Surgeon General and Deputy Assistant Secretary for Health
A filmed lecture presented to the National Institute of Law Enforcement and Criminal Justice, Washington, D.C.
November 24, 1982
(Greetings to hosts, guests)
I appreciate this opportunity to speak to you 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.
Nevertheless, we must raise this issue 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.
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 -- that are torn away by these violent, premature deaths.
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 it seems sturdy enough to follow.
For example, high-risk families 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 the violence within the family -- particularly parental violence toward children -- tends to escalate during periods
of economic stress. Indebtedness . . . lack of work . . . evictions . . . lay-offs . . . repossessions . . . these are the
stuff of trauma for many families. They can overwhelm parents and open them to the terrible impulses of violent acts against
each other and against their children. In some areas of the country we are experiencing very difficult economic conditions
and, if our research and our anecdotal material is any guide, those areas are also experiencing a rise in family violence.
These may show up in marks on battered spouses and abuse children. Such marks 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,
human signals by 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 clues and 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 a 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
The objective, let me repeat, is 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 "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's 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 arguments, which I will summarize:
First, outside of the field of medicine, there seems to be no 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 that come the closest to providing a multidisciplinary approach to research the prevention
of family violence, for example, would be the National Institute of Mental Health in 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 into 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 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, and 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 then done, but I think it's time we looked at this as a serious aspect of pediatric and family practice
for contemporary American society.
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 sociologists, the psychiatrist, the psychologist, or the social services worker. For example, sociologists
Murray Straus of the University of New Hampshire and Richard Gelles of University of Rhode Island are among the leading researchers
in the field of family violence, but I would guess that their work is virtually unknown among physicians.
Physicians tend to be unclear about the roles of people engaged in the social services or social sciences. 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 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, in order 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. Such projects provide the building-blocks of information and methods of practice that, together, can contribute
to the protection of innocent victims of violence, especially family violence, whether the victim is a battered child or a
battered spouse. And from this kind of knowledge base we will be able to draw the elements of an overall primary prevention
strategy, a strategy that one day they liberate both the victim and the perpetrator from the deadly cycle of violence in which
both are locked today.