Violence as a Public Health Issue: One Nurse’s Perspectives

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Student-led March For Our Lives Walk Out/Teach-In event at UCIMC in March, 2018

Another round of mass shootings in the news and once again Americans ask, “What can be done to keep my loved ones safe?”  Sadly, these tragic events are only the tip of a terrible iceberg of violence that devastates families and communities each day. Despite increases in law enforcement, incarceration, and investigation of criminal networks, the violence continues.  Desperation and fear have even resulted in misguided calls for the arming of teachers or other community members. Rather than adopt quasi-vigilantism, however, we need to address violence as a public health priority. Just as past public health campaigns were effective in decreasing the incidence of communicable diseases and workplace injuries, public health approaches can work to reduce violent acts.

The FBI and Centers for Disease Control (CDC) categorize violence in slightly different ways, but by any measure the impact is appalling. In 2017, there were 1.28 million incidents of violent crime in the U.S, including 19,510 homicides (14,542 by firearms, with 117 killed in mass shootings), another 85,000 non-fatal gun injuries, and 47,000 lives lost to suicide. Violent events also include often under-reported incidents of domestic violence; sexual assault (affecting one out of every six US women); approximately 674,000 victims of child abuse and neglect each year, in addition to victims of trafficking; and law enforcement violence. Each individual victim also represents family members whose lives have been changed forever by an act of violence.

Predictability and Patterns of Violence

My view of violence as a public health issue has developed over decades. As a nursing student in Chicago I worked on a unit for those paralyzed, primarily from gun injuries. I can still see the faces of these boys as they waited for the nursing staff to flip them over in their rotating bedframes. The reality of the loss for these young men, needlessly paralyzed in the prime of their lives as a result of gun violence, was heartbreaking. Equally heartbreaking is that decades later we know much about the patterns that predict violence, but the fear of violence still pushes youths to drop out of school, and destroys community life, both factors that we know increase the risk of future violence.

Like many nurses, I have been personally threatened by patients or family members wielding fingernail files, needles, and knives, and I’ve even found guns among hospitalized patients’ belongings. Some of my colleagues have sustained broken arms and jaws, and other injuries.  This workplace exposure to violence is sadly predictable, according to Occupational Safety and Health Administration data.

Violence outside of work shaped my views as well. In my quiet suburb, a troubled youth at a local school killed his mother. Later investigation revealed that aggression against parents was a pervasive problem in the area and nationally. Other studies reveal that youth who have witnessed violence, including domestic violence between parents, are at higher risk of using violence, and that survivors of violence are more likely to become future victims. Yet despite our knowledge of these predictable patterns, few resources are devoted to early intervention.

The high numbers of violent crimes in heavily populated cities like Chicago often get a lot of publicity, but when I moved to a town in rural Illinois, I was surprised to learn that a nearby city, Danville, had the highest rate of violent crime of any city in the state (1,886 crimes per 100,000 people in 2016)—quadruple the national rate of 396 per 100,000. At the same time, Chicago had a rate of 1,105 violent crimes per 100,000, while Champaign and Urbana had violent crime rates of 717 and 381 per 100,000, respectively.

Statistics should not only help us measure crime, of course, but design more effective responses for each community. For example, suicide rates are higher among white teens, but black males from 20 to 25 years of age may be 20 times more likely to die of murder than white males of similar ages. And, while most persons with mental illness and substance abuse do no harm to others, these populations are at heightened risk for being victims of violence. Knowing the pattern of risk factors and vulnerabilities of a population, we can design more effective public health campaigns tailored to specific communities and populations.

The Economics of Violent Crime

Sadly, another set of statistics illustrates how violence also drains resources, making it even harder for communities to address environmental risk factors. Total medical and productivity-related costs of violence in the US each year are estimated to be over $70 billion. Estimates of incarceration costs to state and federal governments range from $80 to $180 billion, more than is spent nationally on education. Medical expenses for each gun-related injury average $5,254 for an emergency room visit and $95,887 for inpatient costs. Taxpayers often complain about the cost of public health initiatives, but right now the medical and legal costs of violence to every taxpayer add up to about $3,200 each year.

Addressing Violence as a Public Health Crisis

Public health professionals are calling for an approach to violence that uses our knowledge of patterns and risk factors to build comprehensive programs, but they need the public to join them in demanding change in the ways that local, state, and national resources are allocated for violence prevention. For example, in contrast to the current post-crime focus revealed in community funding of criminal and judicial systems, the American Public Health Association calls for specific efforts to improve public health with safe conditions in homes and places of learning, work, or play. These strategies draw on classic public health thought, using scientifically analyzed data to intervene in addressing the risks of violence among different groups, such as age and work cohorts.

Strategies are categorized as prevention “levels,” either tertiary, secondary, or primary, depending on their relation in time to the event. Tertiary prevention includes planning for violent events that have already occurred, such as designing quick responses for first responders to minimize fatalities after an incident. Secondary prevention includes a focus on reducing existing antisocial behaviors among at-risk individuals, including students exhibiting aggression in schools or disgruntled employees in work settings. Finally, primary prevention aims to prevent the onset of aggression or extreme anger before the process even begins. For example, the use of public media for parenting education about mutual respect between boys and girls may deter the occurrence of intimate partner violence and its ripple effects on younger generations.

While all forms of prevention are needed, many public health workers believe primary prevention programs that will deter violent acts in the first place should be a funding priority. For example, comprehensive home visitation programs, with visits by qualified and trained nurses, have proven effective in reducing child abuse. Studies show these programs result in significantly fewer trips to the emergency room for childhood injury and lowered costs to Medicaid, while also addressing the abuse we know is a long-term risk factor for later violence.

Dating violence can also be addressed through primary prevention strategies. Targeted education programs that teach women to detect date rape substances, identify threats at an early stage and negotiate exit before escalation to sexual assault, and practice verbal and physical resistance result in a lower incidence of rape compared to providing only written information.

Public health approaches to youth violence recognize that strengthening social support for families in community settings has been shown to improve mental health indicators and reduce youth involvement in risk behaviors for violence. Thus programs building collaboration between institutions and residents in neighborhoods where multiple risk factors for youth violence exist are a priority. One program focuses on sustaining parental involvement in children’s education during the transition into elementary school. Other programs include outreach to young adult males with social services and mentoring, or the use of trained and experienced “interrupters,” who intervene as mediators to prevent retaliation following a crime event.

Prevention strategies addressing suicide illustrate the use of different levels of intervention. Prevention at the individual level may focus on mental health symptoms, such as hopelessness, while strategies for relational factors may address persons with high levels of recent conflict. Community strategies include improving access to mental health services resources. Finally, societal-level approaches will work to limit access to lethal weapons by persons exhibiting a risk of harm to themselves or others, and will strive to decrease stigma as a barrier to getting care.

Public Health and the Proactive Strategy for Preventing Violence

In contrast to our current national habit of responding to crime with costly legal and incarceration strategies, the public health model aims to deter violence before it takes place. It investigates and responds to specific risk factors and patterns, and designs comprehensive programs to target predictable violence. Effective prevention approaches decrease the broader community impact of violent crime, including the “years of potential life lost,” which indicates the average time a person would have lived had he or she not died prematurely, and the economic burdens of violence. Today, when considering the long-term and widespread impact of violent crime on individual and community life, I and many US citizens feel compelled to declare this time period as the “enough is enough” moment in our nation’s history. It is time to use our public health knowledge to build a better set of responses to addressing the epidemic of crime in America.

Susan Jean Misner, Ph.D., R.N., has been a registered nurse for 48 years. Among other fields of nursing, she has worked in women’s health, public health, and as a university faculty member and coordinator of international research training programs for minority nursing students. She now lives in East Central Illinois.

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