gests, they shifted the responsibility to another institutional sector, the police. Both Flitcraft and Warshaw have found that physicians sidestep the issue
of abuse by prescribing pain medica¬ tions. "Physicians would medicate and thus satisfy their 'medical' obligations, but not face the implications of what or why they were medicating," Warshaw states.
Words Mask Abuse
Perhaps most revealing in Warshaw's study is the language used on the medi¬ cal records to describe the injurycausing event. Physicians commonly used passive, disembodied phrases that disregarded the presence of both the batterer and the victim. "Hit by lead pipe," "blow to head by stick with nail in it," "hit on left wrist with jackhammer" were all recorded as the mechanism of injury. Clearly miss¬ ing from these statements was who hit her, what her relationship to that per-
son is, and what the circumstances of the attack were. Warshaw states that the medical shorthand is "an important shaper of how physicians learn to organize their thinking," and whether it's on a con¬ scious or unconscious level, it obscures the etiology and meaning of the wom¬ an's symptoms. Furthermore, she adds, it sends a message to the patient that the jackhammer and her left wrist are all that are important.
How to Help
Physicians can do much, Flitcraft told the American College of Physicians' au¬ dience, to recognize and care for bat¬ tered women. "We need to identify do¬ mestic violence, to name it as a problem, and to acknowledge that we share the same concern that she has, that this is a The serious problem in her life very acknowledgment that domestic vi¬ olence is going on, and that you and she agree it is a serious problem, is a very ....
powerful and therapeutic first step." Second, Flitcraft says, "Physicians can assess the woman's safety by asking
about the extent of the violence she faces, whether there are weapons in¬ volved, whether the children are being threatened, and if she has a safe place to go." This information will help the phy¬ sician and the woman assess the vio¬ lence she may face when she leaves the office, and establish a baseline to detect escalation of violence in future visits. In addition, Flitcraft says, "Physi¬ cians can provide patients with informa¬ tion about legal and community re¬ sources available for battered women and their children. " "Above all," Flitcraft says, "we need to support the decisions she makes [about how] to best end the violence in her life. And we will have to support each other, as we try to change our clini¬ cal paradigms to understand the prob¬ lems of victims of domestic violence." by Teri Randall
Domestic Violence Begets Other Problems of Which Physicians Must Be Aware to Be Effective WOMEN LIVING in violent relationships pay a heavy price with their physical and mental health, and sometimes even their lives. Thirty-four percent of
all female homicide victims older than 15 years are killed by their husbands or intimate partners, according to Federal Bureau of Investigation homicide data from 1976 to 1987. Besides the acute injuries incurred from their battering relationships, these women also develop a broad range of physical illnesses and psychological
problems. Typically, as the battering escalates, so do their feelings of pro-
found isolation from the institutions and resources\p=m-\including medicine\p=m-\that presumably could help them. Historically, most physicians treated the physical injuries that are a result of domestic violence and did not address their cause, that is, the patient's abusive relationship (Gender and Society. 1989;3:506-517; Int J Health Serv.
1979;9:461-492 [see p 939]). "Physicians will often say, 'I'm not a
law enforcement officer, and I'm not a social worker. I'm here to treat the body, and she needs to see a psychia¬ trist,'" says Mildred Dailey Pagelow, PhD, adjunct research professor of soci¬ ology at California State University,
Fullerton, and a speaker at workshops for physicians and nurses on the recog¬ nition and treatment of domestic vio¬ lence. Yet a growing number of physicians are saying that the treatment of domes¬ tic violence belongs within the realm of medicine. The problem is so prevalent, they say, that it has a major influence on the physical and mental well-being of women.
Second, data from police reports sug¬ gest that domestic assaults occur within
context of repeated violence in the home (Violence and Victims. 1990;5:317). If domestic violence is an ongoing problem in the woman's life, she is at risk for more injuries if the problem is not resolved. a
Violence Hidden, Ignored Serious attempts to determine the prevalence of domestic violence have been attempted only within the last 15 years. Before this time, domestic vio¬ lence was often disguised, ignored, and even accepted as understandable be¬ havior. These attitudes persist to some degree today, making it all the more difficult to quantify and study. Much of the available data represents women seeking police intervention or
Downloaded From: http://jama.jamanetwork.com/ by a UQ Library User on 06/15/2015
visiting hospital
emergency depart¬ representative of the general population. It's difficult, for ex¬ ample, to estimate the number of white, ments and isn't
middle-class women who are victims since many see private physicians for their injuries. This data gap fosters the misconception that domestic violence happens only in poor or minority families. Researchers believe domestic vio¬ lence is one of the most seriously underreported crimes. Many victims don't re¬ port the incident for a variety of reasons, including their fear of reprisal, belief that nothing can be done, and con¬ cern that they couldn't support them¬ selves and their children if their hus¬ band or partner were arrested. Conservative Estimates Staggering In a 1981 national survey of married couples conducted by Murray A.
Straus, PhD, codirector of the Family Research Laboratory at the University of New Hampshire, Durham, 26% of respondents admitted there had been violence in the previous year. Up to 60% had experienced violence at some time, with either wives beating husbands or husbands beating wives. (Continued on p 943.)
(Continued from p 940.)
Based on the population then, this translated into 12 million couples at risk for abuse in the United States (Straus MA, Gelles RJ. Behind Closed Doors: Violence in the American Family. New York, NY: Anchor Books; 1981). Straus1 survey, conducted in person by trained investigators, used a forcedchoice questionnaire that omitted some of the common forms of domestic vio¬ lence, such as attempted strangulation and marital rape. It also studied only married couples. Pagelow and other re¬ searchers believe the numbers could be higher without these méthodologie limitations. Another study, by Lenore Walker, EdD, estimates that 50% of all adult women have been victims of violence more than once by the man they live with in a legal or quasi-legal marriage. This could mean up to 20 million adult married women at risk for abuse (Walk¬ er LE. The Battered Woman. New York, NY: Harper & Row Publishers
Inc; 1979).
Based on these studies and others, Pa¬
gelow, in her landmark text on the sub¬ ject, estimates at least 25% to 30% of all American
women are
at risk for abuse
(Pagelow MD. Family Violence. New York, NY: Praeger Publishers; 1984). "That's my conservative estimate," she says. "It would be higher if ex-hus¬
bands and ex-lovers were included." But even the conservative estimate trans¬ lates into an astounding number of wom¬ en who have and will seek medical care because of domestic violence. Conservative estimates generated by the National Crime Survey project that the annual medical costs incurred be¬ cause of family violence total $44 million each year. Indirect costs include the pro¬ ductivity lost from 175000 days missed from paid work. Morbidity due to family violence causes 21 000 hospitalizations, 99800 days of hospitalization, 28700 emergency de¬ partment visits, and 39900 visits to a physician each year, the survey con¬ cludes (National Crime Surveys: Na¬ tional Sample, 1973-1979. Ann Arbor, Mich: Inter-University Consortium Po¬ litical and Social Research; 1981 and Am J Public Health 1989;70:65-66). "For physicians, assessment of domes¬ tic violence is appropriate in any primary care evaluation. It's more prevalent than we ever dreamed," says Anne Flitcraft, MD, assistant professor of medicine at the University of Connecticut, Farmington, and codirector of Connecticut's Do¬ mestic Violence Training Project, a pro¬ gram for health providers funded under the Family Violence Prevention Act passed by that state.
AMONG ORGANIZATIONS that deal with domestic violence, the National Coalition Against Domestic Violence (NCADV) represents a network of more than 1200 safe houses, shelters, and counseling programs available around the country for battered women and their children (write NCADV, PO Box 34103, Washington, DC 200434103; or call (202) 638-6388). The Michigan Coalition Against Do¬ mestic Violence operates a national tollfree, 24-hour hotline ([800] 333-SAFE) that provides information on a woman's safety and options, referrals to local shelters, and support groups. The hear¬ ing-impaired can call (800) 873-6363.
Sequelae Abundant and Widespread Studies that focus on emergency de¬ partment visits have found that 22% to 35% of women presenting with any com¬ plaint are there because of symptoms re¬ lated to ongoing abuse (JAMA. 1984;51:3259-3264; Ann Emerg Med. 1987:18;651-653; Hasselt VN, et al, eds.
Handbook of Family Violence. New York, NY: Plenum Pub Corp; 1988:293-
318).
One study found up to 64% of hospital¬ ized female psychiatric patients have his¬ tories ofbeing physically abused as adults (Am J Psychiatry. 1987;144:908-913). Another study found that 37% of obstet¬ ric patients, across class, race, and educa¬ tional lines, were physically abused dur¬ ing pregnancy (Am J Public Health.
1987;77:1337-1339). "Injury patterns
of domestic violence and generally in¬ volve contusions or minor lacerations to are
relatively specific,
the face, head, neck, breast, or abdomen, distinguishable from injuries not deliber¬ ately inflicted, which usually involve the periphery of the body," Flitcraft says. But besides the acute injuries, she adds, "women who are in battering relationships present with a host of primary care complaints: chronic headaches, ab¬ dominal pains, complaints of sexual dys¬
function, recurrent vaginal infections, joint pains, muscle aches, sleep disor¬ ders, and eating disorders." Throughout the 1980s, state laws have redefined and extended protections to victims of domestic violence in response to criticism that police interventions were limited and district attorneys failed to
prosecute perpetrators aggressively. These many
changes
were women were
necessary because
increasingly isolated
Downloaded From: http://jama.jamanetwork.com/ by a UQ Library User on 06/15/2015
from institutions that could provide help. Similar change is necessary in medicine because physicians rarely probe into the cause of the injuries or illnesses and in¬ stead prescribe antipain and antidepressant medications for symptomatic relief. Violence Breeds Addictions "You begin to see the development of complex psychosocial problems if wom¬ en are not able to leave or end the vio¬ lence," Flitcraft says. Sixteen percent of battered women go on to abuse alco¬ hol (Handbook ofFamily Violence), for example. Flitcraft estimates that 45% of the women in alcohol treatment pro¬ grams started out as battered women who eventually became dependent on
alcohol. "Husbands often suggest that they beat their wives because their wives drink," notes Linda Saltzman, PhD, criminologist at the Centers for Disease Control, Atlanta, Ga. "But several studies have shown that many battered women start drinking subsequent to the battering. So it may be defensive behav¬ ior on the part of the women, trying to cope with an intolerable situation." The risk of mental illness is high among women who stay within batter¬ ing relationships, Flitcraft says. About 33% ofthese women suffer primary care depression, and suicide attempts are common. About 26% of all women who attempt to commit suicide are victims of domestic violence (Handbook of Family Violence). Most of these are "suicidal gestures, rather than medically emer¬ gent suicide attempts," Flitcraft says. Ten percent of battered women abuse or overutilize drugs, primarily the pre¬ scription medications such as sedatives, sleeping medications, and pain medi¬ cations that are prescribed to alleviate the anxiety and pain of living under the threat of violence (Handbook ofFamily
Violence).
'Are You Safe?' More powerful and beneficial than these medications, says Flitcraft, would be the physician addressing the violence in the woman's life. "Quicker than you can put on a Bandaid, you can acknowl¬ edge the violence, you can assert that this is illegal, not her fault, and that a lot of women are in this situation. You can educate her about the community-based resources available to help her, and ask 'Are you safe?' "These are the important elements that affirm that violence is a problem
and a threat to her mental and physical
health. It is more important than whether she comes back to get her stitches out on Tuesday or Wednes¬
day."
Although both physicians and patients may find this discussion uncomfortable, an open discussion can actually bring comfort to the patient, Flitcraft says. "In my experience, women who are plagued
by the sequelae of domestic violence are relieved to know they have one problem: domestic violence. They don't have two problems: domestic violence and a serious
illness on top ofthat.
It's Peacetime, but War MILITARY COMMANDERS with a sense of history are aware that disease can decimate their troops far more efficiently than virtually any enemy weapon. That specter, epidemic disease raging uncontrolled, became the springboard for the formation, in 1940, ofwhat is known today as the Armed Forces Epidemiological Board. This year, as the board celebrates its 50th birthday, it is evident that the results achieved by these civilian advisers have extended far beyond the uniformed services. "The impact of some research that the board recommended and the military implemented is beyond measure," says Theodore E. Woodward, MD, University of Maryland, Baltimore, the current president. The board's founders, BG James S. Simmons, MC, USA, and COL Stan-
hope Bayne-Jones, MC, USA,
were
of the millions of deaths caused by influenza and pneumonia during World War I, Woodward says. They created the Board for the Control of Influenza and Epidemic Diseases. The seven original members of the board were among the nation's leaders aware
in infectious disease research, including Andrew J. Warren, MD; Ernest W.
More Studies
Against Disease Continues
Goodpasture, MD; Francis G. Blake, MD; and Oswald T. Avery, MD. "An amazing amount of talent," comments
William Jordan, MD, National Institute of Allergy and Infectious Diseases, who has been associated with the board since 1951. For its first three decades, the board dealt with specific situations through a system of commissions named for the problem involved, such as influenza, respiratory diseases, or hospital infec¬ tions. If there was an outbreak of dis¬ ease somewhere, Woodward says,
"they were expected to respond. They
would go to the affected camps and work with the military people. It was one of the best cooperative programs that could be conceived." Adds Edwin H. Lennette, MD: "You could get a group together within 48 hours. They were a fire-fighting team available and ready to go." Lennette, formerly of the California State Depart¬ ment of Public Health, was president of the board from 1973 to 1976. Dealing with these emergencies high¬ lighted the need for research, so stimu¬ lating good study proposals became an¬ other of the commission's tasks. Robert Austrian, MD, University of Pennsyl-
Pending of
WORKERS in the 17 US Department of Energy's nuclear plants around the country are not the only sources of data on the health effects of low-dose radiation exposure (JAMA. 1990;264:553\x=req-\ 557). Those who live near these plants or work in other kinds of nuclear facilities are also candidates for study. This approach in the United States has been prompted in part by the experience in Britain. A series of clusters that involve small numbers of cases of leukemia has been reported there, occurring in several areas where nuclear facilities are located. One of these British studies is making news at the moment. It suggests that, while the risk of childhood leukemia was found (in various studies) to be unre-
"It's a great relief to have a physician reaffirm her suspicion that it is in fact the violence in her life that is the cause of most of her symptoms." by Teri Randall
vania, Philadelphia, a former commis¬ sion member, remembers that in the early 1960s he and a group headed by Harry Feldman, MD, State University of New York Health Science Center,
Syracuse, were called to Fort Ord near Carmel, Calif, to investigate an out¬ break of meningococcal meningitis, an investigation that he says led to a push for the development of meningococcal
vaccines. In the immediate post-World War II days, there was a lag before the great expansion of research supported by the National Institutes of Health occurred. "The types of studies that the board supported and encouraged the Depart¬ ment of Defense to fund were studies that were badly needed at the time but which very few other groups were fund¬ ing," Jordan says, citing, for example, the basic studies on poliomyelitis, inac¬ tivated influenza vaccines, and the dis¬ tinction between what is now known as virus A or infectious hepatitis and virus B or serum hepatitis. There now are new roles for the board to play, Jordan says: "There are prob¬ lems such as how to maintain the health of soldiers [who are maturing] into their 40s," he says. by Charles Marwick
Low-Dose Radiation
lated to various measures of environmental contamination from the nuclear plant at Sellafield in northwest England, there was a slightly increased risk of leukemia if the fathers of the children with leukemia were employed at the plant. In a case-control study (BMJ. 1990; 300:423-434), four of the fathers whose children developed leukemia had been exposed to over 100 mSv of external radiation before their child was con¬ ceived. Leukemia also was diagnosed in children ofthree fathers among the nonexposed control group. In the United States, the Radiation Epidemiology Branch of the National Cancer Institute in Bethesda, Md, is completing a report on the results of a
Downloaded From: http://jama.jamanetwork.com/ by a UQ Library User on 06/15/2015
study of deaths from cancer among pop¬ ulations living near nuclear facilities. Epidemiologists have collected reports of deaths from cancer from 107 counties containing, or adjacent to, 62 nuclear facilities. They are evaluating any changes in cancer mortality rates from the time the nuclear plant that was involved began operating. This work should be com¬ pleted later this month. Meanwhile, the National Research Council is performing a feasibility study about possibly looking into the amount of radiation exposure that workers re¬ ceive in utility companies' nuclear facili¬ ties. If the council goes ahead with the exposure study, it will be breaking new ground. by Charles Marwick
of abuse by prescribing pain medica¬ tions. "Physicians would medicate and thus satisfy their 'medical' obligations, but not face the implications of what or why they were medicating," Warshaw states.
Words Mask Abuse
Perhaps most revealing in Warshaw's study is the language used on the medi¬ cal records to describe the injurycausing event. Physicians commonly used passive, disembodied phrases that disregarded the presence of both the batterer and the victim. "Hit by lead pipe," "blow to head by stick with nail in it," "hit on left wrist with jackhammer" were all recorded as the mechanism of injury. Clearly miss¬ ing from these statements was who hit her, what her relationship to that per-
son is, and what the circumstances of the attack were. Warshaw states that the medical shorthand is "an important shaper of how physicians learn to organize their thinking," and whether it's on a con¬ scious or unconscious level, it obscures the etiology and meaning of the wom¬ an's symptoms. Furthermore, she adds, it sends a message to the patient that the jackhammer and her left wrist are all that are important.
How to Help
Physicians can do much, Flitcraft told the American College of Physicians' au¬ dience, to recognize and care for bat¬ tered women. "We need to identify do¬ mestic violence, to name it as a problem, and to acknowledge that we share the same concern that she has, that this is a The serious problem in her life very acknowledgment that domestic vi¬ olence is going on, and that you and she agree it is a serious problem, is a very ....
powerful and therapeutic first step." Second, Flitcraft says, "Physicians can assess the woman's safety by asking
about the extent of the violence she faces, whether there are weapons in¬ volved, whether the children are being threatened, and if she has a safe place to go." This information will help the phy¬ sician and the woman assess the vio¬ lence she may face when she leaves the office, and establish a baseline to detect escalation of violence in future visits. In addition, Flitcraft says, "Physi¬ cians can provide patients with informa¬ tion about legal and community re¬ sources available for battered women and their children. " "Above all," Flitcraft says, "we need to support the decisions she makes [about how] to best end the violence in her life. And we will have to support each other, as we try to change our clini¬ cal paradigms to understand the prob¬ lems of victims of domestic violence." by Teri Randall
Domestic Violence Begets Other Problems of Which Physicians Must Be Aware to Be Effective WOMEN LIVING in violent relationships pay a heavy price with their physical and mental health, and sometimes even their lives. Thirty-four percent of
all female homicide victims older than 15 years are killed by their husbands or intimate partners, according to Federal Bureau of Investigation homicide data from 1976 to 1987. Besides the acute injuries incurred from their battering relationships, these women also develop a broad range of physical illnesses and psychological
problems. Typically, as the battering escalates, so do their feelings of pro-
found isolation from the institutions and resources\p=m-\including medicine\p=m-\that presumably could help them. Historically, most physicians treated the physical injuries that are a result of domestic violence and did not address their cause, that is, the patient's abusive relationship (Gender and Society. 1989;3:506-517; Int J Health Serv.
1979;9:461-492 [see p 939]). "Physicians will often say, 'I'm not a
law enforcement officer, and I'm not a social worker. I'm here to treat the body, and she needs to see a psychia¬ trist,'" says Mildred Dailey Pagelow, PhD, adjunct research professor of soci¬ ology at California State University,
Fullerton, and a speaker at workshops for physicians and nurses on the recog¬ nition and treatment of domestic vio¬ lence. Yet a growing number of physicians are saying that the treatment of domes¬ tic violence belongs within the realm of medicine. The problem is so prevalent, they say, that it has a major influence on the physical and mental well-being of women.
Second, data from police reports sug¬ gest that domestic assaults occur within
context of repeated violence in the home (Violence and Victims. 1990;5:317). If domestic violence is an ongoing problem in the woman's life, she is at risk for more injuries if the problem is not resolved. a
Violence Hidden, Ignored Serious attempts to determine the prevalence of domestic violence have been attempted only within the last 15 years. Before this time, domestic vio¬ lence was often disguised, ignored, and even accepted as understandable be¬ havior. These attitudes persist to some degree today, making it all the more difficult to quantify and study. Much of the available data represents women seeking police intervention or
Downloaded From: http://jama.jamanetwork.com/ by a UQ Library User on 06/15/2015
visiting hospital
emergency depart¬ representative of the general population. It's difficult, for ex¬ ample, to estimate the number of white, ments and isn't
middle-class women who are victims since many see private physicians for their injuries. This data gap fosters the misconception that domestic violence happens only in poor or minority families. Researchers believe domestic vio¬ lence is one of the most seriously underreported crimes. Many victims don't re¬ port the incident for a variety of reasons, including their fear of reprisal, belief that nothing can be done, and con¬ cern that they couldn't support them¬ selves and their children if their hus¬ band or partner were arrested. Conservative Estimates Staggering In a 1981 national survey of married couples conducted by Murray A.
Straus, PhD, codirector of the Family Research Laboratory at the University of New Hampshire, Durham, 26% of respondents admitted there had been violence in the previous year. Up to 60% had experienced violence at some time, with either wives beating husbands or husbands beating wives. (Continued on p 943.)
(Continued from p 940.)
Based on the population then, this translated into 12 million couples at risk for abuse in the United States (Straus MA, Gelles RJ. Behind Closed Doors: Violence in the American Family. New York, NY: Anchor Books; 1981). Straus1 survey, conducted in person by trained investigators, used a forcedchoice questionnaire that omitted some of the common forms of domestic vio¬ lence, such as attempted strangulation and marital rape. It also studied only married couples. Pagelow and other re¬ searchers believe the numbers could be higher without these méthodologie limitations. Another study, by Lenore Walker, EdD, estimates that 50% of all adult women have been victims of violence more than once by the man they live with in a legal or quasi-legal marriage. This could mean up to 20 million adult married women at risk for abuse (Walk¬ er LE. The Battered Woman. New York, NY: Harper & Row Publishers
Inc; 1979).
Based on these studies and others, Pa¬
gelow, in her landmark text on the sub¬ ject, estimates at least 25% to 30% of all American
women are
at risk for abuse
(Pagelow MD. Family Violence. New York, NY: Praeger Publishers; 1984). "That's my conservative estimate," she says. "It would be higher if ex-hus¬
bands and ex-lovers were included." But even the conservative estimate trans¬ lates into an astounding number of wom¬ en who have and will seek medical care because of domestic violence. Conservative estimates generated by the National Crime Survey project that the annual medical costs incurred be¬ cause of family violence total $44 million each year. Indirect costs include the pro¬ ductivity lost from 175000 days missed from paid work. Morbidity due to family violence causes 21 000 hospitalizations, 99800 days of hospitalization, 28700 emergency de¬ partment visits, and 39900 visits to a physician each year, the survey con¬ cludes (National Crime Surveys: Na¬ tional Sample, 1973-1979. Ann Arbor, Mich: Inter-University Consortium Po¬ litical and Social Research; 1981 and Am J Public Health 1989;70:65-66). "For physicians, assessment of domes¬ tic violence is appropriate in any primary care evaluation. It's more prevalent than we ever dreamed," says Anne Flitcraft, MD, assistant professor of medicine at the University of Connecticut, Farmington, and codirector of Connecticut's Do¬ mestic Violence Training Project, a pro¬ gram for health providers funded under the Family Violence Prevention Act passed by that state.
AMONG ORGANIZATIONS that deal with domestic violence, the National Coalition Against Domestic Violence (NCADV) represents a network of more than 1200 safe houses, shelters, and counseling programs available around the country for battered women and their children (write NCADV, PO Box 34103, Washington, DC 200434103; or call (202) 638-6388). The Michigan Coalition Against Do¬ mestic Violence operates a national tollfree, 24-hour hotline ([800] 333-SAFE) that provides information on a woman's safety and options, referrals to local shelters, and support groups. The hear¬ ing-impaired can call (800) 873-6363.
Sequelae Abundant and Widespread Studies that focus on emergency de¬ partment visits have found that 22% to 35% of women presenting with any com¬ plaint are there because of symptoms re¬ lated to ongoing abuse (JAMA. 1984;51:3259-3264; Ann Emerg Med. 1987:18;651-653; Hasselt VN, et al, eds.
Handbook of Family Violence. New York, NY: Plenum Pub Corp; 1988:293-
318).
One study found up to 64% of hospital¬ ized female psychiatric patients have his¬ tories ofbeing physically abused as adults (Am J Psychiatry. 1987;144:908-913). Another study found that 37% of obstet¬ ric patients, across class, race, and educa¬ tional lines, were physically abused dur¬ ing pregnancy (Am J Public Health.
1987;77:1337-1339). "Injury patterns
of domestic violence and generally in¬ volve contusions or minor lacerations to are
relatively specific,
the face, head, neck, breast, or abdomen, distinguishable from injuries not deliber¬ ately inflicted, which usually involve the periphery of the body," Flitcraft says. But besides the acute injuries, she adds, "women who are in battering relationships present with a host of primary care complaints: chronic headaches, ab¬ dominal pains, complaints of sexual dys¬
function, recurrent vaginal infections, joint pains, muscle aches, sleep disor¬ ders, and eating disorders." Throughout the 1980s, state laws have redefined and extended protections to victims of domestic violence in response to criticism that police interventions were limited and district attorneys failed to
prosecute perpetrators aggressively. These many
changes
were women were
necessary because
increasingly isolated
Downloaded From: http://jama.jamanetwork.com/ by a UQ Library User on 06/15/2015
from institutions that could provide help. Similar change is necessary in medicine because physicians rarely probe into the cause of the injuries or illnesses and in¬ stead prescribe antipain and antidepressant medications for symptomatic relief. Violence Breeds Addictions "You begin to see the development of complex psychosocial problems if wom¬ en are not able to leave or end the vio¬ lence," Flitcraft says. Sixteen percent of battered women go on to abuse alco¬ hol (Handbook ofFamily Violence), for example. Flitcraft estimates that 45% of the women in alcohol treatment pro¬ grams started out as battered women who eventually became dependent on
alcohol. "Husbands often suggest that they beat their wives because their wives drink," notes Linda Saltzman, PhD, criminologist at the Centers for Disease Control, Atlanta, Ga. "But several studies have shown that many battered women start drinking subsequent to the battering. So it may be defensive behav¬ ior on the part of the women, trying to cope with an intolerable situation." The risk of mental illness is high among women who stay within batter¬ ing relationships, Flitcraft says. About 33% ofthese women suffer primary care depression, and suicide attempts are common. About 26% of all women who attempt to commit suicide are victims of domestic violence (Handbook of Family Violence). Most of these are "suicidal gestures, rather than medically emer¬ gent suicide attempts," Flitcraft says. Ten percent of battered women abuse or overutilize drugs, primarily the pre¬ scription medications such as sedatives, sleeping medications, and pain medi¬ cations that are prescribed to alleviate the anxiety and pain of living under the threat of violence (Handbook ofFamily
Violence).
'Are You Safe?' More powerful and beneficial than these medications, says Flitcraft, would be the physician addressing the violence in the woman's life. "Quicker than you can put on a Bandaid, you can acknowl¬ edge the violence, you can assert that this is illegal, not her fault, and that a lot of women are in this situation. You can educate her about the community-based resources available to help her, and ask 'Are you safe?' "These are the important elements that affirm that violence is a problem
and a threat to her mental and physical
health. It is more important than whether she comes back to get her stitches out on Tuesday or Wednes¬
day."
Although both physicians and patients may find this discussion uncomfortable, an open discussion can actually bring comfort to the patient, Flitcraft says. "In my experience, women who are plagued
by the sequelae of domestic violence are relieved to know they have one problem: domestic violence. They don't have two problems: domestic violence and a serious
illness on top ofthat.
It's Peacetime, but War MILITARY COMMANDERS with a sense of history are aware that disease can decimate their troops far more efficiently than virtually any enemy weapon. That specter, epidemic disease raging uncontrolled, became the springboard for the formation, in 1940, ofwhat is known today as the Armed Forces Epidemiological Board. This year, as the board celebrates its 50th birthday, it is evident that the results achieved by these civilian advisers have extended far beyond the uniformed services. "The impact of some research that the board recommended and the military implemented is beyond measure," says Theodore E. Woodward, MD, University of Maryland, Baltimore, the current president. The board's founders, BG James S. Simmons, MC, USA, and COL Stan-
hope Bayne-Jones, MC, USA,
were
of the millions of deaths caused by influenza and pneumonia during World War I, Woodward says. They created the Board for the Control of Influenza and Epidemic Diseases. The seven original members of the board were among the nation's leaders aware
in infectious disease research, including Andrew J. Warren, MD; Ernest W.
More Studies
Against Disease Continues
Goodpasture, MD; Francis G. Blake, MD; and Oswald T. Avery, MD. "An amazing amount of talent," comments
William Jordan, MD, National Institute of Allergy and Infectious Diseases, who has been associated with the board since 1951. For its first three decades, the board dealt with specific situations through a system of commissions named for the problem involved, such as influenza, respiratory diseases, or hospital infec¬ tions. If there was an outbreak of dis¬ ease somewhere, Woodward says,
"they were expected to respond. They
would go to the affected camps and work with the military people. It was one of the best cooperative programs that could be conceived." Adds Edwin H. Lennette, MD: "You could get a group together within 48 hours. They were a fire-fighting team available and ready to go." Lennette, formerly of the California State Depart¬ ment of Public Health, was president of the board from 1973 to 1976. Dealing with these emergencies high¬ lighted the need for research, so stimu¬ lating good study proposals became an¬ other of the commission's tasks. Robert Austrian, MD, University of Pennsyl-
Pending of
WORKERS in the 17 US Department of Energy's nuclear plants around the country are not the only sources of data on the health effects of low-dose radiation exposure (JAMA. 1990;264:553\x=req-\ 557). Those who live near these plants or work in other kinds of nuclear facilities are also candidates for study. This approach in the United States has been prompted in part by the experience in Britain. A series of clusters that involve small numbers of cases of leukemia has been reported there, occurring in several areas where nuclear facilities are located. One of these British studies is making news at the moment. It suggests that, while the risk of childhood leukemia was found (in various studies) to be unre-
"It's a great relief to have a physician reaffirm her suspicion that it is in fact the violence in her life that is the cause of most of her symptoms." by Teri Randall
vania, Philadelphia, a former commis¬ sion member, remembers that in the early 1960s he and a group headed by Harry Feldman, MD, State University of New York Health Science Center,
Syracuse, were called to Fort Ord near Carmel, Calif, to investigate an out¬ break of meningococcal meningitis, an investigation that he says led to a push for the development of meningococcal
vaccines. In the immediate post-World War II days, there was a lag before the great expansion of research supported by the National Institutes of Health occurred. "The types of studies that the board supported and encouraged the Depart¬ ment of Defense to fund were studies that were badly needed at the time but which very few other groups were fund¬ ing," Jordan says, citing, for example, the basic studies on poliomyelitis, inac¬ tivated influenza vaccines, and the dis¬ tinction between what is now known as virus A or infectious hepatitis and virus B or serum hepatitis. There now are new roles for the board to play, Jordan says: "There are prob¬ lems such as how to maintain the health of soldiers [who are maturing] into their 40s," he says. by Charles Marwick
Low-Dose Radiation
lated to various measures of environmental contamination from the nuclear plant at Sellafield in northwest England, there was a slightly increased risk of leukemia if the fathers of the children with leukemia were employed at the plant. In a case-control study (BMJ. 1990; 300:423-434), four of the fathers whose children developed leukemia had been exposed to over 100 mSv of external radiation before their child was con¬ ceived. Leukemia also was diagnosed in children ofthree fathers among the nonexposed control group. In the United States, the Radiation Epidemiology Branch of the National Cancer Institute in Bethesda, Md, is completing a report on the results of a
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study of deaths from cancer among pop¬ ulations living near nuclear facilities. Epidemiologists have collected reports of deaths from cancer from 107 counties containing, or adjacent to, 62 nuclear facilities. They are evaluating any changes in cancer mortality rates from the time the nuclear plant that was involved began operating. This work should be com¬ pleted later this month. Meanwhile, the National Research Council is performing a feasibility study about possibly looking into the amount of radiation exposure that workers re¬ ceive in utility companies' nuclear facili¬ ties. If the council goes ahead with the exposure study, it will be breaking new ground. by Charles Marwick
