Etienne G. Krug

The world report on violence and health

In 1996, the World Health Assembly declared violence a major public health issue. To follow up on this resolution, on Oct 3 this year, WHO released the first World Report on Violence and Health. The report analyses different types of violence including child abuse and neglect, youth violence, intimate partner violence, sexual violence, elder abuse, self-directed violence, and collective violence. For all these types of violence, the report explores the magnitude of the health and social effects, the risk and protective factors, and the types of prevention efforts that have been initiated. The launch of the report will be followed by a 1-year Global Campaign on Violence Prevention, focusing on implementation of the recommendations. This article summarises some of the main points of the world report.

Violence a global public health problem

This article is a version of the Introduction to the World Report on Violence and Health, published by the World Health Organization (WHO). It presents a general description about this phenomenon and points some basic questions: concepts and definitions about the theme; the state of knowledge about it; nature and typology on violence; proposal of a quantitative and qualitative approach of an ecological model; responsibilities and functions of the public health sector and its potentiality to prevent and reduce violence in the world; the responsibilities of the nations and the policy makers in a intersetorial point of view; difficulties and obstacles for actuation and challenges for the health sector.

Armed Conflict as a Public Health Problem

Armed conflict is a major cause of injury and death worldwide, but we need much better methods of quantification before we can accurately assess its effect Armed conflict between warring states and groups within states have been major causes of ill health and mortality for most of human history. Conflict obviously causes deaths and injuries on the battlefield, but also health consequences from the displacement of populations, the breakdown of health and social services, and the heightened risk of disease transmission. Despite the size of the health consequences, military conflict has not received the same attention from public health research and policy as many other causes of illness and death. In contrast, political scientists have long studied the causes of war but have primarily been interested in the decision of elite groups to go to war, not in human death and misery. We review the limited knowledge on the health consequences of conflict, suggest ways to improve measurement, and discuss the potential for risk assessment and for preventing and ameliorating the consequences of conflict. #### Summary points Conflict related death and injury are major contributors to the global burden of disease Information systems break down during conflict, leading to great uncertainty in the magnitude of mortality and disability The World Health Survey may provide a reliable and valid basis for assessing conflict related mortality and disability Forecasting models may provide a plausible basis for assessing risk of conflict and thus prevention Improved collaboration between political scientists and experts in public health would benefit measurement, prediction, and prevention of conflict related death The impact of war on populations arises both from the direct effects of combat—namely, battle deaths—and from the indirect consequences of war, which may occur for several years after a conflict ends.1 Indirect effects of conflict on mortality can be formally …

Epidemiology of violent deaths in the world

Objective—This study describes epidemiologic patterns of mortality due to suicide, homicide, and war for the world in order to serve as a benchmark against which to measure future progress and to raise awareness about violence as a global public health problem. Setting—The world and its eight major regions. Method—Data were derived from The Global Burden of Disease series and the US National Center for Health Statistics to estimate crude rates, age adjusted rates, sex rate ratios, and the health burden for suicide, homicide, and war related deaths for the world and its eight major regions in 1990. Results—In 1990, an estimated 1 851 000 people died from violence (35.3 per 100 000) in the world. There were an estimated 786 000 suicides. Overall suicide rates ranged from 3.4 per 100 000 in Sub-Saharan Africa to 30.4 per 100 000 in China. There were an estimated 563 000 homicides. Overall homicide rates ranged from 1.0 per 100 000 in established market economies to 44.8 per 100 000 in Sub-Saharan Africa with peaks among males aged 15–24 years old, and among females aged 0–4 years old. There were an estimated 502 000 war related deaths with peaks in rates for both sexes among people aged 0–4, 15–29, and 60–69 years old. Conclusion—The number of violence related deaths in the world is unacceptably high. Coordinated prevention and control efforts are urgently needed.

Suicide after Natural Disasters

BACKGROUND Among the victims of floods, earthquakes, and hurricanes, there is an increased prevalence of post-traumatic stress disorder and depression, which are risk factors for suicidal thinking. We conducted this study to determine whether natural disasters affect suicide rates. METHODS From a list of all the events declared by the U.S. government to be federal disasters between 1982 and 1989, we selected the 377 counties that had each been affected by a single natural disaster during that period. We collected data on suicides during the 36 months before and the 48 months after the disaster and aligned the data around the month of the disaster. Pooled rates were calculated according to the type of disaster. Comparisons were made between the suicide rates before and those after disasters in the affected counties and in the entire United States. RESULTS Suicide rates increased in the four years after floods by 13.8 percent, from 12.1 to 13.8 per 100,000 (P<0.001), in the two years after hurricanes by 31.0 percent, from 12.0 to 15.7 per 100,000 (P<0.001), and in the first year after earthquakes by 62.9 percent, from 19.2 to 31.3 per 100,000 (P<0.001). The four-year increase of 19.7 percent after earthquakes was not statistically significant. Rates computed in a similar manner for the entire United States were stable. The increases in suicide rates were found for both sexes and for all age groups. The suicide rates did not change significantly after tornadoes or severe storms. CONCLUSIONS Our study shows that suicide rates increase after severe earthquakes, floods, and hurricanes and confirms the need for mental health support after severe disasters.

Violence and Health: The United States in a Global Perspective

Violence is a public health problem that can be understood and changed. Research over the past 2 decades has demonstrated that violence can be prevented and that, in some cases, prevention programs are more cost-effective than other policy options such as incarceration. The United States has much to contribute to-and stands to gain much from-global efforts to prevent violence. A new World Health Organization initiative presents an opportunity for the United States to work with other nations to find cost-effective ways of preventing violence and reducing its enormous costs.

Trends in diabetes: sounding the alarm.

Diabetes is a major cause of death and disability worldwide. In 2012 it caused as many deaths as HIV/AIDS (1·5 million). Disability resulting from diabetes has grown substantially since 1990, with particularly large increases among people aged 15–69 years. People with all types of diabetes are at risk of developing a range of complications that can endanger their health and survival, and the high costs of care increase the risk of catastrophic medical expenditure. Diabetes is the theme of this year’s World Health Day on April 7, and WHO has published the Global Report on Diabetes to raise awareness and spark momentum for action at the necessary scale. In The Lancet, the NCD Risk Factor Collaboration (NCD-RisC) presents a robust and timely analysis of trends in diabetes prevalence. They provide updated, consistent, and comparable estimates of agestandardised prevalence of diabetes since 1980, derived from 751 population-based measurement studies involving nearly 4·4 million participants. These are the fi rst global estimates and trend analyses published since adoption of the voluntary target to halt the rise in diabetes and obesity (against the 2010 baseline) by 2025. The news is not good. NCD-RisC estimates that the number of people with diabetes quadrupled between 1980 and 2014. Age-standardised prevalence among adult men doubled during that time (from 4·3% [95% credible interval 2·4–7·0] to 9·0% [7·2–11·1]), and age-standardised prevalence among adult women increased by 60% (5·0% [2·9–7·9] to 7·9% [6·4–9·7]). Diabetes prevalence either increased or remained the same in every country. Given these trends, the authors calculate that only a few countries, mostly in western Europe, have even a chance of meeting the target to halt the rise in diabetes by 2025—a sobering wake-up call. With diabetes in the World Health Day spotlight the question is, how will the world and its leaders respond to the alarm? NCD-RisC notes that reducing the global health and economic impact of diabetes requires action to prevent or delay the onset of type 2 diabetes, which accounts for the majority of diabetes worldwide. Overweight and obesity, together with physical inactivity, are responsible for a substantial proportion of the global diabetes burden. Changes at population level to improve access to healthy foods and beverages, and to opportunities for physical activity, facilitate positive behaviour change and are likely to have an impact on the occurrence of type 2 diabetes. The intermediate approach proposed by the authors—supportive intervention to promote changes in diet and physical activity among people at high risk of type 2 diabetes, possibly accompanied by the use of medications—is backed by strong evidence of eff ectiveness. The ultimate advisability of targeted interventions for people at high risk depends heavily on local context, such as availability of suffi cient human and fi nancial resources, as well as essential equipment and technology, to manage the approach at the primary-care level. Hundreds of millions of people live with diabetes today. Many of them do not know it, and many of those who do lack access to the necessary medicines or information. Action to build the capacity of health systems to improve diabetes management and reduce complications is a matter of urgency. Access to eff ective treatment must be expanded through the use of standardised protocols and the implementation of measures to improve the availability of essential technologies for diagnosis and management of diabetes (such as blood glucose measurement) in primary health-care settings, and essential medicines such as life-saving insulin. Diabetes management should be part of overall noncommunicable disease management and incorporated into the package of essential services included in universal health coverage. Published Online April 6, 2016 http://dx.doi.org/10.1016/ S0140-6736(16)30163-5

Child injuries and violence: the new challenge for child health

Injuries and violence are a significant and growing cause of child death and disability, as well as having other health consequences including mental health, behavioural and reproductive health problems. Every year injuries and violence kill approximately 875 000 children (aged less than 18 years of age) and injure or disable tens of millions more. Injury-related causes account for 3 of the top 15 killers of children aged 0–4 years and for 6 of the top 15 killers of children aged 5–14 years. Child maltreatment has been associated with significantly increased risk of alcoholism, drug abuse, depression, suicide attempt, smoking and sexually transmitted disease. The burden from child injury is most felt in low- and middle-income countries, where 95% of all child-injury deaths occur, and where recorded rates of child maltreatment are substantially higher than in high-income countries. This huge public health problem is all that much more tragic because it is avoidable. Through combinations of prevention and care, most high-income countries have considerably reduced rates of child-injury death and child maltreatment. Consequently, there are huge inequities globally, with annual child-injury mortality of 8.6/100 000 in high-income countries compared with 41.8/100 000 in low- and middle-income countries.1 In other words, rates of child-injury death are more than four times higher in low- and middle-income countries. A large burden of death and morbidity could be avoided by bringing violence and injury rates in low- and middle-income countries down to levels similar to those in high-income countries. Such public health benefits could be achieved by use of proven prevention methods, such as implementing and enforcing safety legislation and standards; promoting home and transport safety; modifying products or the environment; and improving care and rehabilitation of injured children. Programmes to promote safe, sustainable and nurturing relationships between children and their parents or caregivers can substantially reduce child maltreatment, and youth violence prevention programmes can significantly reduce violence-related death and injury in adolescents. These strategies, most of which are affordable and sustainable in all countries, need to be better applied globally. Child injury and violence need to be better incorporated into broader child survival strategies. Child injury and violence have been only minimally addressed thus far by the global health community and by most governments. Likewise, these topics have been inadequately addressed in the scientific literature. An upcoming theme issue of the Bulletin (May 2009) on child injury and violence will seek to address these shortcomings, to promote greater attention to these significant public health problems, to promote greater uptake of known effective prevention and treatment interventions globally, and to stimulate more research on low-cost and sustainable ways to confront these problems especially in low- and middle-income countries where most children live. The Bulletin theme issue will examine the spectrum of child injury and violence prevention and control including epidemiology, prevention, care and rehabilitation. It will contain papers in the categories of Perspectives, Policy and practice, Research, and Lessons from the field. Several papers will be commissioned. In addition, submissions from interested authors are highly encouraged. We welcome papers for all sections of the Bulletin that focus on any of the following topics: surveillance and data collection; evaluation of methods to prevent unintentional injury and violence; health systems strengthening or financing for child injury and violence prevention interventions; or methods for strengthening emergency care and/or rehabilitation of injured and maltreated children. We would especially encourage papers that go beyond the health perspective to address the cross-sectoral nature of the problem. For example, papers on transport safety could encompass the multi-sectoral nature of road traffic injury, including human behaviour, roadway infrastructure and vehicle design, and broader issues of urban design. Papers on violence could include coverage of the multi-dimensional determinants of violence, including parenting, childhood exposures and subsequent health and social consequences, and societal-level factors such as socio-economic disparities. Likewise, papers examining responses to violence could discuss actions involving the educational, welfare and criminal justice sectors, as well as the health sector. Papers discussing how child injury and violence issues can be better addressed in the broader child survival and global health agendas are encouraged. These could include discussions of the relationship of child injury and violence and Millennium Development Goals such as Goal 4 (reducing child mortality). Papers from authors in developing countries are especially encouraged. It is hoped that the papers in this issue will contribute important information that will assist public health practitioners, clinicians, researchers and policy-makers to better confront the eminently preventable problem of child injury and violence. The deadline for submissions is 1 September 2008. Manuscripts should be submitted to: http://submit.bwho.org respecting the Guidelines for Contributors and accompanied by a cover letter mentioning this call for papers. All submissions will go through the Bulletin’s peer review process. ■

Global Status Report on Violence Prevention 2014.

INTRODUCTION Interpersonal violence affects millions of people worldwide, often has lifelong consequences, and is gaining recognition as an important global public health problem. There has been no assessment of measures countries are taking to address it. This report aims to assess such measures and provide a baseline against which to track future progress. METHODS In each country, with help from a government-appointed National Data Coordinator, representatives from six to ten sectors completed a questionnaire before convening in a consensus meeting to decide on final country data; 133 of 194 (69%) WHO Member States participated. The questionnaire covered data, plans, prevention measures, and victim services. Data were collected between November 2012 and June 2014, and analyzed between June and October 2014. Global and country-level homicides for 2000-2012 were also calculated for all 194 Members. RESULTS Worldwide, 475,000 people were homicide victims in 2012 and homicide rates declined by 16% from 2000 to 2012. Data on fatal and, in particular, non-fatal forms of violence are lacking in many countries. Each of the 18 types of surveyed prevention programs was reported to be implemented in a third of the 133 participating countries; each law was reported to exist in 80% of countries, but fully enforced in just 57%; and each victim service was reported to be in place in just more than half of the countries. CONCLUSIONS Although many countries have begun to tackle violence, serious gaps remain, and public health researchers have a critical role to play in addressing them.

A promise to save 100 000 trauma patients

2062 www.thelancet.com Vol 380 December 15/22/29, 2012 In The Lancet, Christopher Murray and colleagues present the fi ndings of their 2010 Global Burden of Disease Study, in which they show that injuries cost the global population some 300 million years of healthy life every year, causing 11% of disability-adjusted life years (DALYs) worldwide. Road-traffi c crashes were the number one killer of young people and accounted for nearly a third of the world injury burden—a total of 76 million DALYs in 2010, up from 57 million in 1990. Most of the victims were young, and many had families that depended on them. A study in Bangalore showed that the extra health-care costs and reduced income after a road-traffi c crash force most poor households into debt, with reduced food consumption for the victim’s family. A large share of these road-traffi c injuries could be prevented with available road safety interventions. Violence also accounted for much human suff ering, especially in Latin America and sub-Saharan Africa. Once again, the young bore most (81%) of the burden. Estimation of the global burden of disease and injury is a challenging scientifi c endeavour. Reduction of the global burden of disease and injury is an urgent moral obligation. To reduce the human and economic eff ect of injury, we need better prevention, eff ective and aff ordable treatments, and the tenacity to ensure their universal access. For bleeding trauma patients, we now have an eff ective treatment that is aff ordable and widely practicable. Road-traffi c victims and victims of violence constituted most patients in the CRASH-2 trial, which assessed the eff ect of tranexamic acid in 20 211 bleeding trauma patients from hospitals in 40 countries. Given within 3 h of injury, tranexamic acid reduced the risk of bleeding to death by a third, and at less than US