A bullet pierces a medellin window. Photo by Steve Ferry
Dealing with Risk Factors
By Rodrigo Guerrero
When you think of violence and how to control it, often the first thing that comes to mind is security. However, violence control is no longer seen as the exclusive domain of the police and the criminal justice system. Violence has become a public health issue, and social, political and behavioral scientists, as well as mental and public health specialists, are participating in a lively and transnational discussion.
Violence began to be seen as a public health issue in the modern world only recently. In 1992, U.S. Surgeon General Everett Koop declared violence a public health emergency. In 1993, health ministers throughout the Americas adopted a joint resolution declaring violence prevention a public health priority.
Both in the United States and Latin America, violence was beginning to be understood as an outcome of experience, rather than predominantly genetic factors. Perhaps the most impor¬tant general insight of recent years has been the recognition that life experience can shape brain chemistry in significant ways, and that experience and neurophysiology (nurture and nature) form a seamless web. Children exposed to family violence have a higher risk of violent behavior during adolescent life.
When doctors think of preventing cardiovascular disease prevention, they apply a “risk factors control strategy.” That means, they tell patients to smoke less, exercise more often and to avoid eating fatty foods. Public health campaigns around these issues have impressively decreased cardiovascular disease. Likewise, public health, with its emphasis on reliable data and risk factors control, can be a practical and simple approach to violence prevention.
Some risk factors in Latin America and elsewhere include a pattern of family violence, extensive alcohol or drug use, access to firearms; exposure to constant violence in the media; absence of cultural patterns to regulate urban behavior; inefficient and corrupt judicial and police systems and the presence of organized crime.
The Inter American Development Bank and the World Bank currently consider violence and insecurity to be the major obstacles to development. In the year 2000, the Americas suffered the loss or transference of 14.2% of gross national product (GNP) — US$ 168 billion —because of violence. Noreover, 1.9% of GNP is lost in human capital, an amount equivalent to the region's total expenditures on primary education.
In health terms, intentional violence is the first cause of death in many countries of the region and it is estimated that there are 120 000 homicides a year, and 3 days per person per year are lost to violence. Additionally, 30 to 60% of all emergency visits to hospitals are due to violence. About 60% of all violent acts, whether murders, child abuse, family abuse, assaults, or felonies, are associated with the consumption of alcohol.
When I was elected mayor of Cali in 1992, I found that communicable diseases and diarrhea were no longer the main health issues. Homicides and motor vehicle deaths had become the first cause of death in the general population. Homicide rates had escalated from 23 to 90 homicides per 100,000, in the 10-year period between 1983 and 1993. This significant rise in the rate of crime was accompanied by the public perception of violence and insecurity as the most serious problem in the city. Interestingly, even the poorest people mentioned violence as having priority over other traditionally important issues like unemployment (9 % in 1993) and cost of food. As a physician, I began to think of the possibilities of treating urban violence as a public health problem.
In Colombia, the public health approach were first initiated in Cali in 1992 continued later in Bogotá. Although there were some differences in emphasis, the cities of Bogotá and Cali followed the same basic public health approach.
Both cities adopted the WHO definition of violence: The intentional use of physical force or power, threatened or actual, against oneself, another person that has a high probability of resulting in injury or death. Both cities developed violence information systems that provided periodic, opportune and reliable information to their mayors and other city officials. Among other policies, similar control measures were applied in both cities when alcohol consumption and carrying hand guns were identified as homicide risk factors. An evaluation of the the restriction of hours for the selling of alcohol showed significant reduction of homicides in Bogotá, and of the banning of permits to carry firearms showed a 14% reduction of homicides in Cali and Bogotá.
In Cali, a committee, under the direction of an epidemiologist and with representatives from the police, judiciary, forensic medicine, health and human rights groups met weekly. Cali also engaged in an interesting project involving children in the context of its DESEPAZ program. Given the fact that more than 80% of murders were committed with firearms as well as the need to restrict permission to carry firearms, the municipal government launched “Children Friends of Peace.” The program invited children to give up their war toys in exchange for one-year free use of Cali recreational facilities and training workshops on civic education and peace, culminating with a huge party in the Cali’s largest and best equipped park, with clowns, puppets and raffles.
A Committee was created under the direction of an epidemiologist, This group held weekly meetings in order to analyze crimes committed in the previous week and to prepare a report for Municipal Security Council that met every Thursday.
However, many of the measures adopted in Cali have not been continued, and the city has experienced inconsistent results in violence prevention.
In contrast, Bogotá has applied consistent policies over 12 years. The emphasis on risk factor control, coupled with the recuperation of public space, public transportation and the creation of bicycle paths, has led to a sense of citizenship. Citizens must participate in efforts to reduce violence. It was necessary to change the traditional way of thinking in Colombia, in which violence control is left to the authorities. Empowering the community was a key strategy to improve public safety in Colombia. Violence and crime were considered to be too important to be left in the hands of the police and military alone.
The Colombian experience indicates that public health approach, in association with more traditional methods such as police control and law enforcement, is a valuable contribution to the prevention of violence. Just as early education, ad campaigns and the banning of smoking in public places have made cigarrette use frowned upon in the United States and other parts of the world, a public health approach to violence can help citizens control an epidemic that is threatening not only their health, but their economies and pleasure.
Rodrigo Guerrero, a physician, is the founder and director of DESEPAZ in Cali, Colombia. He was mayor of the city from 1993-1996. Guerrero, former regional director advisor on health and violence for the Pan American Health Organziation (PAHO) and the Inter-American Development Bank, received his doctorate from the Harvard School of Public Health.