In 2016, 385,000 people lost their lives to intentional homicide worldwide. Another hundred thousand died in war. Countless more were injured. But one report found that 1.35 million lives could be saved between 2017 and 2030 if states move to adopting violence prevention methods proven to work.
Tackling violent crime ranks high among citizens’ demands from government, but there is little consensus on how to stop the killings. On the one hand, iron fist approaches are back: from the US to the Philippines, politicians are casting violence as a scourge to be eradicated by the criminal justice system.
But equally, the “public health approach” has found favour from Scotland to Colombia, and it is spreading. London, after a spate of stabbings, has recently announced the establishment of a new violence reduction unit founded on public health insights.
But what does it mean? And can it beat it out traditional criminal justice responses?
When was the public health approach established?
One of the earliest mentions of violence as a public health issue came in 1979, when the Surgeon General of the United States included stress and violent behaviour in his list of America’s health priorities in the coming century.
But what is today understood as the public health approach to violence traces its roots most clearly to the work of American epidemiologists in the mid-1990s.
When Gary Slutkin, an epidemiologist who had spent decades quelling the spread of epidemics in Africa, returned to Chicago in the 90s, he was confronted with an epidemic that he did not expect: gun violence.
“It looked exactly like contagious diseases,” Slutkin recalls, “One event led to another, it had epicentres on maps, clustering, and standard epidemic curves.”
Slutkin reframed the issue. Rather than seeing violence as a side-effect of moral characteristics — bad guys doing bad things — he understood it as a disease which passed from person to person.
Victims often became perpetrators, he realised, but focusing on prevention could help stop the cycle of violence.
How do public health approaches explain violence?
The public health approach understands that, like illness, violence can be encouraged or discouraged by contextual factors.
Witnessing domestic violence as a child is a well-established risk factor for either perpetrating or experiencing violence in later life, while a close relationship with parents or friends can protect against violent behaviours.
The public health methodology contains four stages: understanding the scale and nature of the problem through data collection and analysis; designing interventions and policies to tackle the problem using multiple services; monitoring and evaluating the impact of any interventions; and finally, scaling up successful strategies.
The exact form of those four steps vary from place to place according to the problem, but the process allows for a more sensitive, data-driven engagement with the problem.
In practice, that means working well beyond the criminal justice system using multiple departments and agencies. Understanding violence as a complex phenomenon with multiple causes means engaging more than just one discipline or service.
What actors does the public health approach involve?
Social services, teachers, GPs, sports coaches and community activists all have a role to play.
Anyone working in frontline services can watch out for signs of violence, drug addiction, alcohol misuse mental health crises, homelessness or unemployment.
Providing training can help them to make referrals to the appropriate services, whether counsellors to deal with underlying trauma, grassroots community initiatives, or help with jobs and housing.
Where has it been tried?
This broad framework has taken different forms in countless settings across the world.
In Glasgow, Scotland, aligning the work of police officers, social workers, teachers and doctors to support at-risk residents with new services — including housing support and employment advice — helped to cut the city’s murder rate by 60% in a decade.
In Medellín, Colombia, mapping the locations and drivers of violence allowed the city to target infrastructure spending to offer poor residents a path out of poverty and violent crime. A cable car cut the murder rate by 94% over 15 years in one of the city’s most violent favelas.
And in Cardiff, Wales, an anonymised data sharing model between hospitals, police forces and policymakers cut police-recorded violence by 42% and now saves the city $6.6 million each year violence-related costs.
What are the challenges?
Public health approaches are not without their flaws or ethical hiccups.
The use of data for policymaking raises issues of privacy — particularly when the data collected is shared indiscriminately between services. A database of “at-risk” youths in London was slammed by privacy advocates earlier this year for not only racial profiling but also preventing young people on the list from getting jobs or housing.
Perhaps the biggest challenge to public health-driven policy, however, is political. Being seen as soft on crime can be a death knell for political leaders, and public health approaches are unlikely to offer the certainty — however misplaced — that a police crackdown can.
Despite growing interest in cities and sub-national areas, Scotland is the only country in the world with a public health model embedded across its police force. Public health approaches might be on the rise, but policing still holds power. — Edward Siddons
(Picture credit: Flickr/Maryland GovPics)