TY - JOUR
AU1 - Cole, Thomas B.
AU2 - Flanagin, Annette
AB - This issue of THE JOURNAL, in commemoration of the bombing of Hiroshima, is intended to direct attention to the public health consequence and clinical significance of violence and other violations of human rights. Articles in this issue address important and as yet unresolved problems in the United States, including adolescent violent behavior,1 the costs of firearm violence,2 firearm violence prevention,3 intimate partner abuse,4 and child abuse mortality.5 Articles also address international issues, such as the health status of refugees from Bosnia6 and Kosovo,7 prenatal exposure to wartime famine,8 and human rights violations of girls and women in Turkey.9 These articles are unsettling, not only because of the violent context of the research findings but also because so much remains to be learned about effective violence prevention and control. Recent data from the Youth Risk Behavior Survey1 indicate that violent behavior among US adolescents has been declining, although the most recently available data from this biennial survey are from 1997. Yet gun carrying to school is still common, and multiple homicides on high school campuses seem to be increasing in frequency. These facts are difficult to reconcile, but more important than the issue of whether US adolescents are more or less violent than they were a few years ago is the question of what to do about it. For example, recent killings in US schools10,11 may have been preceded by threats of violent behavior. Do threats predict violence, or are they ubiquitous in adolescence? Threatening behavior may signal an opportunity for intervention. On the other hand, if threats of violence are universal among adolescents, then perhaps a more aggressive disarmament strategy should be considered. Is there any scientific evidence that handguns are so inherently dangerous that developing a national strategy to prevent access of children and adolescents to handguns makes sense? If not, should adolescents be granted the privilege of handgun use only after a period of training and violation-free observation, following the model of graduated driver licensing?12 Some researchers have advocated safe storage of guns in the home to prevent children and adolescents from shooting one another. In this issue of JAMA, Wintemute3 comments on this approach and other firearm injury prevention methods. In theory, safe storage may deter small children from playing with loaded guns, but is it really possible to prevent a motivated teenager from gaining access to a locked and unloaded weapon in the home? Wintemute also discusses safer gun design, but it is not clear that gun safety devices, such as trigger locks and loaded chamber indicators, reduce overall morbidity and mortality from firearms. These questions are important for the design of new guns and for giving gun owners the option of retrofitting their vast supply of privately owned firearms.13 Up to now, gun design has been predominantly market-driven. What is the best way to design safer guns? Are there regulatory, engineering, or injury data-driven analogies to the design of safer cars?14 Despite the unacceptably high cost of gunshot injury in lost or damaged lives and public money,2 public debate on "gun control" has been contentious, in part because of the lack of credible research on the effectiveness of proposed interventions. Gun research should be driving these debates, not impeding them. An axiom of violence propagation theory is that violent behavior is passed down from generation to generation through families. The article in this issue of JAMA by Herman-Giddens et al5 provides solid evidence that the increasing incidence of child abuse is not an artifact of better detection, but is a true increase. Why is abuse increasing, and what impact will it have on family and community violence? Herman-Giddens et al also show that most child homicides are perpetrated by their caregivers. What is the long-term effect of knowing that one's own home is the most dangerous place to be? Also in this issue, Rodriguez and colleagues4 report that a majority of primary care physicians (79%) in California routinely screen injured patients for intimate partner abuse. However, such screening was much less common for noninjured patients, ranging from 9% to 11%, for new patient visits, periodic check-ups, and prenatal care visits. Recent training in intimate partner abuse did not improve screening practices. Physicians working in public clinics reported the highest rate of screening (37%); physicians in private offices and health maintenance organizations reported significantly lower rates of screening, 9% and 1%, respectively. These data bring to question whether and how screening, detection, and referral of abused individuals can be effectively and ethically established in different clinical settings and whether domestic violence prevention programs can work if they are solely institution-centered, rather than coordinated community efforts involving legal, judicial, law enforcement, and social services; shelters; and medical representation. Responding to the visibility of intimate partner abuse as a major public health problem, US legislators have granted additional powers to law enforcement officers called to investigate domestic disputes, and 5 states now have laws mandating health care professionals to report intimate partner abuse. Have these recently enacted laws actually benefited abused intimate partners? Do legal actions such as restraining orders do more good than harm?15 Does mandatory reporting with or without the consent of the abused, as is required in California, do more harm than good?16 In another article, Rodriguez et al17 note that if the patient objects to reporting, 64% of primary care physicians and 25% of emergency physicians would not comply with California's mandatory reporting law because of fears for patient safety and ethical concerns about patient confidentiality, patient autonomy, and the integrity of the patient-physician relationship. Additional research on the actual risks and benefits to patients of mandatory reporting laws is warranted. As with firearm violence, research into intimate partner abuse should be driving, not responding to, legislation. As reported in previous Hiroshima issues of JAMA,18 research in war zones and among the world's refugees continues to document the devastating effects of war, torture, displacement, and famine on unarmed, unprepared civilians and their families. Articles in this issue by Mollica and colleagues6 and Neugebauer et al8 as well as the editorial by Iacopino and Waldman7 emphasize the ongoing human rights violations and explore the associated mental health consequences that occur among civilians and refugees as a result of war. Additional studies are needed to determine how the effects of such violence and other violations of human rights are passed on from generation to generation, to assess how this cycle is influenced by violence on a national scale, and to understand better the long-term physical and psychological sequelae to individuals, families, and communities of violence on a geopolitical scale. We know that violence is widespread, long lasting, and harmful to human health—in short, a major public health problem. Violence prevention is a maturing discipline, and there are still opportunities to characterize poorly understood violence outcomes. However, the current state of knowledge is more than sufficient to emphasize the urgent nature of finding solutions. The problems and questions are complex, yet clear. It's time for some real answers. References 1. Brener ND, Simon TR, Krug EG, Lowry R. Recent trends in violence-related behaviors among high school students in the United States. JAMA.1999;282:440-446.Google Scholar 2. Cook PJ, Lawrence BA, Ludwig J, Miller TR. The medical costs of gunshot injuries in the United States. JAMA.1999;282:447-454.Google Scholar 3. Wintemute GJ. The future of firearm violence prevention: building on success. JAMA.1999;282:475-478.Google Scholar 4. Rodriguez MA, Bauer HM, McLoughlin E, Grumbach K. Screening and intervention for intimate partner abuse: practices and attitudes of primary care physicians. JAMA.1999;282:468-474.Google Scholar 5. Herman-Giddens ME, Brown G, Verbiest S. et al. Underascertainment of child abuse mortality in the United States. JAMA.1999;282:463-467.Google Scholar 6. Mollica RF, McInnes K, Sarajlić N, Lavelle J, Sarajlić I, Massagli MP. Disability associated with psychiatric comorbidity and health status in Bosnian refugees living in Croatia. JAMA.1999;282:433-439.Google Scholar 7. Iacopino V, Waldman RJ. War and health: from Solferino to Kosovo—the evolving role of physicians. JAMA.1999;282:479-481.Google Scholar 8. Neugebauer R, Hoek HW, Susser E. Prenatal exposure to wartime famine and development of antisocial personality disorder in early adulthood. JAMA.1999;282:455-462.Google Scholar 9. Frank MW, Bauer HM, Arican N, Fincanci SK, Iacopino V. Virginity examinations in Turkey: role of forensic physicians in controlling female sexuality. JAMA.1999;282:485-490.Google Scholar 10. Mitka M. Learning lessons from true-life school trauma. JAMA.1999;281:220.Google Scholar 11. Lamberg L. Preventing school violence: no easy answers. JAMA.1998:280:404-407.Google Scholar 12. Koop CE, Lundberg GD. Violence in America: a public health emergency, time to bite the bullet back. JAMA.1992;267:3075-3076.Google Scholar 13. Cook PJ, Cole TB. Strategic thinking about gun markets and violence. JAMA.1996;275:1765-1767.Google Scholar 14. Centers for Disease Control and Prevention. Motor-vehicle safety: a 20th century public health achievement. MMWR Morb Mortal Wkly Rep.1999;48:369-374.Google Scholar 15. Langford L, Isaac N, Adams S. Criminal and restraining order histories of intimate partner-related offenders in Massachusetts, 1991-1995. Presented at: Proceedings of the 1999 Meeting of the Homicide Research Working Group; June 27-30, 1999; Washington, DC. 16. Glass N, Campbell JC. Mandatory reporting of intimate partner violence by health care professionals: a policy review. Nursing Outlook.1998;46:279-283.Google Scholar 17. Rodriguez MA, McLoughlin E, Bauer HM, Paredes V, Grumbach K. Mandatory reporting of intimate partner violence to police: views of physicians in California. Am J Public Health.1999;89:575-578.Google Scholar 18. Theme issue on violence/human rights. JAMA.1998;280:397-488.Google Scholar
TI - What Can We Do About Violence?
JF - JAMA
DO - 10.1001/jama.282.5.481
DA - 1999-08-04
UR - https://www.deepdyve.com/lp/american-medical-association/what-can-we-do-about-violence-Q0MeTsQ3fi
SP - 481
EP - 483
VL - 282
IS - 5
DP - DeepDyve
ER -