Across the world many cities face high levels of criminal violence and murder. A quick search will reveal that in terms of global league tables, certain regions dominate with Latin America, North America and Sub Saharan Africa providing the top 50 violent cities. However, a cursory glance tells us this is a complicated picture with huge variations between and within countries. Complex factors are at play, differing social, economic and legislative environments all have an influence. A brief historical perspective tells us that improvements can be made, that nations and cities can act successfully to reduce the levels of violence experienced by their citizens.
Public health has much to offer here. Developing an understanding of the epidemiology around a specific type of violence, considering its social determinants, a commitment to evidence-based responses and a focus on broad prevention have obvious attractions. It can provide a breadth of focus which allows an opportunity to look beyond the individual and immediate. This is a luxury not always provided to emergency responder agencies and law enforcement.
Public health approaches allow consideration of the harms of violence, for example with a murder, beyond the obvious victim, to consider the impact on their family, friends and community. It can also allow the examination of circumstances beyond the violent incident itself. What other factors may have led to the situation? Is it part of wider phenomena? Are there relevant factors going back years? Facts which might not be pertinent to a criminal justice investigation. This kind of approach is of course demanding in terms of resource, but it offers potential in terms of moving towards the prevention of, rather than merely reacting to, such tragic incidents. Unfortunately, it’s an approach that often only gains significant traction when there is a surge in violence and the political spotlight shifts on to the issue.
The increase in mass shootings within the USA has seen just such a spotlight applied. It has raised interesting and relevant debate about whether these incidents are contagious, with each incident increasing the likelihood of another. Currently in the UK we have just seen a court case conclude where two school children plotted an atrocity, apparently inspired by the Columbine massacre. The Atlantic Ocean and nearly twenty years being apparently no barrier to contagion. Violence seemingly begets violence globally and while this might appear a dismal thought it should encourage us to focus on reducing violence wherever it appears.
While the gun rights lobby remains politically potent there does seem to be movement in tightening access to the most powerful weapons. Many of those who remain committed to the Second Amendment rights (the right to bear arms) have seemingly got to the something must be done stage. We must hope that real progress will be made without the impetus of further school massacres.
However, as President Trump recently referenced, other places also experience high levels of fatal violence. So far this year London has experienced over 60 murders, 37 of these involving knives. These deaths are concentrated amongst young males, many from deprived and underserved communities. This level of tragedy has produced a significant political focus on the problem and resources are being targeted to try and reduce the number of deaths. This has seen interest in what can be learnt from other places and the potential of public health approaches.
Many of the best known and researched schemes are to be found within the USA. There is also interest in the success that Scotland, particularly Glasgow, has achieved in reducing the murder rate. This was achieved by bringing together policing and public health approaches under the auspices of the Violence Reduction Unit (VRU). There is no doubting their success, I have seen compelling presentations on their work, including at a previous City Health International conference, but I know they would acknowledge the debt to lessons learnt in other cities (e.g. Cincinnati). They would also agree that the approaches they adopted required political bravery and a willingness to confront the gut instincts of much of the media.
There is a risk in seeing public health as somehow riding to the rescue of beleaguered law enforcement. Effective policing and a capable criminal justice system are an essential part of any response to violence within communities. Without these its not possible to begin engaging with the community, to bring in the health and education bodies, the voluntary sector and promote economic regeneration. The factors which will improve long term outcomes. Public health approaches offer the most when they recognise the vital role of non-health players and help harness these together. They also offer much in terms of being evidence based, although no City experiencing high levels of violence wants to wait a decade while an evidence base is built. Perhaps one of the most valuable tools public health can offer to tackle violence is in terms of concept.
The importance of reducing health inequalities is now well recognised in many places, it crosses the political divides. Seeking to address inequalities in terms of criminal justice outcomes, in terms of reducing the impacts of crime on those least able to bear it offers the chance to build upon the many projects around the world which have achieved success. I look forward to the City Health 2018 session on Violence as a Public Health issue to further develop our ideas in this area.