Feature

Crimes and misdiagnoses

Crime has serious health impacts, both direct and indirect. But, say Jane Keithley and Fred Robinson, health practitioners are failing to identify the victims of crime. So how should the NHS respond?

Crime poses a serious threat to health and has a substantial impact on the demand for health services. Violent crime results in physical and psychological injury, which can require emergency treatment and long-term intervention. Theft and burglary can materially affect living standards and have psychological effects for the people involved, with consequences for health and health services. And the fear of crime can lead to a wide range of psychological disorders and self-limited mobility.

We have explored the connections between crime and health to obtain a better understanding of the impacts of crime and its implications for policy and practice. We looked at current awareness and concerns in this country, focusing on Northern and Yorkshire NHS Region. Our findings point to growing understanding of, and concern about, the links between crime and health, and increasing debate about the roles of health workers and other agencies.

Our review of mainly UK and US literature found that death and injury through violence are coming to be recognised as a major public health issue. As they are concentrated among younger people, in many countries they constitute a leading cause of potential years of life lost, as well as leaving a large group of individuals with long-term physical disabilities.

Violence disproportionately affects certain groups in society, including young people and those who are deprived. The British Crime Survey shows that these unequal risks extend to other types of crime, such as burglary and vehicle-related theft. In many ways these inequalities mirror those which are found in health, suggesting that crime is likely to be a contributory factor in the substantial and widening health inequalities that exist in contemporary Britain.

There is growing evidence of the extent of injury resulting from domestic violence, with women and children particularly at risk. Estimates of the incidence of domestic violence vary considerably but research suggests that much is unreported and also that, unlike most ‘stranger assault’, domestic violence victims often endure repeated attacks

Individuals who have been the victims of violence and other forms of crime often suffer damage to their health beyond immediate injuries. Damage to physical health can result from the stress caused by the experience of victimisation: for example, the heart attack suffered by the elderly victim of burglary or the self-harm induced by abuse.

The lifestyle changes reported by victims of stalkers and by those who are frightened of crime may also have significant effects on health. In particular, older people, women and children may become constrained in their use of public spaces and make more use of car transport. They may withdraw from social life, including interaction with neighbours, and avoid going out at night. They may take protective or defensive action which can in itself pose a threat to health: for example, carrying a weapon, or barricading themselves in their homes.

All these can be damaging to physical and mental health, as well as to an individual’s broader sense of well-being and quality of life. Exposure to crime may increase the incidence of health-damaging behaviour, such as smoking or excessive alcohol consumption.

So impacts can be direct or indirect; they may be evident immediately or only emerge days, months or years afterwards. Research suggests that abuse in childhood, much of which is never recorded as a crime, is associated with long-term health problems, both physical and psychological. There can also be effects on health arising from excessive or inappropriate use of health services or, conversely, a reluctance to use health services, for example if the victim is fearful of disclosing the crime.

Individual targets of specific criminal acts are the victims, but they are not the only ones. There may be indirect or secondary victims, such as witnesses, or those who live in communities with a high incidence of criminal or ‘nuisance’ activity.

Children who witness domestic violence, older people in areas where the risk of assault or burglary is perceived to be high, and those working in the emergency services responding to the consequences of violence, can all be ‘victims’ and suffer consequent — often unrecognised and neglected — health problems. Also the boundary between victims and perpetrators may not be clear cut, especially in the case of offences associated with street fighting or illegal drugs.

It was clear from our literature search that research in this area is not straightforward and, beyond the visible evidence of physical injury, it is often difficult to demonstrate a clear causal link between a crime and health damage. It is widely acknowledged that crime is generally under-reported, especially domestic violence and sexual assault, making it difficult to assess the overall impact on health and health care.

Many studies focus on people who have sought medical help, and so may not be representative of the general population. They often rely on retrospective accounts and report correlations which do not in themselves demonstrate causal links.

However, the weight of supporting evidence is very persuasive. Crime, and even the fear of crime, is undoubtedly bad for our health, in ways which are complex, multifaceted and both short and long term.

Moreover, these health consequences entail substantial costs for society as well as individuals. The monetary costs to the US health care system resulting from murder and non-fatal acts of violence are estimated at billions of dollars each year. In the UK, research in the London borough of Hackney estimated that domestic violence cost local health services more than £500,000 in 1996, spent on treating physical injuries and psychological harm. Crime is an important issue for the NHS, both at the level of caring for individual victims and from a public health perspective.

We looked in our review at the extent to which health services recognised and responded to the health consequences of crime. Health care providers are likely to come into contact with more victims of crime than the police, especially in the UK. Even in the very different context of US health care, it is thought that more victims of violent assault seek help from health services than report the assault to the police. This is also suggested in relation to GPs and A&E departments in this country. Health care providers are therefore in a good position to identify and respond to the health and other needs of victims.

However, it seems that there is a widespread failure to identify these needs, or even identify the victims of crime. Studies suggest that doctors and other health care practitioners tend to be reactive, to treat ‘presenting symptoms’ rather than exploring underlying problems. They shy away from following up their suspicions, especially in the case of ‘sensitive’ areas, such as sexual assault or domestic violence. To explore these issues is to open Pandora’s box and they are reluctant to do so because of time constraints, fear of causing offence or their own discomfiture and feelings of powerlessness.

Our review of Northern and Yorkshire region found a general awareness among health authorities and trusts of the impacts of crime on health and the consequent demand for health services. There were also signs of increasing involvement in these issues, especially in relation to domestic violence and violence directed towards their own staff. But these concerns and initiatives do not seem to be supported by much information, research or policy.

It was particularly disappointing to find only scant reference to the health impacts of crime in the public health directors’ annual reports and in submissions for Health Action Zones. The responses from victim support schemes in the region reinforced a picture of substantial damage to the physical and psychological health of crime victims, yet a patchy and often limited response from health service staff.

An important issue is how far those working in health care settings can and should be expected to take a more proactive approach to identifying victims of crime. Identification must be followed by a response if it is to serve any useful purpose. This could involve extra demands on health service staff: short-term and long-term care for physical and psychological health; or the provision of social support, requiring time-consuming collaboration with, and referral to, other agencies.

It could also raise difficult issues in relation to collaborating with the police; either in terms of sharing general information about crime and violence, or of how far encouraging individual victims to report crimes is compatible with the ethics of the doctor-patient relationship.

Those who propose a ‘public health’ approach to crime emphasise the important role of health services and health care providers in prevention, rather than simply treating victims. Epidemiologists could use the skills they have developed in relation to mapping the incidence, prevalence and patterns of disease to map crime or violence in society. From this information, appropriate responses (inside and outside the health services) could be developed and tested, accompanied by monitoring and surveillance techniques.

The vision is held up of eliminating crime and violence from our society, or at least of taming them, in the same way, it is claimed, that such information has been effective against the major infectious diseases.

In this vision the questions of costs and demands are obviously important. Health service budgets are large, growing and under strain. Demands for extra expenditure will be difficult to justify. However, some of the literature suggests that an improved health service response would not only improve the quality of care, and thus quality of life, of crime victims but could, in the longer term, save money.

Early and appropriate intervention can minimise damage to health, prevent the development of chronic physical and psychological problems, and discourage inappropriate use of health services. Responding to the impacts of crime represents an enormous, complex and important challenge to the health service.

We wish to thank Northern and Yorkshire NHS Executive for funding, and Sue Robinson and Sue Childs for their support.

Exploring the Impacts of Crime on Health and Health Services: a feasibility study is available for £5 (inc p&p) from the Department of Sociology and Social Policy, Durham University, Durham DH1 3JT, or from j.f.robinson@durham.ac.uk.