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C. Whitney and E. Wartella
Violence as a Problem of Health
In the early 1990s, many policy makers and social
scientists related the problem of community violence
to neighborhoods trapped in struggles among gangs
competing to sell and distribute illegal drugs, especially
cocaine and crack cocaine. From this perspective, the
challenge for communities was to locate and restrain
16192
perpetrators and respond to victims. Gradually, it has
been recognized that community violence, however it
began, affects many segments of the population.
Seemingly clear distinctions between victim and per-
petrator seem to have faded. Heightened exposure to
violence is assumed to increase acts of aggression in
anticipation of violence from another. Effectively, the
timing rather than the nature of an act may differ-
entiate victim from victimizer. In such an environment,
the sense of unease may seem constant, the need for
vigilance continuous, and suspicion of others required.
That state may, in turn, disrupt sleep, upset vegetative
functions, impair interpersonal relationships, and
disable effective concentration on work and studies.
Together, these characteristics produce an environ-
ment marked by ‘pervasive community violence’
(PCV), an ecological situation with significant impact
on emotional, behavioral, and psychological health.
PCV, therefore, negatively alters the essence of
community life, broadly disrupts its functioning and
presumably thereby impairs residents’ general health.
The potential for such broad impact must be ap-
preciated and respected before one can enlist com-
munities to join in investigating PCV’s nature and
consequences. Investigators who do not appreciate
that quality may be surprised by the reluctance of
community leaders (e.g., school administrators,
county health officer, and representatives of the
mayor’s office) to participate in its study. The leaders
may deny the problem’s extent or hesitate to make
public the negative quality of their neighborhood or
community. For them genuine partnerships require
time accumulated through historical involvement and
future commitment. History enables disclosure and
trust. Intimate aspects of a community are rarely
shared with strangers. Assurance that the investigator
will be there in the future (even after external funds are
gone) is important, given community leaders’ appreci-
ation of the intransigence of social problems and the
fickleness of social scientists. Thus, from the outset it
must be appreciated that to study and alter the nature
and consequence of PCV requires a genuine and long-
term partnership between communities and social
scientists.
1. Definition of Terms
As one reviews the growing PCV literature, the need
for defining relevant terms becomes apparent. Violence
refers to both acts and consequences of the intentional
use or threat of use of force to cause injury, harm, or
death to another. The qualifier ‘intentional’ excludes
unintended or accidental acts and consequences.
Determining intent represents an as yet unresolved
methodological challenge. For PCV, the consequences
of
iolent acts refer to the rippling health and mental
health effects experienced by: (a) individuals directly
victimized by an act or threat of violence; (b) indivi-

duals indirectly victimized as a bystander, witness,
acquaintance, or loved one of a direct victim; and (c)
individuals indirectly victimized by their awareness of,
and anxiety about, the occurrence of acts or threats of
violence. Community
iolence locates the acts and their
consequences in a geographic setting (e.g., a neighbor-
hood or a school), an identifiable social grouping (e.g.,
a grade cohort, a gang, a nuclear or extended family)
or both. Per
asi
e community
iolence (PCV ) refers to
the chronic and widespread occurrence of acts or
threats of violence within such settings or social
groups.
Thus, PCV exists when substantial acts and conse-
quences of violence are encountered across multiple
settings and circumstances over extended time. To
investigate PCV systematically, the qualifiers ‘sub-
stantial,’ ‘multiple,’ and ‘extended’ must be opera-
tionally defined and rigorously measured. Information
must be gathered about a community’s rate of violent
acts and about rates of individual encounters with
violent acts. For methodological and political reasons,
PCV measures vary in their consideration of violence
occurring within or outside of the home. The majority
of such measures limit their focus to outside encoun-
ters. Yet, by definition, PCV implies cross-setting
exposure. At its most extreme, PCV represents the
absence of any sanctuary or setting in which relief and
a sense of safety is possible. Thus, the most serious
impacts on physical and psychological health are likely
to be observed in those exposed at home, at work or
school, and en route between the two.
In a series of papers and chapters, I have proposed
consideration of PCV as an en
ironmental contaminant
with measurable effects on health and mental health
(Cooley-Quille and Lorion 1999, Lorion 1998, 1999,
2001, Lorion et al. 1998, Lorion and Saltzman 1993).
From that perspective, PCV contaminates settings
and thereby the actions and interactions of at least
some inhabitants. Contamination refers to the cor-
rosive or pathogenic effect of PCV exposure on
community climate. Slowly investigators are docu-
menting PCV’s negative effects on: (a) individual
assumptions about the threatening quality of others,
(b) the need to limit one’s contact with others, and (c)
the urgency of responding aggressively to actual or
anticipated attacks. This ecological contamination
appears to vary in its pace as well as intensity across
individuals, situations, and settings. Understanding
the determinants and mechanisms of such patterns
and their malleability within and across individuals
should inform the design of interventions to limit PCV
exposure and reduce its consequences.
2. Measuring PCV
Investigation of PCV’s environmental influence re-
quires the availability of measures to estimate its
presence and to confirm its impacts. Applying a
Violence as a Problem of Health
common measurement approach across diverse popu-
lations and settings, Richters and associates (Lorion
and Saltzman 1993, Martinez and Richters 1993,
Osofsky et al. 1993, Richters and Martinez 1993)
scientifically documented the extent of children’s
exposure to violence. They also provided early evi-
dence of the relationship between PCV exposure and
children’s emotional and behavioral functioning. Sub-
sequent investigations of such relationships (e.g., Hill
and Madhere 1996, Singer et al. 1995) confirmed the
seriousness of such links.
Measures of exposure to community violence share
many similarities with the Survey of Children’s Ex-
posure to Community Violence (Richters and Saltz-
man 1990). Instructed explicitly not to include media
exposure (i.e., what was seen or heard about on radio,
television, or in movies), respondents indicate along a
five-point Likert scale (from 0 l ne
er to 4 l a lot of
the time) how often they have been victimized by,
heard about, or witnessed violent events or related
activities (e.g., shooting, stabbing, mugging, seeing a
dead body). For each instance of reported exposure,
respondents provide information about: (a) where the
exposure occurred (i.e., in or near school, in or near
home, in the neighborhood); (b) who perpetrated the
violence (e.g., a stranger, a family member); (c) who, if
not the respondent, was victimized (e.g., a stranger, a
family member); and (d) when the incident occurred
(e.g., one week ago, five years ago).
Variations of this measure were applied by Martinez
and Richters (1993) and Osofsky et al. (1993) in
studies of mothers of elementary graders and by
Richters and Martinez (1993) and Saltzman (1992) in
their studies of fifth and sixth graders. A cartoon-
based version of this measure was designed by Richters
and Martinez (i.e., Things I Have Seen and Heard,
1990) to assess PCV exposure in primary graders.
Test–retest reliability was a most acceptable r l 0.81.
A second cartoon-based measure, Levonn, assessed
distress symptoms associated with exposure (Richters
et al. 1990). Subsequently, Fox and Leavitt (1995)
developed the Violence Exposure Scale for Children
(VEX-R) as a cartoon-based measure of PCV ex-
posure in children from preschool through the el-
ementary grades. Using this measure, Shahinfar et al.
(2000) documented PCV’s impact on preschoolers.
The negative behavioral consequences of such ex-
posure was confirmed in a sample of Israeli elementary
school children by Raviv et al. (2001).
A further variation of the Richters and Saltzman
(1990) measure was applied by Saltzman (1995) to
examine PCV exposure’s link to adolescent involve-
ment in antisocial and delinquent behaviors. Building
on these variations, Singer et al. (1995) designed the
Recent Exposure to Physical Violence and the Past
Exposure to Violence surveys to obtain adolescent
reports of exposure during the prior 12 months or
‘while growing up, not including the past year,’
respectively. The acts of violence surveyed by Singer et
16193
Violence as a Problem of Health
al. included threats, slapping, hitting, punching, beat-
ings, knife attacks, and shootings. Separate reports
for each (other than knife attacks and shootings)
were obtained for home, school, and neighborhood.
Respondents were also asked how often they had
witnessed someone else victimized at each of the
aforementioned sites. Two additional items inquired
about respondents’ having been ‘made to do a sexual
act’ or having witnessed someone else ‘being made to
do a sexual act.’ Overall, measurement efforts to
date support the conclusion that psychometrically
acceptable reports of PCV exposure can be obtained
from youth ranging in age from preschoolers to
adolescents.
In addition to the above work, Jenkins and associ-
ates (Bell et al. 1988, Jenkins and Thompson 1986)
designed and conducted qualitative studies of African-
American children’s encounters with violence. Results
from four studies are summarized in Bell and Jenkins
(1993). Using related measures, Jenkins and colleagues
obtained information about youth’s exposure in terms
of: (a) knowing someone who was a victim of violence;
(b) having witnessed violent events in real life; (c)
having been a victim of a violent incident; and (d)
having perpetrated a violent act. Comparable to the
work mentioned above, information about such forms
of exposure was obtained from students enrolled in
grades 2 through 12.
Although not a universal experience, victimization
occurs at levels approaching 50 percent for threats and
40 percent for forced entry into their home. Indirect
victimization (e.g., being a witness to a violent act)
levels were consistently higher for incidents ranging
from drug use to shootings, stabbings, and muggings.
Reports of seeing a dead body in the neighborhood
ranged from 24 to 40 percent. Using an extension of
the Richters and Saltzman measure, Singer and col-
leagues (Singer et al. 1995, Song et al. 1998) validated
these reports in their surveys of high-school students
(N l 3,735). As expected, considerable variability is
present across settings. Nevertheless, levels of victimi-
zation and witnessing (both at home and in school)
justify recognition of PCV as a major environmental
contaminant. Apfel and Simon’s (1996) description of
communal violence as referring to settings in ‘which
every child has witnessed or expects to witness violence
and has been or expects to be violated’ (pp. 4–5), seems
to apply to many of the nation’s neighborhoods and
schools.
3. Assessing PCV’s Health Impact
The aforementioned studies also report on PCV’s
toxicity. Saltzman (1992), for example, observed sig-
nificantly higher levels of generalized emotional dis-
tress in PCV-exposed fifth and sixth graders. This
pattern is also reported by Richters and Martinez
(1993), Martinez and Richters (1993), Osofsky et al.
16194
(1993), and Bell and Jenkins (1993). Across these
studies of preadolescents, PCV exposure relates posi-
tively to affective and vegetative signs of depression
and indices of stress-related disorders. With both
preadolescents and adolescents, Singer et al. (1994)
linked PCV exposure and increased aggression, con-
duct disorder, running away, and decreases in self-
esteem and social competence. Support for the link
between PCV exposure and involvement in violent
acts is reported by Saltzman (1995). In Saltzman’s
study, PCV exposure significantly related to ado-
lescent involvement in antisocial and violent acts
independent of peer, familial, and other recognized
predictors of aggression during that developmental
period. Rubinetti (1996) linked PCV exposure and
violent activity most strongly in youth with decreased
empathy, hopefulness, and self-esteem. Provocatively,
Song et al.’s (1998) findings suggest that indirect
victims are more likely than direct victims to aggress in
anticipation of violent acts. Although further study is
needed, PCV may create interpersonal distance among
the residents of an affected setting, desensitize them to
the consequences of violence on others, while heighten-
ing the need to defend oneself against assault. Overall,
there appears to be substantial evidence that heighten-
ed exposure to PCV increases the likelihood that one
will engage in violence. In turn, the resulting acts of
violence increase levels of PCV exposure, providing a
mechanism for a continuing cycle.
Two recent studies (Cooley-Quille and Lorion 1999,
Scarpa et al. 2000) have begun to examine the physical
impacts of PCV exposure. Each study found physio-
logical concomitants of PCV exposure, including
increased heart rate, respiration, and cortisol levels,
long-established indices of heightened stress and
arousal. Cooley-Quille and Lorion (1999) also repor-
ted preliminary evidence of a link between PCV and
sleep disorders. Anecdotal reports from youth living in
PCV-heightened neighborhoods report difficulty fall-
ing asleep, repeatedly waking up in response to
gunshots, loud noises, and police activity and, gen-
erally, only rarely sleeping throughout the night. If
these reports are confirmed along with further in-
formation about the vegetative effects of PCV ex-
posure, new understandings may emerge which change
existing assumptions about the lack of impulse control
and academic failure, often associated with urban
poverty, from attributions about personal failure to
questions about environmental toxicity. Thus, al-
though examination of the physiological consequences
of living or working within settings characterized by
high PCV levels is just beginning, preliminary results
suggests that these impacts are real, extensive, and
potential triggers for further pathogenesis across
multiple parameters of functioning.
Such findings support the hypothesized toxicity of
PCV exposure which appears to impair cognitive,
emotional, behavioral, and biological functioning
simultaneously, sequentially, or synergistically. As yet

unexamined systematically, however, is the breadth of
these ‘PCV-consequences’ (assuming they are causally
linked) within settings and communities. In essence,
we have yet to study how the toxin spreads and the
transmission routes by which the occurrence of violent
events (presumably their nature, frequency, and in-
tensity would influence the spread of effects) con-
taminates the environment. Longitudinal information
is necessary to causally link exposure and its observed
concomitants. It is also necessary to determine at what
point interventions can be introduced to protect
against or, if necessary, to treat such effects.
It should be recognized that what is presently known
about PCV relates almost entirely to school-aged
youth. We know little about the effect of maternal
PCV exposure on neonates, of exposure on toddlers
and preschoolers, and even less about the nature,
extent, and consequences of exposure on adults. What
of the parents, grandparents, and others who live in
such neighborhoods? Within schools, what of the staff
and teachers who may live in such neighborhoods,
travel through such neighborhoods, or hear the tales
of their students? Work reported to date pays little
attention to these members of exposed communities,
except perhaps to suggest that they could buffer youth
against the impacts of PCV. Whether we can assume
the capacity of exposed adults to do so merits careful
examination.
We must therefore examine exposure across the
entirety of a community’s population and settings.
Anecdotal reports, informal focus groups, and clinical
encounters suggest that exposure reduces the quality
of teachers’ instructional effectiveness, capacity to
apply classroom management strategies, and avail-
ability to students before or after the school day.
Reasonably, one might expect that PCV similarly
disrupts parent–child, parent–teacher, and teacher–
teacher interactions. As reported above, Song et al.
(1998) found a significant link between indirect ex-
posure and anticipatory aggression. Ambiguous inter-
personal cues may be interpreted by youth (and
perhaps adults?) as threatening, leading to what is
assumed by the perceiver as a defensive act. Pre-
sumably (although we do not really know), when self-
defense seems unlikely to succeed, ambiguity leads to
retreat, avoidance, or perhaps acquiescence with
stated or unstated demands.
If this explanation of Singer’s finding is valid, would
it not extend to adult interactions within and across
generations? Might it not explain, at least in part, what
from the outside appears as hypersensitivity to insult
or disrespect, the immediacy with which one asserts
one’s right, or the reluctance to give way, lest courtesy
be mistaken for weakness or fear? Might it not explain
urban parents’ use of physical discipline or its reverse,
that is, seeming inability or unwillingness to control
their children’s behavior? What of neighborhoods in
which the elderly limit, and the young have limited,
time outside of the home because of concerns about
Violence as a Problem of Health
danger and vulnerability? Would not isolated streets
facilitate violence with immunity? Would not the
biological concomitants related to stress, sleep depri-
vation, and concentration impair adults’ (be they
teachers, storekeepers, bus drivers, or neighbors)
capacity to interact comfortably with each other and
to neutralize or at least dilute PCV’s toxicity and
thereby protect youth? To ignore the status of adults
in such settings implies that they are unaffected by
PCV or other community toxins.
Albeit at levels of concern, PCV is linked to
increased but not universal pathology. Not only does
a majority of those exposed not manifest pathology,
but most residents do not report exposure. PCV
exposure appears to relate not only to the occurrences
of violent acts, but also to awareness of those
occurrences. Somehow, many exposed are seemingly
unaware of that and, potentially, for them there is
some bliss in ignorance. What individual and eco-
logical factors determine sensitivity remains to be
investigated. That such differences exist, however,
argues for attending to issues of adaptation, coping,
and wellness. As noted recently:
By implication it seems reasonable to view wellness as
representing the outcome of normative developmental pro-
cesses, in programming terms, as the default option. In the
absence of that relatively rare combination of individual and
situational circumstances, individual development appears to
proceed within socially expected and appropriate boundaries
reflecting the general capacity to adapt to situational demands
and cope with stressful events. Just as canalization accounts
for the limits within which genetic processes emerge within
species (Gottlieb 1992), an analogous process may account
for the human capacity to adapt to a multitude of settings and
circumstances, and to cope with seemingly debilitating and
pathogenic stressors. (Lorion 2000, pp. 13–14)
If wellness, adaptation, and adjustment represent
the default option in human development, and indi-
viduals, families, neighborhoods, schools, and com-
munities in general cope with PCV, economic
(dis)advantage, familial instability, critical life events,
inadequate school budgets, etc. (the length of one’s list
merely underscores the point), understanding those
mechanisms may inform the design of interventions to
protect those who cannot cope. Answers to questions
about how to optimize development and coping must
be out there, in the homes, the schools, the classrooms,
and the neighborhoods. To find those answers, we in
the social sciences must enter the communities to
observe, inquire, and learn. I propose we go not as
experts bringing esoteric knowledge, but as students
and collaborators, hopefully bringing tools and pers-
pectives whose utility will be determined relative to
what already exists, and what can be sustained over
time and across levels of resources.
See also: Community Health; Ecology and Health;
Environmental Health and Safety: Social Aspects
16195
Violence as a Problem of Health
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Copyright # 2001 Elsevier Science Ltd.
All rights reserved.
Violence, History of
Violence in its various forms has been an aspect of
historical descriptions since Thucydides, but to this
day there is no independent specialty in historical
research on violence. The history of violence is thus
written as part of military and war history, of research
on revolution and protest, and of the history of gender
and the body. In Europe and elsewhere, it cuts across
the institutional and disciplinary logic of the study of
history. This lack of independence has two conse-
quences for historical research on violence. First, it is
always interdisciplinary and includes approaches
ISBN: 0-08-043076-7