John Ashton and Zara Quigg: The public health approach to violence prevention — beyond the rhetoric
(By John Ashton and Zara Quigg — First appeared in The BMJ)
At a time of Brexit induced policy paralysis, it seems that only one matter can break through the news headlines. Daily reports of murders and injuries caused by rising knife crime in London and the other cities in the UK have galvanised a call for action against violence on the nation’s streets.  The media have called for us to adopt a public health approach to solve the crisis. Many column inches of print and characters on social media have been expended, but there is still confusion about what the “public health approach” means in practice.
It is now 17 years since the World Health Organization (WHO) published its Global report on Violence and Health — a document that remains the key reference point for subsequent work.  In the foreword Nelson Mandela stated that the twentieth century would be remembered as a century marked by violence with its burden of mass destruction and violence never seen, or possible, before in human history. But as Mandela pointed out “Less visible, but even more widespread is the legacy of day to day individual suffering. It is the pain of children abused by people who should protect them, women injured or humiliated by violent partners, elderly persons maltreated by their caregivers, youths who are bullied by other youths, and people who inflict violence on themselves.” The current focus on knife crime and other street violence is the latest manifestation of the dark side of human nature, in which the most dangerous place for a woman is in the home and for a young man on the street.
The WHO report based on global epidemiological analysis identified seven types of violence that need to be addressed: child abuse, youth violence, intimate partner violence, sexual violence, self-directed violence, abuse of the elderly and collective violence (including gangs, terrorism and war).  In calling for action the WHO drew attention to the orphan nature of violence prevention with criminal justice systems and health services picking up the pieces, but nobody being responsible for prevention. It also asserted, based on comparisons at a population level and the evidence of interventions, that fatalistic acceptance of the status quo is an error; that violence can indeed be prevented, but to do so requires concerted action and a whole systems approach which is intelligence led and in which all parties of society recognise their roles and responsibilities. This lies at the heart of the public health approach.
Case studies of effective action have been accumulating from as far afield as New York, Cali, Glasgow and Cardiff:
In the 1980’s faced with widespread violence and mayhem on the streets, New York responded with an approach that came to be known as “broken windows” in which a zero tolerance of low level behavioural nuisance such as graffiti in the public realm seemed to change the culture out of which more violent incidents emerged. 
In Cali, Colombia, the one-time homicide capital of the world, public professor and Mayor, Rodrigo Guerrero and his public health colleague Alberto Concha-Eastman more than halved the murder rate over a period of years using a classical epidemiological based intervention. Maps of time, place and person captured the violent incidents and episodes with targeted interventions at policy, programme, and community level. 
This approach was subsequently picked up across the Americas and informed the WHO report in 2002.  More locally, work in Cardiff and Glasgow have replicated elements of the Cali approach with substantial effect. 
So now the time has come to roll out this evidence based practical approach to a pressing issue. In Merseyside a strategy is being developed with 1.5 and 10 year horizons. It will be grounded in shared intelligence between all the statutory agencies of the county together with that of many others.  Violence prevention will no longer be an orphan. Clinicians, the police, and local government are joining forces to find a solution to violent crime, at family, neighbourhood, school, employer and statutory levels.
The time for shifting responsibility has ended. A lifecycle approach will form the framework for action, beginning with “SureStart 2.0” which provides a focus on a child’s first thousand days of life, intervening with children who have experienced, or may be at risk of experiencing adverse childhood events, and emphasising the shared responsibility for ensuring readiness for school by the age of 5 years. During the school years themselves, strengthening mental health support in the classroom and for parents will be a priority. The aim is that school exclusions should become a thing of the past.
Positive rites of passage and diversionary activities, such as youth engagement programmes focusing on sport, healthy lifestyles and employability championed by ‘Everton in The Community’,  should ensure that the grooming of children to become gang members with involvement in ‘County Lines’ drug dealing and ritual violence, lose their attraction and all teenagers are ready for the world of work and adult life. And for those who have already begun to lose their way, imaginative new initiatives such as the Bootle Complex Cases Court, chaired by a judge will divert those who can benefit, away from custodial sentences into wrap around packages of psychological treatment and support for the benefit of themselves, their families and the community at large.
The development and success of the Merseyside Violence Prevention strategy requires strong cross-sector commitment, leadership and evidenced-based targeted action. Judging from the response from all those approached so far on Merseyside, the time is right for this work to succeed. Partners from health, police, education, local government, community and voluntary groups, and universities are committed to promoting a public health approach to violence prevention. Much work is already underway and additional evidenced-based preventative approaches will be implemented, enabling long lasting change for the people of Merseyside.  In the dark days of Brexit gloom let us hope that this light can bring some hope.
John Ashton is the Public Health Adviser to the Merseyside Police and Crime Commissioner. He was formerly regional director of public health for the North West of England and president of the UK Faculty of Public Health.
Conflicts of interest: None declared
Zara Quigg is reader in Behavioural Epidemiology at the Public Health Institute, Liverpool John Moores University, UK. She leads the World Health Organization Collaborating Centre for Violence Prevention, working at a local, national and international level to support and promote the public health approach to violence prevention.
Concha-Eastman A, Espitia VE, Espinosa R and Guerrero G. Epidemiology of homicides in Cali, Colombia, 1993–1998: six years of a population-based model. Pan American Journal of Public Health, 2002 12(4): 230–239.
Florence C, Shepherd JP, Brennan I, and Simon, TR. An economic evaluation of anonymised information sharing in a partnership between health services, police and local government for preventing violence-related injury. Injury Prevention, 2014 20(2): 108–114. https://injuryprevention.bmj.com/content/20/2/108