Gabriele Amersbach
A father walked for days, carrying his eight-year-old wounded son to the hospital during Mozambique's grueling civil war. Amputating the boy's leg would be Etienne Krug's wrenching introduction to the terrible cost of random violence. Fresh out of medical school, Krug had joined Médecins Sans Frontières (MSF), or Doctors Without Borders, the organization known for providing apolitical health services in the middle of the world's worst calamities. Within weeks, he had amputated limbs for the first time, stitched up babies with machete wounds, and became an expert in obstetrics because there was often no one else to help. Originally from Belgium, Krug spent six years with MSF, including two years each as clinical director of a rural hospital in Mozambique and as country director of MSF in El Salvador, with shorter stints in Cuba, Haiti, and Sudan. In these intense and often psychologically devastating situations, Krug tried to stay emotionally removed enough to function in his job, but his experience with MSF set the course of his career: "I learned about the devastation of violence firsthand and knew I wanted to work to prevent it."
Despite his extensive experience in conflict-torn regions, it was only when he entered the master's program at the Harvard School of Public Health that Krug viewed violence prevention in terms of public health. After completing his M.P.H. degree in 1995, he worked in violence prevention at the Centers for Disease Control and Prevention and joined the World Health Organization (WHO) as medical officer in 1999. At the end of 2000, Krug was asked to head WHO's new Department of Injuries and Violence Prevention. One of the main projects of this department is to produce a global report on violence and health that includes information on the risk factors and health consequences of violence as well as promising prevention techniques from around the world. The World Report on Violence and Health is due to be published by spring 2002. "Interest in violence prevention has spiraled since 1996 when the World Health Assembly, the annual meeting of all health ministries from around the world, passed a resolution on violence as a public health issue," Krug explains. "There is now enough knowledge for a global publication."
His department also supports violence prevention programs around the world, especially those that emphasize scientific data collection and evaluation. In Algeria, Uganda, and other African countries, WHO supports efforts to gather data on predominant types of violence and their causes. In Mozambique, WHO has held workshops for the highest levels of government officials to determine the major causes of violence and to develop prevention programs. In many countries, says Krug, interventions begin with one local person who takes a firm stand-from a Philippines physician who started a prevention campaign after treating one too many victims of child abuse to an Iranian female lawyer who founded an antiviolence NGO. "Even in some of the most conservative countries, we find local experts committed to violence prevention," he explains.
When completed, the World Report on Violence and Health will offer additional support to these programs by providing definitions, data, promising violence prevention techniques, and procedures on how to treat victims. In some countries, according to Krug, up to 25 percent of women report having been sexually assaulted by their husband or boyfriend during their lifetimes, yet many countries lack formal guidelines for handling the victims of a rape or assault. "Often women don't know if they should go to the police or to a health setting," says Krug. "Police may do nothing or even blame the victim. At a hospital, she may be told to shower, and the evidence is washed away. In many cases, the girl or woman is treated clinically, but her psychological trauma is ignored." Through detailed instructions and illustrations from other countries, the WHO guidelines may lead to a more sensitive treatment of victims and lower a society's acceptance of assault as an appropriate means to control women, children, or groups of low status.
Krug is quick to add that young men must not be left out of prevention programs. He notes that male youth are the most common victims of homicide and most often the perpetrators of violent crimes. The illicit trade of small arms and social acceptability of violence has led to unprecedented rates of gun deaths in some regions of the world like Brazil, where gun deaths, mostly among young men, have increased 200 to 300 percent in 20 years. Yet, little information is available on the impact of weapons on health globally. Krug and his staff regularly bring together experts from around the world to develop action plans that can have a major impact on how a country solves these public health crises. In addition, the department sponsors a biannual international conference on injury and violence prevention as a platform for information exchange.
For Etienne Krug, preventing whole populations from suffering the horrors of violence and injury may be even more challenging than saving one small boy in the bloody battle fields of Mozambique. "Violence is a very complex problem," he summarizes. "It's a mistake to try to oversimplify and attribute it to one issue-guns, drugs, or the media-it's a mixture of a wide range of factors." The new director of WHO's Department of Injuries and Violence Prevention and his staff are working to address them all.
Harvard Public Health Review Winter 2002/text version
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