Violence: Can We End the Epidemic?

Nov 6, 2013, 10:16 AM


“We live in a culture of violence,” said Larry Cohen, MSW, founder and executive director of the Prevention Institute, in a morning session on violence prevention at the American Public Health Association (APHA) Annual Meeting, held this year in Boston, Mass.

“Just as air, water and soil affect our health, the social environment affects the spread of violence through our communities,” said Cohen.

One of the most important factors in the environment that influences the perpetration of violence is actually more violence. Basically, violence begets violence. It spreads like a disease.

“It’s like the flu,” said Gary Slutkin, MD, PhD, Founder and Executive Director of Cure Violence. “The greatest predictor of a case of the flu is a preceding case of the flu. It’s the same thing with violence. Violence is an infectious disease.”

Slutkin shared a study of one community that found that exposure to community violence in one form or another was associated with a 30 times increased risk of committing violence—but what was most striking is that statistic held true, even controlling for poverty, race, crowded housing and other factors that could have an impact on violence. The effect is also “dose dependent,” according to Dr. Slutkin. That is, the more violence you witness or experience, the more likely you are to perpetrate violence.

The good news is that “we know how to prevent epidemics,” said Slutkin. “We need to recognize that this is a preventable problem. We need to build a movement,” agreed Cohen.

Cure Violence focuses on the very same steps used to prevent the spread of infectious disease in their work to help prevent the spread of violence:

  1. Detect and interrupt the transmission of violence, by anticipating where violence might occur.
  2. Change the behavior of those most at risk for spreading violence.
  3. Change community norms to discourage the use of violence as an acceptable and even encouraged way to handle conflict.

“The day will come when it will not be the social norm to have easy access to guns and difficult access to mental health services,” said David Satcher, MD, PhD, former U.S. Surgeon General and Assistant Secretary for Health, who also served on the panel.

So how do we change norms? Several panelists talked about the drastic change around the social acceptability of smoking over the last few decades as a major success story. One of the reasons for that success was the change in policies and taxes, but “norms don’t only change because of laws—what truly changes behavior is changing what you think your friends expect of you. That is the principle driver of behavior. That’s why I wore my tie today. That’s the same thing people are doing in neighborhoods where they’re shooting,” said Slutkin. “It’s the unconscious force.”

Community-based work with intention is what will help change what people think is expected of them, said Slutkin.

This approach to violence as akin to an infectious disease has proven immensely effective as part of the work of Cure Violence, which is being implemented at more than 55 sites in 15 U.S. cities and eight countries abroad. In Chicago, Cure Violence was associated with reductions in violence between 41 and 73 percent, and some communities had a 100 percent reduction in retaliation homicides. In South Africa, there was a 78 percent reduction in shooting and a 66 percent reduction in killings in just the first five months of the program.

In addition to interrupting the spread of violence, the very design of our communities and built structures can help stem the spread of violence as well. For example, the Washington, D.C., Metro system was designed with safety in mind—it has clear, visible corridors; booth staff have a view down onto the platforms in many stations; and all are well-lit at all hours. As a result, said Cohen, the D.C. metro system has about one-third less violence than other public transit systems in major cities.

Other environmental changes to help curb violence include regulations on liquor outlets, according to Cohen. Diadema, Brazil, cut violence by more than 50 percent in a few years by closing late-night alcohol stores, and Los Angeles shut down 200 liquor stores in 3 years with a 27 percent reduction in crime in a four-block radius.

Every sector can play a role in violence prevention, too. Several presenters mentioned that businesses have a pretty large incentive to help: protecting their bottom line.

“Community safety is our number one concern,” said an executive at a major corporation, as quoted in Cohen’s slides. “If our employees feel unsafe or our patrons feel unsafe, we’re not going to open up a store.”

“Grass can’t grow if the field is burning,” said Slutkin, to make the point that violence prevention critical to help build healthy, economically viable communities.

>>Read the related post, "Violence: Q&A with David Satcher."

>>Read more about the long-term effects of violence on children.

>>NewPublicHealth will be on the ground throughout the APHA conference speaking to public health leaders and presenters, hearing from attendees on the ground and providing updates from sessions, with a focus on how we can build a culture of health. Follow the coverage here.

This commentary originally appeared on the RWJF New Public Health blog.