VIOLENCE AS A PUBLIC HEALTH PRIORITY FOR BLACK AMERICANS Dona Schneider, PhD, MPH, Michael R. Greenberg, PhD, and Daiwoo Choi New Brunswick, New Jersey
This study investigated the extent to which black public health and political leaders believe that reducing violence should be a national public health priority for black Americans when compared with other public health problems such as acquired immunodeficiency syndrome, low birthweight, and access to health care. A survey asking whether violence in the black community is amenable to change and who (or what institutions) should be responsible for the reduction of violence was sent to 427 black health leaders, 326 black mayors, and 467 black legislators. Three hundred twenty responses were returned. Virtually all respondents placed violence as one of the top five, if not the highest, public health priority for black Americans. Health and political leaders differed in their beliefs about whether violence and violence-related behaviors can be ameliorated, and who should bear responsibility for the reduction of violence. While this survey had limitations, more than 300 black public health and political leaders indicated that violence among black Americans should be made a national public health priority. Policy implications are discussed, and a proactive role for the National Medical Association is advocated. (J Nat! Med Assoc. 1992;84:843-848.) From the University of Medicine and Dentistry of New JerseyRobert Wood Johnson Medical School, the Department of Urban Studies and Community Health, and the Department of Statistics, Rutgers University, New Brunswick, New Jersey. This research was performed under a grant from the Environmental and Occupational Health Sciences Institute (EOHSI), Piscataway, New Jersey. Requests for reprints should be addressed to Dr Dona Schneider, Dept of Urban Studies and Community Health, Rutgers University, New Brunswick, NJ 08903. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 10
Key words * violence * homicide * black Americans * drug and alcohol abuse Homicide and suicide account for approximately 2.5% of all American deaths each year.' In addition, domestic violence, violent crime, child and elder abuse, rape and sexual abuse, and the violence associated with drug and alcohol abuse contribute substantially to the nation's psychological and physical morbidity. Yet violence has not always been within the purview of public health. It was long considered a social problem, the result of bad economics, poor education, cultural predispositions, weak gun control legislation, and an inadequate criminal justice system. The National Medical Association (NMA) noted the problem of black male homicide in 1986,2 legitimizing it as a public health concern for physicians. But, as Rosenberg3 and Harrison4 recently pointed out, homicide is only the tip of the iceberg. Violence, fatal and nonfatal, is a serious public health problem-one that needs to be studied, understood, and prevented. Within the black community, violence is pronounced, especially in relation to homicide. The problem is so severe that the US Department of Health and Human Services report, Healthy People 2000, sets the year 2000 target for homicide for black males 15 to 34 years of age 72.4 per 100 000, or 10 times the national estimate of 7.2 per 100 000 for all Americans.5 Black Americans not only suffer from high rates of homicide, they also suffer from high rates of injury from violent and abusive behavior.6 Blacks have 1.2 times the risk of being a victim of violent crime compared with whites,7 and black women are disproportionately victimized by rape.8 The problems generated by violence in the black community were recognized in 1991 by the president of the NMA, Dr Alma Rose George, who noted the obligation of NMA members to work with other professionals, organiza843
VIOLENCE AS A PUBLIC HEALTH PRIORITY
TABLE 1. HEALTH OBJECTIVES FOR BLACK
* * * * * * * *
* * * * * * * *
AMERICANS Reduce tobacco use Reduce alcohol and other drug abuse Improve nutrition Increase physical activity and fitness Improve mental health and prevent mental illness Reduce violent and abusive behavior Increase access to family planning services Promote health education and communitybased health programs Improve environmental public health Improve occupational health and safety Prevent and control unintentional injuries Improve oral health Improve food and drug safety Increase clinical preventive health services Prevent and control HIV infection and AIDS Prevent and control sexually transmitted diseases
* Immunize against and control infectious diseases
* Improve maternal and infant health * Prevent, detect, and control hypertension, heart disease, and stroke * Prevent, detect, and control cancer * Prevent, detect, and control diabetes and other disabling conditions
vided a self-selected cross section of black public health leaders generally unavailable elsewhere. We also surveyed 326 black mayors listed in the 1991 Mayors RosterlI and 443 black state legislators listed in the Directory of African-American State Legislators as of March 31, 1991.12 Public health practitioners were selected because they should be the most familiar with the scientific evidence about public health problems. Political leaders were selected because they have the power to set priorities and fund public health legislation. In other words, these groups-along with healthcare practitioners-are the primary candidates to guide public health policy toward violence reduction. The questionnaires were coded to reflect the status of the respondent: health leader, mayor, or legislator. No follow-up surveys nor reminder cards were sent due to financial constraints. At the end of 2 months, our response rate was 40% for health leaders (n = 169), 22% for mayors (n =73), and 17% for legislators (n = 78). Although the overall response rate was low, more than 300 surveys were completed. Responses were biased toward northeastern and midwestern states and toward major urban centers-regions where large numbers of black Americans reside.
Survey Instrument tions, and community groups to become part of the solution to violence.9 This article describes a study conducted to determine the views of two other important groups: black public health and political leaders. Those surveyed were asked to indicate the relative importance of violence for black Americans compared with other public health issues such as chronic diseases, prevention of acquired immunodeficiency syndrome (AIDS), low birthweight, and access to health care. The questionnaire also asked whether the problem of violence is amenable to change and, if so, who should be responsible for leading the effort.
METHODS
Study Population A one-time mail questionnaire was sent to 427 black health leaders and 24 black congressional legislators. The health leaders included national, state, and local public health officials; directors and chief executive officers of hospitals, clinics, and long-term care facilities; and public health educators. The congressional legislators were listed in the National Black Health Leadership Directory 199O-1991,W" which pro844
The questionnaire asked how important each of 21 specific health objectives listed in Healthy People 2000 are for black Americans, how amenable to change the objectives are, how important they are in rank order, and who should bear responsibility for achieving each objective. A listing of the 21 objectives is provided in Table 1. Responses to questions on importance and amenability to change were scaled from 1 to 5, with 1 being not important or not amenable, 3 being important or amenable, and 5 being most important or most amenable.
Analysis All responses were entered into a database and analyzed for mean response, 95% confidence intervals, and ranks and percentages of responses. The results were tabulated by group: health leaders, mayors (as local political leaders), and legislators (as state and national political leaders). One original goal had been to compare national and state political leaders with each other as well as with local political leaders and health officials. This goal was abandoned because the number of responses for national black legislators was too low.
RESULTS The results are presented for the two public health JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 10
VIOLENCE AS A PUBLIC HEALTH PRIORITY
TABLE 2. IMPORTANCE OF REDUCING VIOLENCE AND VIOLENCE-RELATED BEHAVIORS FOR BLACK AMERICANS % of No. 5 n Rank* Meant Lower Limit Upper Limit Responses Reduce Alcohol and Drug Abuse Health leaders 1 169 4.72 4.71 4.73 79.29 Mayors 1 4.71 73 4.69 4.73 82.19 Legislators 1 78 4.82 4.81 4.83 85.90
Reduce Violence and Abusive Behavior Health leaders 2 169 Mayors 4 73 Legislators 78 3
4.66 4.60 4.69
4.65 4.58 4.68
4.67 4.62 4.71
75.59 72.60 76.92
*1 = highest priority and 21 = lowest priority.
tOn a scale of 1 to 5, with 1 being not important, 3 being important, and 5 being most important. objectives related to violence: reducing alcohol and drug abuse, and reducing violence and abusive behavior. Both of these objectives were included because of the strong link between alcohol and drug abuse and violence.
Importance Table 2 shows that for reducing alcohol and drug abuse, responding health leaders ranked it first in importance of the 21 objectives, with a mean of 4.72 on a scale of 1 to 5. This objective was given a 5 (most important) by 79% of the health leaders. Responding mayors and legislators also ranked drug and alcohol abuse first in importance. More than 80% of these respondents gave this objective a 5. Reducing violence and abusive behavior ranked second in importance for health leaders, and third and fourth among legislators and mayors, respectively. Mayors selected preventing and controlling human immunodeficiency virus (HIV) infection and AIDS (rank 2) and preventing, detecting, and controlling hypertension, heart disease, and stroke (rank 3) as more important than reducing violence and abusive behaviors. Legislators selected preventing and controlling HIV infection and AIDS (rank 2) as more important. Overall, both public health and elected black leaders regard controlling violence as one of the most important public health problems facing black Americans.
Amenability to Change Responses to the second question regarding amenability to change are listed in Table 3. While reducing alcohol and drug abuse are ranked 1 in importance among all three categories of black leaders, they are only ranked 12, 13, and 15 when it comes to JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 10
amenability to change. For reducing violence and abusive behavior, the ranks are somewhat higher, ranging from 9 to 10. This means that respondents believe the reduction of violence and abusive behaviors is somewhat more amenable to change (less entrenched) than the reduction of alcohol and drug abuse. An examination of the confidence limits in Table 3 shows that elected officials gave significantly higher scores than health leaders to both questions. In other words, responding elected officials have more confidence than responding public health officials that violent behaviors among black Americans are amenable to change.
Primary Responsibility for Achieving Objectives The questionnaire listed nine possibilities and provided a write-in space for who (or what organization) should bear primary responsibility for achieving each objective. Table 4 lists the percentage of respondents who selected each category. Health leaders chose the individual as bearing responsibility for change more often than any other choice (35% for reducing alcohol and drug abuse and 27% for reducing violent and abusive behaviors). The federal government was their second choice for drug and alcohol abuse reduction (31 %) while the second choice for reducing violence and abusive behavior was the family (20%). Mayors, representing local political leadership, most often selected the federal government as the party responsible for reducing alcohol and drug abuse (45%). Reducing violence, however, brought a different reply. Mayors most often selected the individual as who should bear responsibility, followed by the federal government and the family (26%, 24%, and 21%, 845
VIOLENCE AS A PUBLIC HEALTH PRIORITY
TABLE 3. AMENABILITY TO CHANGE FOR VIOLENCE AND VIOLENCE-RELATED BEHAVIORS AMONG BLACK AMERICANS % of No. 5 Responses Upper Limit Lower Limit Meant n Rank* Reduce Alcohol and Drug Abuse 8.28 3.16 3.14 3.15 15 169 Health leaders 32.88 12 3.62 3.56 3.60 73 Mayors 23.68 3.58 3.53 3.55 13 78 Legislators Reduce Violence and Abusive Behavior 10 169 Health leaders 10 73 Mayors 9 78 Legislators
3.51 3.60 3.76
3.50 3.57 3.73
3.52 3.63 3.79
21.69 27.40 32.89
*1 = highest priority and 21 = lowest priority.
tOn a scale of 1 to 5, with 1 being not amenable, 3 being amenable, and 5 being most amenable. respectively). In other words, responding local political leaders believe alcohol and drug abuse reduction should rank high as a national public health priority for black Americans (rank 1 in Table 2), and the responsibility for its reduction should be borne primarily by the federal government. Our sample of mayors also believe violence should be a high national public health priority for black Americans (rank 4 in Table 2), but responsibility for its reduction should be shared by the individual, the federal government, and the family. Legislators responded that alcohol and drug abuse reduction should be the responsibility of the federal government (34%). The individual was cited second most often (28%). The responses of legislators were significantly different from health leaders and mayors about reducing violence and abusive behavior. Legislators cited the federal government as responsible only 5% of the time. Rather, they indicated that the individual and family should bear the responsibility for reducing violence (30% and 28%, respectively). In other words, our sample of legislators felt the federal government should bear the responsibility for reducing alcohol and drug abuse among the black population, but it should have little responsibility for reducing violence. They hold the individual primarily responsible for reducing violent and abusive behavior.
CONCLUSIONS Collectively, the black health and political leaders who responded to the survey felt the reduction of alcohol and drug abuse should be the most important public health priority for black Americans. Reducing violence and abusive behavior also ranked among the top four in importance. But average scores for importance were 1 to 1.5 points higher than scores for 846
amenability to change. In other words, respondents were more confident about identifying violence as an important public health problem than they were about solving the problem. The difference between responding mayors and legislators in assigning responsibility for ameliorating violent and abusive behavior was striking. Each pointed to the other. Mayors pointed to the federal government (24%); legislators did not (only 5%). Legislators thought that local government should play a role (9%); mayors did not (only 3%). Our sample of legislators also emphasized the responsibility of the individual (30%) and family (28%) more than mayors (26% and 21%). Compared with elected officials, responding black public health leaders emphasized local government (12%) and community/religious organizations (17%). Because we did not have direct contact with each black leader, we have no way of knowing what the motives of each respondent were in assigning responsibility. Yet the overall results make sense when one considers the concerns and roles of the survey respondents. For example, federal and state legislators face enormous pressure to provide funds for every problem and initiative. Shifting this responsibility away from the federal and state governments back to the individual, family, and local government may be their assessment of the limitations of federal and state resources in the 1990s. Likewise, the low proportion of responsibility assigned by mayors to local government and the high proportion assigned to the federal government may be indicative of the pressure mayors feel to provide police, social, and other services during a period of severe budget deficits and antitax sentiment. Finally, responding health leaders' strong support for local government JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 10
VIOLENCE AS A PUBLIC HEALTH PRIORITY
TABLE 4. PERCENT RESPONSES FOR WHO SHOULD BEAR RESPONSIBILITY FOR ACHIEVING HEALTH OBJECTIVES Mayorst Health Leaders* Legislators* Reduce Alcohol and Drug Abuse 34.04 44.68 30.91 Federal government 8.51 4.26 5.45 State government 0 0 5.45 Local government 0 1.82 2.13 Schools 4.26 0 2.73 Business and labor 6.38 8.51 6.36 Community/religion 2.13 2.13 3.64 Mass media 17.02 8.51 9.09 Family 27.66 27.66 34.55 Individual 0 2.13 0 Other 100 100 100 Total
Reduce Violence and Abusive Behavior 13.13 Federal government 5.05 State government 12.12 Local government 2.02 Schools 0 Business and labor 17.17 Community/religion 3.03 Mass media 20.20 Family 27.27 Individual 0 Other 100 Total
23.53 5.88 2.94 5.88 0 11.76 0 20.59 26.47 2.94 100
4.65 4.65 9.30 6.98 0 11.63 4.65 27.91 30.23 0 100
*n= 169. tn =73.
tn =78. may reflect the desire of the public health profession to make the community a focal point for public health outreach. Coalitions of physicians, public health, and local community leaders hold more hope for the reduction of violence than awaiting formation of a future national public health policy. The NMA is in a unique position to form such coalitions. Within the organization, the Community Health Coalition Project already exists to address the three broad goals of the Healthy People 2000 report: increasing the healthy life span of Americans, reducing health disparities among Americans, and achieving access to preventive health-care services.13 We suggest that reducing violence fits within the project's scope, that it should be a priority issue, and that coalitions with other black leadership groups should be explored. At the state and national levels, the NMA can join other lobbying groups for specific programs aimed at violence reduction. At the community level, individual members can join with other public health and political leaders to formulate local proactive violence prevention JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 10
programs. The time has passed when physicians can wring their hands and lament the results of violence as it rolls into the emergency room. They have obligations for prevention efforts, not only for politically correct causes such as access to health care, but for those we sweep under the rug as social problems-drug and alcohol abuse, and violence. This survey should be repeated for white, Hispanic, Asian, and native Americans in order to complement surveys being conducted by state and other organizations following the publication of the year 2000 goals. During a period when we can expect few public health initiatives, we need to be informed about the support for violence reduction that can be expected from different populations, and from medical, public health, and political leadership. Unless we clearly demonstrate that the reduction of violence is a high-ranking public health priority, that it has broad-based support crossing racial and ethnic lines, and that it is supported by medical, public health, and political leaders, large-scale programs aimed at ameliorating violence and abuse will 847
VIOLENCE AS A PUBLIC HEALTH PRIORITY
publication PHS 91-50212. 6. Rosenberg ML, Mercy JA. Introduction. In: Rosenberg ML, Fenley MA, eds. Violence in America: A Public Health Approach. New York, NY: Oxford University Press; 1991:1-13. 7. Rosenberg ML, Mercy JA. Assaultive violence. In: Rosenberg ML, Fenley MA, eds. Violence in America: A Public Health Approach. New York, NY: Oxford University Press; 1991:14-50. 8. The Crime of Rape. Washington, DC: US Dept of Justice; 1984. 9. George AR. The past, the present, the year 2000, and beyond: inaugural address. J Natl Med Assoc. 1991;83:757760. 10. National Black Health Leadership Directory 1990-199 1. Washington, DC: NRW Associates Inc; 1991. 11. 1991 Mayors' Roster Atlanta, Ga: National Conference of Black Mayors Inc; 1991. 12. Directory of African-American State Legislators as of March 31, 1991. Washington, DC: National Black Caucus of State Legislators; 1991. 13. George AR. No one will save us from us but us. J Natl Med Assoc. 1992;84:115-116, 200.
not be strongly supported financially nor advocated politically. Literature Cited 1. Vital Statistics of the United States 1988: Volume Il-Mortality (Part B). Washington, DC: Government Printing Office; 1990. US Dept of Health and Human Services publication PHS 90-1102. 2. Bell CC. Black on black homicide: the National Medical Association's responsibilities. J Natl Med Assoc. 1986;78:11391 141. Letter to the Editor. 3. Rosenberg ML. Violence is a public health problem. In: Maulits RC, ed. Unnatural Causes: The Three Leading Killer Diseases in America. New Brunswick, NJ: Rutgers University Press; 1989:147-168. 4. Harrison DD. An anthropologist's views of the roots of violence in the United States. J Natl Med Assoc. 1991;83:638642. 5. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington, DC: Government Printing Office; 1991. US Dept of Health and Human Services
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This study investigated the extent to which black public health and political leaders believe that reducing violence should be a national public health priority for black Americans when compared with other public health problems such as acquired immunodeficiency syndrome, low birthweight, and access to health care. A survey asking whether violence in the black community is amenable to change and who (or what institutions) should be responsible for the reduction of violence was sent to 427 black health leaders, 326 black mayors, and 467 black legislators. Three hundred twenty responses were returned. Virtually all respondents placed violence as one of the top five, if not the highest, public health priority for black Americans. Health and political leaders differed in their beliefs about whether violence and violence-related behaviors can be ameliorated, and who should bear responsibility for the reduction of violence. While this survey had limitations, more than 300 black public health and political leaders indicated that violence among black Americans should be made a national public health priority. Policy implications are discussed, and a proactive role for the National Medical Association is advocated. (J Nat! Med Assoc. 1992;84:843-848.) From the University of Medicine and Dentistry of New JerseyRobert Wood Johnson Medical School, the Department of Urban Studies and Community Health, and the Department of Statistics, Rutgers University, New Brunswick, New Jersey. This research was performed under a grant from the Environmental and Occupational Health Sciences Institute (EOHSI), Piscataway, New Jersey. Requests for reprints should be addressed to Dr Dona Schneider, Dept of Urban Studies and Community Health, Rutgers University, New Brunswick, NJ 08903. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 10
Key words * violence * homicide * black Americans * drug and alcohol abuse Homicide and suicide account for approximately 2.5% of all American deaths each year.' In addition, domestic violence, violent crime, child and elder abuse, rape and sexual abuse, and the violence associated with drug and alcohol abuse contribute substantially to the nation's psychological and physical morbidity. Yet violence has not always been within the purview of public health. It was long considered a social problem, the result of bad economics, poor education, cultural predispositions, weak gun control legislation, and an inadequate criminal justice system. The National Medical Association (NMA) noted the problem of black male homicide in 1986,2 legitimizing it as a public health concern for physicians. But, as Rosenberg3 and Harrison4 recently pointed out, homicide is only the tip of the iceberg. Violence, fatal and nonfatal, is a serious public health problem-one that needs to be studied, understood, and prevented. Within the black community, violence is pronounced, especially in relation to homicide. The problem is so severe that the US Department of Health and Human Services report, Healthy People 2000, sets the year 2000 target for homicide for black males 15 to 34 years of age 72.4 per 100 000, or 10 times the national estimate of 7.2 per 100 000 for all Americans.5 Black Americans not only suffer from high rates of homicide, they also suffer from high rates of injury from violent and abusive behavior.6 Blacks have 1.2 times the risk of being a victim of violent crime compared with whites,7 and black women are disproportionately victimized by rape.8 The problems generated by violence in the black community were recognized in 1991 by the president of the NMA, Dr Alma Rose George, who noted the obligation of NMA members to work with other professionals, organiza843
VIOLENCE AS A PUBLIC HEALTH PRIORITY
TABLE 1. HEALTH OBJECTIVES FOR BLACK
* * * * * * * *
* * * * * * * *
AMERICANS Reduce tobacco use Reduce alcohol and other drug abuse Improve nutrition Increase physical activity and fitness Improve mental health and prevent mental illness Reduce violent and abusive behavior Increase access to family planning services Promote health education and communitybased health programs Improve environmental public health Improve occupational health and safety Prevent and control unintentional injuries Improve oral health Improve food and drug safety Increase clinical preventive health services Prevent and control HIV infection and AIDS Prevent and control sexually transmitted diseases
* Immunize against and control infectious diseases
* Improve maternal and infant health * Prevent, detect, and control hypertension, heart disease, and stroke * Prevent, detect, and control cancer * Prevent, detect, and control diabetes and other disabling conditions
vided a self-selected cross section of black public health leaders generally unavailable elsewhere. We also surveyed 326 black mayors listed in the 1991 Mayors RosterlI and 443 black state legislators listed in the Directory of African-American State Legislators as of March 31, 1991.12 Public health practitioners were selected because they should be the most familiar with the scientific evidence about public health problems. Political leaders were selected because they have the power to set priorities and fund public health legislation. In other words, these groups-along with healthcare practitioners-are the primary candidates to guide public health policy toward violence reduction. The questionnaires were coded to reflect the status of the respondent: health leader, mayor, or legislator. No follow-up surveys nor reminder cards were sent due to financial constraints. At the end of 2 months, our response rate was 40% for health leaders (n = 169), 22% for mayors (n =73), and 17% for legislators (n = 78). Although the overall response rate was low, more than 300 surveys were completed. Responses were biased toward northeastern and midwestern states and toward major urban centers-regions where large numbers of black Americans reside.
Survey Instrument tions, and community groups to become part of the solution to violence.9 This article describes a study conducted to determine the views of two other important groups: black public health and political leaders. Those surveyed were asked to indicate the relative importance of violence for black Americans compared with other public health issues such as chronic diseases, prevention of acquired immunodeficiency syndrome (AIDS), low birthweight, and access to health care. The questionnaire also asked whether the problem of violence is amenable to change and, if so, who should be responsible for leading the effort.
METHODS
Study Population A one-time mail questionnaire was sent to 427 black health leaders and 24 black congressional legislators. The health leaders included national, state, and local public health officials; directors and chief executive officers of hospitals, clinics, and long-term care facilities; and public health educators. The congressional legislators were listed in the National Black Health Leadership Directory 199O-1991,W" which pro844
The questionnaire asked how important each of 21 specific health objectives listed in Healthy People 2000 are for black Americans, how amenable to change the objectives are, how important they are in rank order, and who should bear responsibility for achieving each objective. A listing of the 21 objectives is provided in Table 1. Responses to questions on importance and amenability to change were scaled from 1 to 5, with 1 being not important or not amenable, 3 being important or amenable, and 5 being most important or most amenable.
Analysis All responses were entered into a database and analyzed for mean response, 95% confidence intervals, and ranks and percentages of responses. The results were tabulated by group: health leaders, mayors (as local political leaders), and legislators (as state and national political leaders). One original goal had been to compare national and state political leaders with each other as well as with local political leaders and health officials. This goal was abandoned because the number of responses for national black legislators was too low.
RESULTS The results are presented for the two public health JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 10
VIOLENCE AS A PUBLIC HEALTH PRIORITY
TABLE 2. IMPORTANCE OF REDUCING VIOLENCE AND VIOLENCE-RELATED BEHAVIORS FOR BLACK AMERICANS % of No. 5 n Rank* Meant Lower Limit Upper Limit Responses Reduce Alcohol and Drug Abuse Health leaders 1 169 4.72 4.71 4.73 79.29 Mayors 1 4.71 73 4.69 4.73 82.19 Legislators 1 78 4.82 4.81 4.83 85.90
Reduce Violence and Abusive Behavior Health leaders 2 169 Mayors 4 73 Legislators 78 3
4.66 4.60 4.69
4.65 4.58 4.68
4.67 4.62 4.71
75.59 72.60 76.92
*1 = highest priority and 21 = lowest priority.
tOn a scale of 1 to 5, with 1 being not important, 3 being important, and 5 being most important. objectives related to violence: reducing alcohol and drug abuse, and reducing violence and abusive behavior. Both of these objectives were included because of the strong link between alcohol and drug abuse and violence.
Importance Table 2 shows that for reducing alcohol and drug abuse, responding health leaders ranked it first in importance of the 21 objectives, with a mean of 4.72 on a scale of 1 to 5. This objective was given a 5 (most important) by 79% of the health leaders. Responding mayors and legislators also ranked drug and alcohol abuse first in importance. More than 80% of these respondents gave this objective a 5. Reducing violence and abusive behavior ranked second in importance for health leaders, and third and fourth among legislators and mayors, respectively. Mayors selected preventing and controlling human immunodeficiency virus (HIV) infection and AIDS (rank 2) and preventing, detecting, and controlling hypertension, heart disease, and stroke (rank 3) as more important than reducing violence and abusive behaviors. Legislators selected preventing and controlling HIV infection and AIDS (rank 2) as more important. Overall, both public health and elected black leaders regard controlling violence as one of the most important public health problems facing black Americans.
Amenability to Change Responses to the second question regarding amenability to change are listed in Table 3. While reducing alcohol and drug abuse are ranked 1 in importance among all three categories of black leaders, they are only ranked 12, 13, and 15 when it comes to JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 10
amenability to change. For reducing violence and abusive behavior, the ranks are somewhat higher, ranging from 9 to 10. This means that respondents believe the reduction of violence and abusive behaviors is somewhat more amenable to change (less entrenched) than the reduction of alcohol and drug abuse. An examination of the confidence limits in Table 3 shows that elected officials gave significantly higher scores than health leaders to both questions. In other words, responding elected officials have more confidence than responding public health officials that violent behaviors among black Americans are amenable to change.
Primary Responsibility for Achieving Objectives The questionnaire listed nine possibilities and provided a write-in space for who (or what organization) should bear primary responsibility for achieving each objective. Table 4 lists the percentage of respondents who selected each category. Health leaders chose the individual as bearing responsibility for change more often than any other choice (35% for reducing alcohol and drug abuse and 27% for reducing violent and abusive behaviors). The federal government was their second choice for drug and alcohol abuse reduction (31 %) while the second choice for reducing violence and abusive behavior was the family (20%). Mayors, representing local political leadership, most often selected the federal government as the party responsible for reducing alcohol and drug abuse (45%). Reducing violence, however, brought a different reply. Mayors most often selected the individual as who should bear responsibility, followed by the federal government and the family (26%, 24%, and 21%, 845
VIOLENCE AS A PUBLIC HEALTH PRIORITY
TABLE 3. AMENABILITY TO CHANGE FOR VIOLENCE AND VIOLENCE-RELATED BEHAVIORS AMONG BLACK AMERICANS % of No. 5 Responses Upper Limit Lower Limit Meant n Rank* Reduce Alcohol and Drug Abuse 8.28 3.16 3.14 3.15 15 169 Health leaders 32.88 12 3.62 3.56 3.60 73 Mayors 23.68 3.58 3.53 3.55 13 78 Legislators Reduce Violence and Abusive Behavior 10 169 Health leaders 10 73 Mayors 9 78 Legislators
3.51 3.60 3.76
3.50 3.57 3.73
3.52 3.63 3.79
21.69 27.40 32.89
*1 = highest priority and 21 = lowest priority.
tOn a scale of 1 to 5, with 1 being not amenable, 3 being amenable, and 5 being most amenable. respectively). In other words, responding local political leaders believe alcohol and drug abuse reduction should rank high as a national public health priority for black Americans (rank 1 in Table 2), and the responsibility for its reduction should be borne primarily by the federal government. Our sample of mayors also believe violence should be a high national public health priority for black Americans (rank 4 in Table 2), but responsibility for its reduction should be shared by the individual, the federal government, and the family. Legislators responded that alcohol and drug abuse reduction should be the responsibility of the federal government (34%). The individual was cited second most often (28%). The responses of legislators were significantly different from health leaders and mayors about reducing violence and abusive behavior. Legislators cited the federal government as responsible only 5% of the time. Rather, they indicated that the individual and family should bear the responsibility for reducing violence (30% and 28%, respectively). In other words, our sample of legislators felt the federal government should bear the responsibility for reducing alcohol and drug abuse among the black population, but it should have little responsibility for reducing violence. They hold the individual primarily responsible for reducing violent and abusive behavior.
CONCLUSIONS Collectively, the black health and political leaders who responded to the survey felt the reduction of alcohol and drug abuse should be the most important public health priority for black Americans. Reducing violence and abusive behavior also ranked among the top four in importance. But average scores for importance were 1 to 1.5 points higher than scores for 846
amenability to change. In other words, respondents were more confident about identifying violence as an important public health problem than they were about solving the problem. The difference between responding mayors and legislators in assigning responsibility for ameliorating violent and abusive behavior was striking. Each pointed to the other. Mayors pointed to the federal government (24%); legislators did not (only 5%). Legislators thought that local government should play a role (9%); mayors did not (only 3%). Our sample of legislators also emphasized the responsibility of the individual (30%) and family (28%) more than mayors (26% and 21%). Compared with elected officials, responding black public health leaders emphasized local government (12%) and community/religious organizations (17%). Because we did not have direct contact with each black leader, we have no way of knowing what the motives of each respondent were in assigning responsibility. Yet the overall results make sense when one considers the concerns and roles of the survey respondents. For example, federal and state legislators face enormous pressure to provide funds for every problem and initiative. Shifting this responsibility away from the federal and state governments back to the individual, family, and local government may be their assessment of the limitations of federal and state resources in the 1990s. Likewise, the low proportion of responsibility assigned by mayors to local government and the high proportion assigned to the federal government may be indicative of the pressure mayors feel to provide police, social, and other services during a period of severe budget deficits and antitax sentiment. Finally, responding health leaders' strong support for local government JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 10
VIOLENCE AS A PUBLIC HEALTH PRIORITY
TABLE 4. PERCENT RESPONSES FOR WHO SHOULD BEAR RESPONSIBILITY FOR ACHIEVING HEALTH OBJECTIVES Mayorst Health Leaders* Legislators* Reduce Alcohol and Drug Abuse 34.04 44.68 30.91 Federal government 8.51 4.26 5.45 State government 0 0 5.45 Local government 0 1.82 2.13 Schools 4.26 0 2.73 Business and labor 6.38 8.51 6.36 Community/religion 2.13 2.13 3.64 Mass media 17.02 8.51 9.09 Family 27.66 27.66 34.55 Individual 0 2.13 0 Other 100 100 100 Total
Reduce Violence and Abusive Behavior 13.13 Federal government 5.05 State government 12.12 Local government 2.02 Schools 0 Business and labor 17.17 Community/religion 3.03 Mass media 20.20 Family 27.27 Individual 0 Other 100 Total
23.53 5.88 2.94 5.88 0 11.76 0 20.59 26.47 2.94 100
4.65 4.65 9.30 6.98 0 11.63 4.65 27.91 30.23 0 100
*n= 169. tn =73.
tn =78. may reflect the desire of the public health profession to make the community a focal point for public health outreach. Coalitions of physicians, public health, and local community leaders hold more hope for the reduction of violence than awaiting formation of a future national public health policy. The NMA is in a unique position to form such coalitions. Within the organization, the Community Health Coalition Project already exists to address the three broad goals of the Healthy People 2000 report: increasing the healthy life span of Americans, reducing health disparities among Americans, and achieving access to preventive health-care services.13 We suggest that reducing violence fits within the project's scope, that it should be a priority issue, and that coalitions with other black leadership groups should be explored. At the state and national levels, the NMA can join other lobbying groups for specific programs aimed at violence reduction. At the community level, individual members can join with other public health and political leaders to formulate local proactive violence prevention JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 10
programs. The time has passed when physicians can wring their hands and lament the results of violence as it rolls into the emergency room. They have obligations for prevention efforts, not only for politically correct causes such as access to health care, but for those we sweep under the rug as social problems-drug and alcohol abuse, and violence. This survey should be repeated for white, Hispanic, Asian, and native Americans in order to complement surveys being conducted by state and other organizations following the publication of the year 2000 goals. During a period when we can expect few public health initiatives, we need to be informed about the support for violence reduction that can be expected from different populations, and from medical, public health, and political leadership. Unless we clearly demonstrate that the reduction of violence is a high-ranking public health priority, that it has broad-based support crossing racial and ethnic lines, and that it is supported by medical, public health, and political leaders, large-scale programs aimed at ameliorating violence and abuse will 847
VIOLENCE AS A PUBLIC HEALTH PRIORITY
publication PHS 91-50212. 6. Rosenberg ML, Mercy JA. Introduction. In: Rosenberg ML, Fenley MA, eds. Violence in America: A Public Health Approach. New York, NY: Oxford University Press; 1991:1-13. 7. Rosenberg ML, Mercy JA. Assaultive violence. In: Rosenberg ML, Fenley MA, eds. Violence in America: A Public Health Approach. New York, NY: Oxford University Press; 1991:14-50. 8. The Crime of Rape. Washington, DC: US Dept of Justice; 1984. 9. George AR. The past, the present, the year 2000, and beyond: inaugural address. J Natl Med Assoc. 1991;83:757760. 10. National Black Health Leadership Directory 1990-199 1. Washington, DC: NRW Associates Inc; 1991. 11. 1991 Mayors' Roster Atlanta, Ga: National Conference of Black Mayors Inc; 1991. 12. Directory of African-American State Legislators as of March 31, 1991. Washington, DC: National Black Caucus of State Legislators; 1991. 13. George AR. No one will save us from us but us. J Natl Med Assoc. 1992;84:115-116, 200.
not be strongly supported financially nor advocated politically. Literature Cited 1. Vital Statistics of the United States 1988: Volume Il-Mortality (Part B). Washington, DC: Government Printing Office; 1990. US Dept of Health and Human Services publication PHS 90-1102. 2. Bell CC. Black on black homicide: the National Medical Association's responsibilities. J Natl Med Assoc. 1986;78:11391 141. Letter to the Editor. 3. Rosenberg ML. Violence is a public health problem. In: Maulits RC, ed. Unnatural Causes: The Three Leading Killer Diseases in America. New Brunswick, NJ: Rutgers University Press; 1989:147-168. 4. Harrison DD. An anthropologist's views of the roots of violence in the United States. J Natl Med Assoc. 1991;83:638642. 5. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington, DC: Government Printing Office; 1991. US Dept of Health and Human Services
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