VIOLENCE AND PUBLIC HEALTH: UPDATE

BY

~C. EVERETT KOOP, M.D., SC.D,

PRESENTED BEFORE THE COMMISSIONED OFFICER’S ASSOCIATION
JUNE 17, 1986
WASHINGTON, D.C.
VIOLENCE AND PUBLIC HEALTH: UPDATE

LATE IN THE 1950’S A NUMBER OF REPORTS WERE RECEIVED BY THE
CHILDREN’S BUREAU CONCERNING THE PHYSICAL ABUSE OF CHILDREN BY
PARENTS AND OTHERS RESPONSIBLE FOR THEIR CARE. THEN IN 1961 ONE
OF THE SOCIAL WORKERS OF THE BUREAU BROUGHT TO DR. KATHERINE BAIN
A HANDFUL OF NEWSPAPER CLIPPINGS ABOUT CHILDREN WITH ADULT
INFLICTED SERIOUS INJURIES, SUBSEQUENTLY, IN JANUARY OF 1962 DR,
BAIN ARRANGED FOR A WORKSHOP TO WHICH WERE INVITED 25
PEDIATRICIANS, PSYCHIATRISTS. SOCIAL WORKERS, PUBLIC HEALTH
NURSES, AND JUDGES FROM JUVENILE COURTS. THEIR CHARGE WAS TO
CONSIDER WHAT NEEDED TO BE DONE. FROM THESE SMALL BEGINNINGS
FLOWED MANY OF THE CURRENT ACTIVITIES OF THE PUBLIC HEALTH

SERVICE.

TWENTY-THREE YEARS LATER THE PRESENT SURGEON GENERAL IN AN
EDITORIAL IN PUBLIC HEALTH REPORTS FOR JANUARY/FEBRUARY OF 1986

SAID THIS:
"THROUGHOUT OUR HISTORY, AMERICANS HAVE REMAINED COMMITTED
TO A SOCIAL CONTRACT THAT RESPECTS THE RULE OF LAW, THAT PROMOTES
PEACEFUL INTERCOURSE AMONG CITIZENS AND THAT HAS AS ITS HIGHEST

VALUE THE PROTECTION OF HUMAN LIFE.”

I FURTHER NOTED THAT EACH YEAR MILLIONS OF AMERICANS BECOME
THE VICTIMS OF VIOLENCE AND RECOGNIZING THAT VIOLENCE AFFECTS
PUBLIC HEALTH IN A PROFOUND MANNER, I HAD CONVENED A WORKSHOP ON
VIOLENCE AND PUBLIC HEALTH IN LEESBURG, VIRGINIA IN OCTOBER OF

1985,

BETWEEN THAT INITIAL ACTION OF DR. BAIN’S AND THE FINAL
ACTION OF MINE IN LEESBURG, I HAD MADE A CONCERTED AND
PROGRESSIVE EFFORT TO CALL ATTENTION TO VIOLENCE AS A PUBLIC

HEALTH ISSUE.
FIRST, I TALKED TO THE PEDIATRICIANS, STRESSING THAT THEY
WERE THE ONES THAT COULD PICK UP AGRESSIVE BEHAVIOR IN YOUNGSTERS

AND PERHAPS PREVENT VIOLENT BEHAVIOR LATER ON,

THEN I TURNED TO THE PSYCHIATRISTS, AND SUGGESTED THAT IT

WAS THEIR OBLIGATION TO DO THE NECESSARY BEHAVIORAL RESEARCH,

THE RESPONSE OF PEDIATRICS AND PSYCHIATRY HAS BEEN
ENCOURAGING AND PROGRESS CONTINUES TO BE MADE IN BOTH OF THOSE

FIELDS.
T NEXT TURNED TO THE TELEVISION INDUSTRY AND SUGGESTED THAT
THE TIME HAD COME TO STOP CRITICIZING EACH OTHER'S RESEARCH AND
TO WORK TOGETHER TO FIND OUT WHY PEOPLE WERE ATTRACTED TO
VIOLENCE IN THE FIRST PLACE. THAT LEAD TO ENCOURAGING DIALOGUE
WITH THE TOP BRASS OF ALL THE MAJOR NETWORKS AND INDEED THEY
APPOINTED ONE OF THEIR NUMBER TO BE ON THE PLANNING COMMITTEE FOR
THE LEESBURG WORKSHOP,

T WANT TO CONVEY TO YOU THE SERIOUSNESS WITH WHICH WE, IN
THE UNITED STATES PUBLIC HEALTH SERVICE, LOOK UPON THIS
PHENOMENON OF FAMILY VIOLENCE. AND SECONDLY, I WOULD LIKE TO
INDICATE WHAT THE ROLE OF THE HEALTH AND MEDICAL PROFESSIONAL
IS -- AND MIGHT BE -- IN PROTECTING OUR CITIZENS FROM VIOLENT

INJURY AND DEATH IN THEIR OWN HOMES.
FIRST OF ALL THE PUBLIC HEALTH COMMUNITY HAS BEEN KEPT
APPRISED OF THE OVERALL ISSUE OF VIOLENCE THROUGH THE
RECORDKEEPING OF THE NATIONAL CENTER FOR HEALTH STATISTICS, THE
TABLES AND CHARTS PRODUCED BY THE CENTER OVER THE PAST 25 YEARS
HAVE PROVIDED US WITH SOME MEASURE OF THE DEGREE OF CARNAGE

OCCURRING AMONG OUR PEOPLE.

I‘M SURE YOU HAVE HEARD OVER AND OVER AGAIN THAT THE LARGEST
NUMBER OF VICTIMS ARE THOSE WHO SHOULD BE VALUED THE MOST BY OUR
SOCIETY: THESE ARE OUR CHILDREN AND OUR YOUNG ADULTS AGE 15-24,
AND THOSE WHO BEQUEATH TO US THE MIRACLE THAT IS AMERICAN SOCIETY

OUR PARENTS, OUR SENIOR CITIZENS,
THESE STATISTICS TELL A VERY DISTURBING STORY. HOWEVER,
INCIDENTS OF FAMILY VIOLENCE ARE CONSTANTLY UNDER REPORTED. AS
DISTURBED AS WE MAY BE ABOUT THE DATA WE HAVE. THE TRUE PICTURE
IS DECIDEDLY WORSE, OUR REPORTING SYSTEMS FOR CHILD ABUSE, FOR
EXAMPLE, ARE YIELDING UPWARDS OF 800,000 REPORTS A YEAR. YET
EVERY OTHER INDICATOR WE HAVE -- ASIDE FROM STATISTICS -- TELLS
US THAT THE TRUE UNIVERSE OF INCIDENTS IS AT LEAST 2 MILLION AND

MAY BE CLOSER TO 4 MILLION,

THE SAME IS TRUE FOR THE NEWEST TYPE OF VIOLENCE. - ELDER
ABUSE. EACH YEAR WE NOW RECEIVE ABOUT 1,300 REPORTS OF HOMICIDES
INVOLVING VICTIMS WHO ARE AGED 65 OR OLDER. BUT ACCORDING TO A
SURVEY BACK IN 1980, AN ESTIMATED ONE MILLION CASES OF ELDER
ABUSE OCCUR EACH YEAR AND, OF COURSE, THE NUMBER HAS CLIMBED

SINCE THEN,
FORTUNATELY, NOT ALL OF THEM END IN HOMICIDE, BUT THE
DIFFERENCE BETWEEN THESE TWO FIGURES, 1,300 AND ONE MILLION, IS
MUCH TUO GREAT TO LEAVE US COMFORTABLE WITH OUR DATA. IN FACT,

WE ARE NOT.

DOMESTIC VIOLENCE IS A CATASTROPHE THAT CAN STRIKE ANY
AMERICAN FAMILY, REGARDLESS OF SOCIAL OR ECONOMIC STATUS, OR

RACE. OR ANY OTHER QUALIFICATION.

RESEARCH INTO FAMILY VIOLENCE AND ITS ORIGINS MOVES STEADILY
APACE IN ACADEMIA AND IN OUR OWN NATIONAL INSTITUTE OF MENTAL

HEALTH, 1 TAKE THAT AS A VERY HOPEFUL SIGN FOR THE FUTURE,
HOWEVER. I AM CONVINCED THAT WE NEED TO FOCUS AT LEAST PART
OF THE SPOTLIGHT BACK UPON THE HEALTH AND SERVICE PROFESSIONS
THEMSELVES, THE REASON, I BELIEVE, IS COMPELLING ENOUGH, WE’VE
GOT TO LEARN MORE ABOUT THE PEOPLE WHO -- BY THE NATURE OF THEIR
PROFESSIONS -- ARE ON THE VERY FRONT LINE OF THE PREVENTION AND
CONTROL OF FAMILY VIOLENCE. AND I’M SURE I’M SPEAKING TO SOME OF

YOU WHO FIT THIS DEFINITION OUT THERE,

HOWEVER SWIFTLY WE DO THIS -- AND WE ARE MOVING AHEAD WITH
ALL DELIBERATION -- WE ARE STILL COMING TO THIS PROBLEM LATE,
THERE IS AMPLE EVIDENCE INDICATING THE PROFOUNDLY LOW LEVEL OF
UNDERSTANDING OF VIOLENCE AMONG FAMILY PHYSICIANS, REGISTERED AND
PRACTICAL NURSES, AND -- A CRITICALLY IMPORTANT GROUP -- AMONG
HOSPITAL EMERGENCY ROOM PERSONNEL. I SAY THAT BECAUSE OF

SPECIFIC KNOWLEDGE FROM SEVERAL SOURCES,
ONE EXAMPLE IS THE FIVE YEAR STUDY OF EMERGENCY SERVICES IN
YALE -- NEW HAVEN CONDUCTED BY DRS. FLITCRAFT AND STARK. THEY
FOUND THAT 18.7 PERCENT OF WOMEN ADMITTED AS PATIENTS TO A LARGE
METROPOLITAN EMERGENCY ROOM HAD MEDICAL HISTORIES CLEARLY
INDICATING THAT THEY HAD BEEN BATTERED OR STRONGLY SUGGESTING
THAT THEY HAD BEEN BATTERED, HOWEVER, THE ATTENDING EMERGENCY
ROOM PERSONNEL ACTUALLY CLASSIFIED ONLY ONE PERCENT AS ABUSED
WOMEN AND SIMPLY IDENTIFIED THE OTHERS As TRAUMA VICTIMS, EVEN
IF WE ARE GENEROUS AND ALLOW FOR SOME CONFUSION. FOR SOME
MISREADING OF THE RECORD DURING THE TURMOIL THAT IS
CHARACTERISTIC OF A TYPICAL DAY IN ANY EMERGENCY ROOM, WE STILL
COME AWAY FROM THAT STUDY WONDERING WHAT BECAME OF THE OTHER 17
PERCENT OF ADMITTED WOMEN -- THE ONES WITH RECORDS THAT SOUND

VERY MUCH LIKE BATTERINGS,
-10-

THIS IS PROBABLY ANOTHER INSTANCE OF PEOPLE “FALLING THROUGH
THE CRACKS.” THAT POSSIBILITY WEIGHS HEAVILY UPON MY

PROFESSIONAL CONSCIENCE,

THERE ARE MANY OTHER THINGS THAT CAME OUT OF THAT YALE STUDY

WHICH WOULD WARRANT YOUR FURTHER INTEREST,

UNFORTUNATELY, THE INFORMATION THAT I HAVE JUST RECOUNTED
ABOUT MEDICAL INSENSITIVITY TO BATTERED AND ABUSED WOMEN CAN BE
REPEATED CONCERNING ABUSED AND NEGLECTED CHILDREN AND BATTERED

ELDERLY PERSONS AS WELL,
- jl -

T AM TRYING TO EXPLOIT EVERY MEETING WITH OUR COLLEAGUES IN
ACADEMIA TO RAISE THEIR LEVELS OF CONSCIOUSNESS IN THESE
MATTERS. IT IS THEY WHO CAN, AND OBVIOUSLY DO, INFLUENCE THE
THINKING OF STUDENTS ABOUT TO EMBARK UPON CAREERS IN MEDICINE AND
THE HEALTH CARE PROFESSIONS, THESE SAME FACULTY MEMBERS CAN ALSO
INFLUENCE THE CONDUCT OF PATIENT CARE IN OUR GREAT UNIVERSITY

AFFILIATED HOSPITALS AND MEDICAL CENTERS,

OF COURSE, OUR MESSAGE IS NOT CONFINED TO EMERGENCY
SITUATIONS ONLY. IT IS MY FEELING THAT WHEN A PHYSICIAN OR OTHER
HEALTH PROFESSIONAL SUSPECTS THAT A PATIENT MAY BE PREDISPOSED TO
VIOLENT BEHAVIOR, THAT PATIENT SHOULD BE GIVEN THE SAME KIND OF
COUNSELING OR REFERRAL HELP THAT WOULD BE GIVEN TO THE PATIENT

WHO PRESENTS THE SYMPTOMS OF DIABETES, CIRROHSIS OR
-|]2-

CARDIOVASCULAR DISEASE. IT MIGHT EVEN BE POSSIBLE TO INVOLVE
OTHER MEMBERS OF THE PATIENT'S FAMILY IN THIS COUNSELING PROCESS

-- A SPOUSE, A PARENT, AN OLDER CHILD,

WE NEED TO GIVE OUR BEST PREVENTIONAL STUDY AND ATTENTION TO
THIS AREA OF SERVICE. THE OBJECTIVE IS NOT TO INTERVENE IN A
PATIENT’S PRIVATE FAMILY LIFE FOR INTERVENTION’S SAKE, BUT TO
PREVENT VIOLENT BEHAVIOR FROM OCCURRING AND ENDANGERING THE
HEALTH OR LIFE OF ANOTHER, 1 RECOGNIZE THAT MANY PHYSICIANS
DON’T AGREE WITH MY ASSESSMENT OF THEIR ROLE. THEY OBJECT TO
WHAT I HAVE SAID AS BEING ANOTHER EXAMPLE OF THE MEDICALIZATION
OF SOCIAL PROBLEMS, I FULLY APPRECIATE THE UNEASINESS FELT BY
MANY PHYSICIANS AND OTHER HEALTH PROFESSIONALS WHEN SOCIETY
CASUALLY ASKS MEDICINE TO SOLVE WHAT MAY SIMPLY NOT BE A HEALTH
-~ 13 -

OR MEDICAL PROBLEM, BUT WITH VIOLENCE, I THINK THERE IS A
DIFFERENCE, MEDICINE DOES HAVE A CONTRIBUTION TO MAKE AND WE

SHOULD BE BOUND, IN ALL GOOD CONSCIENCE, TO MAKE IT,

EVERY ABUSED CHILD WE SEE IN AN EMERGENCY ROOM REPRESENTS

ANOTHER FAILURE FOR US,

EVERY BATTERED WOMEN GIVEN SHELTER BY NEIGHBORS OR RESCUED

BY POLICE REPRESENTS THE FAILURE OF COMMUNITY RESOURCES,

EVERY ELDERLY PERSON WHO IS BEATEN OR OTHERWISE ABUSED BY
ADULT CHILDREN OR BY VIOLENCE~PRONE GRANDCHILDREN, - EACH ONE IS

ANOTHER INDICATION THAT WE HAVE FAILED.
- [4 -

WE NEED TO BREAK THE CYCLE OF VIOLENCE THAT ENTRAPS SO MANY
PEOPLE, WOMEN IN PARTICULAR, WHAT WE MUST REALIZE IS THAT WE ARE
LOOKING AT A THREE GENERATIONAL PHENOMENON, THE ELDERLY PERSON
WHO IS MOST OFTEN THE VICTIM OF ABUSE IS A WOMEN 75 YEARS OF AGE
OR OLDER, THE PERSON ABUSING HER IS HER OWN MIDDLE-AGED DAUGHTER.
AND IT IS VERY LIKELY THAT THE MOTHER HAD ABUSED THE DAUGHTER IN
SOME LASTING, UNFORGETTABLE WAY. THE CHANCES ARE ALSO GOOD THAT

THE DAUGHTER HAS ABUSED HER OWN CHILDREN AS WELL.

BECAUSE OF THAT GRISLY CYCLE, WE IN PUBLIC HEALTH ARE
COMPELLED TO LOOK UPON OUR ULTIMATE GOAL AS PREVENTING VIOLENCE

FROM TAKING PLACE,

LET ME CLOSE THIS PRESENTATION IF I MAY WITH THIS

OBSERVATION,
- 15-

WHEN I ASSUMED THE OFFICE OF SURGEON GENERAL, IN LATE 1981,
I WAS CONCERNED THAT VIOLENCE AS AN ISSUE OF PUBLIC HEALTH WAS
NOT GENERALLY RECOGNIZED EITHER INSIDE OR OUTSIDE OUR
GOVERNMENT, EXCEPT FOR THE WORK BEING DONE IN THE NATIONAL
INSTITUTE OF MENTAL HEALTH, VIOLENCE WAS LEFT TO LAW ENFORCEMENT

AND THE COURTS.

AND CERTAINLY THE CRIMINAL JUSTICE SYSTEM DOES PLAY A MAJOR
ROLE IN CONTROLLING THE VIOLENT ELEMENTS WITHIN OUR RESPECTIVE
SOCIETIES. BUT THAT IS AFTER THE FACT. THE POLICE AND THE
COURTS ARE SOCIETY'S MECHANISM FOR MAKING SURE THAT VIOLENT
ACTIONS DO NOT OCCUR AGAIN, BUT THEY ARE OF VERY LIMITED USE FOR

MAKING SURE THAT VIOLENCE DOES NOT OCCUR IN THE FIRST PLACE.

FOR THE PREVENTION OF VIOLENCE WE MUST TURN TO OUR SOCIAL
AND COMMUNITY SERVICES, IN PARTICULAR, I BELIEVE, TO OUR PUBLIC

HEALTH SERVICES,
- l6-

HENCE, VIOLENCE -- WHEREEVER IT OCCURS, ON THE STREETS -- ON
TV -- IN SCHOOLS -- IN OUR HOMES -- VIOLENCE AS A POTENTIAL
THREAT TO INDIVIDUAL, FAMILY, AND COMMUNITY LIFE. IS VERY MUCH AN
ISSUE OF PUBLIC HEALTH, VIOLENCE HAS BECOME INTEGRATED INTO THE
AGENDA OF THE UNITED STATES SURGEONS GENERAL IN THIS CENTURY IN
THE WAY THAT SMALLPOX, TUBERCULOSIS. AND MALARIA WERE THE BIG
ISSUES FOR MY PREDECESSORS IN THE PREVIOUS TWO CENTURIES. THERE
IS, OF COURSE, NO MAGIC VACCINE TO USE WITH PERSONS WHO ARE PRONE
TO COMMITTING VIOLENCE. NEVERTHELESS, WE ARE BEGINNING TO LEARN
HOW TO IDENTIFY THOSE PERSONS -- AND THE PEOPLE WHO ARE THEIR
VICTIMS -- AND I BELIEVE THAT WE WILL SEE VIOLENCE REDUCED TO THE
DIMENSIONS OF TUBERCULOSIS -- NOT YET WIPED OUT, BUT EVENTUALLY,

FINALLY UNDER CONTROL,

THANK YOU,