Plenary Session I

Welcome and "Charge" to the Participants

Prescntcd by C. Everett Koop, MD
Surgeon General of the U.S. Public Health Service
Sunday evening, October 27, 1985

Let me personally thank you all for accepting my invitation and coming
to this workshop. Before we end our work on Tuesday, I hope I will have
been able to thank each of you in person.
I will be here throughout the workshop, and I hope to visit each work
group once to catch at least the sense of your deliberations.
I have also assigned each member of my "Ad Hoc Planning and Advisory
Committee" to a specific work group. I have asked each one to be helpful
to the chair when needed and in other ways carry my personal interest to

- and from - those important work sessions.
I will also rely on them to help me frame my response to the recom-
mendations that arc to be presented in the fourth plenary session on Tuesday
afternoon.

Because they've been so important to the planning of this workshop over
the past 13 months - and because they continue to be important to the
way we proceed - I'd like to take a moment to introduce them to you in

3


alphabetical order: Ann Burgess, Ted Cron, Margo Gordon, Dave Heppel,
Tom Lalley, Bob McGovern, Nikki Millor, David Nee, Eli Newberger,
Delorcs Parron, Mark Rosenberg, Saleem Shah, and Alan Wurtzel.

If you're still wondering by what magic your name came to my attention,
please be assured that it wasn't through magic at all but rather through
the diligence of this committee reaching out into the larger community.
They spent almost 6ve months searching out the best possible people to
come together to share what they know and what they see as the things
still to be done.

Let me hasten to add that many excellent people arc not here and their
absence may be noted. First, it is possible that WC did invite them, but
they either had to decline or, after accepting, found they could not make
it after all. Others did not receive an invitation for the time-worn but
unsatisfactory reason of space: We asked Xerox for just so many spaces . . .
150 of them . . . a number we felt was the maximum for a workshop in
which we hope everyone will contribute.

But I would be very disappointed if this were both the first and the last
workshop on this subject. I am hoping that our experience here will be
repeated in the coming months in every region of our country and that,
as a result, many of the people who arc missing from this workshop will
have a chance to contribute in the future through those follow-up events.
1 understand that such may well be possible in the southwest, thanks
to the people here from Texas. And later this week, my staff will be talking
with some people from the midwest about a follow-up meeting there.
But the prize for immediate follow-up ought to go to the nurses who
arc here. A contingent of the "Leesburg Nurses" will form a panel and
present the recommendations of this workshop on Friday evening, at the
opening session of the "First National Nursing Conference on Violence
Against Women," being held N ovember 1 through 3 at the University of
Massachusetts at Amherst.
Congratulations . . . good for you.
For most of you, I'm sure this will not be your only conference on
violence this year. Some of you will have attended several before the year
has ended.

But I hope the Leesburg Workshop will be different in one major respect:
Our focus will be squarely on how the health professions might provide
better care for victims of violence and also how they might contribute to
the prevention of violence.

It is clear that the medicine, nursing, psychology, and social service
professions have been slow in developing a response to violence that is

4


integral to their daily professional life. As a result, WC arc not sure if the
estimated 4 million victims of violence this year will receive the very best
care possible.

Nor can we be sure that enough will be done to prevent violence from
claiming 4 million or more victims again next year.
I think we all share these nagging suspicions. Fortunately, we also seem
to share the same notions about what can be done about them and how
we can do it.

That is one of the interesting outcomes of the "Delphi" survey that so
many of you took part in over the summer. According to the final report,
we generally agree on many ideas that lead directly to action.

Multidisciplinary Approach

One such idea is that the best approach the health professions can make
to interpersonal violence is a multidisciplinary approach.
We know we have not been as successful as we would like to be in the
care and treatment of victims of violence because of the way our health
professionals continue to indulge in compartmentalization . . . the vertical
separation of one life-saving service or discipline from all others.
It's a frustrating habit we've developed, but one which we agree should
be ended as soon as possible and as effectively as possible.
For just that reason, we have a range of disciplines, skills, and experience
represented at this workshop. Through our own multidisciplinary delib-
erations, we might produce recommendations for the profession of medi-
cine, for example, that not only reflect actual and potential medical practice,
but also reflect the contributions of social services, nursing, and law en-
forcement, as appropriate.

Ideally, the multidisciplinary approach we're taking here in Leesburg
ought to be replicated in every community in the Nation. I say "ought
to," but I know it can't be accomplished in most of the country. Therefore,
reality dictates that we produce here the kinds of recommendations that
reflect the thinking of many disciplines, yet recommendations that can be

- themselves - the stimuli of change and progress everywhere.
Here, again, through the "Delphi" technique, we seem to have reached
general agreement on another idea, and that is the fact that we've had
ample time to develop our theories and concepts. What we need now -
and what the country needs now - is action.
Our recommendations, then, ought to be framed in such clear, direct
language that our colleagues in medicine, nursing, psychology, and social

5


service anywhere in the country can absorb them, understand them, and
put them into practice.

. We need to make such recommendations for all the health services

. . . how they might be organized, how they should interact, how they
ought to respond to the needs of victims of violence, and how they should
contribute to the prevention of violence. To say we're in favor of a
multidisciplinary approach is obviously not enough. We need to focus
in on those current multidisciplinary programs that seem to work . . .
to isolate and describe their elements . . _ and then indicate how they
can be replicated in any community or institution.

. We also need to be just as pragmatic in the area of education and
information. How can we get certain life-protective messages across to
young people? . . . to our elderly? . _ . and to our colleagues in the
health professions? And what role could our public schools, our profes-
sional schools, and our professional associations play in this educational
effort? And what ought to be the role of the media . . . television, radio,
newspapers, magazines?

. While we might feel we have learned enough from research and ex-
perience to move forward into action, there are still many areas -
especially in the field of human behavior - where we could use more
specific information based on good research and demonstrations. I hope
these will be discussed here and later put forward among your recom-
mendat ions, also.

From these two days of hard work should come a document that can be
read in two ways. One way would be to read the recommendations, one
by one, for the evaluation and treatment of victims and for the prevention
of violence. These recommendations could apply to the various professions,
to local and state governments, to voluntary organizations, and to academia
according to a cross-grid of the different kinds of interpersonal violence:
child abuse, spouse abuse, rape, and so on.

The second way to read the document would be not as specifics but as
an overall strategic design.

One of the great deficits of our health delivery system generally has been
its stubborn resistance to the development of any overall strategy of care.
I will not concede that there's a good reason for this because there isn't.
But there is a bad reason. And that reason is our own unwillingness to

6


really try. We have become so used to a health system that grows and
changes incremently that we think that's the way things ought to be.
But that's not so.

And so I would hope that here at Leesburg we would not fall into the
same particularistic trap that we bemoan as existing everywhere else.
Let's not do that. Let us instead arrive at a set of recommendations that
make sense by themselves . . . but make even more sense when they are
perceived together, sewn throughout a seamless fabric of lifesaving, dignity-
preserving, quality health care.

I want that to happen here at Leesburg. I believe it's an assignment that
is worthy of the knowledge, experience, and reputations assembled in this
room.
And now a closing word.
It had been our intention to take the recommendations of the Leesburg
Workshop back into Washington, D.C., and hold a press conference on
Wednesday morning to make our findings public. However, I believe we've
been given an opportunity to start the public education effort in a very
important way.

Special Senate Hearing

I'm pleased to report to you that at 11:OO a.m. on Wednesday morning,
we will be appearing before the Senate Subcommittee on Children, Families,
Drugs, and Alcoholism to report on what will have transpired at this
workshop. We are going at the invitation of the Chair of that Subcom-
mittee, Senator Paula Hawkins of Florida, who has been a strong voice in
the Congress on behalf of human life and family values.

I say "we" have been invited because Senator Hawkins has graciously
asked six of our 11 work-group chairpersons to appear with me. They are
Douglas Sargent, Anne Flitcraft, Lee Ann Hoff, John Wailer, Jean Good-
win, and Jordan Kosberg. They will speak not for themselves, obviously,
but on behalf of all of us. I deem it a great privilege to travel in such
company. In fact, I'm delighted to go to Capitol Hill with any company
at all. But especially with these six.

It's getting late and I know many of you are eager to exchange greetings
with colleagues, visit the special presentations arranged in the meeting
rooms as part of the "information exchange" this evening, and prepare for
tomorrow's work.

So I will close with a little quotation from one of my favorite American
writers, Henry David Thoreau. He seems appropriate for this setting.

7


In his marvelous book, Walden, Thoreau wrote, "It is characteristic of
wisdom not to do desperate things."
So let us turn to our work with patience and wisdom, and not out of
desperation. Instead, let us pledge that despair is over . _ . for all our
people.
And let's start here.
Thank you.


Plenary Session II

Interpersonal Violence and Public Health
Care: New Directions, New Challenges

Presented by Marvin E. Wolfgang, PhD
Director, Sellin Center for Studies in Criminology and
Criminal Law, University of Pennsylvania*
Monday morning, October 28, 1985

The Founding Fathers of our nation had the wisdom and foresight to
remind us in the Preamble of the Constitution of the great challenges and
goals that lay ahead. Six national purposes, charges, and mandates for the
future were boldly inscribed there as part of the national consciousness. As
a'nation we have sought in common cause to fulfill those purposes. To
nurture and preserve that more perfect union after which our forebears
sought, the nation has had to remain vigilant to protect its spirit and body
from threats from both without and within. One of the most damaging
and pernicious internal threats that has taken on major proportions over
the course of our history is violence in its many forms and gravities.

Deep and longstanding concern about our nation's violent past and
present produced the presidential appointment of the National Commission

* With Neil Alan Weiner, Research Associate, Sellin Center for Studies
in Criminology and Criminal Law, University of Pennsylvania.

9


on the Causes and Prevention of Violence in 1968. For the first time at
the national level this dark side of our heritage was illuminated system-
atically and in depth. The summary of the 13-volume report prepared by
the Violence Commission chronicled with precision this enduring and per-
vasive national malady (U.S. Violence Commission 1969). Among the
community of nations most similar to our own in culture and history, those
modern, stable democratic states of Western Europe, our nation was planted
at the summit in levels of lethal interpersonal criminal violence and col-
lective civil violence. More recent documentation confirms these observa-
tions and suggests that America is also an international leader in nonlethal
forms of assaultive conduct (Archer and Gartner 1984; Wolfgang and
Weiner 1985). Indeed, as the Violence Commission established, the 1960s
witnessed levels of violence which were substantially greater than those of
preceding decades and ranked among the most violent in our history.

Since the 1969 report of the Violence Commission, levels of violence in
our national community have increased dramatically, if we use official police
records of criminal violence; or they have remained fairly stable since 1973
but at much higher levels than those documented by police sources, if we
use reports of criminal victimizations (U.S. Department of Justice 1984;
Weiner and Wolfgang 1985). Our nation not only suffers losses of stature
and moral example because of its levels of violence, which exceed the
proportions of kindred nation states, but also finds itself at its zenith in
this ignobling respect.

Focus on "Tranquility"

The Violence Commission elected to carry out its charge by focusing on
the means "to establish justice and to insure domestic tranquility," the
first two national purposes penned in the Preamble to the Constitution.
Tensions between justice and public tranquility and order were guiding
concerns in the quest of the Violence Commission to understand and to
prevent violence. In that analytical and philosophical context, violent dis-
order was dissected with the cutting instrument of criminal law and the
system of criminal justice. Although various theories were used to reveal
the causes of violence, the primary inquiry was from the viewpoint of
violative and unlawful behavior.

The Founding Fathers seemed prescient in their deliberations and con-
stitutional framing. They inscribed another viewpoint and objective into
this nation's first legal document: namely, the promotion of the general
welfare. Now this workshop on violence is fueled by that original national
purpose. The disorders of violence are as much a challenge to the general

10


health and welfare of our nation as they are to its system of justice and
law. Our objective at this assembly is to wed to the insights and advance-
ments of law, order, and stability, those of public health and welfare.

Fused to "America the Beautiful" has been "America the Violent." Ours
is a land in which people inflict morbidities and exact premature mortalities
in enormous proportions and in many different ways. The nation has been,
and continues to be, fearful of these assaults and related victimizations
(Weiner and Wolfgang 1984).

The formal promotion of the public health initiative in response to
violence is dated with the presentation of the U.S. Surgeon General's
national health agenda, Healthy People: The Surgeon General's Report on Health
Promotion and Disease Prevention (U.S. Department of Health and Human
Services 1979), which identified 15 priority areas that, with properly tar-
geted preventive interventions, would improve appreciably the health of
the nation. This document was the wellspring from which soon flowed
quantified and feasible policies to reduce violence and other threats to the
national health and vitality (U.S. Department of Health and Human Ser-
vices 1980). Our current workshop on violence, a direct outgrowth of these
milestone precedents, can inaugurate a major and continuing enterprise by
health care professionals to prevent and to heal the many wounds inflicted
by violence on our nation's physical, emotional, and cultural corpus.

A Catastrophe and a Challenge

Many sources can be consulted to document the extent and character of
these lethal and nonlethal interpersonal exchanges. Some of these sources
are more reliable and nationally representative than others. However, one
need not search much beyond the pages of the background papers prepared
for this workshop to obtain a measured and riveting picture of the catas-
trophe and challenge which confronts the nation (U.S. Surgeon General
1985). Consider the most grave interpersonal exchanges. Homicide ranked
as the 1 lth leading cause of death of Americans in 1980. Approximately
24,000 Americans died by the hand of another in that year, resulting in
690,000 potential years of life lost. These deadly assaults comprised one-
seventh of all deaths by injury (Baker, O'Neill, and Karpf 1984). Most
grimly, for a young black male aged 15 to 24, homicide is now the most
likely cause of death. Indeed, over his lifetime, a black male is burdened
by one chance in 2 1, compared to one chance in 13 1 for a white male, of
dying in a lethal encounter (U.S. Department of Justice 1985). But the
proportions of lethal exchanges are dwarfed by the numbers of morbid

11


nonlethal incidents. More than 1.5 million aggravated assaults of Americans
age 12 or older were reported in 1980, representing a substantial number,
indeed, of instances in which a deadly drama might have unfolded and
been played out to a lethal conclusion.

These lethal and gravely assaultive episodes have their contexts of oc-
currence which shape the likelihood and character of the injurious interplay.
It is fitting that the patterns in interpersonal violence which form the
primary focus of this workshop are those imbedded in the family. The
national tranquility is deeply afflicted by these disturbances in the domestic
microcosm.

That intimate nuclear family unit which broke bread together at dusk
and which huddled close to hearth and home forms a rich part of the
national lore and folk imagery. But the American family has also had its
darker side which has rarely turned public. As we are finding increasingly,
the family united in common purpose and objective is frequently more a
myth than a reality. Domestic life is often rent from within, making enemies
of intimates. Domestic tranquility is, as we are becoming more aware,
threatened profoundly by its internal dissentions, disruptions, and injurious
and deadly conflicts.

Tallies vary, but convergent data point to between five and 20 percent
of the adult population as being enmeshed in some form of spousal abuse,
                              _-_.--,_" -. ,-.          `. .-._ ..^ ".
comprising approximately four million domestic partners. Nearly 50 per-
                                  -e-.-.-
cent of those husbands who batter their wives do sx brutal regularity,
three or more times a year. Other data, from the National Crime Survey,
indicate that nearly one-third of the nation's abused women are serially
victimized. Spousal abus    n fact, be the foremost cause of injury to
                    -        -_L_--.- -.~-.- __ _.
women.

Nor are the nation's children immune from assaults and batterings and
sexual attacks by their parents and other guardians and caretakers. A recent
national survey projected that nearly 1.5 million children and adolescents
are subjected to abusive physical violence each year (Gelles and Cornell
1985).

Many abused children are sexually violated, forcefully or through the
implicit threats of a parent or caretaker in a position of authority and power.
Scant information exists but some figures are enlightening and alarming.
In 1984, nearly 125,000 cases of sexually abused male and female children
were reported to authorities. Prevalence figures for women who were sex-
ually abused before age 16 run between 25 and 50 percent. Peak abuse
ages for male and female children fall between 9 and 12. Between one-
quarter and one-half of the abuse cases involve a family member or relative.

12


Little reliable information has been marshalled about the extent and
outcomes of domestic violence suffered by the elderly. What few studies
have been conducted are more exploratory than comprehensive. In view of
the patterns and proportions of other forms of familial violence, it is unlikely
that we will be heartened when these hidden figures are uncovered.
The domestic crucible is becoming increasingly recognized as having
profound effects, both immediate and long-term, on its members who
experience violence directly or indirectly. Physical pain and suffering and
                                                       -,-
related physical morbidities .are. ,the more. .obvious. distressing outcomes.
_c__ - ..----.---
Disturbances in emotional and social development and in irnp&r,-zg-
ni tive skills are ls~-w~~~e~~~~~~u~~-~~-~~~~~~~ ~io~e~~X'lG%e
--._ __-__ .___ .!- __   ,_~_. ,___ ..,..                 -- -_-..-I ._,_
                _..
consequences are now documented with greater regularity, as you are all
aware.

Long-Lasting Effects

Of equal concern is the effect that domestic violence, particularly against
our nation's children, can have on shaping similar behavioral forms beyond
the domestic circle. Perhaps most disquieting children who are battered,
                          II_..  --  r--- -.-- - .__ ~_..
or who witness physical
---- _.. -    assaults among other -family members, are more
likely to carry the force of these episodes into their nonfamilial interactions
__-- .._____. __.- . . r     ,~--   .~.                .-.-_^ ,,._-. ^
in the form of a heightened._chance
~=- i .__-_<..--.~-&.        of employindolence as a presumed
                                          - _.____._ -_- _ __.. .-.. _.- .- .._

legitimate interpersonal St-y, The legacy of the violent family is the
         .- __... -.- .-- -._-
enhanced risk of applying variations of this same violent behavior in contexts
beyond the family setting.

The proportions and gravity of family violence and its facilitation of
collateral forms of interpersonal violence argue persuasively for selecting
the family as the locus of a primary initiative to apply health care approaches
to the reduction and control of violence. The benefits and conquests of the
medical and public health models are well known with respect to controlling
and, in some cases, eradicating disease and the behavioral contributions to
poor hygiene and health. Descriptive and analytical epidemiological re-
search and practice have met great challenges of disease and injury on many
fronts: in identifying high-risk Populations, in tracing the mechanisms by
which theoretical risk is turned into actual malady, and in applying the
tripartite prevention strategy - primary, secondary, and tertiary inter-
ventions - based on epidemiological breakthroughs into preventive and
control regimens. Agents, environments, and hosts have each been proper
foci in meeting the challenge of disease control.

The instruments of the health care provider, the conceptual and meth-

13


odological perspectives employed in public health care, and the modalities
of assistance and intervention that are practiced rourinely in the health care
setting have a legitimate and firm place as part of our national armament
against interpersonal violence. Past medical and health care applications in
this area, primarily in application to crime in general and to violent crime
more specifically, have been restricted to a subordinate part of criminal
justice and social problem perspectives. These applications formed what
has been termed the "rehabilitative ideal" in criminology and criminal
justice. Medical models of disease and pathology were transplanted from
their indigenous public and private health settings and installed within
the coercive regimes of out coutts, prisons, and correctional facilities. The
agents of crime and violence were the target of secondary prevention sttat-
egies. As substantial recent reviews of these efforts have shown, this re-
stricted initial wedding of medical philosophies with criminal and penal
philosophies has had impoverished results (Martin, Sechrest, and Redner
1981; Sechtest, White, and Brown 1979).

Discontent with the rehabilitative ideal has recently turned many of out
colleagues to search for alternative ways to control serious behavioral out-
comes such as lethal and nonlethal violence. Proposals of deterrence and
incapacitation circulate widely and are undergoing continued close scrutiny.
These strategies have unclear feasibilities and uncertain magnitudes of effect
(Blumstein, Cohen, and Nagin 1978).

The time is propitious for public health perspectives to enter the arena
of disciplinary and theoretical thought about the etiology of violent conduct.
There ate now no cleat and strong positions about how to proceed in
containing and, perhaps in some cases, eradicating interpersonal violence.
The wisdom of many perspectives - particularly one such as your own
which has won many battles against injurious hosts, agents, and enviton-

ments - should contribute substantially to efforts to curb the advancement
of interpersonal violence.

As central to the public health approach as its conceptual and meth-
odological armaments is the position that health care is best learned, pet-
formed, and maintained when it is ingrained as part of individual and
community hygiene, as part of daily routines and salient perceptions of
what constitute good health practices. Preventive and control strategies
which do not enlist the routine cooperation of those who are to benefit
from these strategies can have some success but not as much as they might.
Both the American public and those health care practitioners charged with
securing the public safety and welfare must learn to consider violence
prevention and control as part of their daily requirements and responsi-

14


bilities. The American people must feel free to appeal to family life centers,
drop-in crisis centers, and in-home service programs, to name but a few
of out emerging responses to violence, without fear of social stigma, re-
probation, or sanction. Our nation must feel as comfortable controlling its
violent behavioral urges and practices as it does in controlling bacterial,
vital, and physical mechanisms of morbidity and death.

The responsibility to stand firm against interpersonal violence is not the
exclusive preserve and discharge of our contemporary public caretakers and
monitors - our law enforcers. Although criminal justice approaches may
have their place and effectiveness as part of violence control strategies -
such as the recent Minneapolis study of police response patterns to domestic
violence suggests (Sherman and Berk 1984) - these strategies do not enlist
the sensibilities and commitment of our communities. Public health care
has been a leader in taking steps to form alliances and networks to make
health concerns permanent public priorities and part of personal practices.
Winning the public to the cause of treating violence as a health concern
may well be, along with its research and methodological equipment, one
of the major contributions of public health services.

Many participants here today, who represent diverse disciplines, travel
in partnership to a common understanding of interpersonal violence and,
by virtue of that understanding, seek to treat the causes and correlates of
that violence. But there ate barriers to teaching this common understand-
ing, many of which have been articulated by the contributors to the wotk-
shop Sozrm Book.

An Expanded Data Base

Epidemiological approaches to describing and analyzing violence require
reliably gathered and valid information. Particularly important ate longi-
tudinal data that span the lifecourse of subjects and reflect the many settings,
domestic and otherwise, which influence the origins and development of
violent behavior. These data must include persons who are subjected to
violent assaults and those who are responsible for assaults as well as the
situations in which assaults occur. In the lexicon of health care, basic,
extensive, and quality information is needed about hosts, agents, and en-
vironments. With these data, the progression and vicissitudes of violent
careers, as we now refer to them in our criminological pursuits, can be
examined effectively and precisely.

The collection and maximum utilization of primary data sources is, then,
a priority which needs continued and substantial support. Because lifespan
data often demand substantial time for collection and analysis, practitioners

15


who seek to use and apply the fruits of such research data must be patient
while they are gathered and analyzed. Moreover, to realize out goal of
diminishing the ravages of interpersonal violence, solid evaluation of pro-
grams which respond to these physical onslaughts must be initiated. All
who are here should recognize this need. Greater efforts to conduct proper
assessments of violence reduction and control modalities are integral to
rational efforts to establish and perpetuate those modalities which, in a
word, work.

Law and Liberty

Our analytical and social service initiatives must be joined to consid-
erations of law and justice. Complex issues of personal and collective ftee-
dom and protection collide in the arena of violence legislation about
dangerousness. Protective service action exemplifies this legal tension. What
are the proper limits of intervention? At what point may health care prac-
titioners legally and coercively enter domestic settings? When might such
entry constitute an unlawful intrusion, a violation of freedom and liberty
that may be mote deleterious than those practices which the empowerment
legislation was intended to curtail?

No less controversial and complex are legal issues about how to control
responsibly the explosive armaments which take so many lives each year.
We must acknowledge that firearms are used to kill people in the United
States in frighteningly great numbers. Socio-cultural differences aside, the
ready accessibility of firearms in the United States and their near inacces-
sibility in Japan probably play a major role in the IO,7 15 criminal homicides
by firearms in the United States in 1980 in contrast to only 48 in Japan.
Without this mechanism of death so generally and easily accessible, people
would not kill, and people would not die, as frequently as they do.

The resolution of these and other legal questions is a pressing concern
which many here in attendance have already begun to address. More at-
tention to these issues will be required as public health care focuses on
physical violence and dangerousness.

To meet the needs of data preparation and analysis, of program evalu-
ation, and of framing informed and effective legislation, greater public
health efforts to confront violence must be focused and collective.
Surgeon General Koop's challenge to cleanse and to treat the national
wounds of out present violence - a challenge he has laid squarely before
each of us - can be met only if there is a broad-based, comprehensive
agenda and an alliance of participants. Initiatives must be clearly articu-
lated, feasible, and nationally coordinated for the optimum benefit to ensue.

16


The Surgeon General's office has been and will continue to be a seat of
leadership in that enterprise.

But violence cannot be countered by government alone. The strengths
of community and common cause ate also requited to promote health and
well-being in our land. An alliance between public and private sectors
should promote progress toward reducing violence. Some major private
sector initiatives, such as the Eisenhower Foundation, presently exist and
provide comprehensive plans for future action (Curtis 1985).

In summary, our common challenge is one of forging a national agenda
and alliance in response to interpersonal violence and, by so doing, to
promote and safeguard the general welfare. At the vanguard of this enter-
prise is the authority and good offices of out entrusted advocate of the
public health, the Surgeon General. Perhaps this workshop marks the
commencement of a dialogue which will culminate in a message from out
nation's chief public health officer about the clear and present danger posed
to the American people by violent conduct.

Toward achieving, in concert, the goal of forcing a decrease in out nation's
violence, we must act with vigor, imagination, and resolve.

References

Archer, Dane, and Gartner, Rosemary. Violence and Crime in Cross-National Perspective. New
Haven: Yale University Press, 1984.

Baker, Susan P., O'Neill. Brian, and Karpf, Ronald S. The lnjifry Fact Book. Lexingron,
Mass.: D.C. Heath and Company, 1984.

Blumstein, Alfred, Cohen, Jacqueline, and Nagin, Daniel, eds. Dererrennand Incupkfation:
Estimating the Effec of Criminal Sanctions on Cr& Rates. Washington, D.C.: National
Academy of Sciences, 1978.

Curtis, Lynn A., ed. American Violence and Public Poliq. New Haven: Yale University Press,
1985.

Gelles, Richard J. and Cornell, Claire Pedrick. lntimute Violence in Families. Beverly Hills,
Calif.: Sage Publications, 1985.

Martin, Susan E., Sechrest, Lee B., and Redner, Robin, eds. New Directions in the Reha-
bilitation of Criminal Offinders. Washington, D.C.: National Academy of Sciences, 198 1.

Sechresc, Lee B., White, Susan O., and Brown, Elizabeth D.. eds. The Rehabilitation of
Criminal Offemkrs: Problems and Prospects. Washington, D.C.: National Academy of Sci-
ences, 1979.

Sherman, Lawrence W. and Berk, Richard A. "The Specific Deterrent Effects of Arrest for
Domestic Assault." American Soc~ologicai Review. 49 (April 1984):26 l-72.

17


U.S. Deparrment of Health and Human Services, Public Health Service. He&by People:
The Srwgeon General's Report on Health Promotion and Disease Prmnrion. Washington, D.C.:
U.S. Government Printing Office, 1979.

  PromorinK Heah. Prevenmtin~ Disease: Objedves for the Ndion. Washington, D.C.:
U.S. Government Printing Office, 1980.

U.S. Department of Justice, Bureau of Justice Statistics. Criminal Virthizarion 1083,
Bulletin. Washington, D.C.: U.S. Government Printing Office, June 1984.

   The Risk of Violenr Crime. Special Report. Washington, D.C.: U.S. Government
Printing Office, May 1985.

U.S. National Commission on rhe Causes and Prevention of Violence. To Estahfish Justice.
to Insure Domestic Tranquility: Ftnul Report. Washington, D.C.: U.S. Government Printing
Office, 1969.

U.S. Surgeon General. Violenceasa Public He&h Problem. Sourcebook, prepared for the Surgeon
General's Workshop on Violence and Public Health, Leesburg, Virginia, October 27-
29, 1985.

Weiner, Neil Alan, and Wolfgang. Marvin E. `*The Extent and Character of Violent Crime
in America, 1969 to 1982," In American Violence and Pnbiic Policy, edited by Lynn A.
Curtis, 17-39. New Haven: Yale Universiry Press, 1985.

Wolfgang, Marvin E., and Weiner, Neil Alan, eds. "Surveying Violence across Nations:
A Review of the Literature with Research and Policy Implications." United Nurions
International Review of Criminal Policy: Violence Forum, forthcoming.

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Violence and Public Health

Presented by William H. Foege, MD
Assistant Surgeon General, USPHS, and Special Assistant for
Policy Development, Centers for Disease Control
Monday morning, October 28, 1985

I can't pretend to tell you much about the problem of violence. You
come already schooled in the subject, convinced of its importance, and
concerned by its impact. I will instead make a few observations about how
this compares with other public health problems and what we can learn
from our public health experience regarding how to pursue the problem of
violence.

An Historical Preview

Throughout history, the two leading causes of early or premature death
have been infectious diseases and violence. Infectious disease control started
190 years ago with the work of Jenner, when he developed the first vaccine,
smallpox vaccine. Infectious disease control continued along with many
nonspecific social changes, such as better nutrition, better housing, and
education. In the past 50 years, we have returned to some specific tools,
including vaccines, antibiotics, and pesticides.

On the other hand, violence has defied the best minds in health, politics,
religion, and law enforcement, and therefore has often appeared to be
inevitable. This and other forms of fatalism must be actively opposed. That
we live in a cause-and-effect world is as true with violence as with infectious
diseases, an important observation for both public health people and
educators.

Another important observation is that public health is in the business
of continually redefining the unacceptable. This changes the social norm
which in turn changes the problem. For example, 35 years ago, polio was
the inevitable price of summer in this country. With the widespread use
of polio vaccine 30 years ago, the social norm in this country quickly
changed. However, for the hemisphere as a whole, the social norm has
been polio control or relatively low levels of polio disease. On May 14 of
this year, the Regional Director of the Pan American Health Organization
announced that polio would be eliminated from this hemisphere by 1990.

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With that one announcement, the social norm changed, and it instantly
became unacceptable to have any cases of polio in this hemisphere.

This conference is an important step in redefining the unacceptable in
interpersonal violence. It is a major step in enlisting the public health
structure of this country in changing the social norm. It should be under-
stood that many have seen violence as being unacceptable just as many saw
polio as being unacceptable. But until recently, violence has not been
regarded as a public health problem. Rather, it has been viewed as a law
enforcement problem, or as a transportation problem, or a welfare problem.
Dr. Koop is largely responsible for putting this on the public health agenda.

Recent Developments

In 1977, a group began looking at morbidity and mortality in this
country to advise on the 12 most important things that could be done in
prevention. They made popular the notion of not only looking at the leading
causes of death but also looking at the leading causes of years lost before
age 65. While heart disease, cancer, and stroke lead the list of causes of
death, the leading causes of years lost prematurely are accidents, cancer,
heart disease, homicide, and suicide. Therefore, three of the five leading
causes of premature death are related to violence. It was because of this
finding that we started a program of violence epidemiology at CDC and
hired Dr. Mark Rosenberg who has training in both psychiatry and epi-
demiology to head that program.

In 1979, the Surgeon General published his book He&by People, out-
lining the 15 priority areas requiring national attention in prevention. Also
in 1979, the first meetings of health people from around the country were
held to develop the 1990 objectives, a set of over 220 specific objectives
of where the United States should be in health by 1990. These include
specific objectives on homicide rates, child abuse rates, and suicide, as well
as on specific risk factors. This national prevention strategy is a landmark
in public health, and it is important that violence is a part of the strategy.

In 1985, the National Academy of Sciences and the Institute of Medicine
published InjuT in America -A Continuing Public Health Problem. It pointed
out that injury, both intentional and unintentional, remains the major
unaddressed public health problem of our day. While injury accounts for
4.1 million years of life lost before age 65 each year, heart disease and
cancer combined account for only 3.8 million years lost before age 65.
Yet, we spend $1.622 billion per year on research for the latter and only
seven percent of that amount on injury research.

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Basic to every successful public health effort has been the development
of an appropriate surveillance system. This was true of the public health
pioneers, such as Jenner, Snow, and Semmelweiss, who did limited but
rigorous surveillance of a microcosm; but it is also true of the institutional
pioneers who have developed surveillance of cities, provinces, and then
entire countries.

The first nationwide surveillance system for any disease in this country
was not instituted until 1950. That system was developed for malaria and
made the startling discovery that indigenous malaria had quietly disap-
peared from this country some time in the 1940s without being noticed.
We did not organize another nationwide surveillance program for five more
years. In 195 5, because of a problem with polio vaccine which still contained
virulent virus, a nationwide poliomyelitis surveillance program was launched,
literally overnight.

Global surveillance for a disease was not developed until the late 1960s
as part of the smallpox eradication program. While it may appear late to
develop violence surveillance programs, in fact, surveillance in general is
in its infancy.

Surveillance is essential if there is to be a concerted effort in violence
control. We must define all aspects of the problem, collect relevant and
correct data, analyze that data in order to define interventions, and measure
the impact of those interventions. There are no short cuts. While we are
beginning to get better mortality data by age, sex, time, and geography
for homicide, we are only beginning to understand the dimensions of
nonfatal outcomes. As Mark Rosenberg has pointed out, that may represent
an even larger social problem than mortality. And we are a long way from
knowing how best to use that information to suggest the generic changes
most likely to have a favorable impact.

The Context of Violence

While good national surveillance is one key lesson, another is the need
to understand violence in its broad context. Most certainly, we should view
intentional and unintentional violence together. The surveillance network
needs are similar; the risk groups overlap; the risk factors, such as alcohol
and depression, overlap; and the instruments, such as cars and guns, over-
lap. But in addition, violence is not limited to physical injury. Deprivations
of many kinds are forms of violence. Discrimination is a form of social
violence, as is poverty. Indeed, Gandhi once said that poverty is the worst
form of violence. And the threat of nuclear war constitutes a violent cloud
over all of us.

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While study requires us to narrow the focus, just as we do when studying
the nervous system or the gastrointestinal system, this study must be done
within a conceptual framework that understands the broad scope of violence.
It is important to capture the momentum of nonviolent movements and
prevent fragmentation of our efforts. The recognition of the International
Physicians for the Prevention of Nuclear War for this year's Nobel Peace
Prize is a significant indication of anti-violence movements which should
be incorporated in the total effort.

Role of Health Departments

Health departments should be seen as crucial and essential but not
sufficient. This is a lesson learned in many areas, even in what is regarded
as standard public health. Health departments are simply not strong enough,
sufficiently influential, nor rich enough to carry out programs by them-
selves. Around the world, we see this with immunization programs which
become possible only when political leaders and others provide their sup-
port. In the United States, polio immunization rates were as low as 65
percent in 1977. It was not until the executive and legislative branches of
government became involved with the states and counties, as well as ed-
ucation departments, PTAs, volunteer groups, etc., that immunization
rates in this country went to 80 percent, 90 percent, and finally to 97
percent. This comes close to a program of perfection, but it could not have
been done by health departments alone.

With violence, it is even more important to have the largest diversity
of professional and volunteer groups possible if a significant impact is to
be realized.

What then should be the role of health departments? First, health de-
partments could assist to get violence into the mainstream of public health.
Public health could provide the constituency that anti-violence now lacks.
Second, health departments could be involved in problem definition, an area
of considerable experience and expertise. Third, health departments could
be involved in the education of politicians and those who could change
what is now done, education of children through the development of ap-
propriate curricula, and education of the public by providing information
to the media. Fourth, health departments should develop intervention strat-
egies and evaluate their impact. Fifth, health departments must work to
keep this interest from being a fad. They must develop the stabilizing
interest to sustain a search for answers into the future. This is particularly
true if early intervention efforts turn out to be misplaced.

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It is .important for the Federal Government to provide leadership, as is
being done with this conference. But it is essential that you not wait for
the Federal Government to develop a program. Most health programs at
the federal level have evolved because of convincing demonstrations at local
levels. This was true for the immunization program which was built on
many private, local, and state demonstrations. One of the telling examples
is the use of child restraints in this country. The Federal Government for
a variety of reasons could not or did not provide leadership. A pediatrician
and local health officer in Tennessee worked at county and then the state
level to get the first child restraint law passed in Tennessee. In only a few
years, all states had followed the example.

It is important to promote a groundswell of trials, demonstrations, and
suggestions from private sources as well as local and state health depart-
ments. Many pilot projects of varied types increase the chance of funding
some interventions that are worth replicating. You force the federal estab-
lishment best by demonstrating something so compelling that it has to be
replicated (as with child restraints).

International Implications

Finally, remember the international aspects of violence. We saw the
disparity in homicide rates by country and the exceptionally high burden
of violence endured by many., Although the developing world is quite
correctly concerned with reducing its infectious disease rate, some Third
World countries are already losing more premature years to violence than
to infectious diseases. A broad perspective in studying violence and de-
veloping intervention strategies will serve the world most completely.

Smallpox is the only disease to have been eliminated from the world.
As a person interested in that program, as well as international health
generally, I can assure you that you are on the ground floor of something
more fundamental and ultimately more important than smallpox eradica-
tion. The single most important lesson of smallpox eradication was the
demonstration that it is possible to plan a rational health future. What
you are now doing is a step - a vital step - in planning a rational future
for combatting violence.

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Plenary Session III

Interpersonal Violence: A Comprehensive
Model in a Hospital Setting - From
Policy to Program

Presented by Karil S. Klingbeil, MSW, ACSW
Assistant Professor, School of Social Work, and Assistant Administrator,
Director of Social Work, Harborview Medical Center, University of
Washington, Seattle

Monday morning, October 28, 1985

Over the past several years, there has been an increasing focus on famiily
violence: the issues, the characteristics, the components, the etiology, and
intervention/prevention strategies. This focus on violence comes at a time
when we have evidenced dramatic changes in the health of our citizenry.
Many successful advances in treating illness and communicable disease are
well known. The attention to traumatic injuries, then, and the development
of major emergency facilities and trauma centers across the nation have
literally forced health care providers to deal with all types of catastrophic
injuries. Included are trauma injuries from interpersonal violence, both
intra-family violence and extra-family violence. Gunshot wounds, knifings,
physical beatings from other "lethal" weapons, sexual assaults, elder abuse,
and the psychological aftermath plague the provider. The picture that has

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