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Rapid Responses: Rapid Responses published:
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Violence and Nutrition
- Jane A Metcalf (11 October 2002)
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Terrorism and inequality within and across nations
- Graham V Vimpani (20 October 2002)
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All together now, again
- Peter Davies (24 October 2002)
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Violence as a public health problem
- Jonathan P Shepherd (24 October 2002)
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Violence Prevention: A Priority for Health
- Dinesh Sethi, Jo Nurse (SpR in Public Health, London School of Hygiene and Tropical Medicine) (25 October 2002)
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Violence, the NHS and Community Safety
- Richard Shircore (7 November 2002)
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do we need a Tsar for the Spiritual Health of the Nation?
- Brian M Higginson (16 January 2003)
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Jane A Metcalf, GP Newport, Shropshire TF10 7HG
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Interesting subject and one that is set to run and run unless the underlying causes of violence can be identified and addressed. A recent paper by C B Gesch (2002) has identified 'antisocial behaviours in prisons, including violence are reduced by vitamins, minerals and essential fatty acids with similar implications for those eating poor diets in the community.' So far this work seems to have attracted very little attention, but I feel that it is very important and hope that the Home Office will take on board the message 'this research strongly suggests that the effect of diet on antisocial behaviour has been underestimated and more attention should be paid to offenders' diet.' Poverty and poor diet go hand in hand so could addressing the issues of poverty eventually filter through to improved nutrition and a reduction in violence. The paper found that there was a need to improve dietary education as well as providing more nourishing diets. Can we afford not to improve the nutrition of young offenders when it has been demonstrated that a substantial proportion will re-offend? REFERENCE Gesch C B, Hammond S, Hampson S, Eves A, Crowder M, 2002, Influence of supplementary vitamins, minerals and essential fatty acids on the antisocial behaviour of young adult prisoners. B J PSYCHIATRY. 181:22-28 |
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Graham V Vimpani, Professor of Paediatrics and Child Health University of Newcastle, NSW, Australia
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As an Australian, deeply affected by last weekend's massacre in Bali, I found your editorial to be especially prescient in calling our attention to the links between all forms of violence, and infering from what you said, the extent to which the perceived injustices of economic inequality drives violent acts like terrorism. As inequality grows between the wealthiest countries of the west and the third world, and whilst within many third world countries inequality thrives, the seeds are sown for the expression of anger, hatred and resentment by some of the most disaffected at those they perceive to be their oppressor, inevitably giving rise to the kind of appaling events directed at wealthy westerners that we have seen over the last 13 months. And for those of us who are convinced of the evidence around the importance of experiences and environments encountered in the early years for the rest of the lifecourse, we worry about the messages that young children are being given who grow up in those environments, and what that might mean for the future of relationships between the different tribal groups who inhabit this planet. A sustainable future must mean more than one in which exploitation of the physical environment out of avarice is ceased, but all forms of exploitation of the weak by the powerful is lessened. The war against terrorism will be lost unless the west, in partnership with the exploited third world, grapples with this issue and devises effective ways of reducing socioeconomic inequality. Sadly, the history of our capacity as humans to make the sacrifices involved in acting out of what is ultimately going to be enlightened self-interest does not fill me with confidence. History suggests that we often just go on blaming and attacking the victims. |
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Peter Davies, GP Mixenden Stones Surgery,Halifax,HX2 8RQ
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Sir, I welcome the approach taken by Heath in this editorial (1). It has long struck me as noteworthy just how much of the psychological and physical symptoms of distress seen by GPs and at A+E departments has its roots in violence. Classically men get upset, angry and end up in jail for fighting, whereas women get upset, sad and end up seeing doctors with depression. I have long wanted a frame of thinking which would allow these two needless streams of human misery to be turned off at source. I no longer see the case by case treatment of individuals as being a sufficient response to these problems. Heath is very careful to look at the roles of both individual agency and societal structures in contributing to the problem of violence. The idea of taking the soil away from the seeds of violence is highly appealing. She then goes on to say that electorates, and so governments, are unwilling to allocate more resources to poor areas and families. A similar point was made by Watt in 1996.(2) There is a moral argument to ask the richer classes to fund the poorer classes but this on its own cuts little ice with the middle class voter. What strikes me about the apparent refusal of wealthier classes to fund redistibution is how short sighted a policy it is. What is the use of a large private house if you need CCTV to vet all your visitors before opening the security gates? The middle classes are paying the high costs of inequality in their fears of being a victim of crime,and the cost of insuring their cars and their property. Perversely whatever money they are saving in tax they are probably paying out for insurance and security, and still not feeling very secure after paying this. A more ecological(3) approach to give a better outcome for all sections of society could trade off higher tax as a worthwhile investement in reducing crime and violence by reducing inequality. Reducing inequality would also be an investment for the health not just of poorer people, but of the rich as well. Have we reached the stage where we as individuals could back a political party that tried to sell us such a policy that could benefit us all? Or do we still think our insurance policies are a better buy? Refs. 1. Heath,I Treating violence as a public health problem. BMJ (5/10/02)325:726-7 2. Watt,G All together now: why social deprivation matters to us all. BMJ 1996 312:1026-1029 3. Hall,LM The Ecology Check as a Meta-State http://www.neurosemantics.com/Articles/ecology-check.htm |
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Jonathan P Shepherd, Professor of Oral and Maxillofacial Surgery University of Wales College of Medicine, Department of Oral Surgery, Heath Park, Cardiff, CF14 4XY
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EDITOR - Although treating violence as a public health issue is not new, the WHO report on violence and health is an important reminder of the suffering we inflict, intentionally, on each other.1 However, making violence a health issue should take into account the fact that the causes of violence are assailants and that there are therefore issues of justice which must be addressed. In recent years it has been realised by policy makers that tackling crime and violence needs more than the efforts only of the police and other components of criminal justice systems. For example in the UK, the Crime and Disorder Act 1998, places a statutory obligation on health authorities to work with the police and local authorities to tackle crime. Surprisingly though, given the WHO plea for public health to take a lead, the police and local authorities in England and Wales have found the NHS reluctant to engage. One reason for this is that, so far, the contributions of public and other health services have not been well defined. Being an anti-violence advocate and acting as a convenor of the different parties needed to address violence 1 is simply not specific enough. Public health and other health services should contribute because: 1. A great deal of violence which results in medical treatment is not reported to or recorded by the police. This means that there are substantial opportunities for health services to collect unique information about the circumstances of violence which, combined with police data, can be used to target violence prevention resources at particular locations, times and vulnerable individuals and groups.2 Since most of the injured are treated by accident and emergency services, they should be a major focus of preventive effort. 2. In the UK, the analytic capability of police services is rudimentary compared to expertise available in public health. This is perhaps not surprising since there are no university police schools where crime epidemiologists can be trained. Importantly, tackling violence as a problem of intentional injury provides a framework for prevention which has substantial advantages over highly complex and fragmented criminal justice approaches. There is an urgent need for local public health services to contribute their analytic expertise not just to data derived from health facilities but also to data from health and police sources combined. 3. A&E-derived information is proving an objective and unique measure of violence with which to complement crime survey data.3 Recent studies have found that these data correlate with measures of unemployment, poverty and alcohol expenditure for example. These data can be collected without extra resource by A and E clerical staff and have successfully been used to target local police activity. They have potential as evidence relevant to alcohol and entertainment licensing: a recent study found correlation between licensed premises capacity and injury sustained in local street violence (assaults in the street and on the pavements).4 These findings justify a multi-agency approach to which health contributes. Iona Heath rightly draws attention to the human rights perspective. Nowhere is this more important than in relation to the rights of the many victims of violence who come to the attention of health services. Since most victims’ services are accessed through the police, it is incumbent on health professionals to access services for victims.5 These range from accident and emergency departments making links with victim support schemes, through initiating permanent protection orders which public health researchers have demonstrated reduce the risk of repeat domestic violence, to the provision of liaison psychiatry services. Just as crime is too important an issue to be left just to the police, it is also too important to be left to public health. What is needed is a combined approach in which public health, accident and emergency services, primary care, the police and other components of the criminal justice system join forces. Only by doing this will communities which are both safe and just be achieved. Jonathan Shepherd, Professor of Oral and Maxillofacial
Surgery/Director:Violence Research Group, University of Wales College of
Medicine, Heath Park, Cardiff, CF14 4XY 1 Krug EG, Dahlberg LL, Mercy JA, Zwi A, Lozano R, eds. World report on violence and health. WHO, Geneva, 2002 2 Shepherd JP, Sivarajasingam V, Rivara FP. Using injury data for violence prevention. BMJ 2000;321:1481-2. 3 Sivarajasingam V, Shepherd JP, Matthews K, Jones S. Trends in violence in England and Wales 1995-2000: an accident and emergency perspective. J Pub Health Med 2002;24:219-26. 4 Warburton A, Shepherd JP. The use of emergency department-derived assault data for violence prevention. J Dent Res 2002;81:492. 5 Shepherd JP. Supporting victims of violent crime. BMJ 1988;297:1353. |
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Dinesh Sethi, Honary Senior Lecturer in Public Health/ PCT Consultant Health Policy Unit, London School of Hygeine and Tropical Medicine, Keppel St, London WC1E 7HT, Jo Nurse (SpR in Public Health, London School of Hygiene and Tropical Medicine)
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Editor, The recently published World Report on Violence and Health has highlighted violence as a leading health problem which affects all peoples, irrespective of age, sex, socio-economic class or ethnic group, particularly where there are large inequalities in the distribution of power.1,2 The report proposes a public health approach to tackle the problem. 2 However, Heath argues that a human rights perspective based upon the philosophy of the freedom of choice of individuals to make moral decisions should also be emphasised. 1 A human rights approach can make a valuable contribution to violence prevention through advocacy and changes in legislation. However, emphasising that individuals should exercise freedom of choice not to act violently is flawed, as in the real world, this choice is very restricted and violent acts occur.2 The argument for free choice, is therefore tantamount to arguing for doing very little that works. Such an argument can be manipulated perversely, as shown by the pro-gun lobby in the USA. Instead the public health approach offers a science based approach which is action orientated to finding and implementing solutions. We would therefore like to advocate that not only should the main emphasis for violence prevention be the public health approach, but that in the UK, the health sector could play a much larger role in its prevention. Presently, other than a few welcome initiatives such as strategies for suicide prevention, a health professional response to domestic violence, and stopping violence against NHS staff, the Department of Health has done little to advance this arena of health.3,4 This omission has contributed to a failure to realise the potential contribution that the health sector in the UK can make in surveillance, defining risk factors, and evaluating and implementing interventions. In contrast, the Centers for Disease Control (CDC) in the USA, have developed a much more comprehensive approach to violence research and prevention.5 For example, CDC has assisted the development of improved surveillance systems, joint child health and domestic violence initiatives, school based and youth violence prevention interventions, and pro-social violence prevention initiatives in day-care and prison settings. 5 By providing leadership and a research strategy, the Department of Health would encourage more health professionals to play their part in a multidisciplinary approach. This is particularly relevant, given the renewed potential for Primary Care Trusts to undertake cross-sectoral working in Local Strategic Partnerships and Community Safety Plans. References 1. Heath I. Treating violence as a public health problem. BMJ 2002; 325:726-7. 2. Krug EG, Dahlberg LL, Mercy JA, Zwi A, Lozano R, eds. World report on violence and health. Geneva: WHO, 2002. 3. Domestic violence: a resource manual for health care professionals. London: DoH, 2000. 4. http//www.doh.gov.uk accessed 18.10.02 5. http//www.cdc.gov/health/violence.htm accessed 18.10.02 |
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Richard Shircore, secondement to Thames Valley Partnership (Crime Reduction Charity) St. Marks Hospital, SL6 6DU
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I have read with interest the ongoing debate regarding the level of violence within society. I would like to make the following observations based on my secondement of looking at violence from the perspective of community and personal safety. Firstly violence is frequently realted to inequalities, without much attention being given to the defining characteristcs of these inequalities. My studies suggest a defining charactersitic is the loss of personal autonomy caused by living within a hostile or threatening enviroment. The threat may be either physcial e.g. loss of street lighting or, more often human, e.g. the violent partner of a domestic violence victim. In any event the end result is the same. People experienceing a loss of sense of safety lose their ability to "act in their own best intersts". They become unable to plan ahead, lose hope for the future and frequently become fatalistic depressed or apparently careless of themselves. The classic example being the high rates of mortality and morbidity of pregnant women and their foetuses from partner violence. The study is yet to be carried out, but I would suggest it is these women who smoke in pregnancy (stress reaction) and who fail to present for ante and post natal checks. It is often forgotten by service planners that to attend NHS clinics requires a level of autonomy that those experiencing a loss of safety and expecting personal violence simply do not possess. If the NHS is to improve health inequalites overall it must acknowledge that the major difference between the have's and the have nots is the formers abilty to live a life free from coercion and threat and able to make positive decisions about ones own health, wellbeing and future. Competing interests: None declared |
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Brian M Higginson, Regional Clinical Lead in substance Misuse for RCGP, GP Wellington Square Medical Centre, 45 Wellington Square, Hastings TN34 1PN
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Editor- The problem of violence in all societies is a problem crying out for a deeper solution than that being offered by WHO 1 or Heath 2. As a GP with a Special Interest in substance misuse looking after patients for whom violence is part of their ‘daily bread’ one is lead to the conclusion that there are many factors, of which diet 3 is one. In a recent study urine tests showed that the average rate of positive tests for illicit drugs, excluding alcohol, was 61 per cent. The equivalent rate including alcohol varied between 72 per cent and 82 per cent of arrestees depending on location. We need to be asking why people drink and take drugs to excess leading them to the crimes of which violence is just one facet4? There is a furore raging at present because Lord Irvine 5 as Lord Chancellor stated on BBC radio’s Today programme that ‘the general principle must be to keep people out of prison if at all possible’. The fact of the matter is that the prisons are full to overflowing. Heroin ‘shooting galleries’ 6 and the legalisation of cannabis7 are driven by a criminal justice agenda. The system is creaking from overload. A study undertaken by the University of York, which is due to be published later this year, estimated that the annual economic and social costs of Class A drug misuse in England and Wales is between £11 and £19 billion 8 Violence and the related substance misuse are now problems of such proportions that they require solutions that tackle the underlying raison d’etre. If this is beyond our reach we should develop an evidence based health promotion strategy which assists abusers to reclaim normality. We are all not exactly equal at any point in time, nor is the capacity to take advantage of opportunities equal to all of us. The truth underlying equality which gives it universal sanction is that we all have within us a part of our being which is identified in different religions but generally held to be unsullied and untouched by our actions; in Christianity it is the soul; in Vedanta philosophy the Atman 8 Assuming all religions are not just the ‘opium of the people’, as stated by Jung, is the time not ripe for the medical fraternity to devote its research capabilities to investigating what methods will bringing people closer to their ‘central being8? What we need is a conference with representatives from all religions and the media to look at this subject and then a Tsar for the Spiritual Health of the Nation! References 1. Krug EG, Dahlberg LL, Mercy JA, Zwi A, Lozano R, eds. World report on violence and health. Geneva: World Health Organization, 2002. 2. Heath I. Treating violence as a public health problem. BMJ 2002; 325: 726-727 (5 October 2002) 3. Metcalf, JA. Violence and Nutrition Letter BMJ (11 October 2002) 4. Bennett T et al. Drug use and offending: summary results from the first year of the NEW-ADAM research programme. Findings 148. Home Office Research Developement and Statistics directorate. 2001 5. Grimston J and Cracknell D. Crime but no punishment. p1.15 Sunday Times. 12 January,2002 6. The Government’s reply to the Third Report from the Home Affairs Committee Sesson 2001-2002 HC 318. The Government's Drugs Policy: Is It Working? HMSO July 2002 7. Wodak A, Reinarman C et al. Cannabis control: costs outweigh the benefits. BMJ 2002;324:105-108 ( 12 January ) 8. Sri Aurobindo. The Life Divine. 1939. Sri Aurobindo Ashram Press. Pondicherry. India Competing interests: Undertaking a sabbatical shortly to research the potential use of Ayurvedic medicine in treating drug addicts |
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