Director-General

First Latin American Encounter on "Training of health and human resources for comprehensive care of persons affected by violence and violation of their human rights"

Lima, Peru
12 March 2004

Honourable Minister, Ambassador, distinguished guests, colleagues and friends. Greetings from the World Health Organization.

I congratulate you on your initiative to bring together this group to take a closer look at violence in Latin America and at the means at your disposal to prevent acts of violence and to care for those affected by it.

On a global scale, violence kills 1.6 million people a year. It leaves millions more with injuries, disabilities and mental disorders. Its causes are complex and its consequences are devastating.

In order to provide the latest information about violence, WHO launched the World Report on Violence and Health in 2002. This is the first report to provide a comprehensive view of the magnitude of violence around the world, the factors that lead to violence and, at the same time, the potential that exists to tackle this global public health problem.

It provides data from around the world on suicide, child abuse, youth violence, sexual violence, abuse of the elderly, violence between intimate partners and other areas of personal and social conflict.

The World Report on Violence and Health has three main goals. The first is to raise awareness of violence as a global public health problem. It is not simply an issue for the police and justice departments, for the military or for international security councils.

Secondly, the Report highlights the contributions of public health to understanding and preventing violence.

The Report’s third goal is to increase the level of action taken by the public health community in response, to prevent violence. The aim is a better balance between the health problems caused by violence and the resources invested in preventing it.

Deaths are only a very small part of the problem of violence. For each death caused by violence, there are many other people who suffer the social, psychological and physical consequences of violence. Nevertheless, when deaths caused by violence are compared with deaths caused by other global public health problems, the importance of violence becomes alarmingly clear.

In 2000, there were over 1.6 million deaths due to violence. This is about half the number of deaths due to HIV/AIDS in that year, and about equal to the number of deaths due to tuberculosis. In 2000, violence took more lives than road traffic crashes and malaria.

At the broadest level, violence is divided into three major categories: self-directed, interpersonal and collective. So we differentiate between violence a person inflicts upon himself or herself; violence inflicted by another individual or small group of individuals; and violence inflicted by larger groups or states.

The three broad categories are each further divided to reflect more specific types of violence. Self-directed violence is divided into suicidal behaviour and self-abuse. Interpersonal violence is divided into family and partner violence – largely occurring in the home, though not exclusively; and community violence - which includes violence between individuals who are unrelated, such as youth violence, rape and sexual assault by strangers, and violence in institutional settings like schools, workplaces, prisons and nursing homes.

Collective violence is divided into social, political and economic violence. It can take a variety of forms: armed conflict within and between states, genocide, repression and other human rights abuses, terrorism and organized violent crime.

When we speak of violence it is important to understand these different categories. However, it is also crucial to understand that they are closely interrelated. First, many risk factors are common to all forms of violence. These include alcohol, drugs, firearms and economic and social inequalities. Reducing these risk factors will reduce all types of violence.

Therefore, preventing one type of violence will help prevent other kinds too.

Facts and figures clearly demonstrate the enormous impact of violence on public health and health systems. But, behind these figures are individuals and human tragedies. Violence of all types has a dramatic effect on the lives of the victims, the perpetrators and their families, often for a lifetime and sometimes for several generations. I would like to show you a short film: "The Challenge of Violence". This film illustrates one particular type of violence, child abuse, and how it is intricately linked to other types of violence. It gives us an insight into the consequences of violence encountered in the earliest and most vulnerable years of life.

To begin to tackle the problem of violence, we need to know its magnitude. Contrary to the impression given by the media, the largest number of violent deaths in 2000 was due not to war but to suicide: 815,000 cases - or one suicide every forty seconds. Interpersonal violence accounted for 520,000 deaths: or one murder per minute. There were 310,000 deaths directly due to collective violence.

The data available show that for different types of violence, rates of death vary by country, region and economic level. This map shows homicide rates in the different continents. Homicide rates were highest in Africa, Latin America and Central and Eastern Europe, and lowest in Western Europe and some countries in the western Pacific. Studies show a strong relationship between homicide rates, economic development and economic inequality with poorer countries tending to have higher rates of homicide than wealthier countries.

Among regions, Latin America has the highest homicide rate among young people between ten and twenty-nine years of age, 36.5 per 100 000. Where data are available, some of the highest rates are in Colombia, El Salvador and Puerto Rico.

Suicide rates show a very different geographical distribution to homicide rates. Except for central and eastern Europe which have high homicide and high suicide rates, the highest rates of suicide occur in the regions where homicide is lowest. At the country level, wealthier countries tend to have higher levels of suicide than poorer countries. Low rates of suicide are found in Latin America, notably Colombia and Paraguay.

These data are essential to understanding the issues we face. But currently there is no adequate information on the numbers of people killed by violence in more than half the world’s countries. The numbers we have almost certainly underestimate the true extent of the problem. And, as I mentioned, deaths are only a very small part of the problem.

Non-fatal health outcomes are far more likely, and to count these we must begin by looking at cases reported to health agencies or to the police. But we know that this is only a small proportion of them. Studies from a variety of countries show that for every victim reporting to the police there are at least two more that report only to health agencies. For instance, for every young person murdered, there are at least twenty to forty other young people who receive hospital treatment for a violent injury.

A larger proportion of violence is reported in surveys and special studies. These have shown, for instance, high rates of physical and sexual violence. For example, depending on the country and the study, about one in three women have been physically assaulted by an intimate partner at some point in their lives and sexually abused by a partner in one-third to over one-half of these cases.

In some studies, nearly half of the parents interviewed reported that they had hit, kicked or severely beaten their children.

About 4 - 6% of the elderly report having been abused in their homes by caregivers. Many have also been subjected to abuse in institutions. Large numbers of women and girls have been bought and sold into prostitution or subjected to violence in schools, health care and refugee settings.

A lot of violence never gets reported. Sometimes this is because of fear or shame or because violence is accepted as “normal”. Other times it is due to inadequate reporting and recording systems.

No single factor can explain why one individual, community or society is more or less likely to experience violence. Violence is the result of a complex interaction of factors ranging from the biological to the political. It is essential to understand these factors and how they are interrelated in order to prevent violence and reduce its consequences.

An ecological model organizes the risk factors for violence into four interacting levels:

• Individual-level risks include demographic factors such as age, income and education; psychological and personality disorders, alcohol and substance abuse, and a history of engaging in violent behaviour or experiencing abuse.

• The relationship level examines how families, friends, intimate partners and peers increase the risk of becoming a victim or perpetrator of violence. It takes into account such factors as poor parenting and family dysfunction, marital conflict and friends who engage in violent or delinquent behaviour.

• The community level refers to social settings such as neighbourhoods, schools, workplaces and other institutions. Some characteristics of these settings increase the risk for violence – for example, poverty, high residential mobility and unemployment, social isolation, the existence of a local drug trade, and weak policies and programmes within institutions.

• At the societal level, there are broad factors that help to create a climate that encourages violence. This includes polices that maintain or increase economic and social inequalities; social and cultural norms that support the use of violence; the availability of means (such as firearms) and weak criminal justice systems that do not adequately prosecute perpetrators.

There are several proven and promising strategies for preventing violence at these different levels: • At the individual level, approaches to changing behaviour include pre-school enrichment and social development programmes, as well as vocational training and incentives to complete secondary schooling. These approaches can help ensure academic success, manage anger, and build skills. Similar life-skills and educational approaches around issues of gender, relationships and power, have been used to address physical and sexual violence against women. Effective treatment and counselling can do much to reduce the risk of suicide or the potential for further physical and psychosocial harm associated with other forms of violence.

• At the relational level, some of the most effective strategies are those delivered in early childhood, such as parenting programmes. This involves providing support and advice through home visits in the first three years of a child’s life or family therapy for dysfunctional families. These strategies have yielded reductions in child abuse and violent and delinquent behaviour among young people.

• Measures that can be taken at the community-level include reducing the availability of alcohol, creating extracurricular activities such as sports for young people, improving institutional settings (such as schools, workplaces, hospitals and long-term care institutions for the elderly), and improving health care and access to services.

• At the societal level, accurate public information about the causes of violence, about its risks and how to prevent it, is key to raising awareness and stimulating action. It is equally important to strengthen law enforcement and judicial systems, to implement policies and programmes to reduce poverty and inequalities of all kinds, and improve support for families. It is also important to reduce access to the means of violence and to promote adherence to international treaties. For example, Latin America is a pioneer in the global process of ratifying the Convention on the Rights of the Child. National parliaments have passed laws which have led to official recognition of the role of the family in child care and development.

I would like to close with a quick look at the work around the Report here in this region. Several governments and nongovernmental organizations have rallied around the call to action and joined WHO’s Global Campaign for the Prevention of Violence. In just one year, following the launch of the report, national launches have taken place in Brazil, Colombia, Costa Rica, Ecuador, Honduras, Mexico Nicaragua, Panama, Peru and Puerto Rico. A national report on violence has been released in Costa Rica and Mexico.

One of the report’s recommendations calls for increased collaboration and exchange of information. To this end, I launched the Global Interpersonal Violence Prevention Alliance just two months ago. This alliance brings together partners from around the world with expertise in violence research, training, advocacy and prevention programming. Here in Latin America, there are already many such networks, such as the Inter-American Coalition for Violence Prevention, working to implement the report’s recommendations.

There are also many examples of cooperation among WHO, PAHO and experts in countries throughout the region, including the WHO Collaborating Centre for Violence Prevention in Cali, Colombia, el Centro de Investigaciones de Salud y Violencia. In addition, WHO and UNDP have recently announced their collaboration on a programme to reduce violence involving firearms. This effort, the armed violence prevention programme, will help selected countries in this region to develop policies to address armed violence and to develop and evaluate of violence prevention practices.

In this region and around the world, we are faced with great challenges in violence prevention and the care of those affected by violence. Millions of lives are touched by violence. But we have the knowledge to reduce the harm it does to these lives. WHO is calling for increased political commitment at all levels to reducing violence. Countries should identify a focal point in the government for violence prevention activities. National reports and plans of action should be developed and implemented. Data collection and the provision of services for victims must be prioritized.

The enthusiasm here is great, and the momentum for change is strong. There are many lessons to be learned from your experiences and your progress. I am sure that this workshop will build further upon these lessons.

Here today, by sharing your experiences with me and with each other, you are playing an active part in the global effort to address violence. Thank you for the opportunity to talk to you at this important event. I wish you a very successful seminar.

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