Violence in public health and preventive medicine

by James Gilligan, The Lancet, 2000; 355:1802-1812

When a man is suffering from an infectious disease, he is a danger to the community, and it is necessary to restrict his liberty of movement. But no one associates any idea of guilt with such a situation. On the contrary, he is an object of commiseration to his friends. Such steps as science recommends are taken to cure him of his disease, and he submits as a rule without reluctance to the curtailment of liberty involved meanwhile. The same method in spirit ought to be shown in the treatment of what is called 'crime'.

Bertrand Russell

A consensus on the causes and prevention of violence has been emerging over the past few decades among investigators of this subject from virtually every branch of the behavioural sciences. All specialties, independent of each other, have identified a pathogen that seems to be a necessary but not sufficient cause of violent behaviour, just as specifically as exposure to the tubercle bacillus is necessary but not sufficient for the development of tuberculosis. The difference is that in the case of violence the pathogen is an emotion, not a microbe--namely, the experience of overwhelming shame and humiliation. And just as people's vulnerability to tuberculosis is influenced by the state of their body's defence mechanisms, so their vulnerability to violence is influenced by the state of their psychological defence mechanisms.

These defences include the degree to which violent individuals have developed the capacity for an emotion that is antagonistic to shame, and inhibits the violence toward others that shame stimulates, namely, guilt and remorse. And this is a capacity that the most violence-prone individuals and groups notably lack. In addition, their vulnerability or sensitivity to any given experience of shame--the likelihood that they will be so overwhelmed by it as to become violent--is strongly influenced, to a statistically significant degree, by whether or not they possess internal sources of pride and self-esteem, such as education, or external sources of esteem from others, such as wealth or other sources of high social status.

Shame has forty synonyms: feeling slighted, insulted, ridiculed, rejected, disrespected, dishonoured, disgraced, or demeaned; feeling inferior, inadequate, incompetent, weak, ugly, unintelligent, or worthless; suffering 'loss of face', 'narcissistic wounds', or an 'inferiority complex'. There is increasing agreement among students of this subject that people, especially men, engage in violent behaviour when, and only when, they do not perceive themselves as possessing sufficient non-violent means by which to undo the feeling of shame and humiliation.

These conclusions about the aetiology of violence enable us to understand how to engage in its primary prevention. The first principle is to stop the causes--namely, shaming and humiliating people by subjecting them to hierarchical social and economic systems characterised by class and caste stratification, relative poverty, and dictatorship. Violence is caused by the feeling of shame, which is the feeling of inferiority; and inferiority is a relative concept. Thus making one group of people inferior to another in terms of relative wealth or power is a recipe for increasing the level of violence.

Worldwide, the most powerful predictor of the murder rate is the size of the gap in income and wealth between the rich and the poor. And the most powerful predictor of the rate of national or collective violence--war, civil insurrection, and terrorism--is the size of the gap in income and wealth between the rich and poor nations. For the same reasons, the nations with the lowest murder rates are those such as Japan, the nations of Western Europe, Canada, Australia, and New Zealand, which have the highest degrees of social and economic equity. And the nations with the lowest frequencies of national violence are those that have both political democracy and relative national wealth--Japan and the western democracies. Primary prevention can also be described in more positive terms: ensuring that people have access to the means by which they can achieve a feeling of self-worth, such as education and employment, and a level of income, wealth, and power that is equal to that which other people enjoy, by universalising social and political democracy.

When we turn to the tertiary prevention of violence, we can understand why the level of human violence has increased rather than decreased ever since the criminal law and the criminal justice and penal systems were first invented three millennia ago by the first law-givers, from Hammurabi and Moses to Drakon and Solon, as the primary means for dealing with violent people. All those systems have been based, until now, on one huge psychological mistake: namely, the belief that punishment deters, inhibits, or prevents violence. On the contrary, far from inhibiting or preventing violence, punishment is the most powerful stimulant of violence that we have yet discovered. For example, of all the findings from the past 60 years of research on child-rearing, the one that has been most consistently replicated is that the more severely punished children are, the more violent they become--both as children and as adults. Research in prisons on violent criminals reinforces the same conclusion: the more violent the criminal, the more severely he was abused as a child in the name of discipline or punishment. If punishment did deter or prevent violence, then the violent criminals who inhabit our prisons would never have become violent in the first place, for they have already suffered as much punishment as it is possible to inflict on a human being without committing murder. And even the ongoing punishments to which criminals are subjected on a day-to-day basis in prisons leads to the same conclusion: the more severely punished they are by the prison authorities, the more violent they become, until they finally reach a point of such overwhelming rage and despair that they do not care whether they themselves live or die. Many in fact do provoke their own deaths.

But all that is understandable in terms of the aetiological principles discussed earlier, for punishment increases feelings of shame and decreases feelings of guilt. The whole purpose of legal punishment, after all, is to serve as the means by which the criminal expiates his guilt and thus 'pays his debt to society', at the completion of which process he is no longer guilty in the eyes of the law, nor presumably in his own eyes. These same psychological principles have also been institutionalised in the religious sacrament of penance, a ritual that alleviates the feeling of sinfulness, or guilt. And as we have just seen, violence is most likely when shame is maximised and guilt is minimised, which are exactly the conditions created by punishment. So it is not surprising that the most effective way to turn a non-violent person into a violent one is to send him to prison.

Possibly the most successful approach to the tertiary prevention of violence is education. Indeed, in some prison systems (Indiana, Massachusetts, and Folsom Prison in California), achieving a college degree while in prison has proved to be successful in preventing recidivism among murderers and rapists for up to 25 years after discharge. And it is understandable, in terms of the principles underlying the aetiology of violence just summarised, why education would be so successful in preventing violence.

A century and a half ago, public-health and preventive medicine discovered that cleaning up the water supply and the sewer system was more effective in preventing epidemics of illness and death than all the doctors, medicines, and hospitals in the world. When those same medical specialties are applied to the study of violence, we discover that cleaning up the social and economic system, by reducing the huge inequities in income and wealth between the rich and the poor, are more effective in preventing epidemics of violence and death than all the police, prisons, and punishments in the world. It is true that we will presumably always need some form of tertiary prevention for violence, just as we do for illness, since even the best systems of primary prevention cannot be expected to prevent all violence. The most important implication, however, is that it would increase the safety of every person and would endanger no-one, if we removed the inmates from every prison in the world, demolished all the buildings, and replaced them with buildings designed to serve an entirely different set of purposes in as humane and home-like a setting as possible. These would be locked, safe, secure residential schools, colleges and universities, and therapeutic communities with full access to medical, psychiatric, and substance-abuse treatment. It goes without saying that only those who had committed or threatened serious violence would need to be, or should be, deprived of their freedom by being quarantined in these centres for education and treatment.

We can prevent violence if, and only if, we replace the moral and legal approach with the approaches of public health and preventive medicine. This is a matter of vital importance to the future of humanity, in which the medical professionals can serve an invaluable role as educators and leaders. If that seems too political, it is well to remember the words of Rudolph Virchow, one of the greatest physicians of all time, a founder of public health and preventive medicine, pathology and anthropology, who showed how epidemics of disease resulted in part from social conditions, and who therefore also served as a politically progressive statesman in the Prussian Reichstag: "Medicine is a social science, and politics is simply medicine on a larger scale."

Further reading

  1. Gilligan J. Violence: Reflections on a National Epidemic. London: Jessica Kingsley, 1999.
  2. Feshbach S. Dynamics and morality of violence and aggression. Am Psychol 1971; 26: 281-92 [PubMed].
  3. Scheff T, Retzinger S. Emotions and Violence: Shame and Rage in Destructive Conflicts. Lexington, MA: Lexington Books, 1991.
  4. Luckenbill DF. Criminal homicide as a situated transaction. Soc Problems 1977; 25: 176-86 [PubMed].
  5. Ching-Chi H, Pugh MD. Poverty, inequality, and violent crime. In: Kawachi I, Kennedy BP, Wilkinson RG, eds. The Society and Population Health Reader: Income Inequality and Health. New York: The New Press, 1999.