Full text of DOI:10.1001/jama.283.9.1202

E D I T O R ’ S N O T E
The Application of Preventive
Medicine to the Control of Violence
Stuart P. Weisberg and Eric P. Wilkinson
SIR WILLIAM OSLER, IN HIS FINAL PUBLISHED LECTURE, THE EVOLU-
tion of Modern Medicine, discussed with great optimism the emergence
of preventive medicine. He marveled at the successful public health cam-
paigns against malaria and yellow fever that decreased morbidity and
Coeditors
Jonathan H. Lin, PhD
Columbia University
College of Physicians and Surgeons
1
mortality by “up to an order of magnitude”. Since early in the last cen-
Sue Sun Yom, MA
University of Pennsylvania
School of Medicine
tury, scientific data have correlated clinical illness with social behav-
iors and public health advocates have pursued safety legislation. Most
recently, public health measures have legally obligated drivers to fas-
ten their seatbelts and severely restricted smoking. Physicians have now
begun to look more closely at another social factor leading to signifi-
cant clinical morbidity: violence.
Deputy Editor
ON THE COVER
Stefan C. Weiss
Duke University San Diego Sunset
School of Medicine by James Chan,
Senior Editor University of
Michael J. Brenner Rochester School of
Northwestern University Medicine,
Recent research has changed our perception of violence. In 1985,
WilliamFoege, thenExecutiveDirector, TheTaskForceforChildSur-
vival and Development, noted that violence was largely viewed as a
Medical School
Rochester, NY
Senior/Reviews Editor
Alison J. Huang, MPhil
University of California San Francisco
2
law enforcement or welfare problem until the early 1980s. A recent
School of Medicine
literature review tallied the most common types of violence discussed
in the public health context. Youth and gang violence, gun violence,
and domestic violence topped the list. A third of the reviewed articles
justified the role of public health in preventing violence by arguing
that violence is a pervasive threat. This argument invokes one of pre-
ventive medicine’s main tenets: to prevent population exposures that
can inflict injury and death.
The articles in this issue explore the myriad ways in which violence
results in injury and death. Salmaan Keshavjee and Mercedes Becerra
link the current tuberculosis epidemic in Tajikistan to the country’s
civil war and separation from Russia. Sheri Fink describes the con-
flicts of interest faced by humanitarian aid physicians trying to miti-
gatetheviolenceinthewarinKosovo.HowardSpivak,KatherineChrist-
offel, andMarthaWitwerdiscussthetragicconsequencesofyouthvio-
lenceintheUnitedStatesfromclinicalandepidemiologicalperspectives.
Brian Phelps addresses physicians’ failure to properly screen patients
fordomesticviolence. Theauthorsclearlyenvisionviolenceasthedis-
ease, but how can such a disease be cured?
Associate Editors
Jodi Elgart Paik, MFA
University of California San Diego
School of Medicine
Warren Kinghorn
Harvard Medical School
Catherine S. Magid
University of Pennsylvania
School of Medicine
3
Eric P. Wilkinson
Stanford University
School of Medicine
New Media Editor
Stuart P. Weisberg
Columbia University
College of Physicians and Surgeons
JAMA Staff
Charlene Breedlove
Managing Editor
Juliana M. Walker
Assistant Editor
AMA-MSS Governing Council
Ryan J. Grabow, Chairperson
Ali Mendelson, Vice Chairperson
Clifford L. Deal III, Delegate
Keith Borg, Alternate Delegate
Angela Siler-Fisher, At-Large Officer
Mark G. Moseley, Speaker
Christine Kirkendol, Vice Speaker
Matthew Kagan, Student Trustee
Subashini Daniel, Past Chairperson
Preventive medicine transformed the role of the physician from in-
dividual healer to caretaker for the public’s health. Osler calumniated
society’s failure to enact preventive health measures against the un-
1
sanitaryconditionsconducivetotyphus. Butamerebacteriumcauses
typhus, while complex and deeply entrenched societal and govern-
mental attitudes, such as fear of and hostility toward ethnic groups
and the right of citizens to bear arms, contribute to violence and its
terrible sequelae. Such causative agents have proved far harder to dis-
mantle than a simple package of protoplasm. Osler listed the tools of
preventive medicine in his 1913 lecture—“education, organization,
MSJAMA is prepared by the MSJAMA editors
and JAMA staff and is published monthly from
September through May. It provides a forum
for the news, ideas, and opinions that affect
medical students and showcases student
writing, research, and artwork. The articles and
viewpoints in MSJAMA are not necessarily the
policy of the AMA or JAMA. All submissions
must be the original unpublished work of
the author. Submitted work is subject
1
cooperation.” Perhaps information in the following articles will help
hone them against violence.
to review and editing.
Address submissions and inquiries to:
MSJAMA, Sue Sun Yom, Coeditor,
REFERENCES
3
450 Hamilton Walk, Box 650, Philadelphia,
PA 19104; phone (215) 748-5592;
e-mail: syom@mail.med.upenn.edu
1. Osler W. The rise of preventive medicine. In: Osler W. The Evolution of Modern Medicine.
New Haven, Conn: Yale University Press; 1921:218-233.
2
. US Department of Health and Human Services. Surgeon General’s Workshop on Violence
and Public Health. Washington, DC: US Dept of Health and Human Services, Office of Ma-
www.msjama.org
ternal and Child Health; 1986. DHHS publication HRS-D-MC-86-1.
3
4
. Winett LB. Constructing violence as a public health problem. Public Health Rep. 1998;113:
98-507.
1198 JAMA, March 1, 2000—Vol 283, No. 9 (Reprinted)
©2000 American Medical Association. All rights reserved.
Downloaded From: https://jamanetwork.com/ on 11/04/2020

C O M M E N T A R Y
Helping Medical Students Help Survivors of Domestic Violence
Brian P. Phelps, University of California San Francisco School of Medicine
SURVIVORS OF DOMESTIC VIOLENCE GENERALLY PERCEIVE THEIR posure to violence can be incorporated in a medical stu-
health to be poor. They visit physicians twice as often as dent’s interview along with questions about smoking, diet,
patients without a history of abuse, often presenting with and exercise. Second, unlike busier residents who may feel
complaints, such as chronic pain and irritable bowel syn- pressured to take more focused histories, medical students
1
drome, unrelated to trauma. In a recent study of women can take time to discuss with sensitivity whatever issues may
seeking emergency care, the prevalence of ongoing domes- arise. Early and thorough discussion of a traumatic event
7
tic violence was found to be 12%. Sadly, only 2.6% of these may reduce the severity of posttraumatic stress disorder.
patients were screened for domestic violence.
2
Finally, the time pressure in clinic settings often pushes
Growing awareness of the scope of domestic violence has experienced clinicians into maintaining control of the clini-
spawned efforts to expand relevant curricula in medical cal interview. Such interactions can reinforce an abused pa-
4
schools, but progress has been uneven. While the number tient’s expectations of unbalanced power dynamics. Medi-
of medical schools requiring education on intimate part- cal students, at the bottom of hospital power structures, may
3
ner violence increased by 18% over the last 7 years, in- be well suited to provide victims a sense of equality, safety,
struction still primarily occurs during the preclinical years and empowerment that are crucial to the healing process.
4
and is often forgotten on the wards.
The prevalence of ongoing or past family violence among
Why have physicians been so slow to incorporate edu- medical students, about 38%, mirrors that of the general popu-
8
cation on domestic violence into the clinical years? In ad- lation. An important but often overlooked obstacle to pro-
dition to concerns about crowded medical curricula, some viding effective care to those violated is the disruptive and pain-
medical school faculty feel that adding domestic violence ful emotional response that eliciting a painful history can evoke,
awareness is useless if there are “nothing but impotent so- particularly in students who were or are themselves violated.
5
lutions” to the problem. To be effective, an intimate part- Such students will need the support of understanding instruc-
ner violence curriculum should be concise and should high- tors and advisors if we are to expect them to give support to
light the effectiveness of intervention.
patients with similar life histories.
The University of Massachusetts School of Medicine re-
Aneffectiveresponsetovictimsofpartnerviolencerequires
cently designed a third-year “inter-clerkship” that seems to thought and action outside of traditional biomedical models.
satisfy these criteria. Over 3 days and between other re- Elicitingahistoryofdomesticviolenceismuchmorethancol-
quired clerkships, students listen to the stories of domestic lecting information and identifying cases—it can be, in itself,
4
violence survivors, role play how they might identify and a potent intervention. Similarly, educating medical students
give appropriate assistance to those at risk, and discuss and aboutdomesticviolencerequiresnotatraditionaldidacticmodel,
reflect on their own experiences with family violence. This but one in which students interact with survivors of domestic
approach seems to produce sustainable improvements in the violence and discuss their feelings and responses to such in-
attitudes and skills necessary for violence screening and in- teractions.Suchanintegrativemodelcanhelpusshapethetools
6
tervention, but other schools have been slow to follow suit. to effectively care for survivors of domestic violence.
Additionally, there may be resistance to involving medi-
calstudentsinthecareofsurvivors. Duringmyobstetricsand REFERENCES
1
. Koss MP, Heslet L. Somatic consequences of violence against women. Arch Fam
gynecologyrotation, Iwascounseledtolimitmyinteractions
Med. 1992;1:53-59.
witha sexual assaultsurvivor who hadsuffereda vaginal lac- 2. Abbott J, Johnson R, Koziol-McLain J, Lowenstein SR. Domestic violence against
women: incidence and prevalence in an emergency department population. JAMA.
eration. The reasoning was that the resident needed to see
1
995;273:1763-1767.
all of the student’s patients, and the effect of including a stu- 3. Alpert EJ, Tonkin AE, Seeherman AM, Holtz HA. Family violence curricula in
US medical schools. Am J Prev Med. 1998;14:273-282.
dent would be to double the amount of intrusion on the pa-
4. Warshaw C. Intimate partner abuse: developing a framework for change in medi-
tient. While a patient’s request to limit the number of pro- cal education. Acad Med. 1997;72 (suppl):S26-S37.
5
. deLahunta EA, Tulsky A. Resistance to adding curricula about domestic vio-
vidersshouldberespected,suchawishshouldnotbeassumed.
In some cases, excluding a medical student might limit the
amountofsensitivecareprovidedapatientwhoneedsitmost.
The role of medical students in caring for survivors of vio-
lence [letter]. Acad Med. 1998;73:726-727.
6
. Jonassen JA, Pugnaire MP, Mazor K, et al. The effect of a domestic violence
interclerkship on the knowledge, attitudes, and skills of third-year medical stu-
dents. Acad Med. 1999;74:821-828.
7
. Bower GH, Sivers H. Cognitive impact of traumatic events. Dev Psychopathol.
lence should be expanded for 3 reasons. First, third-year 1998;10:625-653.
8
. Cullinane PM, Alpert EJ, Freund KM. First-year medical students’ knowledge
medical students are routinely expected to elicit complete
of, attitudes toward, and personal histories of family violence. Acad Med. 1997;
and detailed histories. Questions about current or past ex- 72:48-50.
©
2000 American Medical Association. All rights reserved.
(Reprinted) JAMA, March 1, 2000—Vol 283, No. 9 1199
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P E R S P E C T I V E
Physician Groups and the War in Kosovo:
Ethics, Neutrality, and Interventionism
Sheri L. Fink, MD, PhD, Human Rights Center, University of California at Berkeley
During the time I was in Kosovo, in 1998 and 1999, I inter-
THROUGHOUT THE 1990S, THE INTERNATIONAL COMMITTEE
of the Red Cross, Doctors Without Borders, other medical
aid groups, and United Nations agencies were present in
Kosovo, a Serbian-ruled province in Yugoslavia with an Al-
banian majority. The aid groups supported Kosovo’s “offi-
cial” and “unofficial” health care systems, the unofficial be-
ing a network of primary health clinics staffed by ethnic
Albanian physicians and nurses, many of whom had been
fired from jobs at public hospitals and clinics after Koso-
viewed international physicians who had treated hundreds of
displacedpersons,discoveredmassacredAlbaniancivilians,and
been harassed by Serbian soldiers. Some viewed the majority
ofKosovo’sSerbianpopulationascomplicitintheseatrocities.
WhenAlbaniansreturnedtotheprovinceinJune1999anden-
gagedinrevengeattacksagainstSerbiancivilians, international
physicians were in a unique position to condemn the attacks,
supportthefewremainingSerbianphysicians, protectvulner-
ableSerbpatients,andremindlocalAlbanianphysiciansoftheir
responsibility to treat all patients regardless of ethnicity. Un-
fortunately, not all overcame their own biases to do so.
Promotion of human rights has become an intimate con-
cern of many physician groups, and conflicts may emerge
between loyalty to human rights and loyalty to medical prin-
ciples. Physicians for Human Rights (PHR) was founded in
the 1980s by health care professionals who use their exper-
tise to research and publicize human rights violations. Af-
ter diplomatic efforts failed to end massacres and human
rights violations against Kosovar Albanian civilians, PHR pub-
licly released a letter to President Clinton calling for mili-
tary intervention in the form of an international ground
1
vo’s status as an autonomous province was revoked in 1989.
Followingtherevocationofautonomy,Kosovo’scitizensvoted
overwhelminglytoformanindependentrepublic. Serbianau-
thoritiesdidnotrecognizethereferendumandengagedinawell-
documentedcampaignofhumanrightsviolationsagainstKoso-
2
vo’s ethnic Albanian majority population. In the late 1990s,
anarmedgroupofethnicAlbaniansknownastheKosovoLib-
eration Army emerged and began armed confrontations with
Serbianforces. TheSerbianresponsewasawidespreadassault
onAlbanianvillages, resultingindisplacementoftheAlbanian
3
population. Checkpoints prevented free movement of Alba-
nianpatientsandphysicians,andacampaignofdetentions,tor-
ture, and killings was launched against Albanian physicians,
whowereseenaspotentialaidstoanarmedAlbanianindepen-
6
force. The statement of support for military action by a group
4
of doctors, whose highest duty is generally considered to
be the preservation of human life, surprised many.
dence movement. In response, international medical groups
begansendingteamsofphysiciansandnursesalongwithmedi-
cationsandsuppliestoreachlargegroupsofdisplacedpersons.
At this point, many difficult ethical issues arose for in-
ternational medical organizations. International health care
workers were frequently threatened by Serbian soldiers and
Although the PHR statement was not founded on a medi-
cal principle, it was arguably founded on the higher moral
duty to oppose attacks on civilians based on their religion
or ethnicity. The idea of a medical group supporting armed
intervention for such a purpose should not be rejected on
principle. Military intervention must not be the first nor the
only choice, but it needs to remain a choice for those who
would act to prevent crimes against humanity.
4
accused of supporting the Albanian war effort. One phy-
sician reported that as a result, her organization began a policy
of not treating soldiers (anonymous physician, oral com-
munication, Pristina, Kosovo, December 1998).
Refusing to treat soldiers who have no other medical op-
tionsisabreachofthefundamentalmedicaltenetthat“aphy- Supporting Foundation.
Funding/Support: This work was supported by funding from the Sandler Family
sician shall give emergency care as a humanitarian duty un-
less he is assured that others are willing and able to give such REFERENCES
5
care.” However, whether to risk compromising an aid effort
by treating soldiers is a complex question for aid organiza-
tions, particularly when even providing medical care to be-
1
. Agovino T. Serbia continues to fail ethnic Albanians [News: Dispatches]. Lan-
cet. 1997;350:1757.
. United Nations. General Assembly resolution 49/204: situation of human rights
in Kosovo. December 23, 1994. Available at: http://www.un.org/ga/49/
2
leagueredciviliansmaybeviewedasawaraction. Todecrease r204.pdf. Accessed January 14, 2000.
3
. International Crisis Group. Kosovo’s long hot summer: briefing on military, hu-
the risk of compromise, some aid groups in Kosovo insisted
manitarian, and political developments in Kosovo. September 2, 1998. Available
thatsoldierswearcivilianclothingwhenseekingmedicalcare, at: http://www.intl-crisis-group.org/projects/sbalkans/reports/kos05mai.htm. Ac-
cessed January 14, 2000.
4
a stipulation with which soldiers reportedly complied.
. Agovino T. Dodging bullets while searching for health care in Kosovo [News:
At times, international physicians develop sympathy for Dispatches]. Lancet. 1998;352:1687.
5. Russbach R, Fink D. Humanitarian action in current armed conflict. Med Global
the violated and anger toward the perpetrators of the human
rights violations they witness. If they remain in the region as
Survival. 1994;1:188-199.
7. World Medical Association. International code of medical ethics. January 10, 1983.
physicians, however, they must carry out their duties accord- Availableat:http://www.wma.net/e/policy/17-a_e.html. AccessedJanuary14, 2000.
6
. Rubenstein LS. PHR calls for ground troops in Kosovo: text of letter to Presi-
ing to standard medical ethics, especially when victims of hu-
man rights violations subsequently become perpetrators.
dent Clinton [Physicians for Human Rights Web site]. January 22, 1999. Available
at: http://www.phrusa.org/new/kosolet.html. Accessed January 14, 2000.
1200 JAMA, March 1, 2000—Vol 283, No. 9 (Reprinted)
©2000 American Medical Association. All rights reserved.
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R E P O R T
Disintegrating Health Services and Resurgent Tuberculosis
in Post-Soviet Tajikistan: An Example of Structural Violence
Salmaan Keshavjee, PhD, Stanford University School of Medicine and Department of Cultural and Social Anthropology,
Stanford University, Calif, and Mercedes C. Becerra, ScD, Harvard Medical School, Deptartment of Social Medicine, Boston, Mass
WHILE VIOLENCE AND THE MORTALITIES OF WAR HAVE BEEN tivetreatmentregimenoffirst-lineantituberculousdrugssuch
5
amongthe20thcentury’sgreatestplagues, amorequietstruc- asisoniazid,rifampin,ethambutol,andpyrazinamide. In1996,
tural violence has also left its mark. Structural violence may in addition to a shortage of chest radiograph material, labo-
bedefinedasincreasedmorbidityandmortalityresultingfrom ratory supplies, tuberculin skin tests, and a breakdown in the
forms of social organization that frequently lead to groups of localsurveillancesystem, thehospitalwasfacedwithasixfold
individuals being marginalized along social axes, often those increase in the number of TB patients compared with a simi-
1
of economic, racial, and gender inequality. Its effects can be larintervalduringtheSovietperiod(KhorogTuberculosisHos-
seenduringwars, inpostwarsituations, andevenduringtimes pital, unpublisheddata, 1996). Thisisconsistentwithnational
ofpeace;insomecases, suchviolenceismarkedbytheabsence trendsshowingadramaticincreaseinreportedTBincidence,
2,3
ofprotectivestateinstitutions. Healthcrisesassociatedwith from 30 per 100 000 in 1995 to more than 250 per 100 000 in
8
massivesocialtransformations—suchastheresurgenceoftu- 1997. WhereasduringtheSovietperiodpatientsweretreated
berculosis in the former Soviet Union— provide an opportu- with at least 3 anti-TB drugs for at least 6 months as per in-
1
0
nity to elucidate this form of violence and its effects.
ternational recommendations, health personnel now often
During thecollapseof the Soviet Unionin1991, Tajikistan havetorelyononly2drugs, isoniazidandrifampin. Giventhe
(
population6.1million),oneofthepoorestSovietCentralAsian high likelihood in the region of already existing resistance to
4
republics, wasembroiledinabloodycivilwar. InTajikistan’s oneoftheseagents, localphysiciansexpect, andinternational
easternmost province of Badakhshan (population 240 000), TB experts agree, that this situation will result in the genera-
11,12
thecessationofsubsidiesandessentialsuppliesfromMoscow, tionandtransmissionofmultidrug-resistantTB. Intheab-
exacerbated by the civil war, led to a dire humanitarian crisis. sence of appropriate therapy, these forms of TB have the po-
12
Only throughtheinterventionof international humanitarian tential to overtake drug-susceptible TB.
Effective, known therapies will stop the spread of this epi-
ti e` res, andtheInternationalFederationoftheRedCrosswere demic,yetinthefaceofincreasinglyprivatizedhealthcarethese
massstarvationanddeathaverted. Tajikistan’seconomywas servicesarenowbeyondthereachofthosewhoneedthemmost:
agenciessuchastheAgaKhanFoundation,M e´ decinsSansFron-
5
alsoincrisis:between1991and1995grossdomesticproduct the urban and rural poor. The result will hardly be surprising:
declined 45%, and in 1996 more than 85% of the population increasedsufferingduetoTBandotherdiseasesandaquietin-
6
was living below the poverty line. Per capita state expendi- crease in more difficult-to-treat drug-resistant TB that will be
ture on health care had dropped from US $300 in 1991 to less heaped on an already overburdened population.
than US $1 in 1998, in a country where 5 kg of beef cost US
7,8
$10 and a bar of soap US $1.
REFERENCES
With the collapse of the Soviet state also came transition 1. Farmer PE. On suffering and structural violence: a view from below. Dæda-
lus.1995;125:261-283.
from a subsidized health care system to modified fee-for-
2
. Bourdieu P, ed. La Mis e` re du Monde. Paris, France: Seuil; 1993:159-167.
service, in which the sick often have to purchase health care 3. Scheper-Hughes N. Death Without Weeping: The Violence of Everyday Life
in Brazil. Berkeley, Calif: University of California Press; 1992:128-215.
on the open market. This has coincided with a downturn in
4. CIA World Factbook, 1999. Available at: http://www.cia.gov/cia/publications/
vital health statistics. Maternal mortality in Tajikistan in- factbook/ti.html. Accessed December 16, 1999.
5
. Keshavjee S. Medicines and Transitions: The Political Economy of Health and
creased from 41.8 per 100 000 live births in 1990 to 65.5 in
Social Change in Post-Soviet Badakshan, Tajikistan (PhD thesis). Boston, Mass:
6
1
997. In Badakhshan, acute childhood malnutrition in-
Harvard University; 1998.
creased from an estimated 3.0% in 1994 to 5.8% in 1996, while 6. UNDPTajikistanCountryReport, 1998. Availableat:http://www.undp.org/popin/
unfpacst/nepal/executive_summary_taji.htm. Accessed December 16, 1999.
chronic childhood malnutrition increased from 40.3% to 44.8%
7
. Najibullah F. Tajikistan: health care remains sickly, Radio Free Europe, 1998.
over the same period; the region also saw an increase in the Available at: http://www.rferl.org/nca/features/1998/02/F.RU.980227152945.
html. Accessed December 16, 1999.
incidence of treatable infectious diseases, including tubercu-
losis (TB).
DuringtheSovietperiod,patientswithTBreceivedpaidleave
fromworkandfreeTBtreatment. Inthecrisisafter1991, how-
ever, the local 40-bed tuberculosis hospital in Badakhshan’s
capital, Khorog (population 20 000), was faced with a short-
8
. World Health Organization. Tajikistan Health Sector Report, 1998. Available at:
http://www.who.int/eha/emergenc/Tajik/111198.htm.AccessedDecember16,1999.
. Kim JY, Millen JV, Gershman J, Irwin A, ed. Dying for Growth: Global Inequal-
ity and the Health of the Poor. Monroe, Me: Common Courage Press; 2000.
0. World Health Organization. WHO Tuberculosis Programme: framework for
effective tuberculosis control. Geneva, Switzerland: World Health Organization;
6
9
1
1
1
994. WHO/TB/94.175.
1. Farmer P, Bayona J, Becerra M, et al. The dilemma of MDR-TB in the global
age of TB medicines. Drugs supplied by international organi- era. Int J Tuberc Lung Dis. 1998;2:869-876.
1
2. The Global Impact of Drug-Resistant Tuberculosis. Boston, Mass: Harvard Medi-
zations sustained the hospital for a short period, but soon the
cal School and the Open Society Institute; 1999. Available at: http://www.soros.org/
hospital was no longer able to provide patients with an effec- tb. Accessed December 16, 1999.
©
2000 American Medical Association. All rights reserved.
(Reprinted) JAMA, March 1, 2000—Vol 283, No. 9 1201
Downloaded From: https://jamanetwork.com/ on 11/04/2020

R E P O R T
Youth Violence Prevention: The Physician’s Role
Katherine Kaufer Christoffel, MD, MPH, Northwestern University Medical School, HELP Network,
Children’s Memorial Medical Center, Chicago, Ill, Howard Spivak, MD, New England Medical Center, Boston, Mass,
and Martha Witwer, MPH, MSW, HELP Network, Children’s Memorial Medical Center, Chicago, Ill
14
VIOLENCE AND VIOLENT INJURY HAVE BECOME MAJOR HEALTH United States have paralleled handgun production. Avail-
issues for children and teenagers in the United States, which able information indicates that guns in the home increase
has the highest rate of youth homicides and suicides among the risk of homicide almost threefold and the risk of sui-
1, 2
15,16
the26wealthiestnations. Whetherasvictims, witnesses, or cide almost fivefold.
These risks are statistically signifi-
perpetrators of violence, the consequences for children and cant and most of the risk is related to handguns. Thus, hand-
3
youthwhoexperienceviolenceareserious. Therecentshoot- guns pose a particular danger, though they are not the most
1
7
ingsinColumbineandotherhighschoolshaveonceagainclearly common or the most powerful guns.
demonstrated that the causes and effects of violence cross all
geographicandsocioeconomicboundaries. Effortstodecrease
morbidityandmortalityfromviolencehavefocusedon2main
areas: control of firearms and social intervention.
What Can Physicians Do to Prevent Gun Violence?
Physicians have been crucial to success in reducing the toll
of other scourges, such as polio, cigarette smoking, and mo-
tor vehicle injuries. Those who seek to reduce gun death and
injury have many opportunities. Effective firearm injury pre-
vention cannot be designed, implemented, or evaluated with-
out good data. The United States has complete state and na-
tional counts of firearm deaths but only estimates for nonfatal
firearm injuries and very little information about the role of
the gun in each injury (type of weapon, whom it belongs to,
how it got to the scene) or the circumstances of the injury.
Physicians and hospitals can help remedy this situation by
compiling regular reports on the number and type of gun in-
juriestheytreatandincludingasmuchdetailaspossibleonclini-
The Role of Guns
Themostlethalformofviolenceisgunviolence.Sincethemid-
1
980s, 10 to 15 Americans under the age of 19 have died ev-
4
erydayfromgunshotwounds. Firearminjuriesrepresentthe
third leading cause of death among Americans aged 10 to 14
and the second leading cause of death among those aged 15
to 24. For every firearm death, there are an estimated 4 non-
fatal firearm injuries, many resulting in severe disabilities.
4
5
Many factors (eg, poverty, family dysfunction, and sub-
6
stance abuse) affect the frequency of youth violence, but guns
18
increase the lethality of violent incidents. The dramatic in-
crease in the US homicide rate from 1985 to 1993 was due
to a steady increase in firearm homicides, especially hand-
calcourseandcost. Individualhospitalscancollaboratewith
oneanotherandwithhealthdepartments,coroners,police,crime
labs, and others to establish an area-wide firearm injury data
7
1
9
gun homicides. From 1987 to 1993, the firearm homicide
system. Several such efforts are under development.
rate doubled for those aged 15 to 24, while the nonfirearm
Beyond seeking to control the most lethal weapons used in
violence,clinicianshavefocusedinterventionsontherootcauses
of violent behavior, and some professional groups have iden-
tifiedwaystheycancontributetoviolenceprevention. These
interventionsencompassmanyactivitiesalreadywithinthepur-
viewofhealthprofessionals, includingscreening, patientedu-
cation, treatment, and advocacy. Physicians particularly well
situatedtoparticipateinviolencepreventionarethoseprovid-
ing primary care, emergency care, and mental health services.
8, 9
homicide rate decreased. Firearm suicides also steadily in-
8
creased during this period among 15- to 24-year-olds. Fire-
2
0
arms are used in roughly 70% of all homicides and in 60% of
all suicides. Among youth aged 15 to 19, the proportions are
7, 10
even higher (80% and 68%, respectively).
Many other countries have rates of violence similar to those
oftheUnitedStates, butmosthavelowerratesoffatalviolence
11
becausefirearmsarelessused. Internationalcomparisonsre-
veal that gun death rates increase along with gun ownership.
Data from 14 countries, as well as Australia, Canada, and the
Violence Prevention in the Clinic
United States, show that gun ownership is significantly asso- Violence at the clinical level should be treated as a recurrent
ciatedbothwiththerateandproportionofhomicidesandsui- chronicdiseasewithdefinableriskfactors. Hospitalreadmis-
12
cides committed with a gun. Further, residents of countries sion rates for patients suffering subsequent assault-related
2
1-23
with low rates of gun ownership did not more frequently use injuries have been noted as high as 44%.
Rates of patients
12
a means other than a gun to commit homicide and suicide. suffering prior assault-related injury and then becoming ho-
The higher firearm homicide rates in the United States are micide victims have been reported as high as 20%.
largely due to handguns. Over time, gun death rates in the lent injury and death occur far more commonly as a result
2
1-23
Vio-
13
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ofargumentsbetweenfamilymembersandacquaintancesthan
from criminal activity involving strangers. Recurring vio- ternists and 72% of surgeons believe that physicians should
lentinjurymaythereforebeduetothepersistenceofviolence be involved in firearm injury prevention, yet fewer than 20%
A recent survey of physicians indicated that 84% of in-
2
4
29
risk factors associated with the patient’s social context.
said they actually are so involved. Physicians and health
Giventhehighrecidivismratesofviolentinjury,thecurrently care professionals should be aware of the importance of their
accepted methods for treating such injuries should be recon- roles as clinicians and advocates and use their considerable
sidered. When patients present with suicide attempts, evalu- credibility to promote practices and policies based on ac-
ationforfutureriskandfollow-uptreatmentareconsideredstan- curate data that will contribute to violence prevention.
dardpractice. However, individualstreatedforviolentinjuries
generallyreceivenofurtherevaluation,althoughrecentlysome REFERENCES
emergencyroomshaveimplementedassessmentprotocolsand
counselingservicesforsuchpatients.Datashowingthattherisk
of recurrent injury and violent death is high suggest the need
1
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firearm-related death among children: 26 industrialized countries. MMWR Morb
Mortal Wkly Rep. 1997;46:101-105.
2
. Krug EG, Dahlberg LL, Powell KE. Childhood homicide, suicide, and firearm
to always evaluate these patients for future risk. Information deaths: an international comparison. World Health Stat Q. 1996;49:230-235.
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. Osofsky JD, ed. Children in a Violent Society. New York, NY: Guilford Press; 1997.
. Hoyert DL, Kochanek DK, Murphy SL. Deaths: Final Data for 1997, National
required to assess this risk includes intent of revenge, the cir-
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5
. Annest JL, Mercy JA, Gibson DR, Ryan GW. National estimates of nonfatal firearm-
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. Christoffel KK. Reducing violence—how do we proceed? Am J Public Health.
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volvement with violence may be readily recognized in clini-
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8
. Centers for Disease Control and Prevention. Compressed mortality report: death
ness violence early in their lives are at particularly high risk
count, all ages, all races, both genders 1987-1997. Available at: http://
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of involvement in subsequent violence. These data suggest wonder.cdc.gov/mortj.shtml. Accessed January 26, 2000.
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. Wintemute GJ. The future of firearm violence prevention. JAMA. 1999;282:
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75-478.
settingsshouldbeseriouslyconsidered. Currently, familyvio- 10. American Association of Suicidology. Percentage of Youth Suicide by Fire-
arms, United States, 1993-1996. Washington, DC: American Association of Sui-
lence screening occurs in emergency departments, obstetri-
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1
1. Zimring FE, Hawkins G. Crime Is Not the Problem. New York, NY: Oxford
personnel properly trained in screening methods, enhanced University Press; 1997.
1
2. Killias M. International correlations between gun ownership and rates of ho-
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and homicide: a tale of two cities. N Engl J Med. 1988;319:1256-1262.
and be comfortable with issues of hidden violence.
1
4. Wintemute GJ. Handgun availability and firearm mortality. Lancet. 1988;2:
Anotheravenueforinterventionincludesimprovedpatient 1136-1137.
1
5. Kellermann AL, Rivara FP, Rushforth NB, et al. Gun ownership as a risk factor
education. Parents would benefit from a better understand-
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veloping violent behavior, including extensive exposure to
for homicide in the home. N Engl J Med. 1993;329:1084-1091.
1
6. Kellermann AL, Rivara FP, Somes G, et al. Suicide in the home in relation to
gun ownership. N Engl J Med. 1992;327:467-472.
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sky JD, ed. Children in a Violent Society. New York, NY: Guilford Press; 1997:48-54.
1
25
televisionviolence, andrepeatedcorporalpunishment. Cli-
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August 23, 1999:1,6.
to violent punishment by promoting the use of “time outs”
1
9. Mercy JA, Ikeda R, Powell KE. Firearm-related injury surveillance: an over-
instead of spanking. Discussing strategies to limit television view of progress and the challenges ahead. Am J Prev Med. 1998;15:6-16.
2
0. American Academy of Pediatrics Task Force on Violence. The role of the pe-
viewing and monitoring what is watched will also help re-
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duce the degree of exposure to violent role modeling. Fore- level. Pediatrics. 1999;103:173-178.
2
1. Poole GV, Griswold JA, Thaggard VK, Rhodes RS. Trauma is a recurrent dis-
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2
2. Goins WA, Thompson J, Simpkins C. Recurrent intentional injury. J Natl Med
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2
3. Riener DS, Pastena JA, Swan KG, Lindenthal JJ, Tischler CD. Trauma recidi-
vism. Am Surg. 1990;56:556-560.
24. Federal Bureau of Investigation. Crime in the United States, 1996: Uniform
Crime Reports. Washington, DC: Government Printing Office; 1997.
Comment
Major medical groups—including the American Medical As-
2
5. Spivak H, Harvey B, eds. The role of the pediatrician in violence prevention:
sociationandmanyspecialtysocieties—nowurgetheirmem- proceedings of a conference: Chantilly, Va, March 4-5, 1994. Pediatrics. 1994;
9
2
4:576-651.
bers to assess patients’ risk for violence and counsel patients
on safety practices related to guns, just as they do on practices
relatedtosubstanceuseandsex. Aspublichealthapproaches
6. American Academy of Pediatrics and Center to Prevent Handgun Violence,
Steps to Prevent (STOP) Firearm Injury. Keep Your Family Safe From Firearm In-
jury (brochure). Elk Grove Village, Ill: The American Academy of Pediatrics; 1996.
26,27
2
7. American Medical Association. Physician Firearm Safety Guide. Chicago, Ill:
28
toreducingguninjurieshavegrown,guninjuryrateshavefallen.
American Medical Association; 1998.
From 1993 to 1997, the firearm homicide rate for 15- to 24- 28. Institute of Medicine. Reducing the Burden of Injury: Advancing Prevention
8
and Treatment. Washington, DC: National Academy Press; 1995:chap 5.
9. Cassel CK, Nelson EA, Smith TW, et al. Internists’ and surgeons’ attitudes to-
wards guns and firearm injury prevention. Ann Intern Med. 1998;128:224-230.
year-oldsfell, 29%from19.9to14.1per100 000persons; rea-
sons for the falling rates are not yet clear.
2
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2000 American Medical Association. All rights reserved.
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