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Rethinking the paradigm on violence

Violence is increasingly viewed as a public health challenge, rather than just a criminal problem. David Lynch explores innovative initiatives both at home and abroad

Violence, as the World Health Organisation (WHO) notes, “has probably always been part of the human experience”.

However, the same document, Violence — A Global Public Health Problem (2013), makes the case that “violence can be prevented and its impact reduced, in the same way that public health efforts have prevented and reduced pregnancy-related complications, workplace injuries, infectious diseases, and illness resulting from contaminated food and water in many parts of the world”.

This idea of treating violence as a public health challenge, rather than principally a moral failing or criminal justice matter, may not yet be widely understood within the general population, but in international medical circles, it has gained significant support in recent decades.

The WHO notes that each year, more than a million people lose their lives and many more suffer non-fatal injuries, as a result of self-inflicted, interpersonal or collective violence.

“Violence can be prevented,” concludes the WHO. “This is not an article of faith, but a statement based on evidence. Examples of success can be found around the world, from small-scale individual and community efforts, to national policy and legislative initiatives.”

But even with such bullish optimism from the WHO, the public health approach towards tackling violence is still taking time to spread.

“I don’t think there is general acceptance across medicine, as most clinicians work on a one-to-one basis with victims of violence,” Prof Joe Barry, Professor of Population Health Medicine at Trinity College Dublin, told the Medical Independent (MI).

Prof Barry said this is not so much a “conscious reluctance” on behalf of doctors, but because the issue of violence does not feature prominently in general discussions. The whole waiting list problem seems to take up all the energy and public debate around emergency medicine, rather than adopting a proactive stance.

“Occasionally, there is a public perspective from clinicians in relation to Halloween bonfires. The violence associated with drugs has resulted in a public health response that involves the gardaí, the HSE, psychiatrists and the communities affected.”

However, Prof Barry also regards experience with other major public health challenges as instructive in dealing with violence.

“If clinicians joined forces with public health practitioners around violence, as happens with tobacco and alcohol, then progress could be made in developing a public health response to violence,” he said.

Examples of how to deploy public health strategies towards violence have been introduced in Scotland, the US and now recently Ireland, within the prison service. 

Prisons

Last December, Minister for Justice Charlie Flanagan told the Dáil the Irish Prison Service’s National Violence Reduction Unit at the Midlands Prison, Portlaoise, was “completed at a cost of approximately €2.7 million and is capable of housing up to 10 prisoners”. The Minister said it “marks a new approach to engaging with prisoners who present a high risk to staff, to other prisoners and to our communities”.

The head of care and rehabilitation in the prison service told this newspaper that although still in its early days, the unit is progressing well.

“The Irish Prison Service (IPS) has approximately 4,000 people in custody on any given day,” Mr Fergal Black, Director of Care and Rehabilitation at the IPS, told MI.

“A very small proportion of prisoners would be regarded as violently disruptive prisoners. These are prisoners who in the main have conducted violent actions against staff and prisoners [and] pose a particular risk to good order within the prison. So we would have at any given day probably between four and eight such prisoners. The proportion is very minuscule.”

Mr Black said that the IPS had begun looking abroad for some ideas.

“We looked at responses in other jurisdictions, particularly in the UK,  where they have close supervision centres,” he said.

“They are intensively staffed; staff are trained in de-escalation and in building a relationship with such offenders. It operated on a kind of twin-track approach, where it is jointly managed by psychology [services] and prison staff.

“We kind of took the model in the UK and adapted it slightly, and developed our own national violence reduction unit in the Midlands Prison, which opened in November.”

Mr Black describes it as a “psychologically-informed unit”.

“We have a senior psychologist, we have officers who are trained, the [joint] heads of the unit is the Governor and the senior psychologist,” he added.

“The whole intention is to work with these guys, effectively to change their volatility, their propensity for violent acts, primarily though building a relational approach. So each offender in the unit would have a personal officer, a prison officer who would work directly with that offender on an ongoing basis. The whole idea would be to mitigate the risk that these offenders pose by working with them and building a relational approach.”

Important role

Doctors and other healthcare workers play an important role in the unit.

“While there are psychologists in the unit, there are other services that visit the unit, so the nursing service would be there, providing medication and treatment,”  Mr Black said.

“There are a number of GPs scheduled on the unit each week. So we would [also] have a consultant forensic psychiatrist who would visit the unit at least once a week, for prisoners who suffer from a medical illness. They would be integral to the support structure… we have a huge emphasis on recording behaviour, triggers, incidents; we would have a dynamic risk assessment meeting in relation to every prisoner in the unit.”

Mr Black stated that the national unit is not expected to grow in size, but the IPS has been in touch with both the HSE and the Department of Health about potentially developing a new, separate service.

“The unit is focussed on a certain type of group, which is very small,” he said. “It is a national unit; we don’t see a requirement for another unit for violent, disruptive prisoners. However, on foot of our experience of this, one of the things we want to do in terms of our next strategy, which will be published in two months’ time, is to develop a personality disorder unit.

“Because people who come to prison, in very simple terms, are poor people. Not just poor economically — they are poor socially, educationally, psychologically. Many people who have come to prison have suffered adverse childhood experience and trauma and abuse. There is a huge preponderance of personality disorder among the prison population, something we recognised. There is also a hugely disproportionate level of serious and enduring mental illness among the prison population.

“We are in deliberation with the Department of Health, the HSE and our own Department in relation to what more we can do in any given week.

“This is a matter of public record; [at any time] there are probably 20-to-25 prisoners who are on the waiting list for admission to the Central Mental Hospital. There are simply not sufficient beds available.

“So we are looking at what we can do to provide better facilities for people with severe and enduring mental illness, notwithstanding the fact it is always going to be a custodial environment… we are not suggesting we would ever be a therapeutic environment.”

Public health initiatives

The Institute of Public Health in Ireland (IPH) agrees with the WHO that violence can at least in part be tackled with public health initiatives.

“Violence is considered a public health issue by the WHO, which recognises that where violence persists, health is compromised,” Dr Helen McAvoy, Director of Policy at the IPH, told MI.

“Violence, like many health issues, is not evenly distributed across population groups. However, evidence shows that violence can be at least partially prevented and its impact reduced through public health approaches.

“Violence is preventable through effective policies, legislation and practice. It can be addressed and the harms mitigated through effective cross-sectoral action between agencies working in health, social services and criminal justice.”

When it comes to Government action in this area, Dr McAvoy praises recent legislation, including the Domestic Violence Act 2018, the Public Health Alcohol Act 2018, and the National Drugs Strategy 2012-2025.

“The enactment of the Domestic Violence Act improves the legal protections available to victims of domestic violence. The legislation also includes the new offence of coercive control. This recognises that the effect of non-violent control in an intimate relationship can be as harmful to victims as physical abuse.

“The legislation is positive from a public health perspective, as domestic violence creates substantial risks to the mental and physical health of the victims, including wider family and children. These new laws have the capacity to help victims seek support and achieve the legal protections they need to move forward with their lives.”

Dr McAvoy also noted that “a  lot of positive work is being done in this area, particularly by the National Office for the Prevention of Domestic, Sexual and Gender-based Violence (COSC). Continued investment and implementation is needed for a public health approach towards violence.”

Like many people, she regards some recent initiatives in Scotland over the last decade as  “positive”.

“The approach taken by the Scottish government to establish the Scottish Violence Reduction Unit (SVRU) is a positive public health approach to violence. The centre aims to diagnose and analyse the root causes of violence in Scotland, then develop and evaluate solutions, which can be scaled-up across the country.”

The Scottish model

Scotland is internationally regarded as being at the forefront of work in this area.

For over a decade, the SVRU has adopted a public health approach which treats violence as a disease. The SVRU runs programmes such as the ‘navigators’, who are people who work in hospital emergency rooms to connect with patients affected by violence and to point them towards social and medical help and support they can receive. They also have Street & Arrow street cafes, which hire people with convictions for 12-month blocks. “During that time, workers are paired with a mentor who can help them master everything, from basic employment skills like turning up to work on time, through to debt management and relationship issues,” according to the SVRU website.

Mr Niven Rennie,  Scotland Director of the SVRU, told MI that the unit was born out of record levels of violence in Glasgow. 

The SVRU was originally established by Strathclyde Police, then later funded by the Scottish government when it became a national unit.

“It was started by the police to try and bring some different way to attack the levels of violence that Glasgow, in particular, was seeing in 2005,” Mr Rennie said. “There were 137 homicides [in Scotland] that year. They [the police] started looking for a new way of doing it. It identified a public health approach, which was raised earlier by the WHO.

“So we embarked down that road. As success started, it was then taken on by the Scottish government and became the Scottish Violence Reduction Unit. We are attached to Police Scotland, but paid for by the government and so therefore, we are an independent agency in that respect.”

But does the unit represent a full shift from regarding violence as a criminal justice matter to public health one?

“That’s possibly simplifying it a bit,” Mr Rennie replied.

“We still have in Scotland all the usual things you would see in any country regarding police enforcement and policing of violence.

“But we, as an SVRU, encourage wider thought than that. We treat violence as an illness, a disease, and like any illness, [it has] symptoms. You tackle these symptoms and then you will reduce the problem. We look for innovative solutions to tackling violence, because our experience in Scotland is that you cannot ‘arrest your way out of it’.

“Numerous police campaigns aimed at stopping weapon-carrying or reducing homicide rates have been successful within themselves- but as soon as you stop these highly expensive enforcement campaigns, the violence returns — it goes back up. We were looking for a long-term, preventive solution which leads to rehabilitations, etc.”

When the unit was set up, according to Mr Rennie, “Scotland was seen as the most violent country per capita in the Western world. Glasgow had the name for being the murder capital of Europe.”

Medics Against Violence

Such a dire situation not only caused concern among the local police service, “our medical profession were totally fed-up with having to see these injuries on a regular basis; they wanted something to be done about it,” he explained.

“They came on board with the SVRU, and in the first instance they were just speaking at our events. That changed and they formed a charity called Medics Against Violence. They have their own funding, although they come under our umbrella.

“These are a group of doctors who have been involved in education programmes in schools, and regularly commenting on violence issues across the UK.

“I am told by these people that they have seen about a 50 per cent reduction in the number of violent events they have to deal with on an annual basis. So we are seeing [the positive impact], not just in the crime figures — we are also seeing in the hospital wards the impact of these initiatives.”

MI asked Mr Rennie is there not, however, natural friction between the medical profession and law enforcement, especially considering doctors have professional obligations to patients, such as maintaining confidentiality and trust.

“There has been a long-term problem between policing and the medical profession in terms of the sharing of information,” he replied.

“I don’t think that has been resolved yet. We are better than we were, but there are still difficulties between the Hippocratic oath and the need for issuing information, etc. So that becomes an issue.

“But in general terms, we have a great relationship with a number of hospitals.”

An American tale

The Cure Violence NGO in the US states that it “envisions a world without violence”.

Working mainly in urban centres, Cure Violence was founded by Dr Gary Slutkin, former head of the WHO’s Intervention Development Unit and Professor of Epidemiology and International Health at the University of Illinois/Chicago School of Public Health.

The organisation says violence “behaves like a contagious problem” and notes that “to date, the health sector and health professionals have been highly under-utilised for the prevention, treatment, and control of violence.”

However, there seems to be growing awareness.

“In medical circles [in the US], there is great support for understanding violence as a public health issue,” Mr Charlie Ransford, Director of Science and Policy at Cure Violence, told MI.

“I was just recently part of a group of medical organisations that was hosted by the American College of Surgeons.  There were 49 organisations present, such as AMA [American Medical Association], AAP [American Academy of Paediatrics], AHA [American Heart Association], APHA [American Public Health Association], etc, represented by the leaders of those organisations, and we all came together to discuss violence as a public health issue and will be issuing a collective statement endorsing violence as a public health issue.”

The growth in understanding in this area has not been confined to medical circles.

“I also think there have been a lot of public signs of the medical community and broader community understanding violence as a public health issue,” he added. “In particular, there have been several social media efforts at this, such as #ThisIsOurLane.  There has also been a significant increase in political leaders calling violence a public health issue.”

However Mr Ransford said the growth in awareness has been uneven.

Contagious

“There is a difference in how people are understanding this — which is basically attributable to it being a new concept that people are understanding in stages,” he said.

“When some people say that violence is a public health issue, they only mean that it is a cause of a high level of morbidity and mortality in people and communities.

“A slightly more advanced understanding is that violence disproportionately affects certain communities, and that the presence of violence in these communities affects the entire community’s health both directly and indirectly.  This indirect effect of violence — through exposure to violent environments — is a very important development. In particular, the research around ACEs [adverse childhood experiences] has spread this understanding.”

He argued that a “more advanced understanding is that violence is contagious — in other words, people who are violent have acquired this behaviour through the same means as other contagious problems — through exposure to the problem.  The evidence on this is large and expanding and goes across types of violence. Understanding violence as contagious means that it can be addressed using epidemiological methods, which is of course a subarea of public health.”

In terms of working examples, he said that “New York City is a great example”. 

“They have a $25 million Cure Violence programme throughout the city, along with wrap-around services to address trauma associated with exposure to violence.  NYC now has a homicide rate below the national average. Chicago is a great example of what happens when you have a public health approach, remove it, and then put it back again — it goes down, then up, then back down.”

Crucial

Is the work of doctors particularly important?

“Yes, on several levels. In the hospital, there is a need for violence intervention programmes that address violence victims, to prevent retaliation and treat mental trauma from exposure to violence,” he stated. 

“Doctors can advocate within their institutions to make sure these services are present.”

But that work also goes on outside hospitals, where “doctors often see victims of violence across specialties. 

“Therefore, this is an opportunity for intervention and treatment to prevent further injury or injury to others. Doctors need to be trained on detecting warning signs and the appropriate responses and referrals to make when someone who has been affected by violence is detected. 

“Furthermore, there is a need for doctors to understand the contagious nature of violence so that they can provide appropriate treatment — including providing treatment or referrals for mental trauma associated with exposure to violence.

“Also, very importantly, doctors are needed to help explain violence as a contagious problem to people. This is both one-on-one conversations with people, as well as acting as spokespeople to the media,” he said.

“Right now, people do not understand violence as a contagion because the information they receive is largely from a moralistic perspective, rather than a scientific perspective. We need people to understand the contagious nature of violence, that those behaving violently have a health problem of exposure, and that those exposed need treatment for that exposure. 

“This is much like how doctors and other health professionals have helped people understand other epidemic diseases and the related need to use safe sex practices, wash hands, and other changes in behaviour. It is also much like how health professionals and others have helped us to re-understand people with alcohol and drug problems as having health problems of addiction, rather than a moral failing.”

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