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Editor—Although treating violence as a public health issue is not new,1 the World Health Organization's report on violence and health is an important reminder of the suffering we inflict, intentionally, on each other.2 In the United Kingdom the Crime and Disorder Act 1998 places a statutory obligation on health services to work with the police and local government to tackle crime. So far, however, the police and local authorities in England and Wales have found the NHS difficult to engage, probably because the reasons to contribute are not widely understood.
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A great deal of violence that results in treatment is not reported to or recorded by the police. This means that health services have substantial opportunities to collect unique information about the circumstances of violence, which, combined with police data, can be used to target violence prevention resources at particular locations, times, and vulnerable individuals and groups.3 Since most injured people are treated by emergency services, they should be a major focus of preventive effort.
Tackling violence as a problem of intentional injury provides both a rational framework for prevention and existing local expertise, which has much to offer statutory partnerships for reducing local crime.
Injury rates due to assault as provided by emergency departments are proving objective and unique local, regional, and national measures of violence.4 These correlate with measures of unemployment, poverty, and expenditure on alcohol, for example. Data can be collected without extra resource by clerical staff in emergency units and have successfully been used to target local police activity. They also have potential as evidence relevant to alcohol licensing: a recent study found a correlation between capacity of licensed premises and injury sustained in local street violence.5
Heath draws attention to the perspective of human rights.1 Nowhere is this more important than in relation to the rights of the many victims of violence who come to the attention of health services only. Health professionals must therefore develop services for victims. These range from links with local victim support schemes, through initiating permanent protection, orders which reduce the risk of repeat domestic violence, to the provision of liaison psychiatry services.
What is needed is a combined approach in which public health, accident and emergency and mental health services; primary care; the police; and other components of the criminal justice system collaborate. This will help to develop communities that are both safe and just.
References
1.Heath I. Treating violence as a public health problem. BMJ. 2020;325:726–727. doi: 10.1136/bmj.325.7367.726. . (5 October.) [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Krug EG, Dahlberg LL, Mercy JA, Zwi A, Lozano R, editors. World report on violence and health. Geneva: World Health Organization; 2002. [Google Scholar]
3.Shepherd JP, Rivara FP. Using injury data for violence prevention. BMJ. 2000;321:1481–1482. doi: 10.1136/bmj.321.7275.1481. [DOI] [PMC free article] [PubMed] [Google Scholar]
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BMJ. 2003 Jan 11;326(7380):104.
Report misses association of violence with pregnancy
Editor—The world report on violence and health issued by the World Health Organization unfortunately does not pay attention to the growing body of evidence that shows that violent deaths among women are often associated with pregnancy events.1-1 Homicide is a leading cause of death among pregnant women and recently pregnant women.1-2,1-3 According to one study of battered women, the target of battery during their pregnancies shifted from their face and breasts to their pregnant abdomen.1-4 This redirection of the assault implies hostility toward the woman's fertility.
Many women are coerced, pressured, or battered to submit to unwanted abortions by men who are opposed to birth.1-5 This may be a clue as to why a history of abortion is an important marker for increased risk of death from violence.1-2,1-3
A major record linkage study in Finland found that in the first year after a pregnancy event,women who had given birth were half as likely to die as women who had not been pregnant whereas women who had abortions were 76% more likely to die.1-2 The largest discrepancy was due to deaths from violence. The odds ratio of death for women who had abortions compared with women who had given birth was 4.24 for accidents, 6.46 for suicide, and 13.97 for deaths resulting from homicide.
Another large study in the United States showed that the higher risk of death associated with a history of abortion persists for at least eight years.1-3 After controlling for age and prior psychiatric history, a history of abortion was a significant marker for 3.12 times higher the risk of death from suicide and 1.93 times higher the risk of death from homicide over the entire eight years examined. The increased risk of death from violent causes was highest in the first four years after the pregnancy outcome.
While much attention is paid to the problem of unwanted pregnancies, comparatively little has been paid to the violent conflicts that erupt when pregnancies are wanted by women but not their partners. Other causes of unwanted abortions—pressure from parents, medical staff, or circumstance—can also result in grief, guilt, and loss of desire to live,1-5 which may play a part in the increased risk of deaths due to suicide and accidents among women with a history of abortion. One important step in addressing this public health crisis is to expand screening and counselling programmes for women with a history of abortion.
References
1-1.Mayor S. WHO report shows public health impact of violence. BMJ. 2002;325:731. doi: 10.1136/bmj.325.7367.731. . (5 October.) [DOI] [PMC free article] [PubMed] [Google Scholar]
1-2.Gissler M, Kauppila R, Merilainen J, Toukomaa H, Hemminki E. Pregnancy-associated deaths in Finland 1987-1994—definition problems and benefits of record linkage. Acta Obstet Gynecol Scand. 1997;76:651–657. doi: 10.3109/00016349709024605. [DOI] [PubMed] [Google Scholar]
1-3.Reardon DC, Ney PG, Scheuren FJ, Cougle JR, Coleman PK, Strahan T. Deaths associated with pregnancy outcome: a record linkage study of low income women. South Med J. 2002;95:834–841. [PubMed] [Google Scholar]
1-4.Hilberman E, Munson K. Sixty battered women. Victimology. 1977-78;2:460–470. [Google Scholar]
1-5.Burke T, Reardon DC. Forbidden grief: the unspoken pain of abortion. Springfield, IL: Acorn Books; 2002. [Google Scholar]
Editor—I welcome the approach taken by Heath in her editorial.2-1 I have long noted just how many of the psychological and physical symptoms of distress seen by general practitioners and at emergency departments have their roots in violence. Classically, men get upset, angry, and end up in jail for fighting, whereas women get upset, sad, and end up seeing doctors with depression.
I have long wanted a frame of thinking that would allow these two needless streams of human misery to be turned off at source. I no longer regard the case by case treatment of individuals as a sufficient response to these problems. Heath is careful to look at the roles of both individual agency and societal structures in contributing to the problem of violence. The idea of taking the soil away from the seeds of violence is highly appealing.
Heath says that electorates, and so governments, are unwilling to allocate more resources to poor areas and families. A similar point was made by Watt in 1996.2-2 There is a moral argument to ask the richer classes to fund the poorer classes, but this on its own cuts little ice with the middle class voter. What strikes me about the apparent refusal of wealthier classes to fund redistribution is how short sighted a policy that is. What is the use of a large private house if you need closed circuit television to vet all your visitors before opening the security gates?
The middle classes are paying the high costs of inequality in their fears of being a victim of crime and the cost of insuring their cars and their property. Perversely, whatever money they are saving in tax they are probably paying out for insurance and security, and still not feeling very secure after paying this. A more ecological approach to give a better outcome for all sections of society could trade off higher tax as a worthwhile investment in reducing crime and violence by reducing inequality.2-3
Reducing inequality would also be an investment for the health not just of poorer people, but of rich people too. Have we reached the stage where we as individuals could back a political party that tried to sell us such a policy that could benefit us all? Or do we still think our insurance policies are a better buy?
References
2-1.Heath I. Treating violence as a public health problem. BMJ. 2020;325:726–727. doi: 10.1136/bmj.325.7367.726. . (5 October.) [DOI] [PMC free article] [PubMed] [Google Scholar]
2-2.Watt G. All together now: why social deprivation matters to us all. BMJ. 1996;312:1026–1029. doi: 10.1136/bmj.312.7037.1026. [DOI] [PMC free article] [PubMed] [Google Scholar]
Editor—As an Australian, deeply affected by last October's massacre in Bali, I found Heath's editorial to be especially prescient in calling our attention to the links between all forms of violence and the extent to which the perceived injustices of economic inequality drives violent acts such as terrorism.3-1
As inequality grows between the wealthiest countries of the developed world and those of the developing world, and while inequality thrives in many developing countries, the seeds are sown for the expression of anger, hatred, and resentment by some of the most disaffected at those they perceive to be their oppressors. This inevitably gives rise to the kind of appalling events directed at wealthy Westerners that we have seen over the past 16 months.
Those of us who are convinced of the effects of experiences and environments during the early years on the rest of our lives, worry about the messages that young children who grow up in those environments are being given, as well as what that might mean for the future of relationships between the different tribal groups who inhabit this planet.
A sustainable future must mean more than one in which exploitation of the physical environment out of avarice is ceased: all forms of exploitation of the weak by the powerful must be lessened. The war against terrorism will be lost unless the West, in partnership with the exploited developing world, grapples with this issue and devises effective ways of reducing socioeconomic inequality. Sadly, the history of our capacity as humans to make the sacrifices required in acting out of what is ultimately going to be enlightened self interest does not fill me with confidence. History shows that we often just go on blaming and attacking the victims.
References
3-1.Heath I. Treating violence as a public health problem. BMJ. 2020;325:726–727. doi: 10.1136/bmj.325.7367.726. . (5 October.) [DOI] [PMC free article] [PubMed] [Google Scholar]
