VIOLENCE AND PUBLIC HEALTH

BY

C. EVERETT KOOP, MD

SURGEON GENERAL

      AND

DEPUTY ASSISTANT SECRETARY FOR HEALTH

DELIVERED TO THE AMERICAN ACADEMY OF PEDIATRICS

         NEW YORK, NEW YORK

          OCTOBER 26, 1982


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(GREETINGS TO HOSTS, GUESTS)

  THE ACADEMY HAS HAD 35 ANNUAL MEETINGS SINCE THE DAY I SAT WITH 7
OTHER SURGEONS IN ATLANTIC CITY AND FOUNDED THE SURGICAL SECTION. OF

THE MEETINGS SINCE THEN -- I'VE ATTENDED TWO-THIRDS, OF THE 7

SURGEONS, 5 HAVE DIED.

  I'M STILL HEREwAND IT IS ALWAYS A COMFORTABLE OCCASION COMING

BACK TO BE WITH YOU,  IN A SENSE, IT'S LIKE A HOMECOMING, IT PROVIDES
ANOTHER OPPORTUNITY FOR ME TO SAY "THANK YOU" ONCE AGAIN TO THE
ACADEMY FOR GIVING THE PEDIATRIC SURGEONS A HAVEN, A PULPIT, AND A

FUTURE,

  I APPRECIATE THIS OPPORTUNITY TO SPEAK TO YOU THIS MORNING ON A
SUBJECT THAT IS UNCOMFORTABLE TO RAISE: VIOLENCE AS A PUBLIC HEALTH

CONCERN.  IT IS UNCOMFORTABLE BECAUSE, WHEN WE DO RAISE THAT ISSUE, WE
ARE REALLY ADMITTING THAT MANKIND STILL HAS QUITE A DISTANCE TO TRAVEL

IN ITS LONG MARCH TOWARD CIVILIZED LIVING.

  I'M NOT LIMITING MY REMARKS JUST TO CHILD ABUSE THIS MORNING.

RATHER, THIS IS A CALL TO ACTION ON YOUR PART -- INDIVIDUALLY AND

COLLECTIVELY -- TO ADDRESS THIS ISSUE OF VIOLENCE BY DISCUSSION,

STUDY, AND RESEARCH,


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  WE'VE GOT TO DO THIS BECAUSE VIOLENCE HAS GROWN TO BECOME ONE OF

THE MAJOR PUBLIC HEALTH PROBLEMS IN AMERICAN SOCIETY TODAY, IT IS NOT

NEW, OF COURSE. VIOLENCE OF SOME KIND -- MURDER, SUICIDE, ASSAULT,

ARMED CONFRONTATION OF NEIGHBOR AGAINST NEIGHBOR -- THESE HAVE

APPEARED IN OUR NATIONAL HISTORY SINCE THE 17TH CENTURY, IN THE PAST

80 YEARS OR SO, AS WE IMPROVED OUR ABILITY TO COLLECT VITAL

STATISTICS, WE HAVE BEEN ABLE TO IDENTIFY PERIODS WHEN THERE WERE

CHANGES IN THE INCIDENCE OF MORBIDITY AND MORTALITY CAUSED BY

VIOLENCE.  WE ARE COMING THROUGH JUST SUCH A PERIOD NOW,

  VIOLENCE IN THIS COUNTRY SURGED IN THE LATE 1960s AND INTO THE

197os,  ALL THE INDICATORS WENT UP.  BUT THE TOLL UPON YOUNG PEOPLE --

PRE-SCHOOLERS, EARLY ADOLESCENTS, AND YOUNG ADULTS -- HAS BEEN

PARTICULARLY HIGH. THE MORTALITY RATES HAVE RISEN DURING THIS PERIOD

AND THERE SEEMS TO BE LITTLE LIKELIHOOD THAT THEY WILL RETURN TO THE

LEVELS OF THE 1950s AND EARLY 196Os,

  LET ME ISOLATE THE RECENT MORTALITY HISTORY JUST FOR 15- TO

24-YEAR-OLDS IN THREE DIFFERENT AREAS OF TRAUMA AND VIOLENCE:

  IN MOTOR VEHICLE FATALITIES, THE DEATH RATE PER 100,000 OF THIS

AGE GROUP IN 1960 WAS 38,  IN 1970 IT HIT ITS PEAK OF 47.2, BY 1978

IT HAD ABATED ONLY SLIGHTLY TO 46.4. THAT IS THE HISTORY FOR ALL MEN

AND WOMEN AGES 15 THROUGH 24.  AMONG WHITE MALES THE NUMBERS ARE FAR


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WORSE:  FROM A 1960 RATE OF 62.7 TO A 1978 HIGH OF 75.4 DEATHS PER

100#000 -- NEARLY TWICE THE RATE FOR THE ENTIRE AGE COHORT. ONE-HALF

OF THE FATALITIES ARE CAUSED BY THE COMBINATION OF DRIVING AND

DRINKING.  WE CAN DO SOMETHING ABOUT THAT.

  THE STORY IN HOMICIDE IS THE SAME. FROM A 1960 LOW OF 5m9 MURDERS

PER 100,000 MEN AND WOMEN AGE 15 TO 24, TO A RATE OF 11.7 BY 1970, AND

TO A HIGH OF 13.2 IN 1978,  THE CARNAGE AMONG BLACK MALES, HOWEVER, IS

PARTICULARLY ALARMING:  FROM A RATE OF 46.4 DEATHS BY MURDER IN 1960

TO A HIGH OF 102.5 A DECADE LATER, AND THEN DOWN TO A HOMICIDE

MORTALITY RATE OF 72.5 IN 1978.

  IN SUICIDE, MY THIRD AND LAST EXAMPLE, THE MORTALITY RATE FOR MEN

AND WOMEN AGES 15 THROUGH 24 ROSE FROM 5.2 IN 1960 TO A PEAK OF 13.6

IN 1977 AND THEN DROPPED SLIGHTLY TO 12,4 IN 1978, THE STORY AMONG

WHITE MALES BEARS SOME STUDY: THEIR RATE HAD BEEN 8.6 BACK IN 1960.

IT THEN ROSE IN VIRTUALLY A STRAIGHT LINE TO A LEVEL OF 20.8 IN THE

LATEST YEAR WE HAVE, 1978.

   MOTOR VEHICLE ACCIDENTS .,.HOMICIDE...SUICIDE...THESE VIOLENT

DEATH CATEGORIES NOW HAVE NEW AND HIGHER DEATH RATES PER 100,000

POPULATION IN ALMOST ANY GROUPING OF PERSONS BETWEEN 1 YEAR AND 24

YEARS OF AGE,  I PICKED THE 15-TO-24-YEAR-OLDS NOT ONLY BECAUSE THEIR

MORTALITY TRENDS ARE SO CLEAR OR BECAUSE THEY ARE ABOUT TO CROSS THE


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THRESHOLD TO ADULTHOOD AND BECOME THE WORKERS AND VOTERS AND LEADERS

OF THIS COUNTRY, THEY ARE ALSO THE PRODUCTS OF THE PEDIATRICIANS'

EFFORTS IN THE PRECEDING DECADE AND A HALF, IF, OF COURSE, THEY HAVE

SURVIVED,

  SOMETHING HAPPENED IN THIS COUNTRY ABOUT A DECADE OR SO AGO, OR

MAYBE WE SHOULD SAY SOMETHINGS, SINCE NO SINGLE CAUSE OR EVENT COULD

BE RESPONSIBLE FOR RESULTS SO WIDESPREAD, SO PERVASIVE, AND SO

DESTRUCTIVE,   AND IT MAY BE TOO SOON FOR US TO KNOW WITH ANY CERTAINTY

WHAT THOSE THINGS WERE,  WE MAY NOT YET HAVE THE HISTORIC DISTANCE,

THE DETACHMENT, TO COME TO ANY REASONABLY SOUND CONCLUSIONS, BUT WE

STILL MUST TRY TO UNDERSTAND, EVEN WITH OUR CONTEMPORARY MYOPIA, JUST

WHAT HAS BEEN HAPPENING AND WHY -- AND WHAT THE EFFECTS SEEM TO BE

UPON THE AMERICAN PEOPLE.  I AM, BY SPECIALTY AND TRAINING, NOT A
SOCIAL HISTORIAN, BUT IT Is MY JOB TO MONITOR THE HEALTH STATUS OF

THE AMERICAN PEOPLE.  IF I SENSE SOMETHING WRONG, I AM OBLIGED TO

BRING IT OUT INTO THE OPEN AND TALK ABOUT IT,

AND THAT'S PRECISELY WHAT I'M DOING RIGHT NOW,

  RATHER THAN RESURRECT MUCH OF THE LITERATURE OF VIOLENCE, WITH

WHICH MANY OF YOU MAY BE FAMILIAR ANYWAY, I WANT TO TAKE A FEW CAREFUL

STEPS FORWARD TO SEE WHAT THE ROLE OF THE PHYSICIAN MIGHT BE IN

UNDERSTANDING AND POSSIBLY PREVENTING THE LOSS OF LIFE -- MILLIONS OF

YEARS OF LIFE -- THROUGH THESE VIOLENT PREMATURE DEATHS,


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  1 HAVE CHOSEN THIS PARTICULAR OCCASION BECAUSE, OF ALL PHYSICIANS,
I BELIEVE THE PEDIATRICIAN HAS A UNIQUE RELATIONSHIP WITH CHILDREN AND
WITH PARENTS, YOU GAIN CERTAIN INSIGHTS ABOUT INDIVIDUALS AND FAMILIES
THAT OTHER PHYSICIANS MAY NOT HAVE THE CHANCE TO SEE.

  I BASE THAT OPINION, BY THE WAY, ON THE REFLECTIONS OF MY OWN
CAREER OF 35 YEARS IN PEDIATRIC SURGERY, DEALING WITH THE YOUNG
CHILDREN WHO WERE MY PATIENTS I SAW FIRSTHAND THE STRESSES OF
CHILDHOOD AND WAS AWARE OF BOTH THE STRENGTHS AND WEAKNESSES OF
CHILDREN TRYING TO COPE.  I ALSO HAD TO UNDERSTAND THE FAMILIES OF

THOSE CHILDREN,  I HAD TO GAIN THEIR CONFIDENCE AND WIN THEM AS ALLIES

IN THE BATTLE TO HELP THEIR CHILDREN,

  IN THE PROCESS, I THINK I BEGAN TO UNDERSTAND A GREAT DEAL ABOUT

THE CONTEMPORARY AMERICAN FAMILY,

  I TRIED TO ABSORB THAT INFORMATION AND THEN FOCUS IT UPON THE

PROBLEM TO BE SOLVED BY SURGERY.  SOMETIMES, WHEN IT WAS CLEAR TO ME
THAT I WAS GAINING INSIGHTS INTO A SERIOUS FAMILY PROBLEM NOT DIRECTLY
RELATED TO THE SURGERY, I WOULD BE OPEN AND AVAILABLE TO THAT FAMILY,
JUST IN CASE THEY WANTED TO TALK IT THROUGH, BUT I KNEW THAT I LACKED
A CLEAR UNDERSTANDING OF THE NEED FOR ME TO BECOME INVOLVED AND m
WHAT EXTENT I SHOULD BECOME INVOLVED AND WHAT I MIGHT HOPE TO

ACCOMPLISH.


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  NOW, AFTER LOOKING AT THE DATA FROM MY NEW VANTAGE-POINT AS
SURGEON GENERAL, AND APPRECIATING THE SPECIAL ACCESS TO -- AND

RELATIONSHIP WITH -- THE AMERICAN FAMILY THAT PEDIATRICIANS DO ENJOY,
I THINK MY MESSAGE TO YOU TODAY ON VIOLENCE IN OUR SOCIETY AND ITS
EFFECTS ON CHILDREN AND FAMILIES IS APPROPRIATE AND NECESSARY.

LET ME PROPOSE AS A STARTING-POINT THE PROPOSITION THAT PHYSICIANS
NEED TO BECOME MORE FAMILIAR WITH THE SYMPTOMS OF VIOLENT PERSONAt ITY
IN CHILD AND PARENT ALIKE.  UNFORTUNATELY, WE DON'T HAVE AVAILABLE
SOME STOCK, OFF-THE-SHELF PROFILES OF PERSONS WHO ARE DISPOSED TOWARD

VIOLENCE.  BUT THE RESEARCH LITERATURE DOES PROVIDE US WITH SOME CLUES
THAT SEEM STURDY ENOUGH TO FOLLOW,

FOR EXAMPLE, ACCORDING TO THE WORK DONE BY DR. DOROTHY OTNOW LEWIS
OF THE N,Y.U, SCHOOL OF MEDICINE, HOMICIDALLY VIOLENT CHILDREN ALSO

TEND TO HAVE A HISTORY OF ATTEMPTED SUICIDE, MANY OF THEM HAVE A
HISTORY OF PSYCHOMOTOR SEIZURES, THEIR FATHERS ARE USUALLY
CHARACTERIZED AS "VERY VIOLENT," PARTICULARLY TO THE MOTHERS. THESE
CHILDREN ALSO TENDED TO HAVE MOTHERS WHO AT SOME TIME HAD TO HAVE
INPATIENT PSYCHIATRIC CARE,  OTHER STUDIES INDICATE THAT VIOLENT
ADOLESCENTS HAD SEEN SEVERE PHYSICAL ABUSE OCCUR AT HOME OR WERE
THEMSELVES THE VICTIMS OF FAMILY VIOLENCE,


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  HIGH-RISK FAMILIES ALSO TEND TO BE SOCIALLY ISOLATED FROM THEIR

NEIGHBORS, THIS IS THE CASE ACROSS ALL SOCIAL, RACIAL, AND ECONOMIC

LINES,  SUCH FAMILIES LACK STRONG FRIENDSHIPS, THEY CAN'T SEEM TO GET
CLOSE TO OTHER FAMILIES, PARTICULARLY FAMILIES THAT DO NOT SHOW
EVIDENCE OF STRESS OR VIOLENT BEHAVIOR, HIGH-RISK FAMILIES HAVE

DIFFICULTY COPING WITH PRESSURES OUTSIDE THEIR OWN HOME -- PRESSURES

ON THE JOB OR PRESSURES WHILE LOOKING FOR A JOB, OR THE INTERNAL

PRESSURES THAT MAY BUILD UP WHILE TRYING TO NEGOTIATE SUCH SOCIAL

TRANSACTIONS AS SHOPPING OR USING PUBLIC TRANSPORTATION, SUCH

FAMILIES ALSO HAVE DIFFICULTY COPING WITH STRESS INSIDE THEIR OWN

HOMES: CHILDREN MAKING NOISE.,,LOUD RADIOS, TELEVISION SETS, OR

STEREOS, ,,AND A WHOLE RANGE OF MARITAL UPSETS, INCLUDING THOSE

PRODUCED BY ALCOHOL AND DRUGS,

  WE KNOW THAT VIOLENCE WITHIN THE FAMILY -- PARTICULARLY PARENTAL

VIOLENCE TOWARD CHILDREN -- TENDS TO ESCALATE DUING PERIODS OF ECONOMIC

STRESS.  INDEBTEDNESSmLACK OF WORK,.,EVICTION,,.LAY-OFFS.,,RE-

POSSESSIONS,, *THESE ARE THE STUFF OF TRAUMA FOR MANY FAMILIES. THEY

CAN OVERWHELM PARENTS AND OPEN THEM TO THE TERRIBLE IMPULSES OF

VIOLENCE AGAINST EACH OTHER AND AGAINST THEIR CHILDREN, IN SOME AREAS

OF THE COUNTRY WE ARE EXPERIENCING VERY DIFFICULT ECONOMIC CONDITIONS

AND, IF THE RESEARCH AND THE ANECDOTAL MATERIAL WE HAVE IS ANY GUIDE,

THOSE AREAS ARE ALSO EXPERIENCING A RISE IN FAMILY VIOLENCE,


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  THESE MAY SHOW UP IN MARKS ON BATTERED SPOUSES AND ABUSED CHILDREN,

THEY ARE NEVER WELL EXPLAINED. THE VICTIMS ARE OFTEN EMBARRASSED,

EVASIVE, OR SIMPLY TIGHT-LIPPED, THE PHYSICIAN NEEDS TO UNDERSTAND

HOW TO "READ" THOSE INTENSELY PERSONAL AND HUMAN SIGNALS OF THE VICTIM

OF FAMILY VIOLENCE.

  I HAVE SPENT SOME TIME ON THE FAMILY BECAUSE OF ITS OVERWHELMING

INFLUENCE IN THE SHAPING OF INDIVIDUAL BEHAVIOR. EDUCATIONAL RESEARCH

HAS DEMONSTRATED AGAIN AND AGAIN THAT A FAMILY ENVIRONMENT THAT

SUPPORTS STUDY AND LEARNING, THAT REWARDS THE CHILD THAT IS SUCCESSFUL

IN SCHOOL, WILL PRODUCE CHILDREN WHO DO WELL IN SCHOOL AND IN LIFE

LATER ON, ALL OTHER THINGS BEING EQUAL,

  AND THE REVERSE IS TRUE, ALSO. A FAMILY ENVIRONMENT THAT IS CRUEL

AND UNCARING WILL SEND CRUEL AND UNCARING CHILDREN INTO THE WORLD AS

AGGRESSIVE, VIOLENT ADULTS,  THESE ARE NOT HARD-AND-FAST RULES, HUMAN

BEINGS ARE NOT PIGEONS AND DON'T FIT INTO NEAT, CONSISTENT PIGEON-

HOLES,  BUT THE WEIGHT OF EXPERIENCE AND EVIDENCE DOES INDICATE THAT

SOME SIGNALS, SUCH AS THE ONES I MENTIONED, OUGHT TO BE NOTED AND

RESPECTED BY THE PHYSICIAN,

  THE PHYSICIAN, SUSPECTING THAT A PATIENT MAY BE PREDISPOSED TO

VIOLENT BEHAVIOR, SHOULD PROVIDE THE SAME KIND OF COUNSELING OR

REFERRAL SERVICE AS IF THE PATIENT SHOWED A PREDISPOSITION TO

CARDIOVASCULAR DISEASE, OBESITY, OR DIABETES, WITH THE PATIENT'S


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CONSENT, IT MAY BE POSSIBLE TO INVOLVE A SPOUSE OR A CHILD IN THE DIS-

CUSSION OF THIS HEALTH PROBLEM.  THIS IS A SENSITIVE AREA AND WE NEED
TO GIVE IT OUR PROFESSIONAL STUDY AND ATTENTION IN ORDER TO PROVIDE
GUIDANCE TO PEDIATRICIANS AND OTHER PRIMARY CARE PHYSICIANS. THE
OBJECTIVE, LET ME REPEAT, IS NOT TO INTERVENE INTO A PATIENT'S PRIVATE
FAMILY LIFE FOR INTERVENTION'S SAKE BUT TO PREVENT VIOLENT BEHAVIOR
FROM OCCURRING AND ENDANGERING THE HEALTH OR THE LIFE OF ANOTHER,

  I RECOGNIZE THAT NOT ALL PHYSICIANS WOULD AGREE WITH THAT

ASSESSMENT OF THEIR ROLE,  THEY WOULD OBJECT TO IT AS BEING YET
ANOTHER EXAMPLE OF THE "MEDICALIZATION OF SOCIAL PROBLEMS," AND I
FULLY APPRECIATE THE UNEASINESS FELT BY MANY PHYSICIANS AND OTHER
HEALTH PROFESSIONALS WITH SOCIETY'S HABIT OF CASUALLY TURNING TO
MEDICINE TO SOLVE WHAT MAY SIMPLY NOT BE A HEALTH OR MEDICAL PROBLEM.

BUT WITH VIOLENCE, I THINK THERE IS A DIFFERENCE,

  THIS POINT WAS ALSO MADE AT A WORKSHOP HELD LAST SUMMER BY THE

INSTITUTE OF MEDICINE.  THE SUBJECT WAS THE PREVENTION OF VIOLENCE.
ON THIS MATTER OF THE "MEDICALIZATION OF VIOLENCE," THE PARTICIPANTS
MADE SEVERAL GOOD POINTS, WHICH I WILL SUMMARIZE:

  FIRST, THERE SEEMS TO BE NO OTHER INSTITUTIONAL FOCUS FOR RESEARCH
INTO THE CAUSES OF VIOLENCE THAT TAKES INTO ACCOUNT THE MULTIPLE
BIOLOGICAL, PSYCHOLOGICAL, SOCIAL, AND SOCIETAL DIMENSIONS OF CRIME,

ITS VICTIMS, AND ITS PREVENTION.  THE INSTITUTIONS CLOSEST TO BEING


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ABLE TO PROVIDE A MULTIDISCIPLINARY APPROACH TO RESEARCH IN THE

PREVENTION OF FAMILY VIOLENCE, FOR EXAMPLE, WOULD BE THE NATIONAL

INSTITUTE OF MENTAL HEALTH AND THE NATIONAL INSTITUTE OF CHILD HEALTH

AND HUMAN DEVELOPMENT.

  SECOND, THE NATIONAL INSTITUTE OF LAW ENFORCEMENT AND CRIMINAL

JUSTICE, THE RESEARCH ARM OF THE JUSTICE DEPARTMENT, SEES "PREVENTION"

AS A WAY OF STOPPING A RECURRENCE OF A CRIMINAL ACT.  IN EFFECT, THE

JUSTICE DEPARTMENT DOES NOT HAVE WHAT WOULD BE IN OUR DISCIPLINE OF

MEDICINE A "PRIMARY PREVENTION" STRATEGY. AND ON REFLECTION, ONE WOULD

HAVE TO ADMIT THAT SUCH A STRATEGY UNDER THE CRIMINAL JUSTICE SYSTEM

COULD VERY WELL COME IN CONFLICT WITH TRADITIONAL CIVIL LIBERTIES,

  AND THIRD, THE WORKSHOP PARTICIPANTS AGREED THAT THE MORBIDITY AND

MORTALITY FROM VIOLENCE ARE EXTREMELY COSTLY TO SOCIETY NOT ONLY IN

PRODUCTIVE YEARS LOST BUT IN THE HARD DOLLAR TERMS OF THE IMPACT UPON

THE HEALTH CARE SYSTEM, THIS IS PARTICULARLY TRUE IN THE CASES OF

ABUSED CHILDREN, WHO FREQUENTLY HAVE CHRONIC DISABILITIES EVEN AFTER

TREATMENT, YOUNG WOMEN WHO HAVE BEEN SEXUALLY ABUSED BY FAMILY MEMBERS

FREQUENTLY DEVELOP CHRONIC ILLNESSES REQUIRING REPEATED INPATIENT

PSYCHIATRIC CARE.  THEY ALSO MAKE INCREASED USE OF GYNECOLOGICAL HEALTH

SERVICES, AS THEIR TOTAL PERSONAL HEALTH STATUS DECLINES,


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  WE MIGHT NOT WANT THIS VERY COMPLICATED ISSUE TO GRAVITATE TOWARD
MEDICINE FOR ANSWERS, BUT I BELIEVE WE NEED TO ACCEPT THE FACT THAT WE
MAY HAVE A CONTRIBUTION TO MAKE, I BELIEVE THAT WE DO AND WE ARE
OBLIGATED TO MAKE THAT CONTRIBUTION'

  IN ADDITION TO LEARNING MORE ABOUT THE ISSUE OF VIOLENCE AND HOW
IT MANIFESTS ITSELF IN PATIENT BEHAVIOR, I BELIEVE PHYSICIANS NEED TO
SEE THEMSELVES AS CAPABLE OF PRESCRIBING SOME RUDIMENTARY, PREVENTIVE

BEHAVIOR FOR SUCH PATIENTS,  THIS MAY BE MORE EASILY PROPOSED THAN
DONE, BUT I THINK IT'S TIME WE LOOKED AT THIS AS A SERIOUS ASPECT OF
PEDIATRIC AND FAMILY PRACTICE FOR CONTEMPORARY AMERICAN SOCIETY.

  I SPOKE BEFORE OF SEEING PATIENTS WITH PREDISPOSITIONS TOWARD
VIOLENCE AS NEEDING OUR HELP, AS IF THEY WERE PATIENTS PREDISPOSED TO
HYPERTENSION. AS PHYSICIANS, WE DO NOT HESITATE TO COUNSEL PATIENTS
TO AVOID SALT AND SALTED FOODS OR TO AVOID SIMPLE SUGARS, AND I THINK
WE ALL WOULD AGREE THAT THERE IS A PROFOUND DIFFERENCE BETWEEN
ADVISING A PATIENT TO AVOID SUGAR -- AND ADVOCATING THAT THE
GOVERNMENT REMOVE ALL SUGARED PRODUCTS FROM THE MARKETPLACE. THE
FORMER IS GOOD MEDICAL PRACTICE,.,THE LATTER IS BAD GOVERNMENT.

  SIMILARLY, IF WE HAVE A PATIENT WITH A PREDISPOSITION FOR VIOLENT
BEHAVIOR, ESPECIALLY AGAINST FAMILY MEMBERS, I THINK WE NEED TO ADVISE
THAT PATIENT TO GET SOME PROFESSIONAL COUNSELING AND ALSO SUGGEST THAT
HE OR SHE MONITOR THEIR ENTERTAINMENT "MENU" AND AVOID THEvsKJNDS OF
TELEVISION OR MOTION PICTURE FARE THAT STIMULATES AND CONTRIBUTES TO


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THE VIOLENCE IN THEIR PERSONALITIES. I DON'T LIKE THE VIOLENCE IN
SO-CALLED "ENTERTAINMENT" SHOWS TODAY, BUT I DO NOT BELIEVE THE ANSWER
IS GOVERNMENT CENSORSHIP,  THAT DOES NOT LEAVE ME POWERLESS AS A

PHYSICIAN, HOWEVER,  I BELIEVE IT WOULD BE COMPLETELY WITHIN THE CANONS
OF MY PROFESSION TO ADVISE PATIENTS PREDISPOSED TO VIOLENCE TO SELF-
CENSOR THEIR ENTERTAINMENT DIET,

  I DON'T KNOW HOW MANY TIMES THE GOVERNMENT HAS TO COME OUT WITH
YET ANOTHER STUDY OF TELEVISION VIOLENCE TO MAKE THE POINT THAT IT IS
HARMFUL TO CHILDREN,  THERE HAS BEEN AN INTERMINABLE AMOUNT OF BEAN-
COUNTING TO QUANTIFY THE OBVIOUS:

0   CHILDREN SPEND AT LEAST 2 HOURS AND A HALF IN FRONT OF A T.V.

SET EACH DAY.,,

0   MANY OF TODAY'S HIGH SCHOOL GRADUATES WILL HAVE SPENT MORE OF
THEIR LIVES IN FRONT OF A TX SET THAN IN THE CLASSROOM,,,

0   BY THE AGE OF 18 A YOUNG PERSON COULD HAVE WITNESSED OVER
18,000 MURDERS ON TELEVISION, THIS DOES NOT COUNT THE
DOCUMENTATION OF VIOLENCE THAT SEEMS TO BE IN EVERY T.V, NEWS

REPORT...

0   ADULTS SPEND ABOUT 40 PERCENT OF THEIR LEISURE TIME WATCHING
TELEVISION, WHICH RANKS THIRD -- BEHIND SLEEP AND WORK .~r- AS AN
OCCUPIER OF AN ADULT'S AVERAGE DAY,


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  LAST YEAR THE CALIFORNIA COMMISSION ON CRIME CONTROL AND VIOLENCE
PREVENTION CONSIDERED THESE AND OTHER FACTS AND CONCLUDED THAT THERE fi
A RELATIONSHIP BETWEEN THE VIOLENCE THAT IS TELEVISED AND THE VIOLENCE

THAT TAKES PLACE IN THE "REAL WORLD," NOT ONLY ARE THE SPECIFIC DE-
TAILS OF A FICTIONAL CRIME RE-ENACTED BY VIEWERS -- OFTEN YOUNG

CHILDREN OR ADOLESCENTS -- BUT THERE IS A STRONG SUSPICION THAT THE
AGGRESSIVE BEHAVIORS BY THE "HEAVIES" ON TELEVISION ARE MIMICKED BY
VIEWERS ALSO, WHETHER CONSCIOUSLY OR UNCONSCIOUSLY, IN A VARIETY OF

RELATIONSHIPS AND SETTINGS.

  THIS IS DIRECTLY RELATED TO ANOTHER POTENTIAL RESULT FROM

EXTENSIVE VIEWING OF TELEVISION OR MOTION PICTURE VIOLENCE: WE BEGIN
TO BELIEVE THAT VIOLENCE IS A SOCIALLY ACCEPTABLE AND CREDIBLE WAY OF
RESPONDING TO FRUSTRATION OR INSULT OR SOME OTHER DIRECT, PERSONAL

HURT,  AND FREQUENTLY, VIOLENT BEHAVIOR THAT STOPS JUST SHORT OF
MURDER SEEMS TO GO UNPUNISHED, CHILDREN ESPECIALLY BECOME "DESENSI-
TIZED" TO VIOLENT INTERPERSONAL CONFLICT AND, WHEN SEEING ANOTHER
CHILD BEING HURT, WILL TEND NOT TO DO THE THING THAT CIVILIZATION

REQUIRES BE DONE -- STEP IN AND PROTECT THE VICTIM. INSTEAD, THEY

WILL WATCH, AS IF THIS TOO WERE DRAMATIZED ENTERTAINMENT.

  I HAVE NOT MENTIONED VIDEO GAMES BECAUSE I DON'T WANT TO DUPLICATE
WHAT ANOTHER SPEAKER ON YOUR PROGRAM MAY PRESETN. ALSO, WE ARE JUST

BEGINNING TO ASSESS THE DATA.  BUT I DO KNOW THESE GAMES ARE NOT


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CONSTRUCTIVE,  WHETHER THEY SHOW SOLDIERS OR SPACE-CRAFT OR MEN FROM
MARS OR JUST FROM "THE OTHER SIDE," WE ZAP THEM -- AND THAT MEANS
ANNIHILATION,

  IT SEEMS TO ME THAT THE WEIGHT OF EVIDENCE -- WHETHER IT HAS A
SOLID RESEARCH BASE OR IS PURELY ANECDOTAL -- THE WEIGHT OF EVIDENCE
STRONGLY SUGGESTS THAT PHYSICIANS OUGHT TO RECOGNIZE THAT A DIET OF
VIOLENT ENTERTAINMENT FOR THE VIOLENCE-PRONE INDIVIDUAL IS AS UNHEALTHY
AS A DIET OF SUGAR AND STARCH IS FOR THE OBESITY-PRONE INDIVIDUAL.

  I HAVE INDICATED THE NEED FOR PHYSICIANS TO RECOGNIZE THE SIGNALS
OF THE VIOLENT PERSONALITY AND THE VIOLENT HOME AND I HAVE SUGGESTED
THAT THERE ARE SOME THINGS WE CAN "PRESCRIBE," SUCH AS A LOWER INTAKE
OF VIOLENT ENTERTAINMENT.  THESE ARE WAYS OF RESPONDING TO THE PHENOM-
ENON OF VIOLENCE AS WE SEE IT DEVELOP OR DEAL WITH ITS AFTERMATH. BUT
THERE ARE THINGS WE OUGHT TO DO, AS PHYSICIANS, THAT ARE N-ACTIVE,
AS WELL AS REACTIVE,

  ONE TASK WE HAVE IS TO PUT THE FULL WEIGHT OF OUR PROFESSION ON THE
SIDE OF STRENGTHENING POSITIVE, HEALTHY FAMILY LIFE IN THIS SOCIETY,
IN THIS MATTER OF VIOLENCE, AS IN OTHER MATTERS, WE TEND TO LOOK ALL
ABOUT FOR OTHER PALLIATIVES,,, MAGIC POTIONS OF ONE SORT OR ANOTHER,
REAL OR FIGURATIVE.,,EXOTIC THERAPIES,,,ALL SORTS OF DIVERTING POSSI-
BILITIES KEEP CROPPING UP, BUT THAT'S WHAT THEY ARE -- DIVERTING. WE
NEED TO RETURN TO THE BUSINESS OF HOLDING THE FAMILY TOGETHER, THE
FUNDAMENTAL, IRREDUCIBLE SOCIAL UNIT.


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  I BELIEVE THAT IT IS PRIMARILY AND SUBSTANTIALLY WITHIN THE
LIMITED PHYSICAL AND EMOTIONAL SPACE OCCUPIED BY THE FAMILY -- ITS

"HOME" _- THAT ONE HUMAN BEING CAN GET USED TO THE WORK OF LOVING AND
TRULY CARING ABOUT THE WELFARE OF ANOTHER HUMAN BEING. OF COURSE, WE
KNOW THAT THE REVERSE IS TRUE, ALSO,  BUT THE FAMILY VIOLENCE WE TALK
ABOUT IS THE EXCEPTION TO THE HUMAN RULE, WE NEED TO DEAL WITH THOSE
EXCEPTIONS,  BUT, IN DOING SO, WE MUST NOT CUT ADRIFT THE HEALTHY
FAMILIES FROM OUR CONSTANT SUPPORT AND ATTENTION.

  THE FAMILY RELATIONSHIP IS RICH -- BUT IT IS ALSO FRAGILE,
PHYSICIANS PROVIDING FAMILY CARE AND CONCERNED ABOUT THE MAINTENANCE
OF PEACE AS WELL AS OF HEALTH IN A FAMILY, NEEDS TO UNDERSTAND THE

INFLUENCE OF WORK -- OR THE INFLUENCE OF THE LACK OF WORK -- UPON

FAMILY MEMBERS., .

  ALSO UNDERSTAND THE SYMBOLISM OF MATERIAL GOODS, WHICH ARE SUPPOSED
TO CONVEY A SENSE OF WELL-BEING FOR THE FAMILY BUT RARELY DO ALL BY

THEMSELVES,, a

  AND ALSO UNDERSTAND THE HEALTHY WAYS IN WHICH PEOPLE GROW UP AND
GROW OLD, AND THE POSSIBILITY THAT SOME FAMILIES FACE THEIR OWN AGING
WITH ANGER AND FEAR,

THIS IS A VERY DIFFICULT REQUEST TO MAKE OF ANY PHYSICIAN, MOST
HAVE NOT BEEN TRAINED IN THESE AREAS, WHICH TEND TO BE MORE THE
PROVINCE OF THE SOCIOLOGIST, THE PSYCHIATRIST, THE PSYCHOLOGIST, OR


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THE SOCIAL SERVICES WORKER,  THE WORK OF SOCIOLOGISTS MURRAY STRAUS OF
THE UNIVERSITY OF NEW HAMPSHIRE AND RICHARD GELLES OF THE UNIVERSITY
OF RHODE ISLAND TEND TO BE UNKNOWN AMONG PHYSICIANS, YET STRAUS AND
GELLES ARE AMONG THE LEADING RESEARCHERS IN THE FIELD OF FAMILY

VIOLENCE,

  PHYSICIANS TEND TO BE UNCLEAR ABOUT THE ROLES OF THESE AND OTHER
PROFESSIONALS,  COMMUNICATION BETWEEN THE PRACTITIONERS OF PHYSICAL
MEDICINE AND THOSE WHO PRACTICE OTHER DISCIPLINES TENDS TO BE LIMITED
AND UNCLEAR. PHYSICIANS ARE ALSO GENERALLY UNFAMILIAR WITH THE
EDUCATION AND TRAINING OF PERSONNEL ENGAGED IN THE DELIVERY OF SOCIAL

SERVICES.  NOR ARE THEY ALWAYS AWARE OF THE SIMILARITY OF ETHICAL
IMPERATIVES SHARED BY BOTH MEDICINE AND THE SOCIAL SERVICES.

  BECAUSE OF THIS, PHYSICIANS -- ESPECIALLY THOSE IN PRIVATE

PRACTICE -- TEND NOT TO REFER PATIENTS AS OFTEN AS THEY SHOULD NOR DO
THEY SEEK THE COUNSEL OF SOCIAL SERVICE PROFESSIONALS WHEN A POSSIBLE
INCIDENT OF FAMILY VIOLENCE COMES TO THEIR ATTENTION.

  THIS MAY BE A PROBLEM NOW, BUT I BELIEVE IT WILL BE LESS OF A
PROBLEM IN THE FUTURE, AS PHYSICIANS BECOME MORE FAMILIAR WITH THE
TOTAL CONSTELLATION OF RESEARCH AND SERVICE BECOMING AVAILABLE FOR THE
PROTECTION OF VICTIMS OF FAMILY VIOLENCE. LET ME NOTE JUST ONE
EXAMPLE WHERE WE ARE MAKING SOME PROGRESS. THIS IS THE WORK OF DR.
ELI NEWBERGER AT BOSTON CHILDREN'S HOSPITAL.


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  DR. NEWBERGER IS A PEDIATRICIAN AND EDITOR OF A NEW BOOK ON CHILD

ABUSE FOR THE LITTLE, BROWN SERIES ON CLINICAL PEDIATRICS, WITH THE

SUPPORT OF THE NATIONAL INSTITUTE OF MENTAL HEALTH, HE HAS BEEN

CARRYING OUT A PROGRAM OF INTERDISCIPLINARY TRAINING AND RESEARCH IN

THE DETECTION AND TREATMENT OF VICTIMS OF FAMILY VIOLENCE.  IN THIS

PROGRAM, DR, NEWBERGER BRINGS TOGETHER A GROUP OF PROFESSIONALS ON THE

STAFF OF BOSTON CHILDREN'S HOSPITAL, THEY INCLUDE PEDIATRICIANS,

SOCIAL WORKERS, RESEARCHERS, PSYCHOLOGISTS AND PSYCHIATRISTS,

SOCIOLOGISTS, AND COMPUTER ANALYSTS,

  WORKING AS A TEAM, THEY PROVIDE HANDS-ON CLINICAL CARE FOR CHILDREN

WHO HAVE BEEN ABUSED. THEY ALSO SEEK TO UNDERSTAND THE CAUSES OF THE

VIOLENCE WITHIN THE FAMILY, TO PREVENT IT FROM RECURRING, THE RESULT

IS A PROGRAM THAT DRAWS UPON A VARIETY OF SKILLS RIGHT AT THE TIME THEY

ARE NEEDED MOST, THE PROGRAM GENERATES NEW INFORMATION REGARDING

FAMILY VIOLENCE AND THIS NEW INFORMATION, PLUS OTHER RESEARCH DATA,

ARE TRANSLATED INTO DIRECT PATIENT CARE.

  THESE ARE THE KINDS OF PROJECTS THAT BENEFIT NOT ONLY THE IMMEDIATE

PERSONS UNDER CARE, BUT CAN ALSO BENEFIT THE PRACTICE OF MEDICINE

ITSELF, THESE PROJECTS ARE DEDICATED TO THE PROTECTION OF INNOCENT


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VICTIMS OF VIOLENCE, ESPECIALLY FAMILY VIOLENCE, I HOPE TO SEE MORE
OF THESE KINDS OF EFFORTS BEGUN, WHETHER SUPPORTED BY GOVERNMENT RE-
SEARCH FUNDING OR NOT. EVENTUALLY, THE MEDICAL PROFESSION SHOULD BE

ENGAGED -- AS A ROUTINE MATTER AND WITHOUT THE BENEFIT OF RESEARCH

DOLLARS -- IN SUCH INTERDISCIPLINARY PRACTICES AS THE TREATMENT OF VIC-
TIMS OF VIOLENCE AND THE PROTECTION OF POTENTIAL VICTIMS AS THEY COME
TO OUR ATTENTTION, WHEN THAT TIME ARRIVES, THEN WE MAY INDEED BE CLOSE
TO UNDERSTANDING AND CONTROLLING VIOLENCE, WHICH IS ONE OF THE MOST
EXTENSIVE AND CHRONIC EPIDEMICS IN THE PUBLIC HEALTH OF THIS COUNTRY.

  I HAVE TALKED OF VIOLENCE ON THE HIGHWAYS, AND OF THE INFLUENCE OF
ALCOHOL AND DRUGS ON OUR ESCALATING VIOLENCE.. ..I HAVE GIVEN YOU SOME

STATISTICS ON HOMICIDE AND SUICIDE... AND I'VE ONCE AGAIN UNDERLINED THE
DESTRUCTIVE IMPACT OF T.V, ON OUR CHILDREN AND I'VE ADDED VIDEO GAMES

TO THE LIST,  I KNOW I HAVE LAID A GREAT BURDEN ON YOU. I SHARE IT,

  CAN WE HANDLE IT? WHEN THAT QUESTION IS ASKED, I AM REMINDED OF
THAT POINT IN THE BOOK CALLED THE LITTLE PRINCE, BY ANTOINE DE SAINT
EXUPERY, IN WHICH THE LITTLE PRINCE TALKS WITH THE FOX, THE FOX SAYS,

RATHER PLAINTIVELY.. m


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"ONE ONLY UNDERSTANDS THE THINGS THAT ONE TAMES. MEN HAVE NO MORE
TIME TO UNDERSTAND ANYTHING, THEY BUY THINGS ALREADY MADE AT THE
SHOPS, BUT THERE IS NO SHOP ANYWHERE WHERE ONE CAN BUY FRIENDSHIP,
AND SO MEN HAVE NO FRIENDS ANY MORE,  IF YOU WANT A FRIEND, TAME

ME,"

THE FOX CAN BE TAMED AND IT CAN BECOME A FRIEND, VIOLENCE CAN ALSO BE
TAMED AND PEOPLE WHO ARE DISPOSED TO VIOLENCE CAN ALSO LEARN HOW TO
LIVE IN PEACE WITH THE REST OF US -- AND ALL OF US SHOULD FEEL SECURE,
IT'S NOT A TASK THAT CAN BE DONE EASILY OR IN A SHORT SPACE OF TIME.
BUT IT HAS TO BE DONE,

THANK YOU,

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