Climate change and the opportunity cost of conflict.

A growing empirical literature associates climate anomalies with increased risk of violent conflict. This association has been portrayed as a bellwether of future societal instability as the frequency and intensity of extreme weather events are predicted to increase. This paper investigates the theoretical foundation of this claim. A seminal microeconomic model of opportunity costs-a mechanism often thought to drive climate-conflict relationships-is extended by considering realistic changes in the distribution of climate-dependent agricultural income. Results advise caution in using empirical associations between short-run climate anomalies and conflicts to predict the effect of sustained shifts in climate regimes: Although war occurs in bad years, conflict may decrease if agents expect more frequent bad years. Theory suggests a nonmonotonic relation between climate variability and conflict that emerges as agents adapt and adjust their behavior to the new income distribution. We identify 3 measurable statistics of the income distribution that are each unambiguously associated with conflict likelihood. Jointly, these statistics offer a unique signature to distinguish opportunity costs from competing mechanisms that may relate climate anomalies to conflict.

Experiences of Community Violence Among Adults with Chronic Conditions: Qualitative Findings from Chicago.

BACKGROUND: Community violence is an important social determinant of health in many high-poverty, urban communities. OBJECTIVE: The purpose of this study was to explore and characterize self-described experiences of community violence among adults with chronic health conditions. DESIGN: Qualitative study design was implemented in 2017 using in-depth, semi-structured focus groups and interviews; data were collected from two clinical sites located in geographic epicenters of high violent crime in Chicago. PARTICIPANTS: Adult patients, ages 35 years and older, who had at least one chronic condition. APPROACH: Data were analyzed using grounded theory and the constant comparison method. KEY RESULTS: The overall sample (N = 51) was predominantly female (67%) and black non-Hispanic (75%); a large proportion had hypertension (65%), arthritis (55%), obesity (53%), and/or diabetes (45%). The majority reported that a close friend or family member was seriously injured or killed due to community violence (71%); a similar proportion had never discussed their experiences of community violence with a healthcare provider (73%). Several major themes emerged: (1) perceived risk of being targeted, (2) chronic stress and worry, (3) hypervigilance, (4) social breakdown, (5) chronic isolation, (6) constrained choice (loss of freedom), (7) limited access to material resources, and (8) inadequate healthcare responses. CONCLUSIONS: Patients often struggled to balance the challenges imposed by community violence with the demands of living with and managing their chronic conditions. Emergent themes may inform practical targets for addressing community violence as a social determinant of health in vulnerable populations.

Shift in U.S. payer responsibility for the acute care of violent injuries after the Affordable Care Act: Implications for prevention.

BACKGROUND: Investment in violence prevention programs is hampered by lack of clearly identifiable stakeholders with a financial stake in prevention. We determined the total annual charges for the acute care of injuries from interpersonal violence and the shift in financial responsibility for these charges after the Medicaid expansion from the Affordable Care Act in 2014. METHODS: We analyzed all emergency department (ED) visits from 2009 to 2014 with diagnosis codes for violent injury in the Nationwide Emergency Department Sample (NEDS). We used sample weights to estimate total charges with adjusted generalized linear models to estimate charges for the 15% of ED visits with missing charge data. We then calculated the share attributable by payer and determined the difference in proportion by payer from 2013 to 2014. RESULTS: Between 2009 and 2013, the uninsured accounted for 28.2-31.3% of annual charges for the acute care of violent injury, while Medicaid was responsible for a similar amount (29.0-31.0%). In 2014, there were $10.7 billion in total charges for violent injury. Medicaid assumed the greatest share, 39.8% (95% CI: 38.0-41.5%, $3.5-5.1 billion), while the uninsured accounted for 23.6% (95% CI: 22.2-24.9%, $2.0-3.0 billion), and Medicare accounted for 7.8% (95% CI: 7.7-8.0%, $0.7-1.0 billion). CONCLUSION: After Medicaid expansion, taxpayers are now accountable for nearly half of the $10.7 billion in annual charges for the acute care of violent injury in the U.S. These findings highlight the benefit to state Medicaid programs of preventing interpersonal violence.

[Forensic preventive assertive community treatment : Pilot project to prevent violent crimes in the context of psychiatric disorders]. / Die Forensische Präventionsambulanz : Modellprojekt zur Vermeidung von Gewalttaten im Rahmen psychischer Erkrankungen.

BACKGROUND: Since 2012, a forensic preventive outpatient clinic has been established at Ansbach District Hospital to fill a gap in general psychiatric care for patients with schizophrenia or severe personality disorders and having a high risk for violent behavior. An interdisciplinary team drawing on forensic psychiatric knowledge applies instruments for forensic risk prognosis and treatment or interventions to prevent violent crimes and to protect potential victims. Admissions depend on certain criteria, e.g., increased risk potential for violent crimes against the background of schizophrenia or severe personality disorders. OBJECTIVE: How can a forensic psychiatric preventive treatment be organized, which helps to avoid detention in a forensic commitment and is complementary to general psychiatric treatment structures? Can such a model project reach the target group? MATERIAL AND METHOD: In forensic preventive outpatient care the treatment is based on violence prevention (e.g., psychoeducation, group training, individual treatment on violence risk co-management). Data are collected using general psychiatric and forensic instruments on, e.g., risk of violence (HCR-20), global functional level (GAF), violent behavior (SDAS-9) on a regular basis. The values with respect to these instruments on admission were compared to published key factors from population samples with general and forensic psychiatric patients. RESULTS: A total of 146 patients between the ages of 18 and 79 years have so far been treated. About 4,000,000 EUR could be saved during the duration of the project because of preventing involuntary admission to a forensic hospital apart from preventing violent crimes. In contrast 3,000,000 EUR had to be spent for the new outpatient service. CONCLUSION: Indications for the efficacy of a forensic preventive care for patients with schizophrenia and severe personality disorders with a risk for violence are confirmed. Therefore, an institutionalization and a statewide implementation of forensic preventive care in terms of the forensic preventive out-patient clinic are recommended.

Preventing violence-related injuries in England and Wales: a panel study examining the impact of on-trade and off-trade alcohol prices.

OBJECTIVE: To examine the influence of real on-trade and off-trade alcohol prices and socioeconomic and environmental factors on rates of violence-related emergency department (ED) attendances in England and Wales over an 8-year period. METHODS: Anonymised injury data which included attendance date, age and gender of patients aged over 18 years who reported injury in violence were collected from a structured sample of 100 EDs across England and Wales between 1 January 2005 and 31 December 2012. Alcohol prices and socioeconomic measures were obtained from the UK Office for National Statistics. Panel techniques were used to derive a statistical model. RESULTS: Real on-trade (ß=-0.661, p<0.01) and off-trade (ß=-0.277, p<0.05) alcohol prices were negatively related with rates of violence-related ED attendance among the adult population of England and Wales, after accounting for the effects of regional poverty, income inequality, youth spending power and seasonal effects. It is estimated that over 6000 fewer violence-related ED attendances per year in England and Wales would result from a 1% increase in both on-trade and off-trade alcohol prices above inflation. Of the variables studied, changes in regional poverty and income inequality had the greatest effect on violence-related ED attendances in England and Wales. CONCLUSIONS: Small increases in the price of alcohol, above inflation, in both markets, would substantially reduce the number of patients attending EDs for treatment of violence-related injuries in England and Wales. Reforming the current alcohol taxation system may be more effective at reducing violence-related injury than minimum unit pricing.

[Injuries under the influence of alcohol]. / Verletzungen unter Alkoholeinfluss.

BACKGROUND: In Germany, an average of 9.5 L of pure alcohol is consumed per capita per year. Alcohol is known to negatively influence psychomotor abilities. The aim of this study was to evaluate injuries that lead to hospital admission with and without prior intake of alcohol. PATIENTS AND METHODS: Over a 7-month period, all 1317 patients who were admitted to the hospital because of an injury were evaluated with respect to their blood-alcohol level. Patient data of both groups (139 injuries under alcohol influence and 1178 injuries without alcohol influence) were compared with respect to the mechanism and type of injury, patient demographics, and treatment costs. RESULTS: At the time of presentation, 11 % (n = 139) of all admitted patients had detectable blood-alcohol levels of more than 0.1 g/L with an average blood-alcohol level of 2.21 g/L. Female patients had an average of 1.96 g/L and males an average of 2.28 g/L (N.S.). Almost every fifth male patient (109 out of 570, 19 %) had a detectable blood-alcohol level, compared to only 4 % of all admitted female patients. Among the patients admitted between 11:00 p.m. and 5:00 a.m., 35 % had detectable blood-alcohol levels and among the 20- to 30-year-old patients, 24 % had detectable blood-alcohol levels. The leading mechanisms of injury among intoxicated patients were falls (50 %, n = 70) and physical violence (18 %, n = 25). The latter was recorded significantly (p = 0.01) less among sober patients (0.17 %, n = 2). The most frequent diagnosis was a mild concussion in both intoxicated (60%, n = 84) and sober (34 %, n = 402) patients (p = 0.04). The time to discharge averaged 4.3 days for intoxicated and 5.6 days for sober patients. CONCLUSIONS: Injuries that occur while under the influence of alcohol that lead to hospital admission are particularly frequent in male patients aged between 20 and 30 years. They do not necessarily lead to more severe injuries.

The Welfare Cost of Homicides in Brazil: Accounting for Heterogeneity in the Willingness to Pay for Mortality Reductions.

This paper estimates the health dimension of the welfare cost of homicides in Brazil incorporating age, gender, educational, and regional heterogeneities. We use a marginal willingness to pay approach to assign monetary values to the welfare cost of increased mortality due to violence. Results indicate that the present discounted value of the welfare cost of homicides in Brazil corresponds to roughly 78% of the GDP or, in terms of yearly flow, 2.3%. The analysis also shows that reliance on aggregate data to perform such calculations can lead to biases of around 20% in the estimated social cost of violence.

Recurrent violent injury: magnitude, risk factors, and opportunities for intervention from a statewide analysis.

INTRODUCTION: Although preventing recurrent violent injury is an important component of a public health approach to interpersonal violence and a common focus of violence intervention programs, the true incidence of recurrent violent injury is unknown. Prior studies have reported recurrence rates from 0.8% to 44%, and risk factors for recurrence are not well established. METHODS: We used a statewide, all-payer database to perform a retrospective cohort study of emergency department visits for injury due to interpersonal violence in Florida, following up patients injured in 2010 for recurrence through 2012. We assessed risk factors for recurrence with multivariable logistic regression and estimated time to recurrence with the Kaplan-Meier method. We tabulated hospital charges and costs for index and recurrent visits. RESULTS: Of 53 908 patients presenting for violent injury in 2010, 11.1% had a recurrent violent injury during the study period. Trauma centers treated 31.8%, including 55.9% of severe injuries. Among recurrers, 58.9% went to a different hospital for their second injury. Low income, homelessness, Medicaid or uninsurance, and black race were associated with increased odds of recurrence. Patients with visits for mental and behavioral health and unintentional injury also had increased odds of recurrence. Index injuries accounted for $105 million in costs, and recurrent injuries accounted for another $25.3 million. CONCLUSIONS: Recurrent violent injury is a common and costly phenomenon, and effective violence prevention programs are needed. Prevention must include the nontrauma centers where many patients seek care.

Are Barroom and Neighborhood Characteristics Independently Related to Local-Area Assaults?

BACKGROUND: Two separate but complementary literatures examine bar-related violence: one has focused on barroom features, and the other has focused on features of neighborhoods near bars. This study unifies these 2 perspectives using a microenvironmental approach. METHODS: In a purposive sample of 65 bars in 4 California cities, we used premise assessments to characterize the physical, social, and economic environments of barrooms (e.g., patron count, average pace of drinking, and restaurant service); and a combination of systematic social observation, census, and alcohol license data to characterize the neighborhoods in which they were located (e.g., physical disorder, alcohol outlet density, and median household income). Hierarchical Poisson models then assessed relationships between these features and counts of police-reported assaults within buffer areas around bars. RESULTS: Aspects of both barroom environments (more patrons, more dancing, and louder music) and neighborhood environments (greater bar density, greater physical disorder, lower population density, and lower income) were independently related to increased incidence of assaults. CONCLUSIONS: Preventive intervention to reduce bar-area violence may be directed at both bar environments (e.g., limiting the number of patrons) and neighborhood environments (e.g., limiting outlet density).

Neighborhood socioeconomic status is associated with violent reinjury.

BACKGROUND: Measures of individual socioeconomic status correlate with recurrent violent injury; however, neighborhood socioeconomic status may also matter. We conducted a review of victims of interpersonal violence treated at our trauma center, hypothesizing that the percent of the population living under the poverty level in their neighborhood is associated with recurrent violent victimization. MATERIALS AND METHODS: We identified victims of interpersonal violence, ages 12-24, in our trauma registry from 2005-2010. Recurrent episodes of violent injury were identified through 2012. The percentage of the population living under the poverty level for the patient's zip code of residence was derived from United States census estimates and divided into quartiles. Multivariable logistic regression was conducted to evaluate predictors of violent injury recidivism. RESULTS: Our cohort consisted of 1890 patients. Multivariable logistic regression confirmed the following factors as independent predictors of violent injury recidivism: male sex (odds ratio [OR] = 2 [1.06-3.80]; P = 0.03), black race (OR = 2.1 [1.44-3.06]; P < 0.001), injury due to firearms (OR = 1.67 [1.12-2.50]; P = 0.01), and living in the lowest zip code socioeconomic quartile (OR = 1.59 [1.12-2.25]; P = 0.01). CONCLUSIONS: For young patients injured by violence, the socioeconomic position of their neighborhood of residence is independently correlated with their risk of violent reinjury. Low neighborhood socioeconomic status may be associated with a disrupted sense of safety after injury and also may alter a person's likelihood of engaging in behaviors correlated with recurrent violent injury. Programs aimed at reducing violent injury recidivism should address needs at the individual and neighborhood level.

The effects of age, gender, hopelessness, and exposure to violence on sleep disorder symptoms and daytime sleepiness among adolescents in impoverished neighborhoods.

Although sleep problems are associated with negative outcomes among adolescents, studies have not focused on sleep disorder symptoms among adolescents living in impoverished neighborhoods and how sleep problems may be related to two factors common in those environments: hopelessness and exposure to violence. This study used data from the longitudinal Mobile Youth Survey (MYS; N = 11,838, 49% female, 93% African-American) to examine trajectories of sleep problems by age (10-18 years) among impoverished adolescents as a function of gender, feelings of hopelessness, and exposure to violence. The results indicate that sleep problems associated with traumatic stress decline with age, with four notable distinctions. First, the steepest decline occurs during the early adolescent years. Second, the rate of decline is steeper for males than for females. Third, exposure to violence impedes the rate of decline for all adolescents, but more dramatically for females than for males. Fourth, the rate of decline is smallest for adolescents with feelings of hopelessness who also had been exposed to violence. To explore the generalizability of these results to other types of sleep disorders, we analyzed cross-sectional data collected from a subsample of 14- and 15-year-old MYS participants (N = 263, 49% female, 100% African-American) who completed a sleep symptoms questionnaire. Four results from the cross-sectional analysis extend the findings of the longitudinal analysis. First, the cross-sectional results showed that symptoms of apnea, insomnia, nightmares, and restless legs syndrome or periodic limb movement disorder (RLS/PLMD), as well as daytime sleepiness, increase as a function of hopelessness. Second, symptoms of insomnia, RLS, and nightmares, as well as daytime sleepiness, increase as function of exposure to violence. Third, symptoms of insomnia and RLS/PLMD are greater under conditions of combined hopelessness and exposure to violence than for either condition alone. Fourth, symptoms of RLS/PLMD are worst for females who have been exposed to violence and experience hopelessness. Overall, the findings suggest that hopelessness and exposure to violence have negative independent and multiplicative effects on adolescent sleep, particularly for females. Understanding the causal factors associated with inadequate sleep in impoverished adolescents is important for three reasons. First, sleep is an important aspect of adolescent development. Second, inadequate sleep has severe consequences for adolescent morbidity, mortality, and overall quality of life. Third, impoverished adolescents are at the most severe risk for poor outcomes, and improvement in their sleep may produce large gains.

Socioeconomic inequalities in premature mortality in Colombia, 1998-2007: the double burden of non-communicable diseases and injuries.

OBJECTIVES: Non-communicable diseases have become the leading cause of death in middle-income countries, but mortality from injuries and infections remains high. We examined the contribution of specific causes to disparities in adult premature mortality (ages 25-64) by educational level from 1998 to 2007 in Colombia. METHODS: Data from mortality registries were linked to population censuses to obtain mortality rates by educational attainment. We used Poisson regression to model trends in mortality by educational attainment and estimated the contribution of specific causes to the Slope Index of Inequality. RESULTS: Men and women with only primary education had higher premature mortality than men and women with post-secondary education (RRmen=2.60, 95% confidence interval [CI]: 2.56, 2.64; RRwomen=2.36, CI: 2.31, 2.42). Mortality declined in all educational groups, but declines were significantly larger for higher-educated men and women. Homicide explained 55.1% of male inequalities while non-communicable diseases explained 62.5% of female inequalities and 27.1% of male inequalities. Infections explained a small proportion of inequalities in mortality. CONCLUSION: Injuries and non-communicable diseases contribute considerably to disparities in premature mortality in Colombia. Multi-sector policies to reduce both interpersonal violence and non-communicable disease risk factors are required to curb mortality disparities.

An economic evaluation of anonymised information sharing in a partnership between health services, police and local government for preventing violence-related injury.

OBJECTIVE: To assess the costs and benefits of a partnership between health services, police and local government shown to reduce violence-related injury. METHODS: Benefit-cost analysis. RESULTS: Anonymised information sharing and use led to a reduction in wounding recorded by the police that reduced the economic and social costs of violence by £6.9 million in 2007 compared with the costs the intervention city, Cardiff UK, would have experienced in the absence of the programme. This includes a gross cost reduction of £1.25 million to the health service and £1.62 million to the criminal justice system in 2007. By contrast, the costs associated with the programme were modest: setup costs of software modifications and prevention strategies were £107 769, while the annual operating costs of the system were estimated as £210 433 (2003 UK pound). The cumulative social benefit-cost ratio of the programme from 2003 to 2007 was £82 in benefits for each pound spent on the programme, including a benefit-cost ratio of 14.80 for the health service and 19.1 for the criminal justice system. Each of these benefit-cost ratios is above 1 across a wide range of sensitivity analyses. CONCLUSIONS: An effective information-sharing partnership between health services, police and local government in Cardiff, UK, led to substantial cost savings for the health service and the criminal justice system compared with 14 other cities in England and Wales designated as similar by the UK government where this intervention was not implemented.

Injuries and violence in the Eastern Mediterranean Region: a review of the health, economic and social burden.

We review current literature and data on the burden of injury and violence in the Eastern Mediterranean Region (EMR) of the World Health Organization (WHO), with a special focus on the health, economic and social burden they impose on individuals, families and society. Injury-associated mortality and disability is on the rise in EMR, especially among economically productive adults, young males and vulnerable road users. In particular, road traffic injuries, the leading cause of injuries, account for 27% of the total injury and violence mortality in EMR according to WHO. Violence including suicide, homicide and war-related injury has also been increasing over the past two decades for both females and males. There is need for greater interest and efforts in slowing and ultimately halting the trend through interventions, legislative actions, and research that examine the special needs and challenges in the Region.

Income inequality, poverty and crime across nations.

We examine the relationship between income inequality, poverty, and different types of crime. Our results are consistent with recent research in showing that inequality is unrelated to homicide rates when poverty is controlled. In our multi-level analyses of the International Crime Victimization Survey we find that inequality is unrelated to assault, robbery, burglary, and theft when poverty is controlled. We argue that there are also theoretical reasons to doubt that the level of income inequality of a country affects the likelihood of criminal behaviour.

Evaluating Firearm Violence After New Jersey's Cash Bail Reform.

Importance: Reducing the pretrial detention population has been a cornerstone of movements to end mass incarceration. Across many US cities, there are ongoing public debates on policies that would end pretrial detention due to the inability to afford bail, with some raising concerns that doing so would increase community violence. Objective: To evaluate changes in firearm violence after New Jersey's 2017 bail reform policy that eliminated financial barriers to avoiding pretrial detention. Design, Setting, and Participants: This case-control study used synthetic control methods to examine changes in firearm mortality and combined fatal and nonfatal shootings in New Jersey (2014-2019). New Jersey was chosen because it was one of the first states to systematically implement cash bail reform. Outcomes in New Jersey were compared with a weighted combination of 36 states that did not implement any kind of reform to pretrial detention during the study period. Data were analyzed from April 2023 to March 2024. Exposure: Implementation of New Jersey's cash bail reform law in 2017. Main Outcomes and Measures: Quarterly rates of fatal and nonfatal firearm assault injuries and firearm self-harm injuries per 100 000 people. Results: Although New Jersey's pretrial detention population dramatically decreased under bail reform, the study did not find evidence of increases in overall firearm mortality (average treatment effect on the treated, -0.26 deaths per 100 000) or gun violence (average treatment effect on the treated, -0.24 deaths per 100 000), or within racialized groups during the postpolicy period. Conclusions and Relevance: Incarceration and gun violence are major public health problems impacting racially and economically marginalized groups. Cash bail reform may be an important tool for reducing pretrial detention and advancing health equity without exacerbating community violence.

Alcohol outlet density and violence: the role of risky retailers and alcohol-related expenditures.

AIMS: The aim of the study was to assess the association between alcohol outlet density and violence controlling for alcohol expenditures and the density of other retailers. METHODS: Cross-sectional ecological study of 1816 block groups in Philadelphia. We obtained 2010 data for aggravated assaults, alcohol outlets, alcohol expenditures, business points, land use and socioeconomic and demographic characteristics. We mapped the spatial distribution of alcohol outlets and aggravated assaults using a geographic information system. We estimated the association between assault density and total, on-premise and off-premise alcohol outlet densities using spatial regression models and controlling for the covariates of urban crime rates, alcohol expenditures, and the presence of other general and risky commercial retail outlets. RESULTS: The strong and positive association between alcohol outlet density and violence remained after controlling for alcohol expenditures and the density of other retailers. CONCLUSION: Findings support the concept that off-premise alcohol outlets in the neighborhood environment may impact health and social outcomes. The positive outlet-violence association in the face of these controls means it is not an association due solely to alcohol availability or to retail density. It also suggests that there is something unique about alcohol outlets or their density that makes them crime generators and links them to violence.

Delinquency best treatments: how to divert youths from violence while saving lives and detention costs.

Youth development and violence prevention are two sides of the same public policy. The focus of much theoretical and empirical effort is identifying delinquency risks and intervening. Given the great costs of homicide and the historically high nationwide prison population, new policies must address increasing violence and rising expenses. Treatments of prenatal care, home visitation, bullying prevention, alcohol-substance abuse education, alternative thinking promotion, mentoring, life skills training, rewards for graduation and employment, functional family and multi-systemic therapy, and multi-dimensional foster care are effective, because they ameliorate age-specific risks for delinquency. At present, these interventions only yield a 10-40% diversion from crime however. Returns on investment (ROIs) vary from $1 to $98. Targeting empirical treatments to those determined to be most at risk, based on statistical models or actuarial testing, and using electronic surveillance for non-violent prisoners significantly diverted youth from violence, improving ROI, while simultaneously saving costs.

Structural violence in the context of drug policy and initiatives aiming to reduce drug-related harm in contemporary Brazil: a review.

Brazil, the 6th largest world economy, has experienced rapid economic, demographic, and social structural changes during the last decade. Notwithstanding, Brazil being one of the most unequal societies worldwide, 40 million of 200 million Brazilians have moved from poverty to middle-class standards during this period. This review analyzes the success of different Brazilian initiatives aiming to reduce drug consumption-related harms, as well as the failed attempts to curb structural violence, despite some very recent initiatives have yet to be fully implemented and evaluated.