Violence and Health

Definition:

Violence is intentional use of force, or power that results in or is likely to result in injury, death, psychological harm, maldevelopment or deprivation.

  • Acceptability of violence in a society/situation is influenced by context culture and ideology
  • Violence has health consequences that are not closely related to concepts of acceptability /justification
  • Violence can be considered as a public health problem (like alcohol use, other drug use)
  • Violence is frequently harmful to both subject and perpetrator
  • Public health interventions aim to and can reduce the use of violence and the impact of violence with associated health benefits
  • Doctors regularly participate and support social and political violence including war and torture.
  • Violence can be hard to talk about (stigmatise)

Some Thoughts about violence:

A valuable response to some situations ?

A necessary response in the real world ?

An enjoyable entertainment ?

A necessary evil ?

 Who is the usual perpetrator?

“ the ones with Power”

  • Drug/Alcohol abuser
  • Low income areas
  • Police (in a riot/war time?)
  • Fighter / atheletes (sport)

Prevalence
  • Each year more than 1.5 million people worldwide lose their lives to violence.
  • For everyone who dies as a result of violence, many more are injured and suffer from a range of physical, sexual, reproductive and mental health problems.
  • Violence is among the leading causes of death for people aged 15-44 years worldwide
    • ~4% of deaths among males
    • ~7% of deaths among females

Causes of Violent Death (2002 report)
  • 1/2 suicide (> M/F: age > 60)
  • 1/3 homicide (> male: 15-45)
  • 1/5 armed conflict*

Violent death is more common in general in low – middle income countries

  • Regional variation:
    • Africa & Americas: Homicide > suicide by 3:1
    • Europe & SE asia: Suicide > homicides 2:1
    • Western Pacific: Suicide > homicide 6:1

Violence & Lovers (intimate partners)

  • Between 15–71% of women report experiencing physical and/or sexual violence by an intimate partner at some point in their lives.

World Medical Association

Guidelines for Medical Doctors Concerning Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment in Relation to Detention and Imprisonment

(Adopted by the 29th World Medical Assembly Tokyo, Japan, October 1975)

Declaration:

The doctor shall not countenance, condone or participate in the practice of torture or other forms of cruel, inhuman or degrading procedures

WHO’s Stance

Violence

Does not consider issues of “justification”:

  • Judgement on legitimacy of use of force are highly subjective /culturally determined

[ Violence has implications for health whether it is considered justified or not ]

WHO’s Classification

Violence

  1. Self-directed: Suicidal behaviour / Self-abuse
  2. Interpersonal:

Family and intimate partner / Community violence/ Violence between unrelated individuals

  1. Collective violence : (you might say organized violence)

 

 

Why do people use violence?

Get people to do things in your own way; to encompass

  • Threats and intimidation
  • Omission or neglect

Violence:

  • Self harm & suicide
  • Actual (harm) & threats
  • Psychological harm & deprivation of (food/water/…)

The intention to use force does not equate to an intention to cause harm (just that it’s likely)

  • Hence “accidental” is not; i.e. road accidents

 

The Social Impact
  • restricts freedoms
  • generates fear
  • costs: what you spend on protecting yourself
  • work related: violence from patients & relatives

The Economic Impact
Billions of Dollars & Resources Expended on

  1. Doing the violence (state & non state actors)
  2. Preventing violence (security & law enforcement)
  1. Dealing with the consequences
  2. Health care
  3. Loss of productivity
  4. Security & law enforcement costs

 

 

Scenarios of Violence

  1. Violence & Children
  2. Violence & Health Care Workers
  3. Violence & Partners
  4. Collective Violence (group)
    1. Social: “terrorism”, racist violence, mob violence
    2. Political: violence by the state or similar agency of governance
    3. Economic: preserving wealth & privilege
  5. Political/State Violence
    1. External: Directed towards another state or political unit (war)
    2. Internal: Directed at exercising control of the governed
  1. Structural Violence
  2. Child Maltreatment
  3. Armed Conflict and Health (rules of war)

 

Violence and Children
Physical / Mental “violence” are frequently used as means to get children to follow directions and learn what is right and wrong behaviour. This is so as they have yet to learn “common-sense” of a socially acceptable behaviour and logic hence does not work well. (reasons: immature, lack self-discipline, duty to teach the child)

  • Is physical punishment necessary to discipline children? To what extent?
  • Is psychological threats acceptable?
    • “If you do not _____, the ghost will come visit tonight”
  • Is there an age where physical discipline becomes unacceptable? What age?
    • Assumption being that the child has now the common sense of what’s the socially acceptable behaviour; and hence can think for themselves.
  • Beating a child vs Beating an adult who is disruptive; is it okay? What’s the difference?
  • In which situation can “violence” then be used? (quantifying misbehaviour)
Similar arguments have been used to explain physical punishment of:

  • People with mental illness, intellectual disability, specific ethnic groups etc.

(although they are not children)

  • Is that acceptable? Or is that just a shortcut to getting things done?

 

Violence and Health Care Workers
  1. Between 8% and 38% of health workers suffer physical violence at some point in their careers.
  1. Many more are threatened or exposed to verbal aggression.
  1. Most violence is perpetrated by patients and visitors.
    1. Also in disaster and conflict situations, health workers may become the targets of collective or political violence.
    2. Attacks on Healthcare Facilities

However, there are also cases where violence are done by the HCWs

 

Violence by State (political)
1. Prevents democratisation (consent of the governed)

2. Limits accountability

3. Silences opposition

  • Allows redirection of resources from Health and Development

 

Structural Violence

“physical and psychological harm that results from exploitative and unjust social, political and economic systems”

Population SUSTAINING High Levels of INEQUITY

Impact on the health of those that are disadvantaged (obvious)

  • Poverty
  • Loss Personal Freedoms (fear)
  • Education
  • Access to Health Care
  • Economic Costs (security/taxation)
  • Loss of human capital
  • Loss of opportunity

 

Child Maltreatment
all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child’s health, survival, development or dignity in the context of a relationship of responsibility, trust or power.

UN Convention

  • “All forms of violence against children, however light, are unacceptable. […]
  • Frequency, severity of harm and intent to harm are not prerequisites for the definitions of violence.
Types of Maltreatment

1. Physical abuse;

2. Sexual abuse;

3. Emotional and psychological abuse;

4. Neglect.

Much physical violence against children in the home is inflicted with the object of punishing*

 

Armed Conflict & Health
Impact on Society:

  • How Many MSF Hospital Bombed in 2016?
  • How many gas attacks in Syria ?
  • How many systematic rapes ?
  • Forced resettlement/ethnic cleansing ?

Impact on Combatants

Good: (privileges)

  • Command Food & Shelter
  • Command Health Care
  • Command Service & Sex

Bad:

  • Major physical trauma (Bullets, shrapnel, blades)
  • Psychological trauma

Impact on Non-Combatants

  • Food & shelter deprivation
  • Psychological trauma
  • Disruption of health care
  • Destruction of basic infrastructure
  • Water, sanitation, power supply,
  • Educational disruption
Rules of Conflict (war)

Landmines:

  • 142 countries have ratified the 1997 Mine Ban Treaty
  • Exceptions: Baltics (Estonia and Latvia) / Gulf States (Bahrain, Kuwait, Oman, Saudi Arabia and the United Arab Emirates) / USA
    • use of self-destructing mines will be permitted without geographical restrictions and long-lived mines may be used until 2010

Arms Trade

Small arms: are those weapons manufactured to military specifications and designed for use by one person (about 900 million small arms worldwide)

Light weapons: are those utilized by several individuals working together as a crew.

UN Draft framework convention on international arms transfers (disarmament)

  • April 2 2013
  • Arms Trade Treaty, aiming to establish the highest possible common international standards for the annual $70 billion business.
Children in Conflict (child soldiers)

Interview:

  • Democratic Republic of the Congo

“When they came to my village, they asked my older brother whether he was ready to join the militia. He was just 17 and he said no; they shot him in the head. Then they asked me if I was ready to sign, so what could I do – I didn’t want to die.” A former child soldier taken when he was 13. (BBC report.)

“Being new, I couldn’t perform the very difficult exercises properly and so I was beaten every morning. Two of my friends in the camp died because of the beatings. The soldiers buried them in the latrines. I am still thinking of them”. Former child soldier interviewed in 2002

 

 

Movements to the Prevention of Violence

International

WHO: Violence and Injury Prevention and Disability (VIP) Program

“ Because it is so pervasive, violence is often seen as an inevitable part of the human condition.”
State

Security Forces:

  • Police / Military / Justice Courts
Public Health Issue

On 24 May 2014, the 67th World Health Assembly (WHA) adopted an historic resolution entitled “Strengthening the role of the health system in addressing violence, in particular against women and girls, and against children”.

  • Especially with regards to child soldiers

The WHA notes that violence persists in every country of the world as a major challenge to public health.