A Major Public Health Crisis

By McAfee, Robert E. | Nieman Reports, Fall 1996 | Go to article overview

A Major Public Health Crisis


McAfee, Robert E., Nieman Reports


We may live in the most violent country in the world. U.S. homicide rates far exceed those in any other industrialized country, and our rates of violent crime are always among the world's highest. Violence does affect all of us -- if not through individual experiences, then through the daily confrontation of news accounts of violence, terrorism and its aftermath. Although violent crime rates appear to have stabilized since 1992, after rising significantly for the previous seven years, increases in juvenile crime, as well as homicide rates in the 18-24 age group, have increased sharply since that time. (Preliminary data for 1995 show a significant drop in youth crime from 1994, but the numbers are still large.) It may be that we are allowing, if not teaching, our children to become violent, and while most agree that violence is learned behavior, there is no question that it is higher in neighborhoods with high poverty, inadequate housing and high unemployment. Much needs to be known about the biology of violence and more research needs to be done.

Because of major medical expenditures in addition to loss of life and disability, the problem of violence, particularly family violence, has been identified by the American Medical Association as a major public health crisis and problem to be solved. Family violence includes child physical and sexual abuse, domestic or partner abuse and elderly abuse. There is, indeed, frequently a connection in all these forms of violence and several studies have indicated that children growing up in an environment in which parents fight, are much more likely to adopt similar behavior when they become parents, as well as be victims of abuse themselves. Elderly abuse probably remains the most underdiagnosed abuse in our society, and yet one that physicians see on a daily basis.

Child abuse remains a reportable condition for all physicians who treat these victims in every state; elderly abuse is reportable in 42 states, and domestic violence is required currently only in a handful of states. This discrepancy takes into account the safety of the victim once reporting has occurred. We have resources by and large to protect the child, as well as the elderly patient, once violence is reported. But there is a paucity of resources to provide the safety net for victims of domestic violence. In fact, that reporting seems at present to increase substantially the danger of violence to the victim. It is for that reason that debate continues as to whether reporting from a public health point of view should be carried out.

The American Medical Association presents an annual Report Card on Violence. The first report, given by me in 1995, indicated an overall grade of "D" for four categories: family violence, sexual assault, public violence and violence in entertainment. The "D" indicates little progress based on four criteria: (1) Whether the problem is getting better or worse according to statistics. (2) The status of public awareness and attitudes toward violence. (3) The effectiveness and availability of treatment and intervention programs. (4) The cost to society in dollars, pain and human suffering. This year's Report Card, presented in June by Dr. Lonnie Bristow, then President of the AMA, also registered a "D." We will continue to monitor those kinds of violence as an ongoing alert to policymakers in this country.

The American Medical Association's "Physicians Coalition Against Family Violence" is now entering its fifth year in an attempt to develop a broad-based coalition of physicians. The coalition was formed after research found that when victims of domestic violence were asked who could have made a difference in their lives, and whom they would have preferred to tell of the repetitive events that may have led up to a near fatal injury their family physician was, surprisingly, identified 87 percent of the time. That was slightly more than would wish to tell their priest, their pastor or rabbi, and considerably more than would wish to tell the police. …

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