To: – Minister of Health and Welfare, Mr. Kostas Stefanos
Subject: Proposal for Promoting an Awareness Campaign on “Violence and Health,” within the Framework of the Greek Presidency of the EU	Athens, 25 October 2002

Honorable Minister,

On October ^3, 2002, the international campaign of the World Health Organization on “Violence and Health” was launched in Brussels. The aim of this campaign is to raise awareness among the public as well as state authorities worldwide, so that the risks posed by violent behaviors and their consequences for individual societies and the world as a whole are fully recognized. Emphasis is placed on the prevention of this phenomenon. Given the importance you also attach to the prevention of public health risks, I believe you will find this initiative of particular interest.

In my capacity as President of the Committee on Women’s Rights and Equal Opportunities of the European Parliament, and given that women and children are particularly affected by the phenomenon of violence, I would like to submit to you a brief report on the issue of violence and a series of proposals for its prevention and resolution.

a) At the national level. The relevant proposals refer to potential opportunities for developing a policy for the prevention and combating of violence by your Ministry.

b) At the international level. As our country assumes the Presidency of the European Union in the first half of 2003, the policies proposed in this report could provide Greece with the opportunity to be the country that initiates and leads the fight against violence and in favor of improving the health and quality of life of citizens at the European level.

In this context, I propose, first and foremost, the organization of an international conference in February 2003 in Athens, in collaboration with the European Parliament – primarily with the Committees on Women’s Rights and the Environment and Health – and the participation of officials from the World Health Organization, possibly including the Director-General, Mrs. Gro Harlem Brundtland, whom I met during the launch of the WHO campaign in Brussels. I am confident that Commissioner Mrs. Anna Diamantopoulou, who was a speaker at the launch of the campaign, will also wish to participate.

I am at your disposal for any clarification and future cooperation.

With deep respect,

Anna Karamanou

VIOLENCE and HEALTH

Campaign for the Combating of Violence

and the Improvement of Quality of Life

Proposal for the Greek Presidency

A N N A K A R A M A N O U

MEP PASOK

President of the Committee on Women’s Rights and Gender Equality of the European Parliament

 

Athens, 25 October 2002

Contents

J. Introduction

ΙΙ. The phenomena of violence and the danger they pose to modern societies

The economic cost of violence

ΙΙΙ. General principles of action against violence.

IV. Policy proposals for combating violence and improving quality of life

A. National Level

B. International-European Level

V. Conclusions

VIOLENCE and HEALTH

Campaign for the Combating of Violence

and the Improvement of Quality of Life

Proposal for the Greek Presidency

Anna Karamanou

European Parliament Member of PASOK

President of the Committee on Women’s Rights and Gender Equality of the European Parliament

J. Introduction

Violence is a serious problem that physically and mentally injures, or even kills, thousands of people worldwide each year. The World Health Organization estimates that, in the year 2000, 1.6 million people around the world lost their lives as a result of violent acts (a rate of 28.8 people per 100,000). However, the global community has not addressed violence as a serious issue that needs to be prevented and eradicated, even though violence affects all countries equally. Violence—physical, sexual, and psychological—is perpetrated on a daily basis, undermining the health and well-being of millions of people, while costing government budgets enormous amounts every year in healthcare, legal expenses, absenteeism from work, and lost productivity.

The problems are very large because the effects of violence on health often last for many years, beyond the initial act of violence, and can include permanent disabilities such as spinal cord injuries, brain damage, and loss of limbs. Significant income disparities within each country—between urban and rural populations, poor and rich communities, and between different racial and ethnic groups—foster violent behaviors that manifest even in the most advanced countries of the planet.

Unfortunately, violence is often considered an integral part of human nature, while the role of health professionals is limited to addressing the consequences without focusing on prevention. The collection of statistical information on violence is very problematic, as violent behaviors are often concealed under a veil of secrecy and hidden behind various taboos. However, these perceptions are gradually diminishing, as it becomes evident how effective prevention approaches are for other public health and quality of life issues (environmental problems, smoking, HIV/AIDS, etc.).

Our goal, therefore, must also be to combat secrecy, cultural taboos, and the perceptions that violent behavior is inevitable. For this, public dialogue needs to be encouraged, so that our understanding of this very complex phenomenon can be increased and cooperation between all stakeholders at all levels can take place, in order to find the best possible solutions to the problem. Transforming the culture of violence into a culture of peaceful and qualitative coexistence among people is one of the greatest challenges of the 21^st century.

ΙΙ. The phenomena of violence and the danger they pose to modern societies

In recent years, incidents of violence have not only increased but have also taken on new, more dangerous characteristics. Our daily lives are flooded with acts of violence that would have been unthinkable a few years ago. Recent terrorist attacks have created a climate of insecurity in our societies. At the same time, the rise in juvenile delinquency (with mass shootings in schools, kidnappings and murders of other children, youth gangs, etc.) has heightened concerns, as the future appears grim. These new developments have made violence one of the greatest problems in modern societies, for the resolution of which drastic measures must be taken as soon as possible.

The cost of violence is reflected in the impact it has on the lives of its victims and the burden it places on healthcare systems. Violent incidents degrade the quality of life for citizens in our society. In addition to immediate physical injury, victims are at risk of a wide range of psychological and behavioral issues, including depression, alcoholism, anxiety, and suicidal tendencies, as well as reproductive health problems such as unwanted pregnancies, sexually transmitted diseases, and sexual dysfunction. The mobilization of authorities is necessary to assist these individuals in every possible way. The state itself stands to gain from combating violence due to the high economic cost of violence, which burdens the national economy and the state budget.

The economic cost of violence

According to the World Health Organization’s Global Report on “Violence and Health,” studies funded by the Inter-American Development Bank between 1996 and 1997 on the economic impacts of violence in six Latin American countries estimated that violence alone cost 1.9% of Brazil’s GDP, 5% of Colombia’s GDP, 4.3% of El Salvador’s GDP, 1.3% of Mexico’s GDP, 1.5% of Peru’s GDP, and 0.3% of Venezuela’s GDP in health services. In 1992, a study in the United States calculated the annual cost of treating gunshot wounds at $126 billion. Stab wounds cost an additional $51 billion. From the available data, it can be inferred that, in general, women who are victims of domestic or sexual violence experience more health problems, incur higher healthcare costs, and make more frequent visits to intensive care units during their lifetime compared to individuals who have not been victims of violence. The same applies to victims of violence and neglect during their childhood.

For the calculation of the cost of violence to the national economy of a state, a wide range of factors that influence it must be considered, beyond the direct costs of medical care and legal matters. Examples of indirect costs include the following:

• The provision of care and safe shelter, as well as the long-term care of the victim.
• The lost productivity as a result of premature death, injury, long-term absence from work, long-term disability, and loss of potential.
• The degradation of quality of life and the reduced ability to care for oneself or others.
• The destruction of public property and infrastructure, leading to the disruption of services such as healthcare, transportation, and food distribution.
• The disruption of daily life as a result of fear for personal safety.
• The deterrence of investments and the discouragement of tourism, which harm economic development.

Rarely is the cost of violence distributed equally. Those who have the fewest choices and opportunities to protect themselves from economic problems are those most affected. Violence, that is, is strongly connected to social inequality, which it reproduces.

 

ΙΙΙ. General principles of action against violence.

Violence can be prevented and effectively addressed. Regarding prevention, it is becoming increasingly apparent that highly effective prevention approaches for other public health problems (environmental issues, smoking, HIV/AIDS, etc.) can be applied to violence prevention as well. In fighting the problem, we must keep in mind a very hopeful element: the degree to which violence will affect its victim depends on their age and personality, as well as whether they will receive help to address the issue. In general, people who react to the violence they endure are more resilient than those who accept it passively. Therefore, there is hope that the effects of violence can be reduced if its victims are convinced to turn to others (either their circle or the healthcare system) for help. However, for this to happen, citizens need to be informed, and the state must develop the necessary infrastructure.

In general, the actions that should be followed are the following:

• The problem of personal risk factors should be addressed, and steps should be taken to change individual risk behavior. Emphasis must be placed on the individual. The goal is to encourage healthy behaviors, since the individual must also be able to accept and utilize the structures and services that society can provide to combat violence problems. This applies both to victims and perpetrators. For example, many men who abuse their wives should have access to specialized counseling centers (which do not exist in Greece), so that:
• Close personal relationships should be influenced, and attention should be given to the creation of healthy family structures, as well as providing the necessary professional help and support to dysfunctional families.
• There should be effective control of public spaces – such as schools, workplaces, and neighborhoods – and measures should be taken to address problems that can lead to violent behaviors.
• The inequality of genders and hostile-conflicting cultural practices and stereotypical behaviors should be addressed.
• The broader cultural, social, and economic factors that lead to violence should be addressed, and measures should be taken to change them, such as, for example, measures to combat poverty and ensure equal access for citizens to goods, services, and opportunities.

The specific policy proposals that follow are addressed at two levels: the national and the international. The national level refers to the measures and policies that the Ministry of Health of our country can develop to address the phenomenon of violence. The international – initially European – level includes proposals that can be implemented through international cooperation. Therefore, as our country assumes the Presidency of the European Union in the first half of 2003, the policies proposed here could provide Greece with the opportunity to be the country that starts and leads the fight against violence and in favor of improving the health and quality of life of citizens at both the national and European levels.

ΙV. Policy proposals for combating violence and improving quality of life.

A. NATIONAL LEVEL

Analyzing the issue of violence, it is found that the phenomenon is addressed in a fragmented way (since there is a fragmentation into various areas of knowledge related to violence) without forming a comprehensive picture. However, this picture is absolutely necessary for addressing the problem. It must be emphasized here the importance of addressing the problem through the lens of Public Health. Public Health does not focus its attention on individuals – the victims of violence – but rather on the health of entire communities and populations. Thus, Public Health interventions focus, where possible, on populations that are at greater risk of being affected, e.g., by a disease. The goal of Public Health should be the prevention of illness or injury. Therefore, the approach through the lens of Public Health is the one proposed by the World Health Organization. Specifically:

Proposal A1. Coordination by the Ministry of Health and Welfare of the collection and utilization of statistical data related to violence.

Statistical data on violence are essential to understand the extent of the phenomenon. Today, the recording of violence incidents worldwide is problematic. Mortality data are the easiest to collect and process. However, they represent only the tip of the iceberg, as for every victim of violence who dies, there are many others who are injured – physically or psychologically – or are left with some form of disability. Since non-fatal violence incidents are much more numerous than fatal ones, additional data are needed to complete the picture we have today. These include:

• Data on diseases, injuries, and other health problems.
• Personal reports on behaviors, perceptions, cultural practices, victimization, and exposure to violence.
• Community data on the characteristics of the population in each area, income levels, education, and employment.
• Data on the characteristics and conditions under which incidents of violence occurred, as well as information on the perpetrators of violence.
• Economic data related to the cost of treatment, social services, and prevention efforts that have been undertaken.
• Legislative and policy data.

Proposal A2: Creation, implementation, and monitoring of a national action plan for the prevention of violence.

This plan should be based on the consensus of the involved stakeholders (both governmental and non-governmental). It should take into account the human and material resources available for its implementation and should include elements such as an assessment of existing legislation and practices, potential proposals for reform, structuring the processes of data collection and research, strengthening victim support services, and developing and evaluating alternative preventive measures. The plan should also include a timeline and an evaluation mechanism, defining a specific organization responsible for the task and that will submit regular progress reports, as well as coordination mechanisms at the local, national, and international levels, to enable collaboration between sectors that could contribute to violence prevention, such as criminal justice, education, employment, health, and social security.

Proposal A3: Strengthening the capacity for data collection on violence.

It is important to have a national organization responsible for linking and comparing information from health services, legal services, and other services that come into contact with victims. The local community level is particularly important because it will determine the quality and completeness of the information being collected. Systems should be designed to be simple and financially sustainable, compatible with the level of staff handling them, and aligned with national and international standards. Furthermore, there should be processes for data exchange between the involved stakeholders (health, justice, and social policy) and other interested parties, as well as the capacity for conducting comparative analysis.

Proposal A4: Setting priorities and supporting research on the causes, effects, costs, and prevention of violence.

The main goal of the research should be to identify the cultural forms of violence, in order to develop appropriate methods of addressing it. At the national level, the research can be conducted by state research centers and funding from universities and independent researchers. At the local level, there should be collaboration with local universities, research centers, and NGOs.

Proposal A5: Promotion of primary interventions for the prevention of violence.

Some of the most important such interventions are the following:

• Prenatal health screening for parents, as well as preschool education and social development programs for children and adolescents.
• Education and training for better parenting and democratic functioning of the family. These two interventions aim to reduce child abuse and neglect, as well as the occurrence of violent behaviors among children and adolescents.
• Improvement of urban infrastructure, both material and socio-economic. This measure aims to address factors that contribute to the occurrence of violence within specific communities – identifying neighborhoods where incidents of violence frequently occur, analyzing the factors that make an area dangerous, and modifying or removing those factors. This measure also concerns the improvement of the socio-economic infrastructure of local communities through increased investments and improved educational and economic opportunities.
• Measures to reduce injuries from firearms and improve safety related to their use.
• Information campaigns to change attitudes, behaviors, and social norms. Since there is still no serious study available that examines to what extent exposure to violence through the media fosters certain types of violent behavior, the media can contribute to raising awareness about violence and its prevention.

Proposal A6: Strengthening policies to support victims of violence.

The National Health System should ensure the provision of high-level care to victims of all forms of violence, as well as rehabilitation and support services that are necessary to prevent potential future complications. The priorities include:

• Improvement of the national response mechanism and the capacity of the healthcare system to treat and rehabilitate victims.
• Recognition of signs of violent incidents or ongoing violent situations and referral of victims to the appropriate agencies for support.
• Ensuring that healthcare services, as well as legal, police, and social services, effectively prevent former perpetrators from repeating their violent actions.
• Social support, prevention programs, and other services that, on the one hand, protect women and children from the risks of violence and, on the other hand, reduce the stress of healthcare service providers.
• Inclusion of courses related to the prevention of violence in the curricula aimed at doctors and nursing staff.

Each of these proposals can contribute to reducing the impacts of violence on citizens and the costs that violence entails for the National Health System. However, the design and implementation of these measures should include safeguards to prevent the “revictimization” of previous victims – that is, measures should ensure that victims do not suffer further violence from the same individuals, be excluded from their families or society, and generally avoid negative consequences due to their prior experiences of violence.

Proposal A7: Integration of violence prevention into social and educational policies – promoting gender equality and social equality.

In many cases, violence is related to racial or social inequalities, as well as gender inequality. From the experience of countries that have improved the status of women and reduced their social exclusion, it is concluded that, in order to achieve these goals, a package of interventions is necessary, such as: legal and judicial reforms, ensuring balanced participation of both genders in democratic institutions and decision-making centers, public awareness and sensitization campaigns, training and oversight of police officers and public officials, educational and economic incentives for less advantaged groups, and combating xenophobia and racism.

Proposal A8: Enhanced cooperation and information exchange related to violence prevention.

Collaboration between international delegations, governments, researchers, networks, and NGOs working on violence prevention is essential to achieve the best possible exchange of knowledge and experience, agreement on the intended goals, and coordination of action. The above can be achieved through the creation of coordination mechanisms to avoid unnecessary duplications and ensure resource and energy savings, by utilizing experience and merging networks, funding, and infrastructures.

The contribution of volunteer support groups – those working on issues such as violence against women, human rights violations, etc. – should be recognized and encouraged with practical measures, such as including these groups in official working groups. The contribution of experts working on violence should be supported by the development of a platform that facilitates information exchange, joint research, and legal processing.

B. INTERNATIONAL – EUROPEAN LEVEL

At the international level, significant initiatives can be undertaken to launch the fight against violence through the Greek Presidency. Most of the aforementioned policies should be adapted and attempted for implementation at the European level. Specifically:

Proposal B1: Strengthening the capacity for data collection on violence.

The development of internationally accepted standards for data collection on violence should be pursued. This would make it easier to compare data between different countries and cultures. The World Health Organization recommends the “International Classification of External Causes of Injuries” and “Injury Surveillance Guidelines” developed by WHO and the U.S. Centers for Disease Control and Prevention. Under the framework of the Greek Presidency, efforts could be made to develop new, Europe-inspired standards.

Proposal B2: Setting priorities and supporting research on the causes, effects, costs, and prevention of violence.

As previously mentioned, the main goal of the research will be to identify the cultural differences between forms of violence in the EU. At the European level, research could be initiated on topics such as: the relationship between violence and globalization (economic, environmental, and cultural impacts), the factors that cause or prevent violence that are common across all cultures and societies, and which violence prevention approaches are sustainable and adaptable to different environments.

Proposal B3: Promoting primary violence prevention interventions.

At the international level, the implementation of policies already mentioned in Proposal A5 could also be pursued. The European Union could take on the financing of research into the role of the media in the emergence of certain types of violent behavior, or launch an international awareness campaign aimed at reducing injuries from firearms. Additionally, the European Commission could incorporate into its policies programs that educate citizens, especially young people, in non-violent communication. These programs could be integrated into the official curricula of educational institutions or operate independently as a category of continuing education. In this way, the chances for harmonious family relationships would increase, along with a reduction in domestic violence, which typically affects women and children.

Proposal B4: Integrating violence prevention into social and educational policies and promoting gender equality and social equality.

At the international level, an exchange of best practices could be pursued between European countries, as some member states of the Union (especially the Scandinavian countries) have made significant progress in eliminating gender inequalities, social inclusion of migrants, and combating social exclusion. These social changes have also led to a reduction in violence. Therefore, the experience of these countries could be utilized within the framework of this campaign.

Proposal B5: Searching for practical and internationally agreed measures to combat the international trade in drugs, weapons, and the sexual exploitation of women and children.

The international trade in weapons and drugs, as well as the trafficking of women and children for sexual exploitation, are linked to violence in all countries of the world. It is estimated that even minimal progress in combating the activities of criminal networks can contribute to addressing violence globally. Therefore, further exploration of ways to combat these issues should be pursued, in collaboration with the relevant government and social agencies.

Proposal B6: Promotion and monitoring of compliance with international treaties, legislation, and other mechanisms that protect human rights

In recent years, many international agreements have been signed aimed at protecting human rights. However, some countries have not taken the necessary steps to align their national legislation with their international obligations. If this is due to a lack of resources, then the European Union should contribute to solving the problem. In other cases, it is essential to apply pressure – primarily through trade and other cooperation agreements that the Union concludes with third countries – in order to bring about the necessary changes in legislation and practice.

Proposal B7: Strengthened cooperation and exchange of information related to violence prevention.

The coordinating mechanisms that will be established at the national and European levels should be created with the support of the WHO, in order to increase both their information and effectiveness, as well as to disseminate the results of their work to larger populations.

V. Conclusions

It is a fact that there are serious gaps in our knowledge about the phenomenon of violence, and therefore further research is necessary. However, the accumulated experience has led us to significant conclusions regarding the prevention of violence and the reduction of its negative consequences:

Violence is often predictable and preventable. There are specific factors that cause violence, something we must keep in mind even when this cause-and-effect relationship is not obvious. Identifying and measuring these factors can provide early warning to the relevant authorities about impending incidents of violence.

Prevention contributes to suppression. It is a global trend for the competent authorities to address violence only after it occurs. However, prevention can be much lower in cost, more effective, and long-term in combating violence.

Understanding the general framework of violence is crucial for designing interventions. All societies face problems of violence, but its general framework—the circumstances under which it occurs, its nature, and society’s attitude towards it—varies from society to society. When designing prevention programs, the context of violence must be understood in order to tailor the interventions to the specific target population.

The various forms of violence are linked in different ways and often have common risk factors. Unfortunately, research and preventive actions are often carried out independently of each other. If fragmentation in research is overcome, the effectiveness of interventions can be enhanced.

Resources should be focused on the most vulnerable population groups. Violence, like many health problems, is not neutral. While all social classes have some experience of violence, research shows that lower socio-economic strata are at greater risk of suffering from it. Therefore, the indifference of many national health systems towards the most vulnerable groups of citizens must be addressed.

Passivity is an obstacle to addressing violence and, in fact, encourages it. This is especially true for the perception—which is dominant in the case of gender inequalities—that sees violence as an inherent part of human nature and society. This resignation to violence is often reinforced by vested interests, such as, for example, the socially accepted right of men in some areas to mistreat their wives. Addressing these perceptions is essential.

Political commitment to addressing violence is vital for public health. No matter how much effort is made by non-governmental organizations and entities, political commitment is ultimately needed for success. This commitment is important both at the European and national levels—where policy, legislation, and funding decisions for related efforts are made—and at the regional and local levels, where the responsibility for the daily management of specific policies lies.

Violence is not inevitable. Much can be done both to address and prevent it. The global community has not yet fully assessed the scale of this task and does not yet have all the necessary tools to accomplish it. However, our knowledge of violence is constantly increasing, and significant experience has already been gained.