Abstract
In recent weeks, the issue of knife crime, street violence and accompanying sudden death, especially of young people, has gathered momentum and even displaced the vexed issue of Brexit from media headlines. By March 2019, there had already been over 100 killings in the UK, including 41 stabbings and the Conservative Party’s reputation as the ‘Party of Law and Order’ was under threat. After years of treating such events as moral failings demanding a policing and criminal justice response, the drumbeat has become the need for a public health approach and to respond accordingly. So what does this mean in reality and in practice?
In reality, violence has for many years been a leading cause of death and disability around the world. There was a historic lull in the toll after World War II, but following the Columbine mass school shootings in the United States in 1999 and a succession of subsequent tragedies together with the terrorist attacks on the World Trade Centre in New York in 2001, the world has become used to a new phenomenon in mass terrorism and civilian casualties. Gang-related homicides, so long ubiquitous in the narcotic growing areas of South America, have now penetrated both urban and rural areas in developed and developing countries alike; most recently, we have become used to talk of ‘County Lines’ in which young people are exploited as drug mules to create supply chains which radiate out from our towns and cities into the remotest country areas. They are often accompanied by grooming, by rituals of gang membership with their own ‘rites of passage’ and, all too frequently, injury and death. In Public Health Disaster parlance, it is still not clear whether we are dealing with a ‘big bang’, a ‘slow burn’ or a ‘rising tide’. Some are suggesting that it is a fashion which will prove as ephemeral as Teddy Boys, Skinheads or Punk. What we know from the historical and sociological study of such diverse moral panics as the ‘Dancing Manias of the Middle Ages’ as described by Justus Hecker and the battles between police and the Mods and Rockers at Clapton in the 1960s as described by Stan Cohen, is that amplification occurs as an outcome of the complex interaction of economics, the social climate of the times and the reaction of the institutions of the state including the media.
The current popular refrain for a public health response is being linked to recent efforts in Glasgow which seem to be having some impact. However, the roots of this approach can be traced to systematic work in Cali, Colombia over the past 30 years. Faced with a horrendous toll of over 1000 drug-related homicides each year, the Mayor of Cali, public health professor Rodrigo Guerrero and his colleague Dr Alberto Concha-Eastman adopted a classical public health model based on an understanding and detailed mapping of time, place and person with appropriate interventions to match; a whole-systems approach of extensive partnerships backed up by effective law enforcement and trust-building with the police. Based on the collation of good-quality epidemiological data, this included restriction of alcohol sales in the affected neighbourhoods and access to weapons, police surveillance and enforcement using 24-hour courts, tackling organised crime, together with a holistic approach to poverty reduction, increased educational and employment opportunity, and the mobilisation of communities including, in particular, the mothers of young men, fearful that their son would be next in the mortuary.
Concha-Eastman 1 proposed a model that subsumed all these interventions within a framework of the structural factors – socioeconomic inequality, poverty, corruption, demographic change, erosion of ethical values, human rights violations, political instability and rapid urbanisation; institutional factors – negative attitudes towards institutions, lack of confidence in the police and judicial systems, poor educational opportunity, lack of sound parenting and family breakdown; and facilitating or direct factors including alcohol and drugs, domestic violence, access to weapons and the role of the media in propagating and glamourising violence. For Concha-Eastman, having passed through two phases in which violence was first seen as a matter for the police and judiciary and, second, one which increasingly identified its multifactorial nature, we are now at a stage which requires stronger community organisation and participation linked to whole-systems action.
Is it asking too much to learn from our colleagues in Cali who have achieved impressive results by adopting this approach with homicides being reduced from 100/100,000 to 47.3/100,000 between 1995 and 2001? (Rodrigo Guerrero, personal communication).