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This Element explores the association between political democracy and population health. It reviews the rise of scholarly interest in the association, evaluates alternative indicators of democracy and population health, assesses how particular dimensions of democracy have affected population health, and explores how population health has affected democracy. It finds that democracy - optimally defined as free, fair, inclusive, and decisive elections plus basic rights - is usually, but not invariably, beneficial for population health, even after good governance is taken into account. It argues that research on democracy and population health should take measurement challenges seriously; recognize that many aspects of democracy, not just competitive elections, can affect population health; acknowledge that democracy's impact on population health will be large or small, and beneficial or harmful, depending on circumstances; and identify the relevant circumstances by combining the quantitative analysis of many cases with the qualitative study of a few cases.
While recent research points to the potential benefits of clinical intervention before the first episode of psychosis, the logistical feasibility of this is unclear.
To assess the feasibility of providing a clinical service for people with prodromal symptoms in an inner city area where engagement with mental health services is generally poor.
Following a period of liaison with local agencies to promote the service, referrals were assessed and managed in a primary care setting. Activity of the service was audited over 30 months.
People with prodromal symptoms were referred by a range of community agencies and seen at their local primary care physician practice. Over 30 months, 180 clients were referred; 58 (32.2%) met criteria for an at risk mental state, most of whom (67.2%) had attenuated psychotic symptoms. Almost 30% were excluded due to current or previous psychotic illness, of which two-thirds were in the first episode of psychosis. The socio-demographic composition of the 'at risk' group reflected that of the local population, with an over-representation of clients from an ethnic minority. Over 90% of suitable clients remained engaged with the service after 1 year.
It is feasible to provide a clinical service for people with prodromal symptoms in a deprived inner city area with a large ethnic minority population.
The comprehensive biopsychosocial approach to violence requires and enables us to ensure the role of social structures is incorporated in explanations of violence and approaches to addressing the problem. Tackling these social formations requires a public health approach which combines many of the interventions we have considered so far but in addition is designed to do so in an integrated programme which coordinates interventions at different levels. There has been significant growth in these integrated interventions over the past twenty years, especially with vulnerable groups in low- and middle-income countries, and we will consider some examples in this chapter. They are integrated in the sense that they often consist of ‘bundles’ of discrete intervention packages (Yount et al., 2017) operating at distinct levels within and between individuals and across whole societies to tackle violent behaviour both directly and indirectly. These programmes often combine primary prevention through broad structural changes with more direct and focussed interventions with high-risk groups. They may aim, for instance, to equip vulnerable women with the skills necessary to assertively set limits when they are exposed to violent behaviour by their partner. At the same time, they may aim to enhance the status of the same women through providing economic resources which empower them more generally in their relationships with men. The same programmes may also be designed to work with the perpetrators to change both their approach to negotiating with their partner in conflict situations and to change their attitudes toward women more generally. So these integrated programmes operate both on violence itself directly and, for example, on gender relations as an indirect factor associated with premature death from violence and from other avoidable causes such as HIV/AIDS.
Effective risk assessment, when it occurs, ideally leads to decisions about effective interventions. The multifactorial nature of violence, with its origins in biological, psychological, and social processes operating separately or together, means that interventions at all of these different levels are available for those who present an identifiable violence risk. The challenge is to identify which intervention, or combination of interventions, is most suitable in each case and to find the necessary resources for successful implementation. The next three chapters will consider interventions at each of the levels and examine some of the evidence currently available with regard to their effectiveness. In public health terms, the medical and psychosocial interventions to be considered, respectively, here and in the next chapter, mainly represent tertiary but also some secondary prevention efforts deployed with at-risk populations, or with relatively high-risk individuals who have already acted violently. In contrast, the integrated interventions considered in Chapter 10 often incorporate a primary prevention element in addition, as part of a truly comprehensive approach to the problem.
Pharmacology clearly has its limitations and dangers as a tool for reducing violence, especially as part of a public health approach which casts its net so widely across many groups who are viewed as more or less challenging for society. Since it is clear from much of the evidence discussed in Part I of this book that many other factors beyond biology contribute to the tendencies some people have toward violence, it is vital to consider what psychological and social options are available with the potential to counter that tendency. These can be much more expensive to implement because of the need for greater human resources, and, however great the leverage, the intervention can ultimately be refused or ignored. In addition, they are often more difficult to test in terms of efficacy for reasons similar to those discussed in the previous chapter. However, it is psychosocial interventions which the WHO approach endorses most strongly in its ‘best buy’ guidance and which therefore need to be examined here in terms of practicality and effectiveness.
Consider the following question. What would be likely to happen if a group of humans was returned to a ‘state of nature’, divested of the elaborate mechanisms of control that we assume restrain our impulses in everyday civilised life? Many people would probably expect that the likeliest result would be a breakdown of order and a resurgence of primeval self-interest, with increasing aggression, possibly spiralling into violence. This is the theme of William Golding’s dystopian novel Lord of the Flies, published in 1954. It is the imagined story of a group of British schoolboys shipwrecked onto a remote oceanic island. While they initially agree a set of rules for communal living, their behaviour soon deteriorates. Factions emerge, and hostilities erupt, followed by ghastly murderous violence. The book became a worldwide best-seller and was later turned into a stage play and several film versions. It was placed on reading lists in schools and colleges in many countries. The story appears to confirm what many people assume: that once the veneer of socialised conduct is stripped away, human beings naturally resort to ‘the law of the jungle’ based on evolutionary survival strategies.
There is general agreement among scientists that biological factors form an essential ingredient of a comprehensive explanation for human violence. As we have already noted, displays of aggression, fighting, and other forms of violent behaviour are easy to find across many species, and it is mostly the case that aggression pays off when survival is at stake, if there are no other means of ensuring it. It is deployed in acquiring and protecting resources, for self-defence and to promote chances of reproductive success. Yet the public health approach in this area often appears to shy away from the issue of biological factors in human violence, especially from the potential role genes might play in a tendency toward such behaviour. One of the WHO’s key statements, the World Report on Violence and Health (Krug et al., 2002), gives only brief consideration to the possible role of genetic biomarkers as risk factors for self-directed violence, but notes that what individuals may inherit is a risk of mental disorder linked to suicide rather than a propensity toward suicide in itself. The subsequent Global Status Report on Violence Prevention (World Health Organization, 2014, p. 27) in contrast acknowledges that ‘violence is a multifaceted problem with biological, psychological, social and environmental roots’. However, neither of these two landmark publications allots any space to detailed consideration of biological processes, and neither mentions genetic factors in relation to violence at all. Both reports depict violence as a problem which encompasses biological as well as the other identified influences. Yet could it be that simultaneously they render genetic influences on human aggression as something of an ‘elephant in the room’? At issue again is the question of whether we consider this strategy to be integral to our biologically evolved makeup, to an extent whereby as humans we are incapable of refraining from it. Can we leave that history to one side in explaining and addressing violence, and is the WHO on secure ground in paying minimal attention to biological influences?
So far we have been reviewing evidence for and against the idea that human beings are ‘hard-wired’ for violence. We have been suggesting that there is limited evidence for the strong proposal that acting violently is an integral part of ‘human nature’ and that there is plentiful support for the alternative perspective. At the very least, the charge of biological determinism for human violence remains unproven. To be sure, this is not to discount the plentiful evidence that violence has obviously been a recurrent feature of human life at both individual and societal levels for millennia. It is awareness of this long-standing characteristic that may sustain the seemingly widespread but as yet unjustified assumption that we are inherently motivated toward violence, or that we cannot stop ourselves from engaging in it. However, we must remind ourselves again that the simple occurrence of violent events even if frequent does not on its own confirm or deny the supposition that the cause of them lies in our basic nature, or that such a pattern is inescapable and we are perennially bound to repeat it. All that counting violent events can ever do is support the self-evident position that we have a capacity for violence that in some circumstances is expressed. The extent and manner of that expression shows large variations, between individuals, between social groups, and over time, as a function of developmental, cognitive, situational and historical factors. These variations provide the key to understanding the more likely reasons for human violence and the degree to which environment and culture counterbalance any hypothetical innate drive toward aggression and destruction.
As we have now seen, any act of violence is a result of many factors in the perpetrator’s life. The most obvious of them are immediate and concrete situational triggers such as a perceived insult or attack. The trigger here is proximal, closely linked in time and space to when and where the act of violence occurs. Such factors are usually not difficult to discern and their relationship to the act of violence is clear and specific, so they are relatively easy to identify, isolate, and address. But many other factors, just as important, are far removed in time and space from the moment when the violent act takes place. Time-wise, they may lie far back on a lifelong pathway of shaped behaviour, acquired beliefs and restricted choices. We have seen in the last chapter how developmental experiences set up some people for a future of potential violence. Attitudes, assumptions, emotional impulsivity, and violent tendencies all come from a person’s history based on where they grew up and who, if anybody, cared for them. Space-wise, these factors form the micro- and macro-environment the person inhabits at the moment of violence and act as less obvious influences channelling, as Brecht says, the flow of behaviour. Poverty, gender, education, and inequality are not easily perceptible amid the firecrackers of the immediate violent encounter, but they are present nevertheless and play a crucial part in making violence almost inevitable in some circumstances and for some people.
In this book we have posed and attempted to provide answers to a number of questions about the human capacity for violence. The fundamental aim has been to challenge the idea of violence being hard-wired into human nature, and this has led to questions about the potential for ‘rewiring’. This rethink has involved interrogating the evidence for and against various theoretical frameworks through which it is understood. It has implications for strategies to change individuals who have acted violently, the situations they might find themselves in and the societies around them. Brecht complained at the start of this book that our vision is skewed when we see only the violent behaviour of dangerous individuals and what we should always do is take a step back and make ourselves aware of the structures which partly created that person. Even more, we should consider whether the structures themselves are inherently violent because they limit and damage the person who inhabits them. We will gain more from remodelling the banks of the river which create and channel the violent torrent than we do from trying to stop the torrent itself.
Prevention of violence before it occurs is the cornerstone of a public health approach, but whole-population strategies delivered through the media and education channels address only part of the problem. Effective tertiary prevention of further violence by those who have already perpetrated it requires careful appraisal, as far as is possible, of the likelihood of its recurrence. Effective secondary prevention with those deemed at higher risk than the general population requires successful identification of those who would benefit from targeted interventions. Each of these in turn relies upon the development of effective risk assessment tools, and this aspect of violence prevention has developed rapidly over the past three decades. The recognition of separate factors that are associated with the occurrence of violent acts, such as those we surveyed in Chapter 4, has opened up the possibility of using that information to predict when such acts might occur. Attempts to do this usually focus on whether there may be some individuals who are more likely than others to behave this way. As a result of some combination of temperament, upbringing, attitudes, personality traits, poor self-control or other influences, are there people who are likely to resort to violence more readily than most others? More worryingly, are there some who might do so repeatedly, or might commit very serious forms of it? If we can identify them, we might be able to go a stage further and forecast when or against whom they are about to commit an assault.