versión On-line ISSN 1678-4561
Ciênc. saúde coletiva v.11 n.2 Rio de Janeiro abr./jun. 2006
From repression to prevention against violence: a challenge posed to civil society and the health sector
Da repressão à prevenção da violência: desafio para a sociedade civil e para o setor saúde
Alberto Concha-EastmanI; Miguel MaloII
IPan American Health Organization/World Health Organization. 525 23rd St. NW, Washington, DC, 20037, USA. email@example.com
IIPan American Organization/World Health Organization
This article deals with the proposal of the Pan American Health Organization for the prevention of violence, following the precepts of the "World report on violence and health" of the WHO. In this analysis the authors distinguish the approach of public safety (generally based on repression) from the way public health approaches this issue, based on the traditional concepts that constitute its patrimony: promotion of health, prevention of physical and emotional injuries, and the strengthening of citizenship. The authors show that the health sector has already embraced the issue definitively but that even so the problem is still far from occupying the outstanding place it deserves in the public health agenda, together with other health problems of the contemporaneous populations of the world and the Americas. The text concludes establishing a link between prevention of violence and the Millennium development goals, which in principle urge society for taking action towards human rights, solidarity and quality of life.
Key words: Violence and health, Prevention of violence, Citizenship and violence
Este artigo trata da proposta da Organização Pan-Americana de Saúde para a prevenção da violência, seguindo as orientações do "Informe mundial sobre violência e saúde" da OMS. Por meio desta reflexão, os autores diferenciam a abordagem da segurança pública (geralmente fundamentada na repressão) do foco com que a Saúde Pública trata do tema, com os tradicionais conceitos que constituem seu patrimônio: promoção da saúde, prevenção de lesões e de traumas físicos e emocionais, e fortalecimento da cidadania. Os autores mostram que o setor saúde já vem definitivamente assumindo o tema, mas falta ainda muito para que ele adquira um lugar de destaque como outros agravos à saúde da população. O texto termina articulando a prevenção da violência com as metas do Milênio que, em última instância, concitam a sociedade para os direitos humanos, a solidariedade e a qualidade de vida.
Palavras-chave: Violência e saúde, Prevenção da violência, Cidadania e violência
A way ran and yet to run
In 2002, the World Health Organization (WHO) published the World report on violence and health1, which summarized what has been discussed for decades on the need of changing the paradigm of repression and punishment as the only way to face violence. It motivated several countries of the Americas as well as countries in other regions of the world to set a preventive approach to violence as a priority in the government's agendas. Rather than being a spontaneous product, the World report on violence and health was the result of several years of work, research, debates and controversies among different level government officials as well as academics from different fields and institutions.
In the Americas, back in 1993, the Directing Council (DC) of the Pan American Health Organization (PAHO) had approved a resolution urging governments [...] to set national policies and plans, to prevent and control violence with special emphasis in vulnerable groups. Thus, the resolution stood for a different point of view than the repressive policies approach and invited to define with higher accuracy, and based on reliable studies and data, priorities and human groups under higher risk of suffering violence. Later, in 1994, during the Inter-American Conference on Society, Violence and Health, PAHO proposed for the very first time a Regional Action Plan on Violence and Health2, considered a pioneer effort made by an international health organization towards introducing prevention of violent events into the public agenda, as a clear call to the need of developing cross-sectorial works. The strategies and objectives defined in this Plan were aimed at filling in the priority gaps, such as lack of public policies for facing violence, lack of reliable information, the need for fostering research and achieving higher participation of the society in the search for solutions to this problem.
Consequently, in 1996, the 39th PAHO DC enacted Resolution CD39/14, where it was stressed that "[...] violence, in all of its manifestations is a public health priority", and the Director was asked to provide technical cooperation towards strengthening the governments of Member Countries for promoting epidemiological surveys in the field of violence, research, dissemination of information and cooperation among countries. Finally, in 2003 the DC approved the document "Impact of violence on the health in the population of the Americas" and Resolution CD 133/223, which urges the governments to place priority and support to the development of plans, programs and projects at national and municipal levels on prevention against violence of social nature and related to gender, ethnics or social class and to apply the recommendations set forth in the "World report on violence and health".
Among others, the World report on violence and health had the merit of gathering conceptual contributions and intervention proposals in a document of global nature, jointly with elements of reference to public policies on prevention of violence. The World report on violence and health adopts an ecology-based model as a valid theoretical proposal to approach the issue of violence, in its huge complexity, so that when violence-related policies and interventions are being prepared, they take into consideration both planning and actions of cross-sectorial nature, as well as the recognition of an integrated approach comprising from the individual to macro public policies.
Furthermore, the World report on violence and health manages to articulate theoretical-conceptual framework with consensual operational definitions, which assist in advancing in the formulation of proposals. Starting with the general definition of violence as the intentional use of physical strength or power, whether real or by means of threat, against the person itself, another person, or against a group or community that may result or is very likely to result in death, injury, psychological damage, problems of development or deprivation (Chap. 1), with emphasis to the components intentional event, damage and use of power to practice the violent action. It also approaches specific manifestations of violence, such as youth violence (Chap. 2); child abuse and neglect by parent and other caregivers (Chap. 3); violence by intimate partners (Chap. 4); sexual violence (Chap. 6); abuse of the elderly (Chap. 5); self-directed violence (Chap. 7); and collective violence (Chap. 8). Last chapter (Chap. 9) proposes nine recommendations to be considered for national or international application.
Violence is classified in three levels, according to its expression and nature (physical, sexual, psychological or resulting from negligence) and is usually manifested in a combination: 1) interpersonal, which comprises intrafamily violence, by the spouse, and whose victims are women, children and adults; and by the community, on streets and public sites, which is perpetrated by either known or unknown individuals; 2) collective, committed by states, organized groups, organized crime and that may also be social, economic or political; and, finally, 3) self-inflicted, like suicide or suicide attempt and other kinds of self-abuse.
Since the World report on violence and health was launched before national authorities in almost all countries in the Americas among them Costa Rica, Nicaragua, Colombia, Brazil, Honduras, Peru, Mexico, Ecuador, Puerto Rico, Panama, El Salvador, Jamaica, United States and Canada, as well as in several events at municipal levels, we could state that international organizations, Ministries of Health and other governmental and civil society institutions have recognized violence as a social and public health issue of cross-sectorial approach.
Several countries of the Americas and in other regions worldwide are making advances towards placing a preventive view and proposals into an outstanding position in the governmental agendas, since this became a constant demand of the victimized communities.
However, the steps forward were neither sufficient nor are they the only ones for addressing the issue violence with the severity and urgency it deserves. The way to be run remains long. The Violence Prevention Alliance (VPA) promoted by WHO (http://www.who. int/violenceprevention/en/index.html), and the Inter American Coalition for the Prevention of Violence (IACPV), based in Washington DC, and composed by the Organization of American States, the Inter American Development Bank, the World Bank, the Centers for Diseases Prevention and Control, the United States Agency for International Development, the United Nations Educational, Scientific and Cultural Organization and PAHO, are examples of efforts for networking improvement, that also involve governmental and nongovernmental institutions and other international organizations, looking for more coordination and better ways to keep moving ahead violence prevention initiatives.
The reason for health sector involvement in violence prevention
For PAHO, Public Health is the collective intervention by the State and civil society, to protect and improve the health of the people. It is an interdisciplinary social practice4, which emphasizes that the responsibility of the health sector is not limited to recovering diseased individuals or victims of traumatisms; but should rather seek for the population's welfare as a crucial condition to personal and collective development. Therefore, we understand that social issues like violence or lack of security, wherever it may happen, are public health issues. Additionally to the impact on the physical, psychological or sexual health of its victims, social and interpersonal violence causes social effects and affects the overall development.
In cities or countries where violence and the perception of insecurity are high, populations have their everyday life and mobility affected. Therefore, their quality of life is reduced, generating fear, whether based on sound grounds or not, free and safe mobility is inhibited, private space is confined inside walls, public space tends to disappear, affecting health since it limits safe places where people can practice physical or sports activities. Cities gradually loose public and civic spaces, thus generalizing the private-confined urbanization, segregating even more the social, spatial and temporal environments. All that erodes citizenship among populations, reducing its community character5.
As refers to violence against women, perpetrated by their partners, they are affected in their personal and intellectual development. Intrafamily violence erodes the space that has always been considered the safest in society, made up by members linked together by love, respect and protection.
In regard to the economic aspect, violence and public insecurity reduce the possibility of internal or external investment, with negative effects on social profitability. It leads to an "economy" of violence and crime that can be measured by the balance between costs, risks and benefits. In this sense, the possibility of being arrested and punished (what is called impunity when the system fails) is lower than the benefit, leading to a trend towards perpetrating crimes or violent acts6. Surely, the weaker the State, the higher are the possibilities of criminal activity. In terms of social structure, violence produces and generates damages by fomenting behaviors and attitudes that grind down the bases and principles of social life and conflict solution, thus destroying the social capital. And, finally, as Cruz stresses, it affects governability and weakens democracy, particularly in countries where recent history is marked by social and political conflicts, and where social violence has increased7.
In short, violence is a public health issue because:
1) It produces high burden of mortality and morbidity, mainly among children, women and young, a problem still worsened in places reporting high levels of violence, be it interpersonal or collective.
2) It demands for large amounts of financial resources to provide medical care to its victims, usually biasing the care that should be provided to other patients.
3) It affects not only the victim, but also its family and surroundings, producing immediate negative effects on the economic, social and psychological aspects, also with medium and long terms impacts.
4) It also affects the individual responsible for the violent act, his family and the society, since in addition to the cost of police, justice and imprisonment (whenever applicable), in such circumstances the individual has no conditions to contribute to the social and economic development of his family, community and country.
5) It negatively affects the social and economic development of communities and countries.
6) It affects the everyday life, the freedom of movement and the right to enjoy public goods.
The advances achieved in public health towards controlling and preventing diseases and promoting health are also valid and pertinent for facing the problem of violence and unintentional injuries. Preventive actions and those oriented to promote health try to prevent the occurrence of such acts and the worsening of their consequences, while favoring conditions that may restrain the social reproduction of risks (situations) that lead to such facts. The focus on studies and search for solutions to violence is based on scientific evidences, historically employed to solve public health issues. Therefore, the following steps are suggested to move from the problem to the solution8, 9, 10.
· Gathering knowledge about the occurrence of violence by means of systematic data (epidemiological surveillance or information to action) on the magnitude, scope, characteristics and consequences of violence at municipal (local) or national level. This allows not only for establishing the magnitude of the problem in quantitative terms, but also allows identifying likely associations and causalities that should be more deeply explored. Simultaneously, it allows for getting to know which kind of violence affects to a higher or lower degree a given community, be it violence against women, children, sexual, juvenile, self-inflicted or collective violence.
· Research with higher scientific rigor about the causes and/or causal links, providing evidences on:
1) contextual aspects that determine the social reproduction of risk conditions;
2) the causes and/or factors that increase or reduce the risk of occurrence of violent acts;
3) the behaviors, attitudes and beliefs that could be changed through means of cross-sectorial and/or health interventions.
· Outlining strategies and interventions aimed at preventing violence, employing the information described above and that allow for executing, supervising and evaluating interventions. Besides developing, in several circumstances, tested or promising interventions followed by broad dissemination of information and establishment of the programs' cost efficiency.
· Encouraging cross-sectorial work to set the required articulation among several governmental managerial sectors, which should be necessarily involved in the development of an integrated approach to violence, additionally to promoting the permanent participation of the population.
· Output evaluation and reformulation, whenever applicable.
Thus, the health sector is compelled to take on its responsibility in approaching the issue of violence, starting with due care to victims, passing through the generation of quality information, and finally achieving the leadership, facilitation and participation jointly with other sectors to define and execute integral public policies on prevention of violence and health promotion.
The Millennium Development Goals (MDG) and prevention against violence
Although none of the MDGs or indicators to monitor their progress make any reference to violence, one can easily find a link between the 8 MDGs and violence, and therefore contribute, in the light of violence prevention, towards the achievement of such goals. Below we present brief comments on each MDG and its implications on violence against women11, 12, children and youngsters.
MDG 1. Eradicate extreme poverty and hunger
The evidence on the link between poverty and violence is not conclusive, i.e., has not been proved and therefore one cannot accept or state that poor people, for being poor, are more violent than those with economic resources. What is known is that poor people are more vulnerable because of the lack of leisure spaces, lower educational level and other social and environmental deprivations. Hunger and the need for bringing home food lead many people, in despair, to steal and, sometimes, to commit more serious crimes.
It is also known that social inequality, measured by the Gini Index or other indicators, is associated with violence. A 1% increase on the Gini coefficient is associated with a 1.5% increase on homicide rates and a 2.6% increase on the thefts rates. If there is a permanent worsening in income unbalance, the permanent effects are 3.7 and 4.3 times higher for homicides and thefts, respectively. On the other hand, in the light of development, a 1% increase in the GDP leads to a reduction of 2.4% in homicide rates and 13.7% in theft rates13. A study developed by the Inter-American Development Bank (1997) in Latin America estimated that social costs entailed by crime, including the value of stolen goods, are equivalent to US$ 163 billion, or 14.2% of the GDP of the region14. Inequality and poverty are risk factors that increase vulnerability to violence in homes and social environments. Domestic violence is associated (which has also been measured) with families and homes facing poverty but, once again, this is not to be understood as evidence for a direct link between poverty and violence. In case the family income increases, one could expect the violence rates to drop (but this should be associated with other MDGs).
· The participation of women in economics and their economic independence empower them to avoid violence from their partner or spouse, therefore, it would be necessary to expand the number of women who have access to sources of income, independent from their partner or spouse.
· Preventing children, adolescents and youngsters from witnessing violence at home, contributes to avoid the replication of violent behaviors in their future lives.
MDG 2. Achieve universal primary education
Education opens the doors to jobs and knowledge, illiteracy favors abuse. Thanks to ignorance many people do not even know their own rights. Several studies carried out by UNICEF and WHO have broadly disclosed the positive effect of the education of mothers on the health of their children.
· Education of women improves their self-esteem, socialization and participation in social networks, expands their possibility of knowing their rights and helps reducing inequality. Illiterate women suffer violence and do not seek for assistance. The participation of women in social networks has proved to be a factor of protection against violence, thus reducing the risk of repeated violence.
· Children and youngsters with no education report higher tendency to violence and drugs.
· The follow-up by mothers and fathers on school and extracurricular activities of their children reinforces the family ties, favors socialization at home and reduces the risk of violence and/or aggression in the streets.
MDG 3. Promote equality between sexes and empower women
Gender equality is recognized as a prevailing factor in the fight against gender violence and sexual, physical and psychological aggressions against women.
· The higher gender inequality, the greater violence and abuses against women, practiced by their spouses. Achieving gender equality not only empowers women, it is also directly related to reduced violence against them.
· Learning about gender equality since childhood, adolescence and youth is another element that protects against violence and reinforces equality. Young and adults of masculine gender who have a sense of equality do not assault or maltreat their partner.
MDG 4. Reduce infantile mortality
The premature death of children (not as an individual but as a population event) is the consequence of social unbalances, lack of access to health services, and it is also related to poor education and low empowerment of mothers. Therefore, reducing infant mortality is a development factor that contributes to reduce unbalances and generate higher security.
· Some cases of deaths of children are related to violence against their mothers.
· The higher infant mortality, the higher the birth rates, which contributes towards perpetuating the cycle of inequality and poverty.
MDG 5. Improve maternal health
As aforementioned, achieving the other MDGs (1, 2, 3) where women play a major role, it is crucial to achieve development at country level. The issue of pregnant women is particularly sensitive. The improvement of prenatal care, as well as the dissemination of the women's rights, highly contributes towards reducing violence during and after pregnancy.
· There are documental evidences that violence against pregnant women perpetrated by their spouse affects the health of both the mother and the fetus. Violence against pregnant women is unacceptable. Some studies have revealed retardation in the intra-uterine fetal growth due to domestic violence. Other studies suggest that abused women may have premature delivery. There are studies on the links between fetal or infant death and aggressions against the mother. Although they are not yet conclusive, these suggested links should be better explored. Other studies show higher numbers of hospitalizations among abused women, as well as higher possibility of caesarian deliveries.
· Children and youngsters who witness violence against their mother, mainly if she is pregnant, have development problems and run the risk of becoming violent later in their lives. Children from mothers spanked have higher risks of being abused.
MDG 6. Fight HIV/AIDS, paludism and other diseases
The high incidence and prevalence of HIV and AIDS is a factor of social and family instability. Rape is a high risk factor for women and children to be contaminated with the virus.
· The high incidence of infection by HIV and AIDS among women creates instability in their households, then increasing the risk for violence; it is both a cause and a consequence of violence, abandonment and exclusion by their partners.
· Many women do not demand their sexual partner to use condom or undergo a HIV test for fear of violent reactions.
· Child and juvenile prostitution (of both genders) is a kind of violence with high risk for HIV and AIDS.
MDG 7. Guarantee environmental sustainability
The violent conflicts, mainly wars, the so-called medium or low-intensity internal conflicts, the action by organized groups as guerrillas, paramilitary and, nowadays, drug trafficking, damage the environment, generate poverty and hunger among the displaced people, favor rapes and abuse against minors. The link between conflict and environment should be observed to avoid and/or prevent more damages and, probably, more violence.
· In violent collective conflicts, women, mainly those who are alone, are under higher risk of being abused by members of the forces in conflict. On the other hand, they can be a factor of recovery and/or conservation of specific zones.
· The illegal organizations use minors in their actions both in rural and urban areas, many with negative environmental effects. The State and families can play a special role in avoiding that children and youngsters be used for criminal purposes that include environmental damages.
MDG 8. Foment a global development association
Undoubtedly, joint worldwide efforts towards development should influence all the MDGs and, in this connection, should bring about positive effects to the prevention and control of violence.
· It is fair to reaffirm that gender equality, empowerment of women, education and employment are sound steps towards development and thus decisive factors for the reduction of violence against women.
· Healthy environments and families, where youngsters and children can develop, attend school, do not suffer hunger and enjoy social rights will lead to reduced risks for them to become victims or perpetrators of violence.
The reflection about the MDGs and their implications over violence reinforce the need for a preventive policy approach, which has been discussed and promoted for decades. Although the discussion on this topic is not exhaustive, it assists in identifying links that allow for cross-sectorial and interdisciplinary actions oriented to prevention. For example, projects oriented to strengthen families will have impact on the MDGs and on prevention of violence.
Emphasis on prevention
The historical governmental approach of control/repression it is being transformed into prevention, but in a dynamic and interactive way. The evolution in the approach to violence is characterized by three moments.
Moment 1: repression and control
Under the responsibility of the police and judicial system. The theory bases this action on the intimidation effect on potential aggressors, by means of imprisonment and loss of rights as punishments stablished by the State upon those who break the law. This policy did not achieve the expected effectiveness15. Furthermore, one should bear in mind that whoever commits a crime or exercises violence should be subject to an impartial and respecting human rights application of the law.
Moment 2: multicausality and prevention
The need for approaching violence with a broad preventive perspective has increased in the course of the last three decades. This is the cross-sectorial response to the multicausality of violence. Today it is recognized and accepted that different sectors that deal with attention, rehabilitation, care and control of victims and perpetrators of violent acts, should join efforts to prevent violence. Under this view, cross-sectorial action tries to respond to multicausality by working in a preventive and integrating way, from crime control to building citizenship. Preventive programs or interventions should be integrated and responsive to two dimensions.
1) The temporal dimension. The intervention is primary when action is developed prior to the event, for example in the family through the so-called "Parenting School", with nonviolent environments and positive and guiding discipline; at school improving education and reinforcing solidarity; in the community, respecting rules and adopting a culture of social life and citizenship; by the State, showing the example of leaders and correctly managing the public affairs. Prevention, and in particular primary prevention, is essential to PAHO's mission. Primary prevention aims at encouraging a social and individual environment marked by respect and tolerance, social values and personal behavior that favor the nonviolent settlement of conflicts, i.e., it is oriented to avoid the fact of violence. Macro strategies directed to reduce poverty, pursuing social equity, better education, or to recovery of ethics and social control for example, are part of this level of prevention.
Secondary prevention is employed when a violent event has already occurred and the intention is to avoid new or more serious episodes. For violence against women and at individual level, the groups of assistance to victims show positive effects. To have secondary prevention appropriately working in the health sector, it would be necessary to change the attitudes of health professionals so as to qualify them to detect cases, refer them to counseling programs and to carry out epidemiological surveillance, rather than being limited just to the required immediate care. Among the examples on this kind of secondary prevention are the programs that identify individuals who receive care in health facilities for having suffered violent injury and are then referred to programs that intervene in crisis situations, seeking for solutions to the situations that preceded the violent event16. The Counseling Services for women and children, which provide support and care in cases of intrafamily violence, and the home visitation programs by counselors to victims of violence are recognized as effective in both primary and secondary prevention interventions, depending on the moment and the violence experience that people might have suffered 17, 18, 19, 20. Local networks and groups that work on prevention of violence in addition to training of health personnel are preventive alternatives used in several countries21, 22. Secondary prevention is also oriented to male and female aggressors. The males groups and "Parenting School" intend to change aggressive intrafamiliy behavior and spouse relationships. Another alternative are the programs for adolescents involved with gangs, where the young are motivated to analyze and seek for different living options. Examples for this kind of program are Programa Polígono Industrial and Homies Unidos23 in San Salvador.
Tertiary prevention is applied in public health to avoid greater damages to diseased people, improving their quality of life. It stands for rehabilitation. As refers to violence, this kind of preventive action is directed for aggressors, to those who have been convicted and are serving their sentence. The tertiary prevention programs shall focus on teaching productive activities, provide psychological and resocialization assistance. For victims it is focused in rehabilitating the harm and suffering caused by violent events. Tertiary prevention is particularly important for youngsters imprisoned for minor crimes. Frequently, due to the lack of efforts towards rehabilitation, the period spent in prison only serves to learn further criminal activity.
2) The second dimension is the dimension of the target individual or group. It is universal when oriented to the community or society at large, for example to control alcohol consumption or to promote citizenship culture. It is selective when applied to risk groups, for example the home visitation program that should start since pregnancy and reinforced with the family during the children's early childhood. Finally it may be indicated to groups or individuals who have already suffered or are under a higher risk of suffering violence like women, abused children and youngsters in gangs.
Moment 3: recovery of social and human relations
Violence, mainly in large scale, produces and generates damages to the social structure, encourages behaviors that erode the bases and principles of social life and conflict resolution. This is more noticeable in countries where violence levels are high, with multiple and daily expressions. Here, the most significant and concerning example would be drug trafficking, since its economic power has permeated several social and political levels, corrupting the concept of social ethics, respect to the rights of the others, what Savater defines as "the attempt towards improving people"24 in their relationships with the others. This perspective has been strengthened during the last several years. It is necessary that citizens, leaders, communicators, educators, and the society as a whole be committed with the prevention of violence, fighting for the recovery of its ethics and social capital.
For having a positive and holistic impact on the solution of the problem, these three moments should occur concomitantly. They are not mutually exclusive. Greater interaction among them would improve their chances of success.
Regardless the case or the dimension or level of the preventive action, it is necessary to take into consideration that, since we are dealing with a social and public health field with relatively short experience, the proposals should be carefully analyzed. There is no single model or recipe. Interventions must be defined based on scientific evidences, analyzed using criteria, which allow for affirming their impact, cost effectiveness and potential. Interventions should occur through projects that have been reviewed based on clear outlines, experimental ones maybe, as to their effectiveness (statistical significance), possibility of replication in different places, and sustainability in the sense of long-term effects.
Many projects fail because they seek for short-term political impacts (governments are short-term, the recovery of life in society is not), lack the necessary financial support, have a weak leadership (missing true commitment from authorities or managers), poor theoretical framework or are based on not very realistic expectations.
Prevention against violence and civil insecurity must be developed in two dimensions: the objective one, concerning the concrete acts of violence; and the subjective, which has to do with the perception and representation of the citizens with respect to violence. The latter comprises, for example, the image constructed about a city (safe city) or district (red district), the legitimacy of institutions and the self-perception of the population.
If, at social level, we succeed in building a culture of peace and respect for different ideas or beliefs; if we become able to solve our conflicts without making use of aggression or violence; if, at interpersonal level we succeed in preventing a case of homicide, robbery, sexual abuse or aggression in the family environment or a fight between gangs of young people; and if, at State level, wars and internal conflicts turn into something that belongs to the past, we would not only observe a significant decrease in the number of patients victims of violence; we would be living in kinder societies, where efforts can be oriented to seek for equity and contributing to the development of the people. To achieve this, we must be aware that this is a long-term challenge both to the health sector and to the civil society as a whole.
A Concha-Eastman and M Malo have participated to an equal extent in the preparation of the present article.
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Article presented in 4/04/2006
Approved in 19/04/2006
Final version presented in 19/04/2006