rates

of violence for interventions such as parent training and life skills training.

• Scalability –we can do demonstration projects, but don’t know how to scale up programs that work to have national impact

• Delivery—Bottlenecks occur limiting our capacity to implement solutions, a universal problem for global health. Much to be learned from business sector.

Collaboration is rarely easy

17

Multi-sectoral Collaboration is Not Easy

– The science is easy, but people are hard, and institutions are impossible.

– A coalition is like a marriage: it is very easy to get into it but very hard to make it work

• Stakeholders speak different languages, have different cultures and every organization has its standard operating procedures

• There is competition for credit, power, and funding. • Obstacles (and opportunities) occur every day at every

level: global, multinational agencies, regions, countries, communities.

Acknowledgements for those who continue this work

Special thanks to:• Jim Mercy• Fran Henry• Alex Butchart• Joan Serra Hoffman

Rodrigo Guerrero, MD, DrPH• Physician with a Master of Science and Dr. P.H. in Epidemiology from Harvard

University, • Spent his life helping and teaching (Head of Department, Dean of Health

Sciences and President of Universidad del Valle, Secretary of Health of Cali). • Elected Mayor of Cali (1992), developed epidemiological approach to urban

violence prevention • Joined the Pan American Health Organization in Washington, where he started

the Violence Prevention Program• Founding director of bringing together World Bank, Inter-American

Development Bank, Organization of American States, UNESCO, Pan American Health Organization, and US Centers for Disease Control and Prevention

• Elected city counselor of Cali (2008), Mayor of Cali (2012-2015)• Dedicating time to Vallenpaz, a non profit corporation devoted to help

peasants in conflict ridden rural areas of Colombia.

“Knowing is not enough; we must apply. Willing is not enough; we must do.”

Goethe

21With thanks to Don Berwick

Rodrigo Guerrero is a man committed to making things happen

Extra Slides

Joan Serra Hoffman, PhD• Violence prevention specialist with the Latin America and Caribbean Social

Development Citizen Security Team, building strategic partnerships with leading research, practice and policy institutions in the area of citizen security and crime and violence prevention in the U.S., Europe, and Latin America.

• Advisor to governments, multilateral and bilateral organizations and universities in the Americas, participating in the development of national citizen security and violence prevention initiatives in 12 countries.

• Special assistant in youth violence prevention, US Centers for Disease Control and Prevention,

• Founding co-director of Inter-American Coalition for the Prevention of Violence (IACPV),

• Director, US National Network of Violence Prevention Practitioners• Author Beyond Suppression: Global Perspectives on Youth Violence (Praeger

Press, Global Crime and Justice, 2011).