My involvement with issues related to violence stems from my membership in Trinity Lutheran Church in Evanston and my work as an emergency physician in a suburban community hospital. My church is one of the five participating congregations in the Park Ridge Center's Congregations, Health, and Healing project. As a member of Trinity's working group on the project, I am surprised at each meeting at my growing interest. I had hope that by involving myself with this project, I might in some way stem the tide of violence in our society.
I do not treat a great many gun-related injuries in my professional role; however, I still deal with violence daily. Some falls into well-known categories: assaults, rapes, and domestic violence. But other, less often acknowledged, forms of violence take place in the interactions between patients and their families and with the ER staff. What of the daily disrespect, verbal assaults, and "road rage" that never get reported, for example? The worst violence that I witness is generally that of parents telling their children to "shut up," that their child's opinion doesn't matter, that it is perfectly acceptable to pass the time in the ER watching Jenny Jones, Montel Williams, and Jerry Springer.
As a physician, I am accustomed to dealing with problems using the scientific method. Thus, I have gathered data to determine what constitutes violence and how it is expressed. What, for example, is the prevalence of the forms of violence? In what ways is violence a public health problem? How should a health care professional respond? I searched various electronic resources to find statistics to serve as an overview for readers of this issue. I hope the numbers are as mind-boggling to you as they were to me. Of course, there are many more incidents of violence never reported to these resources.
Violence is a major public health problem, with 1.3 million people seen annually by emergency physicians for injuries caused directly by some form of violence, such as domestic violence (intimate partner violence, child abuse, and elder abuse), assaults, and handgun-related violence, especially involving alcohol. A substantial percentage of motor vehicle crashes are also related to violence. Less easily quantifiable harm results from all forms of violence: emotional stress can lead to depression, substance abuse, and chronic pain. It can also complicate treatment for chronic illnesses such as asthma, diabetes, hypertension, and seizure disorders.
Unlike more news-making examples, the effects of violence I see in clinical practice are less public, less fully appreciated. "About 20% of women treated in emergency departments are there for injuries or illnesses associated with domestic violence," according to Dr. Larry Bedard, an emergency physician on President Clinton's Task Force on Violence Against Women. The Centers for Disease Control and Prevention estimate that at least 1.5 million women annually are abused by their partners. Other sources almost triple this estimate. Initial studies suggest similar rates of violence in lesbian, gay, bisexual, and transgender relationships. Victims are often reluctant to volunteer information about abuse, but will admit it if asked privately in the course of a medical examination.
More than three million children witness intimate-partner violence, and child abuse is fifteen times more likely to occur in families in which it takes place. Men who witnessed intimate-partner violence as children are three times more likely to abuse their wives than are men from nonviolent homes. A comparison of delinquent and nondelinquent youth found that a history of family violence or abuse is the most significant difference between the two groups. Once the abuse is recognized, resources must be made available to the victims, including police, social workers, psychological counseling, and shelters.
Child abuse is another major public health issue. In 1998, there were over one million cases of confirmed child abuse and neglect. Of these cases, physical abuse occurred in 25%, emotional abuse in 3%, and sexual abuse in 10%. Neglect occurred in 51% of reported cases.
Elder abuse is also a growing concern for public health. 293,000 cases of elder abuse within the family context were reported in 1996, of which 55% involved neglect, 15% physical abuse, 12% financial or material exploitation, 8% emotional, and 0.3% sexual abuse. Because it usually occurs within the home, this abuse is thought by experts to be grossly underreported. Estimates are that only one in fourteen incidents is reported to authorities.
Firearms are perhaps the most well-known cause of violence in the U.S., where there are 192 million privately owned firearms. Guns kept in the home are twenty-two times more likely to kill a friend or family member than to be used in self-defense. A gun in the home triples the risk of homicide for residents there and increases the risk of suicide fivefold.
In 1994, there were 38,505 firearm-related deaths in the U.S.; 17,800 of these were homicides, 18,700 suicides, and 1,300 were unintentional. (The remainder were not classified.) Firearms affect younger people in highly significant ways. They were the number two killer of the ten to twenty-four year-old age group in 1994 and the leading cause of death for African-American males ages 15-34.
The economic impact of gun-related violence is staggering. In 1990, firearm injuries cost more than $20 billion, both in direct medical care costs, and in indirect costs for long-term disability and premature death. Factoring in lost productivity raises the cost more than $113 billion. Further, at least 80% of the economic costs of treating firearm injuries are borne by taxpayers.
Statistics tell only part of the story of violence in our society. As a physician I see the daily results of violence as I hear to the stories of the everyday lives of real people. As a church member and a participant in the Congregations, Health, and Healing project, I hope to change these stories, healing all involved.
Web Resources
Family Violence Prevention Fund
www.famvi.com
Prevent Child Abuse America
www.preventchildabuse.org
National Center on Elder Abuse
www.gwjapan.com/NCEA
Handgun Control
www.handguncontrol.org
CDC: National Center for Injury Prevention and Control
www.cdc.gov/ncipc
