Violence and Public Health: Delivered to the American Academy of Pediatrics, New York City, New York
During his two terms as U.S. Surgeon General, Koop applied public health methods and approaches, namely epidemiological study,
disease prevention strategies, and information on health promotion, to several issues that had not previously been regarded
as matters of public health. Violence, especially domestic violence, was one such issue, as this speech--one of his first
on the issue--demonstrated. Long treated as the domain of law, law enforcement, and criminology, the "epidemic of violence"
in the United States, as Koop called it, produced a range of physical and psychological health consequences that he explored
in speeches, workshops, and reports. He also thought that violence, particularly domestic and sexual violence, could be prevented
through appropriate health messages, health education, and psychological screening and counseling.
Number of Image Pages:
20 (1,345,621 Bytes)
1982-10-26 (October 26, 1982)
Koop, C. Everett
This item is in the public domain. It may be used without permission.
Medical Subject Headings (MeSH):
Reproduction and Family Health
"Violence and Public Health: Delivered to the American Academy of Pediatrics, New York City, New York" [Reminiscence]
"Violence and Public Health" (draft) (October 26, 1982)
Surgeon General and Deputy Assistant Secretary for Health
Delivered to the American Academy of Pediatrics
New York, New York
October 26, 1982
(Greetings to hosts, guests)
The Academy has had 35 annual meetings since the day I sat with 7 other surgeons in Atlantic City and founded the surgical
section. Of the meetings since then -- I've attended two-thirds. Of the 7 surgeons, 5 have died.
I'm still here . . . and it is always a comfortable occasion coming back to be with you. In a sense, it's like a homecoming.
It provides another opportunity for me to say "thank you" once again to the Academy for giving the pediatric surgeons
a haven, a pulpit, and a future.
I appreciate this opportunity to speak to you this morning on a subject that is uncomfortable to raise: violence as a public
health concern. It is uncomfortable because, when we do raise that issue, we are really admitting that mankind still has quite
a distance to travel in its long march toward civilized living.
I'm not limiting my remarks just a child abuse this morning. Rather, this is a call to action on your part -- individually
and collectively -- to address this issue of violence by discussion, study, and research.
We've got to do this because violence has grown to become one of the major public health problems in American society
today. It is not new, of course. Violence of some kind -- murder, suicide, assault, armed confrontation of neighbor against
neighbor -- these have appeared in our national history since the 17th century. In the past 80 years or so, as we improved
our ability to collect vital statistics, we have been able to identify periods when there were changes in the incidence of
morbidity and mortality caused by violence. We are coming through just such a period now.
Violence in this country surged in the late 1960s and into the 1970s. All the indicators went up. But the toll upon young
people -- preschoolers, early adolescents, and young adults -- has been particularly high. The mortality rates have risen
during this period and there seems to be little likelihood that they will return to the levels of the 1950s and early 1960s.
Let me isolate the recent mortality history just for 15-to 24-year-olds in three different areas of trauma and violence:
In motor vehicle fatalities, the death rate per 100,000 of this age group in 1960 with 38. In 1970 it hit its peak of 47.2.
By 1978 it had abated only slightly to 46.4. That is the history for all men and women ages 15 through 24. Among white males
the numbers are far worse: from a 1960 rate of 62.7 to a 1978 high of 75.4 deaths per 100,000 -- nearly twice the rate for
the entire age cohort. One-half of the fatalities are caused by the combination of driving and drinking. We can do something
The story in homicide is the same. From a 1960 low of 5.9 murders per 100,000 men and women aged 15 to 24, to a rate of 11.7
by 1970, and to a high of 13.2 in 1978. The carnage among black males, however, is particularly alarming: from a rate of 46.4
deaths by murder in 1960 to a high of 102.5 a decade later, and then down to a homicide mortality rate of 72.5 in 1978.
In suicide, my third and last example, the mortality rate for men and women ages 15 through 24 rose from 5.2 in 1960 to a
peak of 13.6 in 1977 and then dropped slightly to 12.4 in 1978. The story among white males bears some study: their rate has
been 8.6 back in 1960. It then rose in virtually a straight line to a level of 20.8 in the latest year we have, 1978.
Motor vehicle accidents . . . homicide . . . suicide . . . these violent death categories now have new and higher death rates
per 100,000 population in almost any grouping of persons between 1 year and 24 years of age. I picked the 15-to-24-year-olds
not only because their mortality trends are so clear or because they are about to cross the threshold to adulthood and become
the workers and voters and leaders of this country. They are also the products of the pediatricians' efforts in the preceding
decade and a half. If, of course, they have survived.
Something happened in this country about a decade or so ago. Or maybe we should say some things, since no single cause or
event could be responsible for results so widespread, so pervasive, and so destructive. And it may be too soon for us to know
with any certainty what those things were. We may not yet have the historic distance. The detachment, to come to any reasonably
sound conclusions. But we still must try to understand, even with our contemporary myopia, just what has been happening and
why -- and what the effects seem to be upon the American people. I am, by specialty and training, not a social historian.
It is my job to monitor the health status of the American people. If I said something wrong, I am obliged to bring it out
into the open and talk about it.
And that's precisely what I'm doing right now.
Rather than resurrect much of the literature of violence, with which many of you may be familiar anyway, I want to take a
few careful steps forward to see what the role of the physician might be in understanding and possibly preventing the loss
of life -- millions of years of life -- through these violent premature deaths.
I have chosen this particular occasion because, of all physicians, I believe the pediatrician has a unique relationship with
children and with parents. You gain certain insights about individuals and families that other physicians may not have the
chance to see.
I base that opinion, by the way, on the reflections of my own career of 35 years of pediatric surgery. Dealing with the young
children who were my patients I saw firsthand the stresses of childhood and was aware of both the strengths and weaknesses
of children trying to cope. I also had to understand the families of those children. I had to gain their confidence and win
them as allies in the battle to help their children.
In the process, I think I began to understand a great deal about the contemporary American family.
I tried to absorb that information and then focus it upon the problem to be solved by surgery. Sometimes, when it is clear
to me that I was gaining insights into a serious family problems not directly related to the surgery, I would be open and
available for that family, just in case they wanted to talk it through. But I knew that I lacked a clear understanding of
the need for me to become involved and to what extent I should become involved and what I might hope to accomplish.
Now, after looking at the data from my new vantage-point as Surgeon General, and appreciating the special access to -- and
relationship with -- the American family that pediatricians do enjoy, I think my message to you today on violence in our society
and its effects on children and families is appropriate and necessary.
Let me propose as a starting-point the proposition that physicians need to become more familiar with the symptoms of violent
personality in child and parent alike. Unfortunately, we don't have available some stock, off-the-shelf profiles of persons
who are disposed toward violence. But the research literature does provide us with some clues that seem sturdy enough to follow.
For example, according to the work done by Dr. Dorothy Otnow Lewis of the NYU School of Medicine, homicidally violent children
also tend to have a history of attempted suicide. Many of them have a history of psychomotor seizures. Their fathers are usually
characterized as "very violent," particularly to the mothers. These children also tended to have mothers who at some
time had to have inpatient psychiatric care. Other studies indicate that violent adolescents had seen severe physical abuse
occur at home or were themselves the victims of family violence.
High-risk families also tend to be socially isolated from their neighbors. This is the case across all social, racial, and
economic lines. Such families lack strong friendships. They can't seem to get close to other families, particularly families
that do not show evidence of stress or violent behavior. High-risk families have difficulty coping with pressures outside
their own home -- pressures on the job or pressures while looking for a job, or the internal pressures that may build up while
trying to negotiate such social transactions as shopping or using public transportation. Such families also have difficulty
coping with stress inside their own homes: children making noise . . . loud radios, television sets, or stereos . . . and
a whole range of marital upsets, including those produced by alcohol and drugs.
We know that violence within the family -- particularly parental violence toward children -- tends to escalate during periods
of economic stress. Indebtedness . . . lack of work . . . eviction . . . layoffs . . . repossessions . . . these are the stuff
of trauma for many families. They can overwhelm parents and open them to the terrible impulses of violence against each other
and against their children. In some areas of the country we are experiencing very difficult economic conditions and, if the
research and the anecdotal material we have is any guide, those areas are also experiencing a rise in family violence.
These may show up in marks on battered spouses and abused children. They are never well explained. The victims are often embarrassed,
evasive, or simply tight-lipped. The physician needs to understand how to "read" those intensely personal and human
signals of the victim of family violence.
I spent some time on the family because of its overwhelming influence in the shaping of individual behavior. Educational research
has demonstrated again and again that a family environment that supports study and learning, that rewards the child that is
successful in school, will produce children who do well in school and in life later on, all other things being equal.
And the reverse is true, also. A family environment that is cruel and uncaring will send cruel and uncaring children into
the world as aggressive, violent adults. These are not hard-and-fast rules. Human beings are not pigeons and don't fit
into neat, consistent pigeonholes. But the weight of experience and evidence does indicate that some signals, such as the
ones I mentioned, ought to be noted and respected by the physician.
The physician, suspecting that a patient may be predisposed to violent behavior, should provide the same kind of counseling
or referral service as if the patient showed a predisposition to cardiovascular disease, obesity, or diabetes. With the patient's
consent, it may be possible to involve a spouse or child in the discussion of this health problem. This is a sensitive area
and we need to give it our professional study and attention in order to provide guidance to pediatricians and other primary
care physicians. The objective, let me repeat, if not to intervene into a patient's private family life for intervention's
sake but to prevent violent behavior from occurring and endangering the health or the life of another.
I recognize that not all physicians would agree with that assessment of their role. They would object to it as being yet another
example of the "medicalization of social problems." And I fully appreciate the uneasiness felt by many physicians
and other health professionals with society's habit of casually turning to medicine to solve what may simply not be a
health or medical problem. But with violence, I think there is a difference.
This point was also made at a workshop held last summer by the Institute of Medicine. The subject was the prevention of violence.
On this matter of the "medicalization of violence," the participants made several good points, which I will summarize:
First, there seems to be no other institutional focus for research into the causes of violence that takes into account the
multiple biological, psychological, social, and societal dimensions of crime, its victims, and its prevention. The institutions
closest to being able to provide a multidisciplinary approach to research in the prevention of family violence, for example,
would be the National Institute of Mental Health and the National Institute of Child Health and Human Development.
Second, the National Institute of Law Enforcement and Criminal Justice, the research arm of the Justice Department, sees "prevention"
as a way of stopping a recurrence of a criminal act. In effect, the Justice Department does not have what would be in our
discipline of medicine a "primary prevention" strategy. And on reflection, one would have to admit that such a strategy
under the criminal justice system could very well come in conflict with traditional civil liberties.
And third, the workshop participants agreed that the morbidity and mortality from violence are extremely costly to society
not only in productive years lost but in the hard dollar terms of the impact upon the health care system. This is particularly
true in the cases of abused children, who frequently have chronic disabilities even after treatment. Young women who have
been sexually abused by family members frequently develop chronic illnesses requiring repeated inpatient psychiatric care.
They also make increased use of gynecological health services, as their total personal health status declines.
We might not want this very complicated issue to gravitate toward medicine for answers, but I believe we need to accept the
fact that we may have a contribution to make. I believe that we do and we are obligated to make that contribution.
In addition to learning more about the issue of violence and how it manifests itself in patient behavior, I believe physicians
need to see themselves as capable of prescribing some rudimentary, preventive behavior for such patients. This may be more
easily proposed than done, but I think it's time we looked at this as a serious aspect of pediatric and family practice
for contemporary American society.
I spoke before of seeing patients with predispositions toward violence as needing our help, as if they were patients predisposed
to hypertension. As physicians, we do not hesitate to counsel patients to avoid salt and salted foods or to avoid simple sugars.
And I think we all would agree that there is a profound difference between advising a patient to avoid sugar -- and advocating
that the government remove all sugared products from the marketplace. The former is good medical practice . . . the latter
is bad government.
Similarly, if we have a patient with a predisposition for violent behavior, especially against family members, I think we
need to advise that patient to get some professional counseling and also suggest that he or she monitor their entertainment
"menu" and avoid the kinds of television or motion picture fare that stimulates and contributes to the violence in
their personalities. I don't like the violence in so-called "entertainment" shows today, but I do not believe
the answer is government censorship. That does not leave me powerless as a physician, however. I believe it would be completely
within the canons of my profession to advise patients predisposed to violence to self-censor their entertainment diet.
I don't know how many times the government has to come out with yet another study of television violence to make the point
that it is harmful to children. There has been an interminable amount of bean counting to quantify the obvious:
- Children spend at least two hours and a half in front of a TV set each day . . .
- Many of today's high school graduates will have spent more their lives in front of the TV set than in the classroom
. . .
- By the age of 18 a young person could have witnessed over 18,000 murders on television. This does not count the documentation
of violence there seems to be in every TV news report . . .
- Adults spend about 40 percent of their leisure time watching television, which ranks third -- between sleep and work --
as an occupier of an adult's average day.
Last year the California Commission on Crime Control and Violence Prevention considered these and other facts and concluded
that there is a relationship between the violence that is televised and the violence that takes place in the "real world."
Not only are the specific details of a fictional crime reenacted by viewers -- often young children or adolescents -- but
there is a strong suspicion that the aggressive behaviors by the "heavies" on television are mimicked by viewers also,
whether consciously or unconsciously, in a variety of relationships and settings.
This is directly related to another potential result from extensive viewing of television or motion picture violence: we begin
to believe that violence is a socially acceptable and credible way of responding to frustration or insult or some other direct,
personal hurt. And frequently, violent behavior that stops just short of murder seems to go unpunished. Children especially
become "desensitized" to violent interpersonal conflict and, when seeing another child being hurt, will tend not to
do the thing the civilization requires be done -- step in and protect the victim. Instead, they will watch, as if this too
were dramatized entertainment.
I have not mentioned video games because I don't want to duplicate what another speaker on your program may present. Also,
we are just beginning to assess the data. But I do know these games are not constructive. Whether they show soldiers or space-craft
or men from Mars or just from "the other side," the zap them -- and that means annihilation.
It seems to me that the weight of evidence -- whether it has a solid research base or is purely anecdotal -- the weight of
evidence strongly suggests that physicians ought to recognize that a diet of violent entertainment for the violence-prone
individual is as unhealthy as a diet of sugar and starch is for the obesity-prone individual.
I have indicated the need for physicians to recognize the signals of the violent personality and the violent home and I have
suggested that there are some things we can "prescribe," such as a lower intake of violent entertainment. These are
ways of responding to the phenomenon of violence as we see it develop or deal with its aftermath. But there are things we
ought to do, as physicians, that are proactive, as well as reactive.
What task we have is to put the full weight of our profession on the side of strengthening positive, healthy family life in
this society. In this matter of violence, as in other matters, we tend to look all about for other palliatives . . . magic
potions of one sort or another, real or figurative . . . exotic therapies . . . all sorts of diverting possibilities keep
cropping up. But that's what they are -- diverting. We need to return to the business of holding the family together,
the fundamental, irreducible social unit.
I believe that it is primarily and substantially within the limited physical and emotional space occupied by the family --
its "home" -- that one human being can get used to the work of loving and truly caring about the welfare of another
human being. Of course, we know that the reverse is true, also. But the family violence we talk about is the exception to
the human rule. We need to deal with those exceptions. But, in doing so, we must not cut adrift healthy families or Mark constant
support and attention.
The family relationship is rich -- but it is also fragile. Physicians providing family care and concerned about the maintenance
of peace as well as of health and the family, needs to understand the influence of work -- or the influence of the lack of
work -- upon family members . . .
Also understand the symbolism of material goods, which are supposed to convey a sense of well-being for the family but rarely
do all by themselves . . .
And also understand the healthy ways in which people grow up and grow old, and the possibility that some families face their
own aging with anger and fear.
This is a very difficult request to make of any physician. Most have not been trained in these areas which tend to be more
the province of the sociologist, the psychiatrist, psychologist, or the social services worker. The work of sociologists Murray
Straus of the University of New Hampshire and Richard Gelles of the University of Rhode Island tend to be unknown among physicians,
yet Strauss and Gelles are among the leading researchers in the field of family violence.
Physicians tend to be unclear about the roles of these and other professionals. Communication between the practitioners of
physical medicine and those who practice other disciplines tends to be limited and unclear. Physicians are also generally
unfamiliar with the education and training of personnel engaged in the delivery of social services. Nor are they always aware
of the similarity of ethical imperatives shared by both medicine and the social services.
Because of this, physicians -- especially those in private practice -- tend not to refer patients as often as they should
nor do they seek the counsel of social service professionals when a possible incident of family violence comes to their attention.
This may be a problem now, but I believe it will be less of a problem in the future, as physicians become more familiar with
the total constellation of research and service becoming available for the protection of victims of family violence. Let me
note just one example where we are making some progress. This is the work of Dr. Eli Newberger at Boston Children's Hospital.
Dr. Newberger is a pediatrician and editor of a new book on Child Abuse for the Little, Brown Series on Clinical Pediatrics.
With the support of the National Institute of Mental Health, he has been carrying out a program of interdisciplinary training
and research in the detection and treatment of victims of family violence. In this program, Dr. Newberger brings together
a group of professionals on the staff of Boston Children's Hospital. They include pediatricians, social workers, researchers,
psychologists and psychiatrists, sociologists, and computer analysts.
Working as a team, they provide hands-on clinical care for children who have been abused. They also seek to understand the
causes of the violence within the family, to prevent it from recurring. The result is a program that draws upon a variety
of skills right at the time they are needed most. The program generates new information regarding family violence and this
new information, plus other research data, are translated into direct patient care.
These are the kinds of projects that benefit not only the immediate persons under care, but can also benefit the practice
of medicine itself. These projects are dedicated to the protection of innocent victims of violence, especially family violence.
I hope to see more of these kinds of efforts begun, whether supported by government research funding or not. Eventually, the
medical profession should be engaged -- as a routine matter and without the benefit of research dollars -- in such interdisciplinary
practices as the treatment of victims of violence and the protection of potential victims as they come to our attention. When
that time arrives, then we may indeed be close to understanding and controlling violence, which is one of the most extensive
and chronic epidemics in the public health of this country.
I have talked of violence on the highways, and of the influence of alcohol and drugs on our escalating violence . . . I have
given you some statistics on homicide and suicide . . . and I've once again underlined the destructive impact of TV on
our children and I've added video games to the list. I know I have laid a great burden on you. I share it.
Can we handle it? When that question is asked, I am reminded of that point in the book called the Little Prince, by Antoine
de Saint Exupery, in which the Little Prince talks with the Fox. The Fox says, rather plaintively . . .
"One only understands the things that one tames. Men have no more time to understand anything. They buy things already
made at the shops. There is no shop anywhere where one can buy friendship, and so men have no friends any more. If you want
a friend, tame me."
The Fox can be tamed and it can become a friend. Violence can also be tamed and people who are disposed to violence can also
learn how to live in peace with the rest of us -- and all of us should feel secure. It's not a task that can be done easily
or in a short space of time. But it has to be done.