Public health approaches to the UNPoA

Maria Valenti and Cathey Falvo
IPPNW and the IANSA Public Health Network

In 1981, the World Health Assembly adopted resolution 34.38 that stated, “The role of  physicians and other health workers in the preservation and promotion of peace is the most significant factor for attainment of health for all.” Fifteen years later, the 49th World  Health Assembly (The World Health Organization’s [WHO] governing body) declared violence as a leading worldwide public health problem. Subsequently, the WHO developed the landmark document Small Arms and Global Health prepared for the first UN Conference on Illicit Trade in Small Arms and Light Weapons (SALW) in 2001. The WHO states that “Violence is an important health problem – and one that is largely preventable. Public health approaches have much to contribute to solving it.”

International Physicians for the Prevention of Nuclear War (IPPNW) responded to the call for  health professionals to address violence by convening the major conference “Aiming for Prevention: International Medical Conference on Small Arms, Gun Violence, and Injury” in Helsinki, Finland 28-30 September 2001. This meeting was held shortly after the initial PoA meeting in New York and brought together for the first time hundreds of medical professionals, scientists, and public health experts to address the humanitarian dimensions of small arms violence.

In his address at the Helsinki meeting, Dr. Etienne Krug, Director of the newly-formed  Department for Injuries and Violence Prevention of the WHO in Geneva, addressed the importance of recognizing the tremendous influence on health of SALWs. “Small arms have an important impact on health. This impact is present in developing and a developed country….This aspect was very much marginalized in the UN conference…”

In the past ten years, this has not changed substantively. The focus of the PoA remains on the supply side of arms and barely considers the demand side – the root causes of armed violence and its health impact as well as public health prevention approaches. For example, the country reporting template asks nothing about programs or policies to help prevent violence at the country level, despite the fact that Part III paragraph 18 of the PoA (Implementation, International Cooperation and Assistance) states: “States, regional and subregional and international organisations, research centres, health and medical institutions, the United Nations System, international financial institutions and civil society are urged as appropriate, to develop and support action-oriented research aimed at facilitating greater awareness and better understanding of the nature and scope of the problems associated with the illicit trade in small arms and light weapons.”

At the 2001 health conference on small arms, Dr. Krug went on to address deaths and injuries from SALW and the need for more rigorous evidence-based research and analysis. “I don’t think we know how many deaths there really are. There are several hundreds of thousands, that’s for sure,” he stated. Over ten years later, not much has changed. Comprehensive and long-term investments in action-oriented research, including evaluations of intervention programs, called for in the PoA have not been made. Only a handful of countries in Africa have emergency-room injury surveillance initiatives, which is a key data source for injuries from gun violence.

So what has been accomplished in the past ten years to address the health consequences of gun violence? There is greater awareness that firearm violence, as a subset of violence in general, is a serious health problem and that it is preventable. This is largely due to health organizations such as the WHO and the US Centers for Disease Control and Prevention. For example, WHO has established violence focal points at Health Ministries in over 100 countries and has encouraged countries to develop national policy documents and/or produce national reports on violence and health (Brown et al, WHO, 2007). In general, however, violence focal points are not interacting with National Commissions on Small Arms established by the PoA and thus missing an opportunity to enhance each other’s efforts.

Prior to the 9th World Conference on Injury Prevention and Safety Promotion held in March 2008 in Merida, Mexico, a meeting of Ministers of Health of the Americas was held to discuss the occurrence of violence and injury and their implications in the region. This resulted in a Ministerial Declaration on Violence and Injury Prevention in the Americas. The Ministries of Health committed to 13 points of action including development, implementation and evaluation of national, state and municipal plans for violence injury prevention, and strengthening the collection of epidemiological data including information on risk and protective factors, as well as on injury and death statistics and costs related to injuries and violence. Nonetheless, many areas in the Americas region remain rife with high levels of crime and violence (World Bank, 2011). It is second only to the African region in deaths from interpersonal violence (Zavala et al. Understanding violence-the role of injury surveillance systems in Africa, 2009).

The Geneva Declaration on Armed Violence and Development has now been signed by over 100 countries and has helped broaden the dialogue on armed violence as a health issue. It has shined a spotlight on the huge costs of armed violence to development and has called for more donor investment in violence prevention. The PoA can and should dovetail more with the goals of the Geneva Declaration. The WHO companion report, Preventing Violence and Reducing Its Impact: How Development Agencies and Governments Can Help, details the health effects of violence and how it obstructs achievement of the Millennium Development Goals. The report identifies data collection and research on violence prevention (especially evaluation) as a top priority and engagement with the health sector as one of 4 “best buys” for donor investment for reducing consequences of violence. However, major investments in this area are not yet evident.

The WHO Violence Prevention Alliance (VPA), of which IPPNW is an active member, has reported, every two years since 2004, on promising and successful violence prevention initiatives in different regions in five Milestones of a Global Campaign for Violence Prevention. Countries committed to realizing the full potential of the PoA should support these promising efforts and make long-term investments to enable useful evaluations and hopefully ensure ongoing success of programs. The VPA is now shepherding a new Global Plan of Action for the Global Campaign for Violence Prevention 2012-2020, which is a set of policy, legal and programme-delivery goals at the national level. Global violence prevention efforts should be directed towards these goals. The PoA can take advantage of these initiatives and national governments should work closely with the range of organizations in the VPA including NGOs.

Although little progress has been made on systematically integrating public health measures into preventing and reducing small arms violence, we do, in fact, know how to do it. It will take political will, dedicated resources, and action-oriented research that should receive much more support from donor countries. At present, such research remains largely in the domain of small pilot studies by NGOs with some notable exceptions of more systemic programs in a few countries supported by the WHO and local health and UNDP partners. Hospital-based data on gun violence injuries in the global South are scarce. In a recent audit of a major hospital in Monrovia, Liberia, IPPNW research found that intentional injury data are not currently collected routinely or systematically in the emergency room. Records also indicated 46% of patients injured from assaults were female, while only 23% of the violence cases reported to the Liberian Armed Violence Observatory (LAVO) from other sources (such as police data, media reports) were female. From this small review, we see the potential for huge gaps in reported data and how these gaps may be impeding the development and implementation of tailored interventions to prevent gun violence.

In the 2012 UN PoA Review conference, countries need to redouble their commitments to not only prevent illegal transfer of small arms, but to address the root causes of conflict. Given the proper resources, the health community stands ready to assist in this effort.