VIOLENCE AND PUBLIC HEALTH

BY

C, EVERETT KOOP, MD

SURGEON GENERAL

      AND

DEPUTY ASSISTANT SECRETARY FOR HEALTH

        A FILMED LECTURE PRESENTED TO THE

NATIONAL INSTITUTE OF LACJ ENFORCEMENT AND CRIMINAL JUSTICE

             WASHINGTON, DL

             NOVEMBER 24, 1982


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(GREETINGS TO HOSTS, GUESTS)

  I APPRECIATE THIS OPPORTUNITY TO SPEAK TO YOU ON A SUBJECT THAT IS

UNCOMFORTABLE TO RAISE: VIOLENCE AS A PUBLIC HEALTH CONCERN, IT IS

UNCOMFORTABLE BECAUSE, WHEN WE DO RAISE THAT ISSUE, WE ARE REALLY

ADMITTING THAT MANKIND STILL HAS QUITE A DISTANCE TO TRAVEL IN ITS

LONG MARCH TOWARD CIVILIZED LIVING,

  NEVERTHELESS, WE MUST RAISE THIS ISSUE BECAUSE VIOLENCE HAS GROWN

TO BECOME ONE OF THE MAJOR PUBLIC HEALTH PROBLEMS IN AMERICAN SOCIETY

TODAY,  IT IS NOT NEW, OF COURSE. VIOLENCE OF SOME KIND -- MURDER,

SUICIDE, ASSAULT, ARMED CONFRONTATION OF NEIGHBOR AGAINST NEIGHBOR --

THESE HAVE APPEARED IN OUR NATIONAL HISTORY SINCE THE 17TH CENTURY,

IN THE PAST 80 YEARS OR SO, AS WE IMPROVED OUR ABILITY TO COLLECT

VITAL STATISTICS, WE HAVE BEEN ABLE TO IDENTIFY PERIODS WHEN THERE

WERE CHANGES IN THE INCIDENCE OF MORBIDITY AND MORTALITY CAUSED BY

VIOLENCE,  WE ARE COMING THROUGH JUST SUCH A PERIOD NOW,

  RATHER THAN RESURRECT MUCH OF THE LITERATURE OF VIOLENCE, WITH

WHICH MANY OF YOU MAY BE FAMILIAR ANYWAY, I WANT TO TAKE A FEW CAREFUL

STEPS FORWARD TO SEE WHAT THE ROLE OF THE PHYSICIAN MIGHT BE IN

UNDERSTANDING AND POSSIBLY PREVENTING THE LOSS OF LIFE -- MILLIONS OF

YEARS OF LIFE -- THAT ARE TORN AWAY BY THESE VIOLENT, PREMATURE

DEATHS,


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  LET ME PROPOSE AS A STARTING-POINT THE PROPOSITION THAT PHYSICIANS
NEED TO BECOME MORE FAMILIAR WITH THE SYMPTOMS OF VIOLENT PERSONALITY

IN CHILD AND PARENT ALIKE,  UNFORTUNATELY, WE DON'T HAVE AVAILABLE
SOME STOCK, OFF-THE-SHELF PROFILES OF PERSONS WHO ARE DISPOSED TOWARD

VIOLENCE,  BUT THE RESEARCH LITERATURE DOES PROVIDE US WITH SOME CLUES

THAT SEEM STURDY ENOUGH TO FOLLOW.

  FOR EXAMPLE, HIGH-RISK FAMILIES TEND TO BE SOCIALLY ISOLATED FROM

THEIR NEIGHBORS.  THIS IS THE CASE ACROSS ALL SOCIAL, RACIAL, AND

ECONOMIC LINES.  SUCH FAMILIES LACK STRONG FRIENDSHIPS. THEY CAN'T
SEEM TO GET CLOSE TO OTHER FAMILIES, PARTICULARLY FAMILIES THAT DO NOT
SHOW EVIDENCE OF STRESS OR VIOLENT BEHAVIOR, HIGH-RISK FAMILIES HAVE
DIFFICULTY COPING WITH PRESSURES OUTSIDE THEIR OWN HOME -- PRESSURES
ON THE JOB OR PRESSURES WHILE LOOKING FOR A JOB, OR THE INTERNAL
PRESSURES THAT MAY BUILD UP WHILE TRYING TO NEGOTIATE SUCH SOCIAL
TRANSACTIONS AS SHOPPING OR USING PUBLIC TRANSPORTATION.

  SUCH FAMILIES ALSO HAVE DIFFICULTY COPING WITH STRESS INSIDE THEIR
OWN HOMES: CHILDREN MAKING NOISE,,,LOUD RADIOS,,,TELEVISION SETS OR

STEREOS ,,,AND A WHOLE RANGE OF MARITAL UPSETS, INCLUDING THOSE

PRODUCED BY ALCOHOL AND DRUGS,


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  WE KNOW THAT VIOLENCE WITHIN THE FAMILY -- PARTICULARLY PARENTAL

VIOLENCE TOWARD CHILDREN -- TENDS TO ESCALATE DURING PERIODS OF
ECONOMIC STRESS, INDEBTEDNESSmLACK OF WORK,.,EVICTIONS,,.LAY-OFFS,,,
REPOSSESSIONS,,,THESE ARE THE STUFF OF TRAUMA FOR MANY FAMILIES, THEY
CAN OVERWHELM PARENTS AND OPEN THEM TO THE TERRIBLE IMPULSES OF VIOLENT
ACTS AGAINST EACH OTHER AND AGAINST THEIR CHILDREN, IN SOME AREAS OF
THE COUNTRY WE ARE EXPERIENCING VERY DIFFICULT ECONOMIC CONDITIONS AND,
IF OUR RESEARCH AND OUR ANECDOTAL MATERIAL IS ANY GUIDE, THOSE AREAS

ARE ALSO EXPERIENCING A RISE IN FAMILY VIOLENCE,

  THESE MAY SHOW UP IN MARKS ON BATTERED SPOUSES AND ABUSED CHILDREN,
SUCH MARKS ARE NEVER WELL EXPLAINED, THE VICTIMS ARE OFTEN EMBAR-
RASSED, EVASIVE, OR SIMPLY TIGHT-LIPPED. THE PHYSICIAN NEEDS TO
UNDERSTAND HOW TO "READ" THOSE INTENSELY PERSONAL, HUMAN SIGNALS BY

THE VICTIM OF FAMILY VIOLENCE,

  I HAVE SPENT SOME TIME ON THE FAMILY BECAUSE OF ITS OVERWHELMING
INFLUENCE IN THE SHAPING OF INDIVIDUAL BEHAVIOR, EDUCATIONAL RESEARCH
HAS DEMONSTRATED AGAIN AND AGAIN THAT A FAMILY ENVIRONMENT THAT

SUPPORTS STUDY AND LEARNING -- THAT REWARDS THE CHILD THAT IS SUCCESS-

FUL IN SCHOOL -- WILL PRODUCE CHILDREN WHO DO WELL IN SCHOOL AND IN

LIFE LATER ON, ALL OTHER THINGS BEING EQUAL,


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AND THE REVERSE IS TRUE, ALSO,  A FAMILY ENVIRONMENT THAT IS CRUEL

AND UNCARING WILL SEND CRUEL AND UNCARING CHILDREN INTO THE WORLD AS
AGGRESSIVE, VIOLENT ADULTS,  THESE ARE NOT HARD-AND-FAST RULES, HUMAN
BEINGS ARE NOT PIGEONS AND DON'T FIT INTO NEAT, CONSISTENT PIGEON-

HOLES,  BUT THE WEIGHT OF EXPERIENCE AND EVIDENCE DOES INDICATE THAT
SOME CLUES AND SIGNALS, SUCH AS THE ONES I MENTIONED, OUGHT TO BE
NOTED AND RESPECTED BY THE PHYSICIAN,

  THE PHYSICIAN, SUSPECTING THAT A PATIENT MAY BE PREDISPOSED TO
VIOLENT BEHAVIOR, SHOULD PROVIDE THE SAME KIND OF COUNSELING OR
REFERRAL SERVICE AS IF THE PATIENT SHOWED A PREDISPOSITION TO
CARDIOVASCULAR DISEASE, OBESITY, OR DIABETES, WITH THE PATIENT'S
CONSENT, IT MAY BE POSSIBLE TO INVOLVE A SPOUSE OR A CHILD IN THE DIS-
CUSSION OF THIS HEALTH PROBLEM.  THIS IS A SENSITIVE AREA AND WE NEED
TO GIVE IT OUR PROFESSIONAL STUDY AND ATTENTION IN ORDER TO PROVIDE
GUIDANCE TO PEDIATRICIANS AND OTHER PRIMARY CARE PHYSICIANS,

  THE OBJECTIVE, LET ME REPEAT, IS NOT TO INTERVENE INTO A PATIENT'S
PRIVATE FAMILY LIFE FOR INTERVENTION'S SAKE BUT TO PREVENT VIOLENT
BEHAVIOR FROM OCCURRING AND ENDANGERING THE HEALTH OR THE LIFE OF

ANOTHER,


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  1 RECOGNIZE THAT NOT ALL PHYSICIANS WOULD AGREE WITH THAT ASSESS-

MENT OF THEIR ROLE,  THEY WOULD OBJECT TO IT AS BEING YET ANOTHER
EXAMPLE OF THE "MEDICALIZATION OF SOCIAL PROBLEMS," AND I FULLY
APPRECIATE THE UNEASINESS FELT BY MANY PHYSICIANS AND OTHER HEALTH
PROFESSIONALS WITH SOCIETY'S HABIT OF CASUALLY TURNING TO MEDICINE TO
SOLVE WHAT MAY SIMPLY NOT BE A HEALTH OR MEDICAL PROBLEM, BUT WITH
VIOLENCE, I THINK THERE IS A DIFFERENCE,

  THIS POINT WAS ALSO MADE AT A WORKSHOP HELD LAST SUMMER BY THE
INSTITUTE OF MEDICINE.  THE SUBJECT WAS THE PREVENTION OF VIOLENCE.
ON THIS MATTER OF THE "MEDICALIZATION OF VIOLENCE," THE PARTICIPANTS
MADE SEVERAL GOOD ARGUMENTS, WHICH I WILL SUMMARIZE:

  FIRST, OUTSIDE OF THE FIELD OF MEDICINE, THERE SEEMS TO BE NO
INSTITUTIONAL FOCUS FOR RESEARCH INTO THE CAUSES OF VIOLENCE THAT
TAKES INTO ACCOUNT THE MULTIPLE BIOLOGICAL, PSYCHOLOGICAL, SOCIAL, AND
SOCIETAL DIMENSIONS OF CRIME, ITS VICTIMS, AND ITS PREVENTION, THE
INSTITUTIONS THAT COME THE CLOSEST TO PROVIDING A MULTIDISCIPLINARY
APPROACH TO RESEARCH IN THE PREVENTION OF FAMILY VIOLENCE, FOR
EXAMPLE, WOULD BE THE NATIONAL INSTITUTE OF MENTAL HEALTH AND THE
NATIONAL INSTITUTE OF CHILD HEALTH AND HUMAN DEVELOPMENT,


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  SECOND, THE NATIONAL INSTITUTE OF LAW ENFORCEMENT AND CRIMINAL
JUSTICE, THE RESEARCH ARM OF THE JUSTICE DEPARTMENT, SEES "PREVENTION"
AS A WAY OF STOPPING A RECURRENCE OF A CRIMINAL ACT, IN EFFECT, THE
JUSTICE DEPARTMENT DOES NOT HAVE WHAT WOULD BE IN OUR DISCIPLINE OF
MEDICINE A "PRIMARY PREVENTION" STRATEGY. AND ON REFLECTION, ONE WOUL
HAVE TO ADMIT THAT SUCH A STRATEGY UNDER THE CRIMINAL JUSTICE SYSTEM
COULD VERY WELL COME INTO CONFLICT WITH TRADITIONAL CIVIL LIBERTIES,

D

  AND THIRD, THE WORKSHOP PARTICIPANTS AGREED THAT THE MORBIDITY AND
MORTALITY FROM VIOLENCE ARE EXTREMELY COSTLY TO SOCIETY NOT ONLY IN
PRODUCTIVE YEARS LOST BUT IN THE HARD DOLLAR TERMS OF THE IMPACT UPON
THE HEALTH CARE SYSTEM. THIS IS PARTICULARLY TRUE IN THE CASES OF
ABUSED CHILDREN, WHO FREQUENTLY HAVE CHRONIC DISABILITIES EVEN AFTER

TREATMENT,  YOUNG WOMEN WHO HAVE BEEN SEXUALLY ABUSED BY FAMILY MEMBERS
FREQUENTLY DEVELOP CHRONIC ILLNESSES REQUIRING REPEATED INPATIENT
PSYCHIATRIC CARE, THEY ALSO MAKE INCREASED USE OF GYNECOLOGICAL HEALTH
SERVICES, AS THEIR TOTAL PERSONAL HEALTH STATUS DECLINES.

  WE MIGHT NOT WANT THIS VERY COMPLICATED ISSUE TO GRAVITATE TOWARD
MEDICINE FOR ANSWERS, BUT I BELIEVE WE NEED TO ACCEPT THE FACT THAT WE
MAY HAVE A CONTRIBUTION TO MAKE.  I BELIEVE THAT WE DO AND WE ARE
OBLIGATED TO MAKE THAT CONTRIBUTION,


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  IN ADDITION TO LEARNING MORE ABOUT THE ISSUE OF VIOLENCE AND HOW
IT MANIFESTS ITSELF IN PATIENT BEHAVIOR, I BELIEVE PHYSICIANS NEED TO
SEE THEMSELVES AS CAPABLE OF PRESCRIBING SOME RUDIMENTARY, PREVENTIVE
BEHAVIOR FOR SUCH PATIENTS,  THIS MAY BE MORE EASILY PROPOSED THAN
DONE, BUT I THINK IT'S TIME WE LOOKED AT THIS AS A SERIOUS ASPECT OF
PEDIATRIC AND FAMILY PRACTICE FOR CONTEMPORARY AMERICAN SOCIETY,

  THIS IS A VERY DIFFICULT REQUEST TO MAKE OF ANY PHYSICIAN, MOST
HAVE NOT BEEN TRAINED IN THESE AREAS, WHICH TEND TO BE MORE THE
PROVINCE OF THE SOCIOLOGIST, THE PSYCHIATRIST, THE PSYCHOLOGIST, OR T
SOCIAL SERVICES WORKER,  FOR EXAMPLE, SOCIOLOGISTS MURRAY STRAUS OF
THE UNIVERSITY OF NEW HAMPSHIRE AND RICHARD GELLES OF THE UNIVERSITY
OF RHODE ISLAND ARE AMONG THE LEADING RESEARCHERS IN THE FIELD OF
FAMILY VIOLENCE, BUT I WOULD GUESS THAT THEIR WORK IS VIRTUALLY
UNKNOWN AMONG PHYSICIANS,

HE

PHYSICIANS TEND TO BE UNCLEAR ABOUT THE ROLES OF PEOPLE ENGAGED IN

THE SOCIAL SERVICES OR SOCIAL SCIENCES, COMMUNICATION BETWEEN THE
PRACTITIONERS OF PHYSICAL MEDICINE AND THOSE WHO PRACTICE OTHER
DISCIPLINES TENDS TO BE LIMITED AND UNCLEAR, PHYSICIANS ARE ALSO


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GENERALLY UNFAMILIAR WITH THE EDUCATION AND TRAINING OF PERSONNEL
ENGAGED IN THE DELIVERY OF SOCIAL SERVICES, NOR ARE THEY ALWAYS AWARE
OF THE SIMILARITY OF ETHICAL IMPERATIVES SHARED BY BOTH MEDICINE AND
THE SOCIAL SERVICES,  BECAUSE OF THIS, PHYSICIANS -- ESPECIALLY THOSE

IN PRIVATE PRACTICE -- TEND NOT TO REFER PATIENTS AS OFTEN AS THEY
SHOULD NOR DO THEY SEEK THE COUNSEL OF SOCIAL SERVICE PROFESSIONALS
WHEN A POSSIBLE INCIDENT OF FAMILY VIOLENCE COMES TO THEIR ATTENTION,

  THIS MAY BE A PROBLEM NOW, BUT I BELIEVE IT WILL BE LESS OF A
PROBLEM IN THE FUTURE, AS PHYSICIANS BECOME MORE FAMILIAR WITH THE
TOTAL CONSTELLATION OF RESEARCH AND SERVICE BECOMING AVAILABLE FOR THE
PROTECTION OF VICTIMS OF FAMILY VIOLENCE, LET ME NOTE JUST ONE
EXAMPLE WHERE WE ARE MAKING SOME PROGRESS, THIS IS THE WORK OF DR,
ELI NEWBERGER AT BOSTON CHILDREN'S HOSPITAL,

  DR. NEWBERGER IS A PEDIATRICIAN AND EDITOR OF A NEW BOOK ON CHILD
ABUSE FOR THE LITTLE, BROWN SERIES ON CLINICAL PEDIATRICS, WITH THE
SUPPORT OF THE NATIONAL INSTITUTE OF MENTAL HEALTH, HE HAS BEEN
CARRYING OUT A PROGRAM OF INTERDISCIPLINARY TRAINING AND RESEARCH IN


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THE DETECTION AND TREATMENT OF VICTIMS OF FAMILY VIOLENCE. IN THIS

PROGRAM, DR, NEWBERGER BRINGS TOGETHER A GROUP OF PROFESSIONALS ON THE

STAFF OF BOSTON CHILDREN'S HOSPITAL. THEY INCLUDE PEDIATRICIANS,

SOCIAL WORKERS, RESEARCHERS, PSYCHOLOGISTS AND PSYCHIATRISTS,

SOCIOLOGISTS, AND COMPUTER ANALYSTS,

  WORKING AS A TEAM, THEY PROVIDE HANDS-ON CLINICAL CARE FOR CHILDREN

WHO HAVE BEEN ABUSED.  THEY ALSO SEEK TO UNDERSTAND THE CAUSES OF THE

VIOLENCE WITHIN THE FAMILY, IN ORDER TO PREVENT IT FROM RECURRING. THE

RESULT IS A PROGRAM THAT DRAWS UPON A VARIETY OF SKILLS RIGHT AT THE

TIME THEY ARE NEEDED MOST,  THE PROGRAM GENERATES NEW INFORMATION

REGARDING FAMILY VIOLENCE AND THIS NEW INFORMATION, PLUS OTHER RESEARCH

DATA, ARE TRANSLATED INTO DIRECT PATIENT CARE,,

  THESE ARE THE KINDS OF PROJECTS THAT BENEFIT NOT ONLY THE IMMEDIATE

PERSONS UNDER CARE, BUT CAN ALSO BENEFIT THE PRACTICE OF MEDICINE

ITSELF,  SUCH PROJECTS PROVIDE THE BUILDING-BLOCKS OF INFORMATION AND

METHODS OF PRACTICE THAT, TOGETHER, CAN CONTRIBUTE TO THE PROTECTION

OF INNOCENT VICTIMS OF VIOLENCE, ESPECIALLY FAMILY VIOLENCE, WHETHER

THE VICTIM IS A BATTERED CHILD OR A BATTERED SPOUSE, AND FROM THIS


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KIND OF KNOWLEDGE BASE WE WILL BE ABLE TO DRAW THE ELEMENTS OF AN
OVERALL PRIMARY PREVENTION STRATEGY, A STRATEGY THAT ONE DAY MAY
LIBERATE BOTH THE VICTIM AND THE PERPETRATOR FROM THE DEADLY CYCLE OF
VIOLENCE IN WHICH BOTH ARE LOCKED TODAY,

THANK YOU.

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