The difficult and slow inclusion of violence on the health sector agenda
Maria Cecília de Souza Minayo
Centro Latino-Americano de Estudos sobre Violência e Saúde Jorge Carelli, Escola Nacional de Saúde Pública, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
Violence is first and foremost a social issue, and is thus not an object per se of the health sector. It becomes an issue for the health field due to: (1) its impact on quality of life because of the physical, psychological, and moral injuries it entails and the resulting demands for medical and hospital care and (2) the expanded concept of health, whereby violence is the object of inter-sector approaches, including the approach by the field of social medicine.
Although no one doubts that violence and accidents are problems that affect health, over the years these phenomena have been treated as the exclusive object of public security. It was not until the 1990s that the health sector began to deal with them officially. Observing the changes in morbidity and mortality profiles in most of Latin America, beginning in 1993 the Pan-American Health Organization began to insist that member countries include the theme in their agenda for intervention. Later, perceiving how serious the situation was in other parts of the world, not only in the Americas, the World Health Organization (WHO) prioritized the issue during the World Health Assembly in 1997. And in 2002, the WHO published an extensive report entitled the World Report on Violence and Health, sharing reflections on both its specific and inter-sector responsibilities.
In Brazil as well, it was difficult to introduce the subject of accidents and violence into the health policy agenda, although since the 1980s they have constituted the second cause of death in the overall mortality profile. Since then this situation has been identified and highlighted by researchers and scholars of the concept and data on "external causes", the overall item used by the International Classification of Diseases to classify deaths, injuries, and trauma resulting from the phenomenon. In the late 1990s, more precisely in 1998, after the World Assembly in 1997 that focused on the issue, the Brazilian Ministry of Health set up a Technical Committee aimed at diagnosing and proposing specific measures for the health sector. I had the privilege of chairing this Committee, sharing with more than 150 professionals from all over Brazil a discussion on the proposal, which was subsequently analyzed and approved by the tripartite tiers of the Unified National Health System (SUS) and the National Health Council. On May 16, 2001 (and not without several setbacks and delays), the document was officially adopted by a government ruling, with the following title: National Policy for the Reduction of Morbidity and Mortality from Accidents and Violence. This document contains the definition of concepts, diagnosis of the situation, guidelines, and strategies for inter-sector action, highlighting each sector's responsibilities.
Several actions are currently under way at the National, State, and Municipal levels to prevent violence and accidents; some of these actions existed before the government ruling establishing the policy, while others were inspired by it. An Action Plan is currently in the drafting process that will orient and integrate the various national perspectives and initiatives. The entire process has been very slow, and there are reasons for this. The main reason is that in a field dominated by the biomedical mindset, "violence and accidents" are customarily viewed as a foreign object in its conceptual universe. Therefore, everyone urgently needs to know that the Brazilian population's morbidity and mortality profile is now marked more by living conditions, situations, and lifestyles than by the country's traditional diseases. Violence and accidents are among these problems which deserve as much attention as AIDS, cancer, and cardiovascular diseases.