Violence a global public health problem* Violência como um problema global de saúde pública - PDF

277 Violence a global public health problem* Violência como um problema global de saúde pública ARTIGO ARTICLE Linda L. Dahlberg 1 Etienne G. Krug 1 Abstract This article is a version of the Introduction

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277 Violence a global public health problem* Violência como um problema global de saúde pública ARTIGO ARTICLE Linda L. Dahlberg 1 Etienne G. Krug 1 Abstract This article is a version of the Introduction to the World Report on Violence and Health, published by the World Health Organization (WHO). It presents a general description about this phenomenon and points some basic questions: concepts and definitions about the theme; the state of knowledge about it; nature and typology on violence; proposal of a quantitative and qualitative approach of an ecological model; responsibilities and functions of the public health sector and its potentiality to prevent and reduce violence in the world; the responsibilities of the nations and the policy makers in a intersetorial point of view; difficulties and obstacles for actuation and challenges for the health sector. Key words Violence and health, World Report on Violence and Health, External causes Resumo Este artigo é uma versão do que foi publicado no Informe Mundial sobre Violência e Saúde da Organização Mundial de Saúde, como introdução ao tema. Apresenta uma descrição geral da problemática e a posição da OMS. Nele os autores se dedicam a responder algumas questões básicas: o estado do conhecimento sobre o assunto; os conceitos e definições com os quais a OMS trabalha; a natureza e a tipologia sobre violência; as formas de abordagem quantitativa e qualitativa em um modelo ecológico; o lugar e o papel da saúde pública e sua potencialidade com vistas a contribuir para prevenir e diminuir a violência no mundo; as responsabilidades das nações e dos gestores em todos os níveis; os obstáculos para atuação e os desafios para o setor. Palavras-chave Violência e saúde, Informe Mundial sobre Violência e Saúde, Causas externas * Version of the Introduction to the World Report on Violence and Health (WHO): Geneve: WHO, 2002, authorized by the authors. 1 Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, WHO. Atlanta GA. 278 Dahlberg,L.L.& Krug,E.G. Background Violence has probably always been part of the human experience. Its impact can be seen, in various forms, in all parts of the world. Each year, more than a million people lose their lives, and many more suffer non-fatal injuries, as a result of self-inflicted, interpersonal or collective violence. Overall, violence is among the leading causes of death worldwide for people aged years. Although precise estimates are difficult to obtain, the cost of violence translates into billions of US dollars in annual health care expenditures worldwide, and billions more for national economies in terms of days lost from work, law enforcement and lost investment. The human cost in grief and pain, of course, cannot be calculated. In fact, much of it is almost invisible. While satellite technology has made certain types of violence terrorism, wars, riots and civil unrest visible to television audiences on a daily basis, much more violence occurs out of sight in homes, workplaces and even in the medical and social institutions set up to care for people. Many of the victims are too young, weak or ill to protect themselves. Others are forced by social conventions or pressures to keep silent about their experiences. As with its impacts, some causes of violence are easy to see. Others are deeply rooted in the social, cultural and economic fabric of human life. Recent research suggests that while biological and other individual factors explain some of the predisposition to aggression, more often these factors interact with family, community, cultural and other external factors to create a situation where violence is likely to occur. Despite the fact that violence has always been present, the world does not have to accept it as an inevitable part of the human condition. As long as there has been violence, there have also been systems religious, philosophical, legal and communal which have grown up to prevent or limit it. None has been completely successful, but all have made their contribution to this defining mark of civilization. Since the early 1980s, the field of public health has been a growing asset in this response. A wide range of public health practitioners, researchers and systems have set themselves the tasks of understanding the roots of violence and preventing its occurrence. Violence can be prevented and its impact reduced, in the same way that public health efforts have prevented and reduced pregnancyrelated complications, workplace injuries, infectious diseases, and illness resulting from contaminated food and water in many parts of the world. The factors that contribute to violent responses whether they are factors of attitude and behaviour or related to larger social, economic, political and cultural conditions can be changed. Violence can be prevented. This is not an article of faith, but a statement based on evidence. Examples of success can be found around the world, from small-scale individual and community efforts to national policy and legislative initiatives. What can a public health approach contribute? By definition, public health is not about individual patients. Its focus is on dealing with diseases and with conditions and problems affecting health and it aims to provide the maximum benefit for the largest number of people. This does not mean that public health ignores the care of individuals. Rather, the concern is to prevent health problems and to extend better care and safety to entire populations. The public health approach to any problem is interdisciplinary and draws upon knowledge from many disciplines, including medicine, epidemiology, sociology, psychology, criminology, education and economics. This has allowed the field of public health to be innovative and responsive to a wide range of diseases, illnesses and injuries around the world. The public health approach also emphasizes collective action. It has proved time and again that cooperative efforts from such diverse sectors as health, education, social services, justice and policy are necessary to solve what are usually assumed to be purely medical problems. Each sector has an important role to play in addressing the problem of violence and, collectively, the approaches taken by each have the potential to produce important reductions in violence. The public health approach to violence is based on the rigorous requirements of the scientific method. In moving from problem to solution, it has four key steps: 1) uncovering as much basic knowledge as possible about all the 279 aspects of violence through systematically collecting data on the magnitude, scope, characteristics and consequences of violence at local, national and international levels; 2) investigating why violence occurs, that is, conducting research to determine: the causes and correlates of violence; the factors that increase or decrease the risk for violence; the factors that might be modifiable through interventions; 3) exploring ways to prevent violence, using the information from the above, by designing, implementing, monitoring and evaluating interventions; 4) implementing, in a range of settings, interventions that appear promising, widely disseminating information and determining the cost-effectiveness of programmes. Public health is above all characterized by its emphasis on prevention. Rather than simply accepting or reacting to violence, its starting point is the strong conviction that violent behaviour andits consequences can be prevented. Defining violence Any comprehensive analysis of violence should begin by defining the various forms of violence in such a way as to facilitate their scientific measurement. There are many possible ways to define violence. The World Health Organization defines violence2 as: 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. The definition used by the World Health Organization associates intentionality with the committing of the act itself, irrespective of the outcome it produces. Excluded from the definition are unintentional incidents such as most road traffic injuries and burns. The inclusion of the word power, in addition to the phrase use of physical force, broadens the nature of a violent act and expands the conventional understanding of violence to include those acts that result from a power relationship, including threats and intimidation. The use of power also serves to include neglect or acts of omission, in addition to the more obvious violent acts of commission. Thus, the use of physical force or power should be understood to include neglect and all types of physical, sexual and psychological abuse, as well as suicide and other self-abusive acts. This definition covers a broad range of outcomes including psychological harm, deprivation and maldevelopment. This reflects a growing recognition among researchers and practitioners of the need to include violence that does not necessarily result in injury or death, but that nonetheless poses a substantial burden on individuals, families, communities and health care systems worldwide. Many forms of violence against women, children and the elderly, for instance, can result in physical, psychological and social problems that do not necessarily lead to injury, disability or death. These consequences can be immediate, as well as latent, and can last for years after the initial abuse. Defining outcomes solely in terms of injury or death thus limits the understanding of the full impact of violence on individuals, communities and society at large. One of the more complex aspects of the definition is the matter of intentionality. Two important points about this should be noted. First, even though violence is distinguished from unintended events that result in injuries, the presence of an intent to use force does not necessarily mean that there was an intent to cause damage. Indeed, there may be a considerable disparity between intended behaviour and intended consequence. A perpetrator may intentionally commit an act that, by objective standards, is judged to be dangerous and highly likely to result in adverse health effects, but the perpetrator may not perceive it as such. As examples, a youth may be involved in a physical fight with another youth. The use of a fist against the head or the use of a weapon in the dispute certainly increases the risk of serious injury or death, though neither outcome may be intended. A parent may vigorously shake a crying infant with the intent to quieten it. Such an action, however, may instead cause brain damage. Force was clearly used, but without the intention of causing an injury. A second point related to intentionality lies in the distinction between the intent to injure and the intent to use violence. Violence, according to Walters & Parke3, is culturally determined. Some people mean to harm others but, based on their cultural backgrounds and beliefs, do not perceive their acts as violent. The definition used by the World Health Organization, however, defines violence as it relates to the health or well-being of individuals. Ciência & Saúde Coletiva, 11(2): , 2006 280 Dahlberg,L.L.& Krug,E.G. Certain behaviours such as hitting a spouse may be regarded by some people as acceptable cultural practices, but are considered violent acts with important health implications for the individual. Other aspects of violence, though not explicitly stated, are also included in the definition. For example, the definition implicitly includes all acts of violence, whether they are public or private, whether they are reactive (in response to previous events such as provocation) or proactive (instrumental for or anticipating more self-serving outcomes4), or whether they are criminal or noncriminal. Each of these aspects is important in understanding the causes of violence and in designing prevention programmes. Typology of violence In its 1996 resolution WHA49.25, declaring violence a leading public health problem, the World Health Assembly called on the World Health Organization to develop a typology of violence that characterized the different types of violence and the links between them. Few typologies exist already and none is very comprehensive5. The typology proposed here divides violence into three broad categories according to characteristics of those committing the violent act: 1) self-directed violence; b) interpersonal violence; c) collective violence. This initial categorization differentiates between violence a person inflicts upon himself or herself, violence inflicted by another individual or by a small group of individuals, and violence inflicted by larger groups such as states, organized political groups, militia groups and terrorist organizations. These three broad categories are each divided further to reflect more specific types of violence. Self-directed violence is subdivided into suicidal behaviour and self-abuse. The former includes suicidal thoughts, attempted suicides also called parasuicide or deliberate self-injury in some countries and completed suicides. Self-abuse, in contrast, includes acts such as self-mutilation. Interpersonal violence is divided into two subcategories: 1) family and intimate partner violence that is, violence largely between family members and intimate partners, usually, though not exclusively, taking place in the home. Community violence violence between individuals who are unrelated, and who may or may not know each other, generally taking place outside the home. The former group includes forms of violence such as child abuse, intimate partner violence and abuse of the elderly. The latter includes youth violence, random acts of violence, rape or sexual assault by strangers, and violence in institutional settings such as schools, workplaces, prisons and nursing homes. Collective violence is subdivided into social, political and economic violence. Unlike the other two broad categories, the subcategories of collective violence suggest possible motives for violence committed by larger groups of individuals or by states. Collective violence that is committed to advance a particular social agenda includes, for example, crimes of hate committed by organized groups, terrorist acts and mob violence. Political violence includes war and related violent conflicts, state violence and similar acts carried out by larger groups. Economic violence includes attacks by larger groups motivated by economic gain such as attacks carried out with the purpose of disrupting economic activity, denying access to essential services, or creating economic division and fragmentation. Clearly, acts committed by larger groups can have multiple motives. The nature of violent acts Figure 1 illustrates the nature of violent acts, which can be: 1) physical; 2) sexual; 3) psychological; 4) involving deprivation or neglect. The horizontal array in figure 1 shows who is affected, and the vertical array describes how they are affected. These four types of violent acts occur in each of the broad categories and their subcategories described above with the exception of self-directed violence. For instance, violence against children committed within the home can include physical, sexual and psychological abuse, as well as neglect. Community violence can include physical assaults between young people, sexual violence in the workplace and neglect of older people in long-term care facilities. Political violence can include such acts as rape during conflicts, and physical and psychological warfare. 281 Figure 1 A typology of violence. Self-directed Violence Interpersonal Collective Ciência & Saúde Coletiva, 11(2): , 2006 Suicidal behaviour Self-abuse Family/ partner Community Social Political Economic Child Partner Elder Acquaintance Stranger Physical Sexual Psychological Deprivation or neglect This typology, while imperfect and far from being universally accepted, does provide a useful framework for understanding the complex patterns of violence taking place around the world, as well as violence in the everyday lives of individuals, families and communities. It also overcomes many of the limitations of other typologies by capturing the nature of violent acts, the relevance of the setting, the relationship between the perpetrator and the victim, and in the case of collective violence possible motivations for the violence. However, in both research and practice, the dividing lines between the different types of violence are not always so clear. Measuring violence and its impact Different types of data are needed for different purposes, including: 1) describing the magnitude and impact of violence; 2) understanding which factors increase the risk for violent victimization and perpetration; 3) knowing how effective violence prevention programmes are. Some of these types of data and sources are described in table 1. Data on fatalities, particularly through homicide, and on suicide and war-related deaths can provide an indication of the extent of lethal violence in a particular community or country. When compared to statistics on other deaths, such data are useful indicators of the burden created by violence-related injuries. These data can also be used for monitoring changes over time in fatal violence, identifying groups and communities at high risk of violence, and making comparisons within and between countries. Mortality figures, however, are only one possible type of data for describing the magni- 282 Dahlberg,L.L.& Krug,E.G. Table 1 Types of data and potential sources for collecting information. Type of data Data sources Examples of information collected Mortality Death certificates, vital statistics Characteristics of the decedent, registries, medical examiners, cause of death, location, time, coroners or mortuary reports manner of death Morbidity and Hospital, clinic or other medical Diseases, injuries, information on other health data records physical, mental or reproductive health Self-reported Surveys, special studies, Attitudes, beliefs, behaviours, focus groups, media cultural practices, victimization and perpetration, exposure to violence in the home or community Community Population records, local Population counts and density, government records, other levels of income and education, institutional records unemployment rates, divorce rates Crime Police records, judiciary records, Type of offence, characteristics of crime laboratories offender, relationship between victim and offender, circumstances of event Economic Programme, institutional or agency Expenditures on health, housing records, special studies or social services, costs of treating violence-related injuries, use of services Policy or legislative Government or legislative records Laws, institutional policies and practices tude of the problem. Since non-fatal outcomes are much more common than fatal outcomes and because certain types of violence are not fully represented by mortality data, other types of information are necessary. Such information can help in understanding the circumstances surrounding specific incidents and in describing the full impact of violence on the health of individuals and communities. These types of data include: health data on diseases, injuries and other health conditions; self-reported data on attitudes, beliefs, behaviours, cultural practices, victimization and exposure to violence; community data on population characteristics and levels of income, education and unemployment; crime data on the characteristics and circumstances of violent events and violent offenders; economic data related to the costs of treatment and social services; data descr
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