y of Violence The Histor i s s u e 

a P u b l i c H e a l t H 

a s 
Authors
 

Linda L. Dahlberg, PhD, is the Associate Director for Science in the Division of Violence Prevention in the National Center for Injury Prevention and Control of the Centers 

for Disease Control and Prevention (CDC) in Atlanta. In addition to serving as a senior 

science and policy advisor, she coordinates international research and programmatic activities for the division. Her research focuses on the etiology of firearm injuries as well as 

the efficacy of interventions to prevent interpersonal and self-directed violence. 

James A. Mercy, PhD, is the Special Advisor for Strategic Directions of the Division 

of Violence Prevention in the National Center for Injury Prevention and Control of the 

Centers for Disease Control and Prevention (CDC). He received his doctorate in sociology from Emory University in Atlanta. His research focuses on understanding the health 

burden, causes, and prevention of child maltreatment, intimate partner violence, youth 

violence, and firearm injuries. 

Reprinted from: Dahlberg LL, Mercy JA. History of violence as a public health issue. 

AMA Virtual Mentor, February 2009. Volume 11, No. 2: 167-172. Available on-line at 

http://virtualmentor.ama-assn.org/2009/02/mhst1-0902.html. 
The History of Violence 

as a Public Health Issue
 When and how violence was recognized as a matter for 

national—and then global—public health intervention 

Violence is now clearly recognized as a public health problem, but just 30 years ago the 

words “violence” and “health” were rarely used in the same sentence. Several important 

trends contributed to a growing recognition and acceptance that violence could be addressed 

from a public health perspective. First, as the United States became more successful in 

preventing and treating many infectious diseases, homicide and suicide rose in the rankings 

of causes of death. Tuberculosis and pneumonia were the two leading causes of death at the 

turn of the 20th century. By mid-century, the incidence and mortality from these infectious 

diseases along with others such as yellow fever, typhus, poliomyelitis, diphtheria, and pertussis were dramatically reduced through public health measures such as sanitary control of the 

environment, isolation of contagious disease cases, immunization, and the application of new 

therapeutic and medical techniques. Since 1965, homicide and suicide have consistently been 

among the top 15 leading causes of death in the United States.1,2 

There are other reasons why violence became a greater focus for 

public health. The risk of homicide and suicide reached epidemic 

proportions during the 1980s among specific segments of the population including youth and members of minority groups. Suicide rates 

among adolescents and young adults 15 to 24 years of age almost 

tripled between 1950 and 1990.3 Similarly, from 1985 to 1991 homicide rates among 15- to 19-year-old males increased 154 percent, 

a dramatic departure from rates of the previous 20 years for this age 

group.4 This increase was particularly acute among young African 

American males. These trends raised concerns and provoked calls for 

new solutions. 

Another important development was the 

increasing acceptance within the public 

health community of the importance of 

behavioral factors in the etiology and 

prevention of disease. It is now generally accepted that prevention of three of 

the leading causes of death in the United 

States—heart disease, cancer, and stroke— 

rests largely on behavioral modifications 

such as exercise, changes in diet, and 1 
smoking cessation. Successes in these areas encouraged public health professionals to believe that they could accomplish the same for behavioral challenges underlying interpersonal 

violence and suicidal behavior. Finally, the emergence of child maltreatment and intimate 

partner violence as recognized social problems in the 1960s and 1970s demonstrated the need 

to move beyond sole reliance on the criminal-justice sector in solving these problems. 

Calls for Action 

These trends and developments led to the publication of several 

landmark reports that highlighted the public health significance 

of violence. In 1979, the Surgeon General’s Report, Healthy 

People, documented the dramatic gains made in the health of 

the American people during the previous century and identified 15 priority areas in which, with appropriate action, further 

gains could be expected over the course of the next decade.5 

Among the 15 was control of stress and violent behavior. This 

report emphasized that the health community could not ignore 

the consequences of violent behavior in an effort to improve the 

health of children, adolescents, and young adults. The goals for 

violence prevention established in this report were translated 

into measurable objectives in Promoting Health/Preventing 

Disease: Objectives for the Nation.

6 These objectives called for 

substantial reductions by 1990 in: (1) the number of child-abuse 

injuries and deaths, (2) rate of homicide among black males 15 

to 24 years of age, (3) rate of suicide among 15 to 24 year olds, 

(4) number of privately owned handguns, and (5) improvements 

in the reliability of data on child abuse and family violence. In 

1985, the Report of the Secretary’s Task Force on Black and Minority Health identified homicide as a major cause of the disparity in death rate and illness experienced by African Americans 

and other minorities relative to non-Hispanic whites.7 And the 

Violence Prevention Timeline 

1979 

A report from the Surgeon General 

of the United States: Healthy people: The Surgeon General’s report 

on health promotion and disease 

prevention identifies violence as 

one of the 15 priority areas for 

the nation. The report states that 

violence can be prevented and 

should not be ignored in the effort 

to improve the nation’s health. 

1980 

The first measurable objectives 

for violence are established for the 

nation by the Department of Health 

and Human Services – Promoting 

Health/Preventing Disease: Objectives for the Nation. 

1981 

CDC epidemiologists begin one of 

the first collaborative efforts with 

law enforcement to investigate a 

series of child murders in Georgia. 

1983 

CDC establishes the Violence 

Epidemiology Branch to focus its 

public health efforts in violence 

2 prevention. 
 

1989 Report of the Secretary’s Task Force on Youth Suicide provided a comprehensive synthesis of the state of knowledge about youth suicide and recommended a course of action for 

stemming the substantial increases that had occurred over the previous three decades.3 

Response to the Call 

The emergence of violence as a legitimate issue on the national health agenda spurred a variety of responses from the public health sector during the 1980s. In 1983, the CDC established 

the Violence Epidemiology Branch, which was integrated into the Division of Injury Epidemiology and Control (DIEC) three years later. The creation of DIEC was a direct consequence of a National Research Council (NRC) and Institute of Medicine (IOM) report, Injury 

in America: A Continuing Public Health Problem.

8 This report recommended establishing a 

federal center for injury control within the CDC and called for funding that would be commensurate with the size of the problem. Support for the NRC/IOM report recommendations 

contributed to a gradual increase in the number of staff and the size of the budget devoted to 

violence prevention research and programmatic activities at the CDC. 

Further evidence of increased concern from the public health community during the 1980s 

was provided by the Surgeon General’s Workshop on Violence and Public Health in 1985.9 

This workshop was the first time that the Surgeon General clearly recognized violence as a 

public health problem and encouraged all health professionals to respond. 

Applying the Tools of 

Epidemiology 

During the same period, the CDC undertook a number of high-profile epidemiologic investigations, 

looking into a series of child murders in Atlanta and 

a suicide cluster in Plano, Texas.10, 11 These investigations helped to demonstrate that epidemiologic research methods could successfully be applied to in1985 

The Surgeon General’s Workshop 

on Violence and Public Health 

focuses the attention of the public 

health world on violence and encourages all health professionals to 

become involved. 

CDC investigates a pattern of suicides in Texas, the first demonstrated 

use of field epidemiological techniques to identify suicide clusters. 

The Report of the Secretary’s 

Task Force on Black and Minority 

Health is released and underscores 

the importance of addressing 

interpersonal violence as a public 

health problem and identifies 

homicide as a major contributor to 

health disparities among AfricanAmericans. 

1986 

CDC establishes the Division of 

Epidemiology and Control. 

1989 

Report of the Secretary’s Task 

Force on Youth Suicide is released. 

3 
cidents of violence. Public health professionals contributed to the understanding of violence 

through the use of epidemiologic methods to characterize the problem and identify modifiable risk factors. In particular, efforts were made to: (1) describe the problem of homicide 

and suicide as causes of death, (2) monitor public health objectives for homicide and suicide, 

(3) examine epidemiologic characteristics of different types of homicide, (4) characterize 

homicide as a cause of death in the workplace, (5) describe patterns of homicide and suicide 

victimization in minority populations and among children, (6) study physical child abuse, and 

(7) quantify the risks of homicide and suicide associated with access to firearms.12-14 

Determining What Works 

Beginning in the early 1990s the public health approach to violence shifted from describing 

the problem to understanding what worked in preventing it. These efforts were bolstered by 

a number of appropriations from Congress. In 1992, the CDC received its first appropriation aimed at curbing the high rates of homicide among youth. The following year, the CDC 

published The Prevention of Youth Violence: A Framework for Community Action, an influential document that outlined the steps necessary to implement a public health approach to 

youth violence prevention.15 By 1993, 

numerous violence-prevention programs 

were being developed and undertaken 

in schools and communities across the 

United States. In 1993, the CDC received its second appropriation for youth 

violence and used it to evaluate some of 

the more common prevention approaches 

being tried across the United States. 

These evaluation studies were among the 

first randomized control trials to specifically assess the impact of programs on 

Violence Prevention Timeline 

1990 

“Violent and Abusive Behavior” is 

included as 1 of 22 public health 

priority areas in Healthy People 

2000, the national disease-prevention and health-promotion strategy. It calls for “cooperation and 

integration across public health, 

health care, mental health, criminal 

justice, social service, education, 

and other relevant sectors.” 

CDC establishes The Youth Risk 

Behavior Surveillance System to 

monitor priority health risk behaviors among adolescents, including 

violence-related behaviors that 

contribute markedly to the leading 

causes of death and disability in 

the United States. 

1992 

CDC receives its first congressional appropriations for youth 

violence prevention. 

4
 
violence-related behaviors and injury outcomes. Overall, they helped demonstrate that significant reductions in aggressive and violent behavior were possible with applied, skill-based 

violence-prevention programs that address social, emotional, and behavioral competencies, 

as well as family environments. 

The achievements made in the prevention of youth violence throughout the 1980s and 1990s 

were published in Youth Violence: A Report of the Surgeon General, which provided a comprehensive synthesis of the state of knowledge about youth violence, including what was 

known about the different patterns of offending, risk and 

protective factors within and across various domains (e.g., 

peer, family, school, and community), and about the effectiveness of prevention programs.16 The report also highlighted the cost effectiveness of prevention over incarceration and set forth a vision for the 21st century. 

The early successes in youth-violence prevention paved the 

way for a public health approach to other violence problems 

such as intimate partner violence, sexual violence, and child 

maltreatment. Efforts were made to document each problem, understand the risk and protective factors associated 

1993 

A special issue of Health Affairs 

addresses violence as a public 

health issue – the first special issue 

to examine violence as a public 

health problem. 

CDC establishes the Division of 

Violence Prevention within the 

newly created National Center for 

Injury Prevention and Control. The 

Division leads CDC’s 

efforts to prevent injuries and 

deaths caused by violence. 

CDC publishes The Prevention 

of Youth Violence: A Framework 

for Community Action to mobilize 

communities to effectively address 

the epidemic of youth violence 

sweeping the nation. 

5 
with each type of violence, and begin building the evidence-base for prevention. In 1994, 

for example, the CDC and the National Institute of Justice collaborated on the first national 

violence-against-women survey. Conducted over the next two years, the survey produced 

the first national data on the incidence, prevalence, and economic costs of intimate partner 

violence, sexual violence, and stalking.17 In 1994, Congress passed the Violence Against 

Women Act (Title IV of the Violent Crime Control and Law Enforcement Act)—landmark 

legislation that established rape prevention and education programs across the nation, in 

Puerto Rico and six other U.S. territories and called for local demonstration projects to coordinate the intervention and prevention of domestic violence. The CDC was given the federal 

responsibility to administer both efforts. The appropriations for these programs and their 

subsequent reauthorization from Congress were instrumental in building the infrastructure 

and capacity for the prevention of intimate partner violence and sexual violence at the local 

and state level. 

Moving Forward in a Global Context 

As public health efforts to understand and prevent violence gained momentum in the United 

States, they garnered attention abroad. Violence was placed on the international agenda 

in 1996 when the World Health Assembly adopted Resolution 

WHA49.25, which declared violence “a leading worldwide public 

health problem.” The resolution requested the WHO to initiate public health activities to: (1) document and characterize the burden of 

violence, (2) assess the effectiveness of programs, with particular 

attention to women and children and community-based initiatives, and 

(3) promote activities to tackle the problem at the international and 

country level. In 2000, the WHO created the Department of Injuries 

and Violence Prevention to increase the global visibility of unintentional injury and violence and to facilitate public health action. The 

organization’s World Report on Violence and Health, published in 

2002, is used throughout the world as a platform for increased public 

health action toward preventing violence.18 

Violence Prevention Timeline 

1994 

CDC and the National Institute of 

Justice collaborate on the National 

Violence against Women Survey. 

The survey, conducted in 1995-

1996, provides the first national 

data on the incidence and prevalence of intimate partner violence, 

sexual violence, and stalking. 

Congress passes the Violence 

Against Women Act (Title IV of 

the Violent Crime Control and Law 

Enforcement Act) which includes 

support for coordinated community 

responses to prevention intimate 

partner violence and state grants 

for rape prevention and education. 

1996 

The World Health Assembly passes 

a resolution and declares that “violence is a leading worldwide public 

health problem.” 

6
 
 

Next Steps 

As we move into the 21st century, public health is placing greater emphasis on disseminating and implementing effective violence-prevention programs and policies. The need to 

document and monitor the problem and identify effective programs and policies through 

research remains critically important. Nevertheless, a strong 

foundation has been laid for future success. 

1999 

CDC publishes Best Practices of 

Youth Violence Prevention: A Sourcebook for Community Action. 

The U.S. Surgeon General releases 

the Call to Action to Prevent Suicide report. 

2000 

WHO creates the Department of 

Injuries and Violence Prevention. 

CDC receives congressional appropriations to establish 10 National 

Academic Centers of Excellence 

for Youth Violence Prevention. 

2001 

The U.S. Surgeon General releases 

a comprehensive report synthesizing the state of knowledge on 

youth violence and its prevention. 

The National Strategy for Suicide 

Prevention is released by the Department of Health and Human Services. 

CDC receives first congressional appropriations for child maltreatment 

prevention. 7 
References
 

1.	 Centers for Disease Control and Prevention. National Center for Health Statistics. Leading causes of death, 1900-1998. http:// 

www.cdc.gov/nchs/data/dvs/lead1900_98.pdf. Accessed November 18, 2008. 

2.		 Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics 

Query and Reporting System (WISQARS). 2009. http://www.cdc.gov/ncipc/wisqars. Accessed November 18, 2008. 

3.		 Alcohol, Drug Abuse, and Mental Health Administration. Report of the Secretary’s Task Force on Youth Suicide. Vol. 1. Washington, DC: US Government Printing Office; 1989. 

4.		 Centers for Disease Control and Prevention. Homicides among 15-19-year-olds Males—United States, 1963-1991. MMWR 

Morb Mortal Wkly Rep. 1994;43(40):725-727. 

5.		 US Department of Health, Education, and Welfare. Healthy People: The Surgeon General’s Report on Health Promotion and 

Disease Prevention. Washington, DC: US Government Printing Office; 1979. 

6.		 US Department of Health & Human Services. Promoting Health/Preventing Disease; Objectives for the Nation. Washington, 

DC: US Government Printing Office; 1980. 

7.		 US Department of Health & Human Services. Report of the Secretary’s Task Force on Black and Minority Health. Washington, DC: US Government Printing Office; 1985. 

8.		 National Research Council & Institute of Medicine. Injury in America: A Continuing Public Health Problem. Washington, DC: 

National Academy Press; 1985. 

9.		 US Department of Health & Human Services. US Department of Justice. Surgeon General’s Workshop on Violence and Public 

Health Report. Washington, DC: Health Resources Service Administration; 1986. 

10.		 Blaser MJ, Jason JM, Weniger BG, et al. Epidemiologic analysis of a cluster of homicides of children in Atlanta. JAMA. 

1984;251(24):3255-3258. 

11.		 Davidson LE, Rosenberg ML, Mercy JA, Franklin J, Simmons JT. An epidemiologic study of risk factors in two teen suicide 

clusters. JAMA. 1989;262(19):2687-2692. 

12.		 Mercy JA, O’Carroll PW. New directions in violence prediction: the public health arena. Violence Vict. 1988;3(4):285-301. 

13.		 National Center for Injury Prevention and Control. The Prevention of Youth Violence: A Framework for Community Action. 

Atlanta, GA: Centers for Disease Control and Prevention; 1993. 

14.		 Kellermann AL, Rivara FP, Somes G, et al. Suicide in the home in relation to gun ownership. N Engl J Med. 1992;327(7):467-

472. 

15.	 US Department of Health & Human Services, National Center for Environmental Health and Injury Control Division of Injury 

Control, Office of the Assistant Director for Minority Health. The Prevention of Youth Violence: A Framework for Community 

Action. Atlanta, GA: Centers for Disease Control and Prevention; 1992. 

16.	 US Department of Health & Human Services. Youth Violence: A Report of the Surgeon General. Centers for Disease Control 

and Prevention, Substance Abuse and Mental Health Services Administration, National Institutes of Health for the National 

Institute of Mental Health. Washington, DC: US Government Printing Office; 2001. 

17.		 Tjaden P, Thoennes N. Full Report of the Prevalence, Incidence, and Consequences of Violence Against Women: Findings 

from the National Violence Against Women Survey. Washington, DC: National Institute of Justice, Office of Justice Programs, 

United States Department of Justice, Centers for Disease Control and Prevention; 2000. 

18.		 Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R. World Report on Violence and Health. Geneva, Switzerland: World 

Health Organization; 2002. 

Violence Prevention Timeline 

2002 

WHO publishes the first World Report on Violence and Health. 

The National Violent Death Reporting System launches in six 

states. This was the first state-based 

surveillance system to link data from 

multiple sources with the goal of enhancing violence prevention efforts. 

In 2004, the system is expanded to 

include 17 states. 

2006 

CDC launches Choose Respect, the 

first national communication initiative designed to prevent unhealthy 

relationship behaviors and dating 

abuse 

2007 

CDC publishes a study that estimates the medical and productivity-related costs of violence in the 

United States exceed $70 billion 

each year. 

8
 

Department of Health and Human Services
 

Centers for Disease Control and Prevention
 

National Center for Injury Prevention and Control
 

1-800-CDC-INFO • www.cdc.gov/violenceprevention • cdcinfo@cdc.gov