Crime is a public health issue, and partnership is the way to tackle it if experiences in Los Angeles County hold lessons for the UK.
Police departments and police methods were clearly failing to deal with the problem of violence in Los Angeles County in the US in the mid- 1990s.
In 1994, paramedics dealt with 25,000 calls for help from victims of violence compared with 8,000 calls for heart attacks, 30 per cent of women going to accident and emergency departments were victims of domestic violence, and between 1994 and 1996 more than $24m was spent providing care and rehabilitation for people with spinal cord injuries due to gunshot wounds.
'Violence was one of the leading causes of death and disability for people under 35 years of age,' Billie Weiss, an epidemiologist and director of the Injury and Violence Prevention Program at the LA County Department of Health Services, told a conference on crime, fear of crime and public health last week.
'It had become clear that law enforcement alone could not deal with the problem and that it was not only costing lives but billions of healthcare dollars.' That was when public health stepped in.
The public health department in LA had an advantage no other government agency had: it was seen as community-friendly. This enabled public health to bring together groups of stakeholders in the community into a Violence Prevention Coalition to discuss how the violence epidemic might be reduced and prevented, Dr Weiss told the conference in Stirling.
Law enforcement, representatives from hospitals, schools, businesses, universities, churches, community organisations and the media had been brought together in cross-disciplinary committees to look at the issues and come up with solutions.
'We focus on primary prevention,' she stressed. 'We discovered that the most effective way to deal with the problem was to prevent it in the first place.'
An education committee worked with schools, providing information and training on conflict resolution, gun violence prevention and teen relationship violence problems; a healthcare intervention committee trained healthcare workers on how to diagnose, treat, refer and report domestic violence incidents; a community mobilisation committee brought young people together to discuss their perception of violence in their homes, schools and communities; while an epidemiology committee, chaired jointly by a criminologist and a public health specialist, had developed a protocol to evaluate the effectiveness of community-based crime prevention programmes.
There was also a committee that conducted media roundtables to try to influence the media to educate with the facts, said Dr Weiss. 'For example, the perception that women are afraid of being raped by a stranger is countered by pointing out that the real danger is from someone they know and maybe have a relationship with. In LA every five days a woman is killed by an intimate partner.
'We are working to change policy and have been successful in presenting public health data and epidemiological studies to legislators,' said Dr Weiss. One of the Violence Prevention Coalition's greatest achievements so far had been to change the gun laws in 39 cities in LA County. 'We are also very involved in increasing community awareness that violence is a problem that affects us all, but everybody can do something to be part of the solution.'
This public health model provided 'the greatest hope' of maintaining peaceful communities, she added.
Working in partnership with others was the only way crime and anti-social behaviour could be reduced, agreed Scottish health minister Sam Galbraith. 'Just as joint working is crucial to advances in health improvement, so it is vital in tackling crime,' he said.
'Work is already well underway to encourage the development of local crime prevention strategies between the police, local authorities and local communities in Scotland, with local councils now expected to set targets, in collaboration with other agencies, for the reduction of crime and disorder in their areas,' he said.
Urban partnerships set up in areas of deprivation showed that progress could be made, Mr Galbraith added.
'In Wester Hailes (a housing scheme in Edinburgh), for example, crime has been reduced by 42 per cent,' he said.
'A holistic approach to crime prevention has included improving the physical security of people's homes, making public areas safer, providing facilities for young people which take them off the streets, managing housing in a way which sets standards of behaviour for tenants, and taking effective action against those who fall short, giving people a personal stake in the area and promoting a sense of community.
'As our communities become safer and more pleasant, so the potential for health improvement increases.'
But there was still a very long way to go. A report on domestic violence published late last year by the Scottish Needs Assessment Programme provided 'a very worrying overview of the impact of domestic violence on the health and well-being of women and children', said Sue Laughlin, chair of the SNAP group on health and domestic violence and women's health policy co- ordinator with Greater Glasgow health board.
'It has been estimated that between 260,000 and 700,000 Scottish women are experiencing domestic violence. Domestic violence is obviously not conducive to health, and it is likely that the health of all women experiencing domestic violence will be affected in some way,' said Ms Laughlin.
'At worst it is life-threatening. Half the women victims of homicide in Scotland are killed by their partners.'
Domestic violence also had an impact on service delivery, with women who had been battered by their partners attending GP surgeries, other primary care facilities, A&E departments, maternity services, psychiatry and dental services.
A recent economic analysis of health service resources used by women experiencing domestic violence in Greater Glasgow health board area estimated a cost to the board of around pounds20m a year.
'If we are paying the price, directly or indirectly, it is imperative that we build on the initiatives that already exist,' Ms Laughlin told delegates.
'No one agency has either the resources or the requirement to deal with the issue in isolation. We need to adopt a multi-agency approach which will look carefully at combining a strategy for tackling the issue with the development of preventive, community-based measures.'
Angus McCabe, a research fellow at Birmingham University and joint author of Framing the Debate, the Public Health Alliance report on the links between crime, fear of crime and public health, agreed that partnerships to tackle the problem were needed. 'But they depend on a common language and common understanding,' he said.
Responses to the impact of crime on public health were hindered by the absence of a coherent national policy and by the rigidity of departmental boundaries within central government which separate the health and criminal justice systems, he said.
Responses to crime had focused on reaction and defence - tougher sentencing, target-hardening and the use of CCTV - but such measures might actually increase public anxiety and include an element of 'scapegoating' which could further marginalise excluded groups, he believed.
What was needed was closer co-operation between the Department of Health, the Home Office and other ministries to develop integrated crime prevention and health promotion strategies, and the development of shared policy agendas on crime and public health, he concluded.