Brett Bowman

The impact of violence on health in low- to middle-income countries

More than 90% of violence-related deaths occur in low- to middle-income countries (LMICs), where the mortality rate due to violence is almost 2.5 times greater than in high-income countries. Over and above the substantial contribution of violence as a cause of death and physical injuries, victims of violence are also more vulnerable to a range of mental and physical health problems. Several studies describe the deleterious impact of different types of violence on a range of health outcomes, but no review has yet been undertaken that presents a composite overview of the current state of knowledge in LMICs. This paper reviews the scientific literature describing the nature, magnitude and impact of violence on health, describing the current state of violence-prevention policy developments within the global health agenda and highlighting the health consequences, disease burden and economic costs of violence. Although data are limited, the review indicates that costs relating to violence deplete health care budgets considerably and that scarce resources could be better used to address other health threats that hamper development.

Applying upstream interventions for interpersonal violence prevention: An uphill struggle in low- to middle-income contexts

In South Africas Western Cape province, interpersonal violence was identified among the key prevention priorities in the provincial governments Burden of Disease (BoD) Reduction project. To date, there are no adequate systematic reviews of the full range of potential intervention strategies. In response, available data and the literature on risk factors and prevention strategies for interpersonal violence were reviewed with a view to providing policy makers with an inventory of interventions for application. Given the predominance of upstream factors in driving the provinces rates of interpersonal violence, efforts to address its burden require an intersectoral approach. Achievable short-term targets are also required to offset the long-term nature of the strategies most likely to affect fundamental shifts. Documentation and evaluation will be important to drive long-term investment, ensure effectiveness and enable replication of successful programmes and should be considered imperative by interpersonal violence prevention policymakers in other low- to middle-income contexts.

The cost of harmful alcohol use in South Africa

BACKGROUND The economic, social and health costs associated with alcohol-related harms are important measures with which to inform alcohol management policies and laws. This analysis builds on previous cost estimates for South Africa. METHODS We reviewed existing international best-practice costing frameworks to provide the costing definitions and dimensions. We sourced data from South African costing literature or, if unavailable, estimated costs using socio-economic and health data from secondary sources. Care was taken to avoid possible causes of cost overestimation, in particular double counting and, as far as possible, second-round effects of alcohol abuse. RESULTS The combined total tangible and intangible costs of alcohol harm to the economy were estimated at 10 - 12% of the 2009 gross domestic product (GDP). The tangible financial cost of harmful alcohol use alone was estimated at R37.9 billion, or 1.6% of the 2009 GDP. DISCUSSION The costs of alcohol-related harms provide a substantial counterbalance to the economic benefits highlighted by the alcohol industry to counter stricter regulation. Curtailing these costs by regulatory and policy interventions contributes directly and indirectly to social well-being and the economy. CONCLUSIONS; Existing frameworks that guide the regulation and distribution of alcohol frequently focus on maximising the contribution of the alcohol sector to the economy, but should also take into account the associated economic, social and health costs. Current interventions do not systematically address the most important causes of harm from alcohol, and need to be informed by reliable evidence of the ongoing costs of alcohol-related harms.

The impact of violence on development in low- to middle-income countries

Along with the numerous trauma-related impacts of violence and its effects on other health outcomes, the social toll of violence is further exacerbated by economic costs that represent formidable threats to fiscal growth and development. A companion piece to a review of the scientific literature describing the nature, magnitude and impact of violence on health (Matzopoulos, Bowman, Butchart & Mercy, 2008) in this issue, this paper reviews the current knowledge base on violence and development with a specific focus on low- to middle-income countries. It describes how violence impacts on all eight goals of the Millennium Development Plan and exerts a considerable economic burden on already stressed state systems and social spending. Violence will become an increasingly important threat to development and is receiving growing recognition among the global health community and within health ministries. The near absence of violence prevention within the global development agenda is, however, cause for concern. There is an urgent need to mobilise the international development community to provide financial and technical support for intersectoral collaboration, multilateral research cooperation and the development of research capacity towards addressing violence as a significant threat to development.

Children, pathology and politics : a genealogy of the paedophile in South Africa between 1944 and 2004

By the early 1990s the paedophile as a ‘type’ of child sexual abuse (CSA) perpetrator was prioritised for study and intervention by the South African socio-medical sciences, and cases of paedophilia featured prominently in the media reporting of the time. Drawing on the genealogical method as derived from Michel Foucault, this study aimed to account for this relatively recent emergence of the paedophile as an object of socio-medical study and social anxiety within the South African archive. Based on an analysis of archival texts against the backdrop of international biopolitics and local conditions of political possibility, the genealogy contends that the early figure of the paedophile was an instrument and effect of apartheid biopolitics. The paedophile was prioritised for research and escalated as a social threat in the public imagination as part of the broader apartheid project aimed at protecting white hegemony through the ongoing surveillance of and health interventions directed towards South Africas white children. While the apartheid project constructed black children as posing fundamental threats to white supremacy, discourses beginning in the mid-1980s repositioned them as vulnerable victims of apartheid itself. It was from within these discourses that child sexual abuse (CSA) as a public health concern began to crystallise. By locating blackness within the fields of discipline and desire, the material conditions for an ever-expanding net of sexual surveillance were established. The study therefore demonstrates that even the paedophile cannot be effectively researched without considering the historical co-ordinates that so powerfully contoured its emergence as an important object of study and social intervention within South Africas highly racialised systems of thought.

Liberating South African Psychology: The Legacy of Racism and the Pursuit of Representative Knowledge Production

South Africa’s first nonracial, democratic national elections in 1994 brought to a close the period of legislated racism that had rendered the South African state one of the most reviled of the twentieth century. However, despite these watershed elections and South Africa’s new constitution, which expressly proscribes any form of racism, South African society continues to be strongly characterized by the power of “race” and racism as determinants of social division, interaction and identity. This is manifested in a variety of ways, including ongoing residential segregation based on race, the persistent racialized patterns of friendship, the usage of public spaces, and the consistently negative portrayal of blacks (albeit increasingly covert) in the media (Dixon, Tredoux, & Clack, 2005 ; Duncan, 2003 ; Durrheim, 2005 ; Foster, 2005) . However, perhaps the most salient and debilitating manifestation of the enduring impact of racism in South Africa are the persistent racialized patterns of poverty and privilege that still typify this context. For example, in 2000, May, 6 years after the dismantling of the apartheid order, Woolard and Klasen reported that the income of the average white household was five times higher than the average household income of black 1 families. Data released by Statistics South Africa in 2005 reveal that the rate of unemployment among Africans currently stands at 26.7%, compared to 18.6% and 15.4% for coloreds and Indians, respectively. The rate for whites is 4.4%. Commenting on these figures, Pakendorf (in Pienaar, 2005 , p. 8) observes that “No matter how you look at it, black people are still worse off in contemporary South Africa than whites.”

A Qualitative Study of the Multiple Impacts of External Workplace Violence in Two Western Cape Communities

We explore the individual, organisational, familial, and community impacts of external workplace violence in a South African telecommunications company, as perceived and experienced by victims of such violence and the members of management mandated to manage and prevent it. Exposure to violence while working dramatically and directly affected the lives of the individual victims. Moreover, its impacts were felt across and within the organisational, familial, and community settings in which these individuals are located daily. The use of conventional crisis management strategies that are traditionally directed at addressing the individual impacts of trauma through specialised psychological interventions were perceived to be ineffective by all of the research participants. Our findings therefore call into question current understandings of the psychologists role in managing violence in the workplace. Accordingly, ways of re-conceptualising the role and requisite skill set of psychologists working with or in organisations, where violence while working is an everyday reality, are suggested.

Editorial : towards a psychology of South Africa's histories - living with and through the apartheid archive

The articles that constitute this special issue demonstrate that the collapse of formal apartheid has not erased its powerful racist imprint on the psychic lives and subjectivities of South Africans. Together, these articles show that apartheid continues to shape our inner-worlds, everyday relationships and systems of thinking. As such, this special issue ultimately hopes to contribute to the growing body of literature that insists that real South African transformation will never be realised without moving beyond material redress and acknowledging the importance of remembering.

An assessment of counselling and support services for people living with HIV in Gauteng, South Africa: findings of a baseline study.

An increasing body of literature shows that HIV/AIDS and mental health issues are closely related. In spite of this, the mental health correlates of HIV and AIDS remain largely unacknowledged and under-researched in sub-Saharan Africa. Furthermore, despite guidelines by the World Health Organization insisting that counselling with integrated psychological or mental healthcare helps people living with HIV or AIDS (PLHIV) to deal with their disease status and thus increases their quality of life, the services and interventions to address this significant health burden are still lacking, making the HIV/AIDS and mental-health nexus a sizeable social services and health problem. As part of an ongoing research programme at the University of the Witwatersrand to address this, the article reports on a baseline study that sought to identify the nature and extent of counselling and support services available to PLHIV in Gauteng Province. The study found that available counselling and support services are focused largely on voluntary counselling and testing for HIV (VCT), which appears to be primarily an educational intervention rather than a therapeutic modality. Service providers within this framework have inadequate knowledge and capacity to identify mental health problems. The findings of this study point to a strong need for integrated HIV/AIDS services that include assessment of mental health and substance abuse problems and their appropriate management. Appropriate training and supervision of healthcare workers and counsellors is an essential component in the identification and referral of HIV patients with mental health problems.

Bridging risk and enactment: the role of psychology in leading psychosocial research to augment the public health approach to violence in South Africa:

In the wake of apartheid, many in the South African health and social sciences shifted their orientation to understanding violence. Rather than approaching violence as a criminal problem, post-apartheid scholarship surfaced violence as a threat to national health. This re-orientation was well aligned with a global groundswell that culminated in the World Health Assembly’s 1996 declaration of violence as a public health problem. In response, researchers and other stakeholders have committed to the public health approach to violence in South Africa. Despite some unquestionable successes in applying this approach, violence remains a critical social issue and its recalcitrantly high rates signal that there is still much work to be done. One avenue for more focussed research concerns understanding the mechanisms by which upstream risk factors for violence are translated into actual enactments. We argue that South African psychology is well placed to provide greater resolution to this focus. We begin by providing a brief overview of the public health approach to violence. We then point to three specific areas in which the limits to our understanding of the way that downstream psychological and upstream social risk factors converge in situations of violence, compromise the theoretical and prevention traction promised by this approach and chart several basic psychosocial research coordinates for South African psychology. Steering future studies of violence by these coordinates would go some way to addressing these limits and, in so doing, extend on the substantial gains already yielded by the public health approach to violence in South Africa.