World report on violence and health: What it means for children and pediatricians

Abstract

The World Report on Violence and Health (WRVH)1.Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano RE. World report on violence and health. Geneva: World Health Organization; 2002. Available in pdf format at: http://www.who.int/violence_injury_prevention/violence/world_report/en/FullWRVH.pdf. Last accessed: February 13, 2004. It can also be obtained by writing Marketing and Dissemination, World Health Organization, 1211 Geneva 27, Switzerland.Google Scholar was produced by the World Health Organization (WHO) as part of its Plan of Action following resolution WHA49.25 of the 1996 World Health Assembly to address violence as a public health priority.1.Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano RE. World report on violence and health. Geneva: World Health Organization; 2002. Available in pdf format at: http://www.who.int/violence_injury_prevention/violence/world_report/en/FullWRVH.pdf. Last accessed: February 13, 2004. It can also be obtained by writing Marketing and Dissemination, World Health Organization, 1211 Geneva 27, Switzerland.Google Scholar, 2.Krug E.G. Dahlberg L.L. Mercy J.A. Zwi A.B. Lozano R.E. Introduction.in: World Report on Violence and Health. World Health Organization, Geneva2002: ix, xxiiGoogle Scholar It is the first comprehensive summary of the problem of violence on a global scale and a call for action on violence prevention.3.World Health Organization. World report on violence and health: a summary. Geneva. World Health Organization; 2002. Available in pdf format at: http://www.who.int/violence_injury_prevention/violence/world_report/en/Full%20WRVH%20summary.pdf. Last accessed: February 13, 2004.Google Scholar This report provides pediatricians and pediatric institutions with the rationale for elevating the priority of child abuse prevention as a health intervention strategy. It strengthens legitimate claims to resources, whether national, regional, or local; governmental, institutional, or private; and either monetary or human. It promotes appropriate academic, legislative, media, and community attention to this important issue. The stated objectives of the WRVH are to describe the global extent of the problem and its key risk factors; to summarize known responses and their effectiveness; and to make recommendations for action at all levels.4.World Health Organization. World report on violence and health outline. Geneva. World Health Organization; 2002. Available at: http://www.who.int/violence_injury_prevention/violence/world_report/wrvh8/en/print.html. Last accessed: February 13, 2004.Google Scholar The report examines the violence spectrum including child maltreatment, youth violence, elder abuse, violence by intimate partners and collective violence, sexual abuse, and suicide. The report includes a statistical annex with country and regional data derived from the WHO Mortality and Morbidity Database and a list of resources for violence prevention.4.World Health Organization. World report on violence and health outline. Geneva. World Health Organization; 2002. Available at: http://www.who.int/violence_injury_prevention/violence/world_report/wrvh8/en/print.html. Last accessed: February 13, 2004.Google Scholar The definition of violence in the WRVH is “The intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation.”2.Krug E.G. Dahlberg L.L. Mercy J.A. Zwi A.B. Lozano R.E. Introduction.in: World Report on Violence and Health. World Health Organization, Geneva2002: ix, xxiiGoogle Scholar The definition of child abuse, adopted by the WHO in 1999 is, “… all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child's health, survival, development or dignity in the context of a relationship of responsibility, trust or power.”5.WHO, Report of the Consultation on Child Abuse Prevention. Geneva, World Health Organization, 1999 (document WHO/HSC/PVI/99.1; available from Department of Injuries and Violence Prevention, World Health Organization, 1211 Geneva 27, Switzerland). Available in pdf format at: http://www.who.int/violence_injury_prevention/media/en/235.pdf. Last accessed: February 13, 2004.Google Scholar, 6.Krug E.G. Dahlberg L.L. Mercy J.A. Zwi A.B. Lozano R.E. Child abuse and neglect by parents and other caregivers. World Health Organization, Geneva2002Google Scholar Both definitions contain the important elements of potential as well as actual harm and of the multiple consequences of harm. Compared with the WRVH definition, the child abuse definition specifies the relational context in which the violence occurs and includes others forms of ill treatment beyond the use of physical force. The relational aspect in child abuse is the key to the added vulnerability of children because of their developmental immaturity and dependence. Evidence shows that violence, social isolation, high population turnover, and less social investment in the community are among the factors that render children more vulnerable to abuse by those with whom they are in a relationship of responsibility, trust, or power.6.Krug E.G. Dahlberg L.L. Mercy J.A. Zwi A.B. Lozano R.E. Child abuse and neglect by parents and other caregivers. World Health Organization, Geneva2002Google Scholar Therefore, in situations of war or natural disaster, children are at risk not only for those misfortunes but also for maltreatment at the hands of those whose role it would be to protect them. WRVH estimates on the death rates by intentional injury world-wide are based on information provided by member states to WHO, using the International Classification of Diseases (ICD) codes.7.International classification of diseases. 9th revision. World Health Organization, Geneva1978Google Scholar, 8.International statistical classification of diseases and related health problems, 10th revision. Volume I: Tabular list; Volume 2: Instruction manual; Volume 3: Index. Geneva: World Health Organization; 1992-1994.Google Scholar In the year 2000, these deaths were estimated for male and female subjects, respectively, to be 28.8 and 17.3 per 100,000 population. This represents 32.8% and 30.7% of deaths caused by injury and 3% and 1.9% of all deaths. Of these, approximately 50%/61% were suicides for male/female subjects, about 31%/23% were homicides, and the remaining 18%/15% were war-related. Richer nations showed an overall death rate by violence of less than half that of poor and middle-income nations. The homicide rate for young men 15 to 29 years of age was 19.4 per 100,000, about 4.5 times that of their female counterparts. The suicide rate in this age group was 13.9. Children 5 to 14 years of age had a suicide and homicide rate each of approximately 2 per 100,000. The homicide rate in children under 5 years was 2.5 times higher at 5.3. The United States' vital statistics showed that in 2000, homicide ranked 4th in leading causes of death for children under 15 years and 2nd among those 15 to 19 years old.9.MacDorman M.F. Minino A.M. Strobino D.M. Guyer B. Annual summary of vital statistics-2001.Pediatrics. 2002; 110: 1037-1052Crossref PubMed Scopus (133) Google Scholar All of the preceding figures probably are underestimates. In the United States, child deaths by violence are not always captured in official data.10.Crume T.L. DiGuiseppi C. Byers T. Sirotnak A.P. Garrett C.J. Underascertainment of child maltreatment fatalities by death certificates, 1990-1998.Pediatrics. 2002; 110: e18Crossref PubMed Scopus (138) Google Scholar Nonetheless, it is encouraging to note that the homicide rate for children in the United States dropped by 10% from 1999 to 2000, the seventh year that it decreased.9.MacDorman M.F. Minino A.M. Strobino D.M. Guyer B. Annual summary of vital statistics-2001.Pediatrics. 2002; 110: 1037-1052Crossref PubMed Scopus (133) Google Scholar The several theories proposed to explain this decrease involve an improved economy associated with less stress in the care taker, decrease in the use of corporal punishment, and improved responses to child maltreatment, including earlier recognition and reporting, and prevention programs such as those involving home visits.11.Johnson C.F. Child maltreatment 2002: recognition, reporting and risk.Pediatr Int. 2002; 44: 554-560Crossref PubMed Scopus (53) Google Scholar The WRVH considers violence in 3 types: violence against self, interpersonal, and collective violence.12.Krug E.G. Dahlberg L.L. Mercy J.A. Zwi A.B. Lozano R.E. Violence: a global public health problem. World Health Organization, Geneva2002Google Scholar Interpersonal violence is subdivided into family or partner violence and community violence. Child maltreatment fits both under family violence and community violence. In the latter case, the perpetrator may be a teacher, a baby-sitter, or a youth group leader. Children and youth also fit into all other categories, as would any other member of society. The WRVH applies the ecologic model that places the individual within the family and other relationships; the family and those other relationships within the community; and the community within society.12.Krug E.G. Dahlberg L.L. Mercy J.A. Zwi A.B. Lozano R.E. Violence: a global public health problem. World Health Organization, Geneva2002Google Scholar The factors predisposing to violence at each level influence those at all other levels and determine the risk of violence to the individual and the collective.12.Krug E.G. Dahlberg L.L. Mercy J.A. Zwi A.B. Lozano R.E. Violence: a global public health problem. World Health Organization, Geneva2002Google Scholar Although some factors apply to all or several types of violence, each type has its more specific risk factors listed in the WRVH.6.Krug E.G. Dahlberg L.L. Mercy J.A. Zwi A.B. Lozano R.E. Child abuse and neglect by parents and other caregivers. World Health Organization, Geneva2002Google Scholar For child maltreatment, the first consideration is age and sex. Young children are at risk for physical abuse, and older children, particularly older girls, for sexual abuse; infanticide is seen more in girls, whereas beatings and physical abuse are more common in boys. Factors that are associated with disadvantage place the child at greater risk for abuse. Examples of these are having a very young or single parent and living in households with overcrowding or a history of violence. Female care givers are more likely to use corporal punishment against children and male care givers to cause serious injury or death. Abusive care givers are more likely to have unrealistic expectations of the children, to have poor impulse control, to experience stress, and to be socially isolated. Children living in poverty are less likely to have protective relationships available to them. Culture must be seen as part of the ecologic framework interacting with other variables and not as an entity acting alone.6.Krug E.G. Dahlberg L.L. Mercy J.A. Zwi A.B. Lozano R.E. Child abuse and neglect by parents and other caregivers. World Health Organization, Geneva2002Google Scholar, 12.Krug E.G. Dahlberg L.L. Mercy J.A. Zwi A.B. Lozano R.E. Violence: a global public health problem. World Health Organization, Geneva2002Google Scholar, 13.Krug E.G. Dahlberg L.L. Mercy J.A. Zwi A.B. Lozano R.E. The way forward: recommendations for action. World Health Organization, Geneva2002Google Scholar, 14.Korbin J.E. Culture and child maltreatment: cultural competence and beyond.Child Abuse Negl. 2002; 26: 637-644Crossref PubMed Scopus (106) Google Scholar It must be understood to be a heterogeneous entity, including members, beliefs, and practices with both greater and lesser likelihood of being associated with abuse.14.Korbin J.E. Culture and child maltreatment: cultural competence and beyond.Child Abuse Negl. 2002; 26: 637-644Crossref PubMed Scopus (106) Google Scholar Culture and cross-cultural studies are at issue when addressing risk or protective factors in individuals and the kinds of interventions best suited in particular contexts. Therefore, the ability to understand and work with communities other than one's own (ie, cultural competence) is a needed skill for those working with violence.14.Korbin J.E. Culture and child maltreatment: cultural competence and beyond.Child Abuse Negl. 2002; 26: 637-644Crossref PubMed Scopus (106) Google Scholar The WRVH addresses globalization (ie, global integration) as a factor that affects all cultures.12.Krug E.G. Dahlberg L.L. Mercy J.A. Zwi A.B. Lozano R.E. Violence: a global public health problem. World Health Organization, Geneva2002Google Scholar In eroding functional and political boundaries, globalization hastens economic prosperity for some nations while marginalizing others and contributing to their economic and social disintegration. Violence prevention warrants the adoption of strategies that mitigate the negative side of globalization and make use of its positive effects. Inequality of natural, economic, technologic, and educational resources, among others, is associated with economic hardships for the “have-not” nations and predisposes to violence, as does the destabilization caused by rapid social changes. These social changes are caused by political and economic upheavals. Among them is the division of countries, such as the USSR and Yugoslavia, into smaller nations, some with more and some with fewer resources than they had as unions. Another is the higher unemployment and the loss of the social safety net enjoyed under communist regimes that have now dissolved. Communities and families are disrupted by the loss of support systems and by the migration of people in search of greater stability or employment opportunities as well as ethnic tolerance. Easier access to drugs and firearms also follows facilitated global trading and profit-making and further contributes to violence. Similarly, because exposure to violence in the media contributes to aggressive behavior, it follows that as access to media grows, so will such exposure and its consequences.15.Krug E.G. Dahlberg L.L. Mercy J.A. Zwi A.B. Lozano R.E. Youth Violence, Box 2.2. World Health Organization, Geneva2002Google Scholar Conversely, increased linkages across continents and concomitant greater economic development and prosperity in some parts of the world allow the sharing of scientific technologies and resources to prevent violence.12.Krug E.G. Dahlberg L.L. Mercy J.A. Zwi A.B. Lozano R.E. Violence: a global public health problem. World Health Organization, Geneva2002Google Scholar, 16.Krug E.G. Dahlberg L.L. Mercy J.A. Zwi A.B. Lozano R.E. Collective Violence. World Health Organization, Geneva2002Google Scholar The media can be useful tools to raise public awareness, influence public opinion on violence, and provide role models for better parenting.13.Krug E.G. Dahlberg L.L. Mercy J.A. Zwi A.B. Lozano R.E. The way forward: recommendations for action. World Health Organization, Geneva2002Google Scholar Global links provide the means to monitor conflicts and pressure governing bodies to increase accountability and reduce social injustice.12.Krug E.G. Dahlberg L.L. Mercy J.A. Zwi A.B. Lozano R.E. Violence: a global public health problem. World Health Organization, Geneva2002Google Scholar, 16.Krug E.G. Dahlberg L.L. Mercy J.A. Zwi A.B. Lozano R.E. Collective Violence. World Health Organization, Geneva2002Google Scholar They facilitate the development of international child protection legislation and activities and can support their implementation in those nations that have limited resources.12.Krug E.G. Dahlberg L.L. Mercy J.A. Zwi A.B. Lozano R.E. Violence: a global public health problem. World Health Organization, Geneva2002Google Scholar Critical assistance can be provided by connections with nations and professionals who have experience in child protection and can contribute educational materials, training, and models of intersectoral collaboration or consensus building strategies. The WRVH documents the many ill effects of maltreatment that are known and identifies others that are not well studied yet. These ill effects range from the direct physical injury to long-term physical sequelae and psychiatric illness as well as dysfunctional behaviors, such as poor impulse control and dangerous life-style choices, such as substance abuse or multiple sexual partners, which predispose to more adult illness.6.Krug E.G. Dahlberg L.L. Mercy J.A. Zwi A.B. Lozano R.E. Child abuse and neglect by parents and other caregivers. World Health Organization, Geneva2002Google Scholar Violence in the life of children interferes not only with their health, but also with their development in all its aspects, for example, physical, cognitive, and emotional, and the very structure of their brain.17.Glaser D. Child abuse and neglect and the brain: a review.J Child Psychol Psychiatr. 2000; 41: 97-116Crossref PubMed Scopus (567) Google Scholar Abuse in childhood leads to adult risk of depression and posttraumatic stress disorder, harmful behaviors, negative attitudes toward others, and relational difficulties.18.Kendall-Tackett K. The health effects of childhood abuse: four pathways by which abuse can influence health.Child Abuse Negl. 2002; 26: 715-729Crossref PubMed Scopus (306) Google Scholar To go beyond the human costs of violence to its economic costs objectifies the loss of the individual and collective life potential. However, knowledge of the financial burden created by child maltreatment can inform deployment of needed resources, since funding prevention programs such as home visitations are a less costly alternative than intervention after maltreatment has occurred.19.Olds D.L. Prenatal and infancy home visiting by nurses: from randomized trials to community replication.Prev Sci. 2002; 3: 153-172Crossref PubMed Scopus (364) Google Scholar The estimated costs involve investigation of maltreatment reports, care and protection of the child victim through health and social services, mental health care of the victim in adulthood, loss of productivity and earning potential, and apprehension, prosecution, and punishment of the alleged offender through the criminal justice system.6.Krug E.G. Dahlberg L.L. Mercy J.A. Zwi A.B. Lozano R.E. Child abuse and neglect by parents and other caregivers. World Health Organization, Geneva2002Google Scholar In the United States in 1996, available data yielded an estimated cost of $12.4 billion for child maltreatment.6.Krug E.G. Dahlberg L.L. Mercy J.A. Zwi A.B. Lozano R.E. Child abuse and neglect by parents and other caregivers. World Health Organization, Geneva2002Google Scholar As reported in the WRVH,6.Krug E.G. Dahlberg L.L. Mercy J.A. Zwi A.B. Lozano R.E. Child abuse and neglect by parents and other caregivers. World Health Organization, Geneva2002Google Scholar child maltreatment prevention measures have had mixed success. Training in parenting at all levels of prevention have shown some improvement in parenting features, and in some cases, lower risk of child maltreatment. Home visitation programs provided for all or only high-risk families are very promising in preventing youth violence and child abuse. Home preservation programs, in which the intervention is aimed at keeping the child safe while maintaining the family unit, are aimed at families in which abuse has already occurred. Overall, this intervention has not been well studied, but indications are that high participant involvement, building on the strengths of the family, and involvement of social supports produce better results in terms of lower incidence of further maltreatment. Child fatality review teams with professionals from several disciplines improve the accuracy of classification of child deaths caused by maltreatment, but it is not known if this results in less maltreatment. Other areas, whose effectiveness in preventing abuse and neglect has not been well studied, are training programs for health care professionals; reporting of child maltreatment, whether mandated or voluntary; child protection services; and mandated treatment for offenders. School-based programs aimed at teaching children to protect themselves against sexual abuse have been shown to impart knowledge, but little is known about their effectiveness in preventing abuse in actual situations. Multimedia educational campaigns increase disclosure of maltreatment, but it is unknown if this translates into less maltreatment. A wide variety of treatment interventions have been used with children maltreated in various ways. There is a suggestion that they improve mental health, but little else is known. Evaluations of services for children who witness violence are limited, and the few evaluations available on services for adults abused as children show contradictory results, indicating that further study is needed in this area. Societal approaches aimed at improving the lot of children, such as improved economic conditions and education, have shown success in improving child outcomes. However, direct evidence that they decrease the rate of child maltreatment is lacking. The impact of the Convention on the Rights of the Child (CRC)20.Office of the High Commissioner for Human Rights. Convention on the rights of the child. 1989. Available at:http://www.unhchr.ch/html/menu3/b/k2crc.htm Last accessed: February 13, 2004.Google Scholar in protecting children is also unknown. The WRVH marks the third landmark in linking violence and health officially. Interpersonal violence was first inserted in the ninth revision of the International Classification of Diseases adopted in 1976. Specific categories for child battering and other maltreatment and criminal neglect were included and identified a parent, other specified person, and unspecified person as the perpetrators of child maltreatment.7.International classification of diseases. 9th revision. World Health Organization, Geneva1978Google Scholar In 1996, the World Health Assembly passed resolution WHA49.25, which declared violence a public health priority.2.Krug E.G. Dahlberg L.L. Mercy J.A. Zwi A.B. Lozano R.E. Introduction.in: World Report on Violence and Health. World Health Organization, Geneva2002: ix, xxiiGoogle Scholar The WRVH is part of WHO's response to that resolution. The link between violence and health cannot be overemphasized in its implications for violence prevention. Health personnel care for the victims of violence and so occupy a unique vantage point from which to view and intervene in the sequence between health and abusive trauma. Health professionals can recognize individuals at risk or already affected. They can provide anticipatory guidance, educate and support, or treat and rehabilitate, while evaluating the modalities of intervention. The public health approach has already been applied successfully to prevention of infectious disease. Professionals working to prevent child maltreatment have been challenged to emulate the process used in the world-wide eradication of smallpox.21.Fulginiti VA, John TJ. Eradication of smallpox: lessons for child abuse eradication? In: 14th International Congress on Child Abuse and Neglect; 2002; Denver, Colorado; 2002.Google Scholar Ten principles were enumerated as critical to success. Knowledge of the problem, including local factors, needs to be as complete as possible. An effective intervention must be available. There needs to be a system of initial surveillance to identify those affected; a massive educational effort to ensure widespread understanding and compliance with eradication efforts; a secondary surveillance system; and possibly a secondary intervention system. Adequate funding and resources, including establishment and maintenance of a permanent surveillance system, are necessary, and timetables and benchmarks must be practical and established. Of course, smallpox had only one well-defined causal agent, whereas violence has many. The same principles are applicable, but how to apply them will be a much more complex and difficult process. The WRVH is clear that violence occurs throughout the life cycle.12.Krug E.G. Dahlberg L.L. Mercy J.A. Zwi A.B. Lozano R.E. Violence: a global public health problem. World Health Organization, Geneva2002Google Scholar Once it enters the cycle, at one point it is likely to be felt elsewhere. Childhood may well be the point of greatest impact. Maltreated children are more likely to have difficulties as adults, and having dysfunctional parents increases the likelihood of child maltreatment.6.Krug E.G. Dahlberg L.L. Mercy J.A. Zwi A.B. Lozano R.E. Child abuse and neglect by parents and other caregivers. World Health Organization, Geneva2002Google Scholar The WRVH advocates the multidisciplinary approach.13.Krug E.G. Dahlberg L.L. Mercy J.A. Zwi A.B. Lozano R.E. The way forward: recommendations for action. World Health Organization, Geneva2002Google Scholar Joint intervention strategies and collaborative work is needed between health, social, legal, education, and other involved professionals and sectors within child maltreatment and beyond to include professionals and teams dedicated to prevention of other forms of violence. These multidisciplinary, multisectoral groups need to address intervention practices, prevention strategies, and research into causes and deterrents to violence. It makes little sense to continue subdividing violence into separate types; each addressed by its own specialists and dedicated programs. The publication of the WRVH gives the movement for violence prevention a significant boost. In the politics of violence, the scientific evidence-based approach used by the health sector can facilitate nonpartisan discussion. In the matter of health, the WHO has an unrivalled reputation in setting global standards, which arises out of its near universal representation, and ability to convene experts to help determine best practice.20.Office of the High Commissioner for Human Rights. Convention on the rights of the child. 1989. Available at:http://www.unhchr.ch/html/menu3/b/k2crc.htm Last accessed: February 13, 2004.Google Scholar With other actors, such as the World Bank, in the field of global health, WHO is being challenged by globalization to take a more proactive role in setting standards.22.Yamey G. Why does the world still need WHO?.BMJ. 2002; 325: 1294-1298Crossref PubMed Scopus (33) Google Scholar The WRVH is a step toward the setting of such standards and the promotion of international strategies in violence prevention. Since the release of the WRVH, WHO has engaged in the Global Campaign for Violence Prevention to promote the adoption and implementation of the WRVH recommendations around the world.23.World Health Organization. Global Campaign for Violence Prevention. 2003. Available at: http://www.who.int/violence_injury_prevention/violence/global_campaign/campaign/en/. Last accessed: February 13, 2004.Google Scholar This campaign has included the translation of the WRVH into several languages, publications of related journals articles, and a set of posters on violence prevention. In addition, to provide guidance on implementation of specific WRVH recommendations, WHO is in the process of producing various materials such as a “Handbook for the documentation of promising and proven practices in violence prevention” and “Guidelines for medico-legal care of victims of sexual violence,” which contains a section for children.25.World Health Organization. Global Campaign for Violence Prevention. Newsletter No. 2. April 2003. Available in pdf format at: http://www.who.int/violence_injury_prevention/violence/global_campaign/en/Campaign%20Newsletter%202%20English.pdf. Last accessed: February 13, 2004.Google Scholar As of early 2004, about 25 national, subregional, or regional launches of the WRVH have taken place, and more are planned.24.World Health Organization. Global Campaign for Violence Prevention. Newsletter No. 1. January 2003. Available in pdf format at: http://www.who.int/violence_injury_prevention/violence/global_campaign/en/VIP%20Newsletter%201.pdf. Last accessed: February 13, 2004.Google Scholar, 25.World Health Organization. Global Campaign for Violence Prevention. Newsletter No. 2. April 2003. Available in pdf format at: http://www.who.int/violence_injury_prevention/violence/global_campaign/en/Campaign%20Newsletter%202%20English.pdf. Last accessed: February 13, 2004.Google Scholar, 26.World Health Organization. Global Campaign for Violence Prevention. Newsletter No. 3. September 2003. Available in pdf format at: http://www.who.int/violence_injury_prevention/violence/world_report/en/Campaign%20Newsletter%203.pdf. Last accessed: February 13, 2004.Google Scholar In May 2003, 192 member states of the World Health Assembly endorsed resolution 56.24 on implementing the recommendations of the WRVH.25.World Health Organization. Global Campaign for Violence Prevention. Newsletter No. 2. April 2003. Available in pdf format at: http://www.who.int/violence_injury_prevention/violence/global_campaign/en/Campaign%20Newsletter%202%20English.pdf. Last accessed: February 13, 2004.Google Scholar Other UN agencies have taken note of the report and are supporting initiatives against violence. The American Medical Association has endorsed the WRVH; the World Medical Association has adopted a policy document encouraging medical practitioners to participate in violence prevention through data collection, medical training, and coordination of victim assistance.26.World Health Organization. Global Campaign for Violence Prevention. Newsletter No. 3. September 2003. Available in pdf format at: http://www.who.int/violence_injury_prevention/violence/world_report/en/Campaign%20Newsletter%203.pdf. Last accessed: February 13, 2004.Google Scholar WHO and the International Society for Prevention of Child Abuse and Neglect (ISPCAN) are engaged in developing an Integrated Multisectoral Approach to Child Abuse Prevention to respond to the problem of Child Abuse prevention. This development of this tool is a response to some of the recommendations made in the WHO Consultation Report of 1999.5.WHO, Report of the Consultation on Child Abuse Prevention. Geneva, World Health Organization, 1999 (document WHO/HSC/PVI/99.1; available from Department of Injuries and Violence Prevention, World Health Organization, 1211 Geneva 27, Switzerland). Available in pdf format at: http://www.who.int/violence_injury_prevention/media/en/235.pdf. Last accessed: February 13, 2004.Google Scholar This new tool is based on the principles of child-centeredness, rights and evidence, integrated intersectoral collaboration, sociocultural sensitivity, and accessibility. The WRVH concludes with 9 recommendations.13.Krug E.G. Dahlberg L.L. Mercy J.A. Zwi A.B. Lozano R.E. The way forward: recommendations for action. World Health Organization, Geneva2002Google Scholar Six of the 9 are relevant to pediatricians, who can foster their implementation by encouraging discussions on their implications within their institution, at local, regional, national, or international levels. Henry Kempe, who first wrote about child abuse and founded a program, an international society, and a journal to address its prevention, was a pediatrician.27.Kempe C.H. The battered child syndrome.JAMA. 1962; 181: 17-24Crossref PubMed Scopus (1891) Google Scholar, 28.Connolly A.C. The leaders.in: An international movement to end child abuse. International Society for Prevention of Child Abuse and Neglect, Chicago2002Google Scholar Pediatricians, because of their knowledge and advocacy stance, remain in the best position to help set priorities, develop strategies, and monitor the implementation of child maltreatment prevention. In nations without a systematic response to child maltreatment, pediatricians can prompt or participate in the formation of local, regional, or national action plans, and many are doing so. In nations where child protection systems are already in place, significant improvements in identification, management, and tracking of cases as well as universal prevention are still needed. Pediatricians can act through their own practices, professional organizations, and contacts with community leaders and government officials locally or nationally to improve child protection systems, make available more resources for children, and promote coordinated and comprehensive action plans to prevent child maltreatment. Among such initiatives are support for children and families in need and early intervention programs. Child maltreatment data collection is done in many different ways. This makes it very difficult to study and understand the problem, its risk and protective factors, and the criteria for effective intervention. Concerted international efforts to enhance standardized valid data are needed. By identifying and reporting cases and remaining involved as their young charges go through the system, pediatricians can contribute to accurate and meaningful data collection, enhanced capacity for case tracking, and associated evaluations of interventions used. Much has been done by pediatricians to advance knowledge in the medical aspects of child abuse. Much more needs to be done. Pediatricians continue to provide leadership in setting a research agenda29.Theodore A.D. Runyan D.K. A medical research agenda for child maltreatment: negotiating the next steps.Pediatrics. 1999; 104: 168-177PubMed Google Scholar, 30.Behl L.E. Conyngham H.A. May P.F. Trends in child maltreatment literature.Child Abuse Negl. 2003; 27: 215-229Crossref PubMed Scopus (69) Google Scholar and conducting research on various aspects of child abuse and, to a lesser extent, neglect. Such studies and others of a multidisciplinary nature are to be supported to further objective knowledge relating to child maltreatment prevention at all levels. Pediatricians have the opportunity and responsibility to ensure that good parenting and normal child development, including secure attachment, are emphasized and supported from birth. This requires that the ecologic framework be addressed as a whole.31.Daro D. Donnelly A.C. Charting the waves of prevention: two steps forward, one step back.Child Abuse Negl. 2002; 26: 731-742Crossref PubMed Scopus (54) Google Scholar Research and empirical evidence demonstrate that it is necessary to work in partnership with local protection agencies and that prevention programs must have the needed resources to succeed.31.Daro D. Donnelly A.C. Charting the waves of prevention: two steps forward, one step back.Child Abuse Negl. 2002; 26: 731-742Crossref PubMed Scopus (54) Google Scholar Resources that pediatricians can endeavour to secure to this end are public health nurses and social workers working closely with their practices and programs to pay for such associations. Pediatricians must be able to recognize potential child maltreatment and to intervene effectively. This requires knowledge and competence on their part and the ability to contribute to multidisciplinary responses to violence prevention. Where such responses do not exist, pediatricians can spearhead their establishment. The education of physicians in child maltreatment has repeatedly been found to be inadequate.11.Johnson C.F. Child maltreatment 2002: recognition, reporting and risk.Pediatr Int. 2002; 44: 554-560Crossref PubMed Scopus (53) Google Scholar Medical schools and pediatric training programs must make violence prevention and multidisciplinary collaboration for responding to child maltreatment an integral part of their curricula, and licensing bodies and professional associations must expect competence in this area. Pediatricians, through their professional associations, can foster discussions and working relationships that improve the approach to children and their need for safe development. They can advocate for and participate in multidisciplinary programs aimed at reducing conflict and promoting healthy relationships. This can be done by forging partnerships with professionals from other disciplines in the field and those who are working in related fields, such as domestic violence, suicide, or substance abuse as well as drug and gun control. These partnerships should include researchers and clinicians to bring the full range of expertise to bear on this issue. Most pediatricians will not be directly affected by recommendations on social and educational policies to promote sexual equality, adherence to international treaties on human rights, and the global drug and arms trade. However, as informed and influential citizens, they can lend their support and provide expert consultation as needed in these areas. Pediatric institutions and professional societies must address these issues proactively in the appropriate spheres of influence. The WRVH is an important part of current efforts in child maltreatment prevention world-wide. Expert consultations and clarification of the CRC (CRC/C/111) have taken place.32.Office of the High Commissioner for Human Rights. Violence against children within the family and in schools. 2001. Available in pdf format at: http://www.unhchr.ch/html/menu2/6/crc/doc/days/school.pdf. Last accessed: February 13, 2004.Google Scholar This effort indicates a will on the part of the Committee on the Rights of the Child to monitor more specifically signatory states' adherence to the convention's provisions on child maltreatment. In a document entitled “A World Fit for Children,” approved at the Special Session of the United Nations General Assembly on Children in May 2002, participating governments committed to instituting and funding effective national legislation, policies, and action plans to fulfill and protect children's rights and secure their well-being.33.United Nations International Children's Emergency Fund (UNICEF). A world fit for children. 2002. Available in pdf format at: http://www.unicef.org/specialsession/documentation/documents/A-S27-19-Rev1E-annex.pdf. Last accessed: February 13, 2004.Google Scholar In 2001, the UN General Assembly called for a study on violence against children, to be completed in 2005. The purpose of this study is to provide an in-depth analysis of the problem and put forward recommendations on possible effective measures for prevention and rehabilitation.34.Office of the High Commissioner for Human Rights. The United Nations study on violence against children. 2003. Available at: http://www.unhchr.ch/html/menu2/6/crc/study.htm. Last accessed: February 13, 2004.Google Scholar In February 2003, the Independent Expert was appointed to head this study and stated that the WRVH represents an important foundation for this work.25.World Health Organization. Global Campaign for Violence Prevention. Newsletter No. 2. April 2003. Available in pdf format at: http://www.who.int/violence_injury_prevention/violence/global_campaign/en/Campaign%20Newsletter%202%20English.pdf. Last accessed: February 13, 2004.Google Scholar These efforts by the United Nations complement and strengthen the content of the WRVH. Such a blending of perspectives tempers the public health approach espoused in the WRVH with a human rights stance and results in a more comprehensive response to violence prevention.35.Health I. Treating violence as a public health problem.BMJ. 2002; 325: 726-727Crossref PubMed Scopus (17) Google Scholar The health sector will need to be actively involved in the design and implementation of this response and become more active in extending needed services where they do not yet exist. The WRVH is absolutely correct in stating that, “Anything less will be a failure of the health sector.”13.Krug E.G. Dahlberg L.L. Mercy J.A. Zwi A.B. Lozano R.E. The way forward: recommendations for action. World Health Organization, Geneva2002Google Scholar