The need to treat violence as public health problem

Death and disability caused by injuries have risen in recent decades. A model of intervention pioneered in Cardiff and found effective around the world deserves a closer look.
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Among the major threats to human health and wellbeing, violence is seldom listed. It is regarded mostly as a law and order problem when it occurs within a country or war when it is a conflict between countries. Terrorism, whose origins may be domestic or foreign, also results in violence, which invites a police or military response. While doctors and nurses are called upon to treat victims of violence, the medical profession is seldom engaged in identifying the magnitude and principal causes of violence that occur in a community.

The Global Burden of Disease study periodically estimates the varied causes of deaths and disability due to different health disorders across the world. It reports the total disease burden due to injuries (premature deaths or prolonged disability) has risen across the world in the last three decades and accounted for 247.7 million disability-adjusted life years lost in 2020. With increasing levels of domestic and regional conflicts since then, the disease burden due to injuries is likely to have been even higher in 2023 (yet to be reported).

However, these estimates are likely to be lower than reality, as many cases of violence are not reported to the police, who maintain and report such data. Injuries from domestic violence, street brawls, and school bullying are among the causes of injury that may not come to the attention of the police. Even victims of acid attacks, sexual offences and criminal extortion are often afraid to report to the police, having been threatened against approaching law enforcement agencies.

Violence from any cause is not a matter solely of individual concern. Nor is it only a problem to be handled by the police who seek to catch and criminally prosecute the culprits. The causes of violence in a community need to be identified in order to reduce the risk of recurrence. This is true whether the causes are domestic or communal, political or property-related. The levels of violence, types of victims as well as the principal causes need to be identified to prevent violent acts and protect  vulnerable victims. However, this effort requires data related to violence to be as complete and as location-specific as possible.

If the injury is serious, the victim is likely to seek medical attention even while the police may be unaware of the incident. It was noted that only 23 percent of incidents reported in the emergency department of the hospital appeared in police records in the area of Avon and Somerset over the same period.

Concerned that such a high level of data discrepancy can lead to the underestimation of the magnitude of the problem and data blind spots that can impede prevention measures, a novel initiative was launched in Cardiff, UK. It collates and combines police records of violence-related injuries with those recorded in hospitals to obtain a more complete estimate of the number of people who suffered violence-related injuries and as accurate a list of principal causes as possible.

This initiative was also sparked by incidents of violence related to coal miner strikes and clashes around football matches. Discrepancies between police records of injured people and those treated at hospitals led Dr Jonathan Shepard, a trainee in maxillofacial surgery in the early 1980s, to initiate a programme that has come to be known since 1997 as the Cardiff Model for Violence Prevention.

The Cardiff model brings healthcare providers, the police and the local community together. In healthcare-related settings (such as hospitals), violence-related injury data is collected. These include location, time, date and mechanism of injury (type of assault and weapon) collected by the emergency room staff. To ensure protection of privacy and to avoid potential further harm to victims of violence, other personal identifiers (name, date of birth, social security number) are stripped off the database that will be matched and merged with the police database.

The combined database is analysed to identify the magnitude and patterns of violent incidents that result in injury. The analysed data is shared with the local community, with both the police and healthcare providers interacting with community boards. Strategies to predict future incidents are developed together by recognising triggers, patterns and local hotspots.

The model has been evaluated and demonstrated to be impactful in reducing urban violence and resultant injuries. In Cardiff, police patrol routes were adjusted on a weekly basis to include hotspots identified by the combined data. Police officers were redeployed from crime-free areas to city areas of concern at night. Alcohol licensing and sales were suitably regulated. Some streets were pedestrianised. Street lighting and CCTV camera positions were improved.

A multi-year evaluation that compared Cardiff to 14 other cities showed a 32 percent reduction in recorded injuries and a 42 percent reduction in hospital admissions for injury. The cumulative social benefit to cost ratio of the programme estimated a benefit of £82 for each £1 spent. Implementing the programme in Cardiff resulted in cutting the economic and social costs of violence by £6.9 million.

It has been adopted by several other parts of the UK and cities in other countries. Milwaukee, Atlanta and Philadelphia (US), Amsterdam (Netherlands), Kingston (Jamaica) and Bogota (Colombia) are among the cities that adopted the Cardiff model. After evaluation of such global evidence, the World Health Organization has endorsed it and recommended its adoption by other cities.

In India, urban violence is an increasing threat to life and wellbeing. While the many social, economic and political drivers of violence must be studied and addressed in a context relevant manner, the principles of the Cardiff model are worth applying. Data-guided approaches and community engagement are surely better than incomplete police assessments for anticipating and preventing violence in community settings.

All causes of violence will not be adequately identified or tackled, but there will be an opportunity to undertake proactive measures rather than merely react after people have been badly hurt. If nothing else, violence by the police themselves may be reduced by such an expanded database available for community monitoring.

(Views are personal)

(ksrinath.reddy@phfi.org)

K Srinath Reddy

Distinguished Professor of Public Health, PHFI

Author of Pulse to Planet

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