A PUBLIC HEALTH APPROACH TO THE VIOLENCE EPIDEMIC IN THE UNITED STATES

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This paper appeared in Environment and Urbanization (October 1993;5:50-66), a publication of the International Institute of Environment and Development.

By Larry Cohen and Susan Swift

"I've seen a lot of people go... a lot of people close to me deal with some situations where they are very close to death constantly."

"You see a lot of killings and it's not really taken that seriously. So you have a lot of kids going around not really valuing life."

"You just can't avoid the problem. It's not going to go away. If you ignore it, it's going to get worse."

I. Introduction

This paper describes the dimensions and root causes of the problem with violence in the United States. After defining the problem and who is affected, the paper critiques the dominant policy and proposes an alternative, community-based, public health approach to violence prevention.

Violence is among the biggest health threats in the United States. Interpersonal violence has invaded homes, schools, and streets everywhere, reaching what public health experts now conclude are epidemic proportions. Everyone is affected, but the group most affected is youth.

The quotes above come from teenage high school students in Richmond, California, a city where violence prevention efforts include "speak-outs" against violence, classroom instruction in alternative conflict reduction techniques, and leadership training for at-risk youth. In this community of nearly 100,000, many organizations work together to coordinate activities for youth that will build skills, confidence, and character.

The Contra Costa County Prevention Program in northern California, profiled in this paper, focuses its violence prevention initiative in the Greater Richmond area. Contra Costa County is one of five counties in the San Francisco Bay Area, with a population of 803,732 recorded in the 1990 census. The western region of the county includes a number of communities that can be characterized as densely populated urban centers where unemployment is high, the education system is under-funded, and the population is ethnically diverse with a high percentage of new immigrants. This diversity is reflected in Richmond, the largest city in the western region, which is 43 percent African-American, 14.5 percent Latino, 11 percent Asian/Pacific Islander, and 30.5 percent European-American.¹

The Greater Richmond area is an urban location with one of the highest youth homicide rates in California. In 1992, the City of Richmond was hopeful that things were changing when newspapers reported that among major cities around the country, Richmond had the most significant drop in firearm death rates. The city's 1992 rate of 47 deaths per 100,000 population represented a 31 percent decrease from the preceding year.² Despite this decrease, rates remain very high. Discouraging outbreaks of violence interrupt peaceful periods, such as during the last week of June 1993, when more than 20 individuals were injured in shootings during a four-day period.

Interpersonal violence, although most concentrated among youth in densely populated, low-income communities, affects everyone in the United States. An awareness of violence permeates the environment, determining where people prefer to live, where they shop, how they respond to strangers on the streets, where they walk and drive, and how late at night they stay outside of their homes. Unlike any other environmental threat, violence has turned into a public health epidemic. This is reflected in many ways: American television is filled with violent images, for example, and many of its neighborhoods resemble war zones.

What has gone wrong? Is there something intrinsic to urban environments contributing to ever-escalating levels of violence? How do institutions, concerned citizens, and families cope with the constant onslaught of violence in its many forms?

II. History

In 1982, after recognizing that many emergency room visits and chronic medical problems resulted from preventable conditions, the Contra Costa County Health Services Department established the Prevention Program. At that time, other than the treatment of victims of violence, very few health departments in the United States saw the problem as a health issue. The Contra Costa Health Department, however, recognized the tremendous toll that violence was taking and decided that by using a "public health approach" a solution was possible.

The Prevention Program includes one of only a handful of nationally funded violence prevention projects in the United States. The centerpiece of its approach to health promotion is its development of community-based coalitions. At the core of the Prevention Program's violence prevention initiative is a collaboration between the health department and a range of community-based organizations in a coalition called the PACT (Policy, Action, Collaboration, and Training) Against Violence.

For more than ten years, the Program has initiated and sustained coalitions engaged in violence prevention activities. These coalitions often are able to influence key institutions and elected representatives and to forge broader solutions and policies than individual organizations could achieve alone.

Beginning in 1983, the Program joined with community organizations on a number of activities aimed at preventing fights, suicide, and dating violence among adolescents. Recently, the federal government has extended its funding of the Program's neighborhood- and school-based youth violence prevention activities in the West Contra Costa communities of Richmond, North Richmond, and San Pablo. The current initiative involves nine community agencies under contract to the Prevention Program. These agencies guide community-wide violence prevention strategies and provide training to youth participants in a violence prevention leadership program.

III. An Epidemic of Violence

U.S. culture is exported around the globe along with products made by Levi, Pepsi, Nike, and Marlboro. Images of violence are frequently associated with the culture of the United States. Western movies show cowboys conquering Native Americans, and televised music videos exploit young women. Violence is everywhere in the American psyche and culture. But, while it is often referred to as an epidemic, it is not a disease; it is a learned behavior. Because violence is a learned behavior, it is preventable.

A) Scope of the Problem

Cities throughout the country report record numbers of homicides and assaults. The rates of interpersonal violence are higher in the United States than in any other industrialized nation. In comparison with 21 other countries, the United States homicide rate (8.7 per 100,000) was 2.6 times higher than the next highest rate (Finland: 3.3 per 100,000) and four to eight times higher than the rates in most other countries.³ (See Chart 1a and 1b).

For less urbanized and industrialized nations that might model their development on the United States, the problem of violence must be addressed. In 1987, the U.S. homicide rates for males aged 15-24 (21.9 per 100,000) were 4.4 times higher than the next highest rates, which were in Scotland (5.0 per 100,000).⁴ (See Chart 2.) Violent victimization rates increased 11 percent between 1986 and 1991 to reach 31 per 1,000 persons aged 12 and over.⁵ (See Chart 3.) Forty-seven percent of the male prison population is imprisoned for violent crimes.⁶

Homicide was the second leading cause of death for all males aged 15-24 in California during 1988. However, homicide was the leading cause of death for young African-American males and accounted for 57 percent of all deaths. The homicide rate for young African American males was 155.5 per 100,000, more than three times the rate for young Hispanic males (47.7 per 100,000), ten times the rate for Asian/Other (15.4 per 100,000), and 13 times the rate for European-American (12.2 per 100,000) males aged 15-24.⁷ Contra Costa County's 1992 Status Report on Childhood Injury revealed that gunshot wounds were the leading cause of death for the county's children between the ages of 10 and 14. (See Chart 4.)

Although young men have the highest rates of morbidity and mortality, violence against women is rising. It is just as frightening, although less visible, to note that in 1990, more women were raped in the United States than in any prior year. 1990 topped a three-year trend of increases, with up to 12 rapes reported per hour, averaging almost 300 a day. In 1990, the rape rate in the U.S. was 8 times higher than in France, 15 times higher than in England, 20 times higher than in Portugal, 23 times higher than in Italy, 26 times higher than in Japan, and 46 times higher than in Greece.⁸ According to a majority staff report prepared for the Senate Judiciary Committee, at least one out of five women will be sexually assaulted in her lifetime.⁹

According to a majority staff report prepared for the Senate Judiciary Committee, at least one out of five women will be sexually assaulted in her lifetime. (U.S. Judiciary Committee 1990).

Battering is the leading cause of injury to women and accounts for nearly one third of all emergency room visits by women. Each year, domestic violence generates more than 21,000 hospitalizations, 99,800 hospital days, and 39,900 physician visits. While violence against women, in particular spouse and partner battering and sexual assault, is increasing, it is still given less attention than violence directed at men for three reasons:

1. Under-reporting: Often victims do not file reports because of the shame and fear of retribution that generally accompany these types of assaults. The frequent insensitivity of law enforcement and court personnel also discourages reporting.

2. Statistical undercount: Because rape and sexual assault injuries are not always captured by hospitalization and death statistics, their frequency and severity can be underestimated.

3. Extent of injury underplayed: Because the medical and criminal justice systems are still largely administered by men, there may be times when the true scope of pain and injury caused by such assaults are not fully understood and can be downplayed.

In addition to being the victims of rape and domestic violence, women are increasingly the perpetrators as well as victims of other forms of violence. Anecdotal reports from practitioners who work with young girls reveal a trend among girls toward more violent behavior, including a larger number who carry and use weapons, and a growing number who are members of gangs. Sadly, the gap between male and female violence is likely to narrow, not because of a drop in male violence so much as an increase in female violence.

While African-Americans are the most severely affected by violence and the most likely to be jailed for violent offenses, neither race nor ethnicity is a primary risk factor. The disproportionately high levels of violence among the African-American population are indicators of the underlying economic and social conditions in which the population is likely to find itself. According to Dr. Deborah Prothrow-Stith, author of Deadly Consequences, the devastation of these communities by violence is best understood as a reaction to poverty, overcrowding, and an American culture where violence "is as American as apple pie."¹¹

Young people today are growing up with a bitter and hopeless view of reality, especially in places where violence is the norm, not the exception. While epidemiologists cite statistics showing that it is young, poor, African American males who die at significantly higher rates from firearm injuries, injury prevention experts agree that no one is immune from the effects of violence.

Escalating levels of violence in the United States have community as well as individual consequences. Harvey Brenner's studies in the U.S. and England demonstrated that increases in unemployment correlated with increased rates of heart attack and other diseases among entire communities and not just among the unemployed.¹² Similarly, violence radiates from a single source into the environment as a whole.

The effects of violence are never confined to the perpetrator, as a contagion never only affects the person carrying the disease. The aftershocks of a killing frequently travel along the airwaves through the media into homes that may be hundreds or thousands of miles from the incident. And sensationalized acts of violence -- those that take place in unexpected locations such as schools and workplaces, instead of ghettos and barrios -- tend to get even more media attention. It is a reflection of how widespread and commonplace violence has become that it takes an unusual death to provoke a normal response of shock and disbelief.

More damaging than the gruesome, but realistic, news coverage are the action movies and violent cartoons aimed at children. Children have difficulty distinguishing between fiction and fact and they absorb information uncritically from television as if it was always a factual source. Many of a child's earliest and deepest impressions are created by watching the televised world, where violence is a commonplace (daily) occurrence and the commission of violence is generally portrayed as powerful and exciting.¹³

In two surveys of young male felons imprisoned for committing violent crimes (e.g., homicide, rape, and assault), 22 to 34 percent reported that they consciously imitated crime techniques learned from television programs, usually successfully.¹⁴ What are the consequences of this atmosphere (or environment) of fear and violence? Many people in the United States live in self-imposed prisons, hoping to insulate themselves from the violence that is rapidly encroaching on their freedom. People barricade themselves in their homes and fortify their automobiles against theft and vandalism. Women do not walk alone or travel dark streets at night. Parents train children at an early age not to talk to strangers, and this behavior is often reinforced with murky images of evil and violation. School administrators install metal detectors, conduct locker searches, and enforce dress codes in a vain attempt to discourage gang identification. Communities adopt curfews, restrict "cruising" in cars, and form neighborhood crime watch associations.

Some of the most costly consequences of America's violence are: the rise in episodes of Post-Traumatic Stress Disorder (PTSD) in communities under siege; overburdened hospital emergency rooms and related trauma services; economic flight from distressed neighborhoods; and a huge shift of resources from human services into the criminal justice system.

B) Finding Solutions: Understanding the Foundations of Violence

To reduce violence, it is necessary first to understand it "epidemiologically." What are the underlying causes and major risk factors that contribute to violence? The Prevention Program has identified three root causes that generate violence in the United States. These causes are extremely difficult to change and addressing them will require substantial re-ordering of political and social priorities. There are six community risk factors that also exacerbate the frequency and severity of violence. Although these risk factors are also difficult to change, they are more amenable to modification than the three fundamental causes.

Three Root Causes

1. Economics: The depressed economic conditions within a given community, as well as individual cases of unemployment and underemployment, lead to significantly higher levels of violence.

2. Oppression: Oppression, and the resulting feelings of inequality and powerlessness, are underlying components of many types of violence. This category includes sexism, racism, and discrimination based on age, ethnicity, class, and cultural background.

3. Mental health: An unsupportive home life, including physical or psychological abuse, can produce low self-esteem in both the victim and perpetrator. Violence begets violence; it is frequently cyclical. A sense of isolation and fear for one's personal safety can adversely affect one's ability to resolve conflict without violence.

Six Community Risk Factors

1. Guns: By virtue of the fact that guns are involved in the vast majority of homicides and suicides, their availability and lethality is a major concern that needs to be addressed. In 1991, firearms were involved in two thirds of the murders committed in the U.S., and a quarter of aggravated assaults. Between 1986 and 1991, the number of firearms used in the commission of crime increased faster than the number of violent crimes.¹⁵ Even if a reduction of hostilities could not be accomplished, reducing the availability of guns and ammunition would decrease the morbidity and mortality produced by such hostility.

2. Media: The mass media (and especially television executives) justify the sensationalization of violence and sexual objectification by claiming that it is what the public wants for entertainment. By age 16, most North Americans have already witnessed 200,000 acts of violence on television, ranging from fights to rapes to murders.¹⁶ The relationship between real life violence and television and movie violence has been documented, but free speech concerns as well as powerful entertainment industry lobbies have impeded regulation of the industry. Another damaging effect of media results from its amplification and perpetuation of racial, gender, ethnic, and other stereotypes. These powerful images are generalizations that fuel oppression and perceptions of inequality that can lead to anger and violence.

3. Alcohol and Other Drugs: Contrary to popular opinion, research does not generally support a causal link between illicit drug use and violence. Some drugs, however, are strongly associated with violence. The drug most frequently associated with violence is the one subsidized by the government and legally marketed to consumers: alcohol. (The issue of the relationship between alcohol, other drugs, and violence is explored later in this paper.)

4. Incarceration: The number of people in prisons is expanding dramatically in the U.S. Instead of fulfilling its purported role as a deterrent, prison becomes a training ground and communication center for criminals. Building and maintaining prisons uses resources that could be allocated to violence prevention efforts.

5. Witnessing Acts of Violence: Experiencing violence can produce Post-Traumatic Stress Disorder (PTSD) similar to that experienced by war veterans. Exposure to or direct involvement in violence is likely to create the belief that violence is a normal form of expression. Being immersed in a violent culture, and especially growing up in a community where violence is prevalent, is likely to produce further acts of violence. The absence of opportunities to express one's feelings or to "re-visit" these experiences in a supportive environment will perpetuate violence.

6. Community Deterioration: The funding for community services throughout the United States has taken a notable downturn. Schools, health and mental health services, libraries, recreational centers, and parks are all critical institutions that provide buffers against the likelihood of violence. At the same time, the "web" of community participation seems to be unraveling, with people's attention focused more on the needs of their own families than the health of the community as a whole.

C) The Two Headed Hydra: "Lock 'Em Up" and "War on Drugs" Policies

This paper has defined and outlined some of the primary factors that contribute to violence. In looking for long-term solutions, it is useful to understand the impact of existing policy on efforts to reduce violence.

Before the new administration in Washington, D.C. took office, violence prevention was narrowly viewed on a national level as synonymous with deterrence. The recent codification of minimum mandatory sentencing and the expansion of capital punishment are expressions of that policy. The United States is one of few industrialized countries that still executes criminals. Looking at the growth of U.S. prisons, it is not surprising to find that the U.S. has a higher ratio of its population incarcerated in jails (455 per 100,000) than any other industrialized nation, surpassing even South Africa (311 per 100,000).¹⁷

One contributor to the large prison population has been the government's "war on drugs." Because drug use was seen as the primary cause of violence, it was assumed that prosecution and incarceration of users and dealers would also reduce violence. Primarily as a result of mandatory minimum sentences and the climate of fear, more people are being sentenced for drug offenses, and to longer terms. The percentage of inmates in prison for a drug crime rose from 9 percent in 1986 to 21 percent in 1991. Over three times as many inmates were serving a prison sentence for a drug charge in 1991 (150,300) as in 1986 (38,500).

The Prevention Program's paper, "The Relationship between Alcohol, Other Drugs, and Violence,"¹⁸ concludes that illicit drug use is not the cause of violence. The research shows that while some illicit drugs are a contributing factor in violent situations, it is the drug trade, not drug use, that is most closely associated with violence. There is little evidence that strategies aimed at reducing the supply of illegal drugs have a significant impact in reducing drug use or violence.

The research led to four major conclusions:

1. The drug most associated with violence is alcohol. Of course, alcohol use is less discouraged than other drugs, and in many ways it is encouraged in the environment. For example, in the U.S. alcohol advertising is considered a legitimate cost of doing business. A alcoholic beverage company is, therefore, permitted to take deductions from its taxes for such promotional costs.

2. The relationship between drugs and violence is a complex one. While there is clear evidence that they are interrelated in some way, the notion that the relationship is causal is open to serious doubt, particularly in regard to certain drugs. The strongest relationship between drugs and violence seems to stem in many cases from their illegal status, that is, the violence caused by illegal drug sales, rather than their psychopharmacology.

3. In the cases where psychopharmacology does seem to be a factor -- for example crack cocaine use -- there is little evidence that the "war on drugs" approach of intervening to stop the supply works. Although there have been headlines about kingpin arrests, the availability of drugs remains high, and it seems unlikely that any strategies other than reducing demand will work.

4. Strategies to reduce demand are currently only a small portion of "war on drug" expenditures. No adequate drug treatment is available even for those who are most at risk, including the incarcerated, the recently released, and pregnant women.

The research reveals that recent federal policy regarding drugs and violence is not effective. As a method of deterrence, the "war on drugs" campaign aims to lock up drug dealers and users, threatening any others who are contemplating similar activities, and separating the offenders from the rest of society. This deterrence method receives mixed reviews but there are several reasons to believe that it is a failure.

First, while drug use is decreasing and violent crime is increasing, the criminal justice system is directing more of its attention to drug offenses and less to violent crime. This results in an increasing proportion of persons imprisoned for drug offenses and a decreasing proportion imprisoned for violent crimes. While national measurements of drug use show a downward trend over the past few years, drug arrests increased by 25 percent between 1986 and 1991. Even more remarkable, the number of persons imprisoned for drug offenses increased by 327 percent, or 13 times the percentage increase for such arrests.¹⁹ Despite the increase in numbers of people incarcerated for drug offenses, acts of violence have continued to rise.

Secondly, the jail system itself is an effective training ground for violent criminals. The American system has officially given up on the notion of rehabilitation, and prisons are consistently reporting that networks of criminals are enhanced in the jails. Gangs in particular flourish in jails, giving rise to the analogy that jails are a national meeting place or conference center for gang members.

Thirdly, certain peculiarities of the criminal justice system actually seem to encourage the development of criminal behavior. Upon parole, gang members are often not returned to the site of their previous criminal activities. The result of this policy is that gang members spread their influence to other places, such as Los Angeles gang members who have been released into central California farm communities.

While the legal system tries to protect children, it may actually increase the criminal behavior of minors. Because young children do not receive the severe criminal sentences that adults do, they are often groomed as drug runners and direct sales people when as young as eight or nine years old. In this way, very young children are introduced into a life of crime and into the criminal justice system.

The proportion of people released from prisons that re-offend and return to prison is very high in some communities. Much local and state bond money has been allocated to the construction of prisons, with large percentages of tax dollars used for maintaining the jail system. This leaves little money for funding organized programs to stop or slow the growing numbers of people entering prison. There is hardly any drug treatment for prisoners who are addicted to drugs, let alone counseling, training, or treatment for people who want to stay out of jail. Support for the policy of incarceration is most damaging because it directs huge sums of money into jails and prisons that could be better invested in prevention measures such as job creation and education.

Single-focus solutions, such as incarceration or intervention in supply, do not effectively deal with the scope of the problem.

IV. A Public Health Approach to Environmental Change

The underlying analysis that continues to motivate the Prevention Program's violence prevention work is the understanding that violence emerges from multiple and complex personal, social, and economic causes, and violence reduction therefore necessitates multifaceted efforts. This approach was reinforced by the 1990 Centers for Disease Control's "Forum on Youth Violence in Minority Communities," which concluded, "complex causation means that multifaceted solutions are necessary." An effective response requires the marshalling of resources at both national and local levels. The health of a community is a composite of physical, psychological, social, and economic variables. Consequently, the responsibility for overall community health resides in a number of systems, including the family, education, health, work, criminal justice, and social services.

The Prevention Program employs a systematic approach in its work. As a catalyst for bringing key people and organizations together, the Program is able to galvanize support for broad-based and long-lasting change. Three tools are used to maximize collaboration: "Eight Steps to Coalition Building," which describes how to bring people and organizations together; "Spectrum of Prevention," which outlines effective strategies; and "Partnerships for Institutional Change," a method for shifting policies and resources within established organizations.

A) Coalition Building

The U.S. Department of Health and Human Services report Healthy People 2000: National Health Promotion and Disease Prevention Objectives published in 1991 recommends multidisciplinary and multi-agency strategies. At the Prevention Program, local violence prevention initiatives have been developed in conjunction with community-based organizations that are already focused on aspects of the problem.

The Program brings together organizations that are either already concentrating on a particular form of violence (e.g., Battered Women's Alternatives) or serving a population that is particularly at risk (e.g., Familias Unidas or Youth Service Bureau). Employing what is described as a "jigsaw puzzle" model, the Program brings together these different groups to focus on the problem as a whole. Instead of creating new, stand-alone programs, existing community-based organizations join with the Program to form a single coalition that coordinates comprehensive prevention services. These coalitions may also include representatives of governmental agencies, nonprofit groups, funding sources, or businesses.

Coalitions can accomplish a broad range of goals that reach far beyond the capacity of any individual member organization. The work of an active coalition can range from information sharing and coordination of services to advocacy for major environmental or regulatory changes.

Prevention Program staff members are the "glue" that keeps the coalitions functioning. They coordinate meetings, research data, conduct evaluations, search for materials, and adapt programmatic approaches that have been tried successfully in other locations. Usually the Health Department is perceived as a credible and neutral party, and these characteristics strengthen the Prevention Program's ability to foster cooperative solutions.

A list of the agencies involved in the PACT Against Violence coalition demonstrates the breadth of issues and the diversity of organizations that are committed to working collaboratively on violence prevention: Battered Women's Alternatives, East Bay Center for the Performing Arts, Familias Unidas, Girls Inc., Lao Family Community Development, Opportunity West, Police Activities League, Rape Crisis Center, and West County Youth Service Bureau.

Coalition building is one of the Prevention Program's primary strategies for reducing injury and preventing disease in Contra Costa County. Many of the lessons learned from initiating and sustaining dozens of coalitions are synthesized in the paper, Developing Effective Coalitions: An Eight Step Guide, published by the Prevention Program.

An Eight-Step Guide to Coalition Building

1. Analyze the program's objectives and determine whether or not to form a coalition
2. Recruit the right people
3. Devise a set of preliminary objectives and activities
4. Convene the coalition
5. Anticipate the necessary resources
6. Weigh the elements of a successful structure
7. Maintain the coalition vitality
8. Make improvements through evaluation

B) The Spectrum of Prevention

The benefits of a diverse coalition membership are fully realized when the coalition identifies and implements a broad range of strategies. Given the complexity and extent of violence, such a range is needed to reduce violence. The "Spectrum of Prevention" model, based on work by Dr. Marshall Swift of Hahnemann College in Philadelphia, describes the six strategies that are central to the Prevention Program's systematic approach to reducing injury and disease.

Individual education aimed at changing behavior is not enough to prevent injury or illness. The Spectrum of Prevention delineates six levels of activity, all of which reflect the viewpoint that environmental factors are the largest determinant of health status. Changing institutional priorities as well as laws and organizational policies are all essential ingredients for creating safe communities. Only by transforming the environmental and community contributors to poor health status can a prevention-oriented approach actually hope to reduce violence.

Each of the six levels of the Spectrum of Prevention depends on the others to work well. For example, legislation such as gun control ordinances cannot be enacted without well-educated, vocal community supporters. The following descriptions will illustrate how each level of the Spectrum works.

1. Strengthening Individual Knowledge and Skills
   Health education programs reach out to individuals at risk, encouraging them to change their behavior. In the PACT Against Violence project in the Greater Richmond area, 28 youth are being trained as leaders in violence prevention. They are taught about root causes, cultural differences, and how to resolve conflict without resorting to violence.

2. Educating the Community
   A well-coordinated community campaign enhances awareness and builds skills. The Prevention Program collaborated with high schools in the Greater Richmond area to produce Violence Prevention Month. The event consisted of educational activities for teens, including a "Teen Speak-Out Against Violence" and rap and poster contests. Publicity for the event brought the issue to the public's attention, highlighted some of the most important aspects of the problem, and generated extensive media coverage. Frequently, well-planned mass media campaigns are an effective and cost-efficient way to educate the community.

3. Training Providers
   A preventive health approach benefits from cooperative, knowledgeable participation of health and other service providers. Professionals and para-professionals who work in health and other community services have regular contact with people at risk and can encourage adoption of healthy behavior and screen for additional risks. These providers (i.e. clergy, mental health workers, medical personnel, etc.) can also advocate policy change in institutions and laws. A legislative aide trained by the Prevention Program drafted the language for an important California law requiring the inclusion of violence prevention in the curricula of public school health education.

4. Building Coalitions
   Coalitions combine individual and organizational strengths in new ways. The National Coalition of Violence Prevention Programs provides a forum for service providers across the nation to share information, design joint efforts, and explore national policy concerns.

5. Changing Organizational Practices
   The ways in which large organizations operate can affect many people as well the community as a whole. A School Board's decision to establish a Conflict Resolution Program reduced the number of fights and suspensions and improved the overall school climate.

6. Influencing Policy and Legislation
   Legislative and policy activities can produce the broadest changes to the environment. Recently California passed a law banning the sale and transportation of certain types of assault rifles. This victory revealed the vulnerability of a major pro-gun group, The National Rifle Association, and helped to reduce the availability of one type of deadly weapon.

By integrating the six levels of the Spectrum, a preventive health program is able to effectively promote change.

C) Partnerships for Institutional Change

The Prevention Program has applied a "Systems Approach," combining coalition building with the Spectrum of Prevention, for a number of years. Violence prevention efforts, however, have been conducted primarily on a grassroots level with small community agencies pioneering efforts around the country. These isolated projects show promise, but they alone can not stop the rising tide of violence.

Many large institutions have either entirely ignored violence as an issue or have perpetuated the "war on drugs" and "lock 'em up" approaches. Recognizing that violence is an environmental problem means acknowledging that it is a large and complicated problem to deal with. It is now clear that the broad societal changes that are required will take a commitment from institutions as well as community agencies. Because institutions are the pillars of society -- determining priorities, controlling much of the resources, and affecting the culture of a community -- they must have a central role in creating solutions.

An analysis of how a cultural acceptance of violence develops and how it can be dealt with identifies the need for institutional partnerships that combine the jigsaw puzzle model of collaboration with the Spectrum of Prevention. This concept includes the notion that institutions themselves must change their practices to be effective as agents of violence prevention.

Some institutions will be willing and active participants in violence prevention, while others may resist. In the first case, an institution may want to be considered a partner. A representative may become active in a coalition and the institution may contribute money, volunteers, or other resources, such as professional help with outreach campaigns. The institutional partner can add insight as well as influence to programmatic efforts, especially related to campaigns aimed at changing laws or modifying organizational practices.

The second level of institutional involvement is for those institutions that do not recognize violence prevention as relevant to their mission or whose operations may actually impede violence prevention efforts. When institutions are reluctant to become active in violence prevention efforts, they can be encouraged to make specific changes defined as critical by a violence prevention coalition. For example, a chain of 24-hour markets has begun to provide conflict resolution training to store clerks as a way to reduce late night crime. Organizations whose activities actually contribute to the problem of violence may require pressure or regulation to force institutional change. Examples of institutions requiring such pressure are television networks and the other media that perpetuate stereotypes and glorify images of violence.

Government is a good place to initiate partnerships for institutional change. It constitutes a significant part of the institutional environment and controls important resources. In addition, when government sets an example, it receives attention, and the innovation may be replicated by the private sector. One of the most successful examples is the regulation of tobacco use in public. Smoking was first outlawed in public buildings and the ban is now widespread throughout private industry as well as public places in the U.S.

Violence prevention practices have similar potential for collaboration with government. For example, a public works department can be persuaded to install better lighting in a high crime neighborhood. Other possible roles for government include: parks and recreation departments (youth recreation activities), schools (courses on cultural competence and pride, conflict resolution), personnel departments (jobs, mentoring programs), policy makers (gun and ammunition control, rational "alcohol and other drugs" policies), transportation (safe places for waiting), and criminal justice (community policing, rehabilitation in facilities).

Even among health departments, the process of implementing broad violence prevention strategies is yet to be accomplished. When the Prevention Program initiated its efforts in 1983, it was among a handful of health departments nationwide that recognized violence as a health issue. Today, only a few health departments choose to commit significant resources to this problem. Yet the role of a health department is critical. Health care providers and administrators are in a unique position to play a lead role in community coalitions, encourage training of health care practitioners, support advocacy efforts, and conduct data collection and dissemination. They are also able to deploy their mental health staff to sites where incidents of violence are frequent and provide conflict resolution skills and post-traumatic stress debriefings.

V. Conclusion

"When we know how to reduce the torment, but do not do it, then we become the tormentor," states world-renowned Italian novelist Primo Levi, whose many books chronicle the atrocities of World War II. Interpersonal violence in the United States is the new holocaust confronting us. To stop the carnage requires massive attention, resources, and commitment.

Violence produces headlines on the covers of recent newsmagazines. Yet it cannot be viewed as the concern of the month, to be replaced by another issue next month. As a health crisis, violence requires the continuity of a public health approach, that is to say, a comprehensive, community-oriented approach that attacks underlying causes and risk factors with leadership facilitated by public health practitioners.

As an environmental problem, violence demands the concentrated attention of the major institutions that shape our social and physical world. Violence prevention depends on the collaboration of government, businesses (the entertainment industry in particular), and civic, religious, and cultural organizations. An African proverb states, "It takes a village to raise a child." Ending violence will entail people in each neighborhood assuming responsibility for the problem -- even if to do so is risky and frustrating. Stopping the momentum of violence requires a "critical mass" of people who are willing to speak out and to work together to change the structures and policies that frame the way we live. It is also important to recognize these heroes among us, and to acclaim them. Violence is a learned behavior and since we know how to reduce the torment, we must do it.

Footnotes

¹ In this paper, the term African-American is used to refer to peoples of African descent who currently reside in the United States. In many scientific publications and population studies, the term "black" is used to refer to people of African descent. The authors have taken the liberty of changing the term for consistency within this paper. They have also adopted the designation European-American in place of "white."

² San Francisco Examiner (1993), "Bodies piling up in East Palo Alto," January 3.

³ Fingerhut, Lois A. and Kleinman, Joel C. (1990). "International and interstate comparisons of homicide among young males," Journal of the American Medical Association, Vol. 263, No. 24, June.

⁴ Ibid.

⁵ American Bar Association (1993), "The state of criminal justice: an annual report," February.

⁶ U.S. Department of Justice (1993), "Survey of state prison inmates, 1991," March.

⁷ State of California Department of Health Services (1990), "Data summary: homicide rates among young males, by race/ethnicity," December.

⁸ U.S. Senate Judiciary Committee (1990), "Violence against women: the increase of rape in America 1990," a majority staff report prepared for the use of the Committee on Judiciary, United States Senate.

⁹ Ibid.

¹⁰ Health Education Reports (1993), "House acts on public health consequences of battered women," June 3rd.

¹¹ Prothrow-Stith, Deborah (1991), Deadly Consequences, Harper Collins, New York.

¹² Brenner, Harvey (1979), "Mortality and the national economy: a review and the experience of England and Wales 1936-76," The Lancet, September 15.

¹³ Centerwall, Brandon S. (1992) "Television and violence: the scle of the problem and where to go from here," Journal of the American Medical Association, Vol. 267, No. 22, June.

¹⁴ Ibid.

¹⁵ American Bar Association (1993), "The state of criminal justice: an annual report," February.

¹⁶ Toufexis, Anastasia (1989), "Our violent kids: a rise in brutal crimes by the young shakes the soul of society," Time Magazine, June 12.

¹⁷ The Sentencing Project (1992), Americans Behind Bars; One Year Later.

¹⁸ Contra Costa County Health Services Department Prevention Program (1992), "The Relationship between Alcohol, Other Drugs, and Violence," unpublished paper.

¹⁹ American Bar Association (1993), "The state of criminal justice: an annual report," February.

Bibliography

American Bar Association. "The State of Criminal Justice: An Annual Report." February 1993.

Brenner, Harvey, PhD. "Mortality and the National Economy: A Review and the Experience of England and Wales 1936-76." The Lancet, September 15 1979.

Centerwall, Brandon S., MD, MPH. "Television and Violence: The Scale of the Problem and Where to Go From Here." Journal of the American Medical Association (JAMA) June 10, 1992, Vol. 267, No. 22.

Contra Costa County Health Services Department's Prevention Program. "Status Report on Childhood Injury, Contra Costa 1992." April 9, 1992.

Eight Steps to Coalition Building, Prevention Program, Pleasant Hill, California, 1991.

Fingerhut, Lois A. MA, and Kleinman, Joel C., PhD. "International and Interstate Comparisons of Homicide Among Young Males." Journal of the American Medical Association (JAMA) June 27, 1990 Vol 263, No. 24.

Health Education Reports. "House Acts on Public Health Consequences of Battered Women." June 3, 1993.

Prothrow-Stith, M.D., Deborah. Deadly Consequences. New York, NY, Harper Collins, 1991.

San Francisco Examiner. "Bodies piling up in East Palo Alto." January 3, 1993.

The Sentencing Project. America Behind Bars: One Year Later. Washington, D.C., 1992.

"The Relationship Between Alcohol, Other Drugs and Violence." Unpublished, Prevention Program, Pleasant Hill, California, 1992.

State of California Department of Health Services. "Data Summary: Homicide Among Young Males, By Race/Ethnicity." December 1990.

Toufexis, Anastasia. "Our Violent Kids: A rise in brutal crimes by the young shakes the soul of society." Time Magazine June 12, 1989. TIME Inc. New York, NY.

U.S. Department of Justice. "Survey of State Prison Inmates, 1991." March 1993.

U.S. Senate Judiciary Committee. "Violence Against Women: The Increase of Rape in America 1990." A majority staff report prepared for the use of the Committee on the Judiciary United States Senate.

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