# Insights of Anthropology

ISSN: 2578-6482

### Article Outline

REVIEW ARTICLE | VOLUME 2 | ISSUE 1 | DOI: 10.36959/763/487 OPEN ACCESS

# A Comparative Study of the World's Most Dangerous Cities: Violence as the Ultimate Public Heath Challenge

Ming Yin and Carol Camp Yeakey

• Ming Yin 1*
• Carol Camp Yeakey 2
• Department of Education, Washington University in St. Louis, USA
• Faculty of Arts & Sciences, Interdisciplinary Program in Urban Studies, Center on Urban Research & Public Policy, Washington University in St. Louis, USA

Yin M, Yeakey CC (2018) A Comparative Study of the World's Most Dangerous Cities: Violence as the Ultimate Public Heath Challenge. Insights Anthropol 2(1):67-85.

Accepted: February 06, 2018 | Published Online: February 08, 2018

# A Comparative Study of the World's Most Dangerous Cities: Violence as the Ultimate Public Heath Challenge

## Abstract

With the pace of rapid urbanization, people not only live in cities, but in increasingly larger cities, resulting in major changes in daily living and public health conditions. Nation states have made enormous strides in their efforts to improve their population's health conditions, from prenatal care and immunization to hospital care, extending life spans previously thought unimaginable. Unfortunately, interpersonal violence has become one of the major public health issues in major cities in nations with high homicide rates across the globe, with consequences for both direct and indirect victims. Violence is a complex, multifaceted problem, and the result of the complex interplay of individual, relationship, social, cultural and environmental factors. Its damage goes beyond the intangible suffering and impacts on quality of life and well-being, violence impedes human and economic development. For decades, research has demonstrated that public safety, or the lack thereof, is a public health issue. This study focuses on the World's most dangerous cities: Caracas Venezuela, Acapulco Mexico, Detroit Michigan and St. Louis Missouri in the U.S. Building upon the Bronfenbrenner ecological model, this study investigates the risk factors of violence in these four cities through the lenses of their historical, political, economic and social contexts. The study concludes with an analysis of the multi-faceted collateral damage done by the increase in urban violence in each city and with a multilevel intervention approach to mitigate urban violence, from the perspective of public health.

## Keywords

Violence, Public health, Inequality, De-industrialization

Violence has always been part of the human experience that affects people of all ages. In 2007, violence was one of the top 10 leading causes of death in the United States for people from birth to age 64 years [1]. The World Health Organization (WHO) defines violence as: The intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation [2]. Its impacts, in various forms, are in all parts of the world. Violence can exert both health and economic consequences. In the United States alone, the impact of violence on health services for acute medicine, surgery, and psychiatry is repeatedly over $5.6 billion a year [3]. Particularly in urban areas, fear of violence undermines people's health and well-being, which in turn reinforces the necessity, and presence of violence [4]. "Almost all violence is predictable and therefore preventable" [2]. With the pace of rapid urbanization, people not only live in cities, but in increasingly larger cities, resulting in major changes in daily living and public health conditions. Nation states have made enormous strides in their efforts to improve their population's health conditions, from prenatal care and immunization to hospital care, extending life spans previously thought unimaginable. Unfortunately, interpersonal violence has become one of the major public health issues in major cities in nations with high homicide rates across the globe, with consequences for both direct and indirect victims. For decades, research has demonstrated that public safety, or the lack thereof, is a public health issue. This study focuses on the four most violent national and international cities of Detroit, MI; St. Louis, MO; Caracas, Venezuela; and Acapulco, Mexico (Table 1). Data and statistics are compiled through a comparative analysis of both governmental and non-governmental databases and serve to provide the rationale for the four cities chosen for this research. Our focus is less on petty crime, but on homicides in which citizens meet death on the streets where they live. This chapter concludes by suggesting an epidemiological triangle, which depicts a three-level violence prevention program from the public health perspective and a discussion of risk factors and policy implications at multiple levels. While violence is prevalent across the globe, the culture of normalized violence in the U.S, the most advanced nation in the world, cannot be overstated. Largely due to lax gun laws and the lack of political will, the human costs of America's culture of violence and violence incidents just in 2017 are shown in Figure 1. ## Violence from an Ecological Perspective Violence is a complex, multifaceted problem, and the result of the complex interplay of individual, relationship, social, cultural and environmental factors. Prior research suggests that certain demographic factors significantly increase the risk of collective violence, especially civil conflict. These factors include having a high proportion of young adults (more than 40%, referred to as a "youth bulge"), high levels of youth unemployment, rapid rates of urbanization, low availability of cropland (and associated disputes over farmland distribution) and scarcity of renewable fresh water [5]. In addition, having access to weapons, particularly firearms, is an important factor in violent outcomes, particularly deaths from homicide, suicide and unintentional shootings [6]. While biological and other individual factors explain some of the predisposition to aggression, more often these factors interact with family, community, cultural and other external factors to create a situation where violence is likely to occur [2]. Theoretical models [7-10] have examined the role of income and societal inequalities as factors directly related to violence. Inequality between groups in society is an important risk factor for violence, especially collective violence [6]. Wilkinson and Pickett have found evidence that homicide is associated with income inequality (as measured by the Gini indexa) in 23 high-income countries [10-12]. The causes of violence that are deeply rooted in the social, cultural and economic fabric of human life are beyond direct observation. Bronfenbrenner's [13] ecological model of human development for understanding violence has been used extensively by public health and other practitioners and researchers (Figure 2). The framework allows an examination of the multiple levels relating to violent behavior: Each operates in relation to others with individual factors modifying and interacting with relationship, community and societal factors [6]. Building upon the Bronfenbrenner ecological model, five interrelated levels and synergistic factors contribute to interpersonal urban violence: Macro- and exo-social system factors that cause violence, meso-social system factors that foment violence, micro-social system factors that facilitate interpersonal urban violence, and finally the individuals who take violent action. Macro-social system factors include the general attitudes and ideologies of the culture. Exosystem level is usually informed by the macrosystem factors and includes, the increase in social services due to wealth polarization; the pace of industrial and technological change and its impact on high skilled labor with resultant loss of jobs among low-skill workers; the paradox of more schooling with fewer employment opportunities; disinvestment in poor urban communities and neighborhoods through urban renewal and gentrification; the increase in lifetime aspirations and expectations and the impossibility of meeting them. The meso-social system level highlights: Prevalence of low wage work in a high-tech economy; lax gun laws; increased density in poor areas of cities; marked increase in urban segregation; pervasiveness of aggressive ethos in masculinity; and, changes in the local and international drug markets. The micro-social system level includes: An increase in the number of firearms; massive incarceration rates; changes in family structure; both legal and illegal immigration; loss of importance of religion in daily life; lack of family structure and poor parenting; increased gang affiliation; antagonistic relationships between legal authorities and community residents; alcohol consumption; and, lack of positive outlets to articulate feelings and frustrations. Building upon this ecological model, Rutherford and his colleagues summarize the risk factors for violence are at the individual, relationship, community, and societal levels (Figure 3). This model provides a dynamic perspective in identifying the risk factors of violence at multiple levels and their corresponding policy responses. ## The Relationship between Violence and Public Health Thirty years ago, the combination of violence and public health was an emerging field. Starting in the U.S.A, the risk of homicide and suicide reached epidemic proportions during the 1980s among specific segments of the population including youth and members of minority groups [14]. There is increasing recognition of the public health importance of understanding and preventing violence. Violent behavior shows similar features to infectious diseases-being capable of being learned from one generation to the next, from one community to another [15]. First, violence is among the leading causes of death for people aged 15-44 years. This statistic may include extreme violence being experienced in places where the lives of children and civilians are being lost daily through bombs and lack of basic amenities, and the sort of violence experienced in developed countries who do not consider themselves to be 'at war'- the violence in workplaces, schools, and streets [15]. It was estimated that 1.6 million people worldwide died as a result of violence, an overall age adjusted rate of 28.8 per 100,000 [6]. The effects of violence are disproportionately felt by low and middle income countries. In African and Latin American regions of the world, homicide rates are nearly three times higher than suicide rates [16]. Second, the direct and indirect costs of violence on people's long-term physical, mental and sexual health, as well as the major negative economic impact of violence at a global level, also make violence a major public health issue. Violence causes many more injuries than deaths. Mental trauma from exposure to violence has been scientifically shown to increase a person's risk of adopting violent behavior themselves, meaning that violent behavior transmits and spreads based on exposure-just like an epidemic disease [17]. The economic costs of violence include the direct costs of medical, policing and legal services, and the indirect costs of lost earnings and productivity, lost investments in human capital, life insurance costs and reduced quality of life [6]. In the U.S., violence is estimated to cost the equivalent of nearly 3.3% of the Gross Domestic Product (GDP) [18]. The costs of violence in England and Wales have been estimated at US$40.2 billion annually. These staggering costs across the world, however, are borne by the public sector [18].

Another reason why violence has become a greater focus for public health is the increasing acceptance within the public health community of the importance of behavioral factors in the etiologyb and prevention of disease [14]. Public health communities around the globe have a long tradition of working for health improvement, transcending narrow economic and political concerns and the self-interest of individuals, ethnic groups, religions or countries [19]. A public health focus is placed on preventing violence before it occurs; employing a scientific approach to understand the problem and what action can be taken to prevent it; taking a population perspective that places an emphasis on broad-based changes in communities and society that benefit the largest number of people; and, working across sectors of the broader society (eg, health, justice, education) [1]. Moreover, public health complements existing approaches to violence by recognizing that violence is a multifaceted problem. It focuses on changing the behavioral, social, and environmental factors that give rise to violence [16].

Subsequent sections of this research focus upon the four national and international cities with the top murder/violence rate. The four cities include, Detroit Michigan, St. Louis Missouri, Caracas Venezuela and Acapulco Mexico.

## The Cities of Focus: Analysis

### Detroit, Michigan, USA

"The auto industry was like Silicon Valley in the 1980s. It was doing so well that Detroit officials didn't see a need to do anything differently" Kevin Boyle, as cited in New York Times [20].

The city of Detroit, the largest city in the state of Michigan (Figure 4), settled in 1701, became a world-class industrial powerhouse, the capitol of automobile industry and the fourth largest American city by the mid 20th century [21]. As a thriving hub of commerce and industry, the city spread along Jefferson Avenue, with multiple manufacturing firms taking advantage of the transportation resources afforded by the river and a parallel rail line [22]. Detroit was once referred as the Paris of the West for its architecture, and for Washington Boulevard, electrified by Thomas Edison [21]. However, today's Detroit is filled with abandoned factory plants, economic bankruptcy, urban poverty and violence. A 2017 Forbes report named Detroit as the most dangerous city in the United States, with a violent crime rate (homicide) of 2,137 per 100,000 population [23]. Citing FBI survey data, the report found that the city's metropolitan area had a significant rate of violent crimes: Murder and non-negligent manslaughter, rape, robbery, and aggravated assault, and over 65% of homicides in the city were drug related [24].

#### Detroit's economy

Detriot's economic, social and demographic landscape was largely shaped by the Big Three of auto-industry (comprised of Ford, General Motor and Chrysler). Detroit became the Motor Metropolis, going from twenty square miles to several thousand square miles. The Detroit metropolitan area emerged as one of the largest in the United States [25]. Underneath this auto colossus, racial segregation and inequality in housing and employment threatened the city constantly. Decades later, the decentralization of industry had profound effects on the urban geography and on the working-class population of the city. Because of the founding of United Automobile Workers (UAW) union in 1941 and the industry's racially and ethnically diverse labor force, the Big Three started to decentralize facilities and relocate throughout the country in response to labor unrest and strikes [25]. Following World War II, the area witnessed suburban expansion as white-collar workers and elites moved out from the city [26]. The spread of the auto-industry outward in the 1950s was a first stage in the mass migration of industry to low-wage regions of the United States and, increasingly, the world [25]. The auto-industry's intellectual axis also relocated from the auto city to Silicon Valley, CA [26].

Tensions between the races have been high since the 1940s, especially after African Americans from the South began moving to Detroit in search of work at automobile factories. The ultimate torrent was the 1967 riots. Due to the social unrest and the effects of de-industrialization, the city experienced major economic and demographic decline. Businesses followed their customers. Thousands of houses were abandoned as the city's population plunged. The movement of jobs out of the city accelerated the process of suburbanization, as autoworkers, who could move followed their jobs. During the 1950s, the city lost 363,000 white residents while it gained 182,000 African American residents and the number of African American population kept increasing (see Table 2) [20].

African Americans were hit hardest by the loss of jobs in the central city at that time, largely because they were closed out of nearly all white neighborhoods [27]. In the 1960s, social scientists began to observe what they called a "spatial mismatch", between working-class minorities and jobs. Most jobs were being created in outlying communities that excluded minorities [28]. Businesses, such as small shops, bars and restaurants that catered to workers during their lunch breaks or at shift change shut their doors [27]. People who lived in the neighborhoods near closed plants moved. The center city was downsizing. The loss of property taxes, wage taxes, and population was devastating, particularly as urban governments faced the costs of providing education and social services to an increasingly impoverished population [25,28].

With the rise of globalization, the auto-industry fell on even harder times in the 1970s and the 1980s. The motor city struggled to overcome new challenges, including economic recession that grew with the combination of oil shortages, rising fuel prices, and intense international competition, particularly with auto-manufacturers in Japan and Germany [25].

Detroit's former economic strength has been in unprecedented decline, and the city's depleted economic base, political instability, massive debt burden, and below-average financial management, along with the 2008-2009 recession, ultimately deteriorated its credit profile. During the most recent recession, Detroit's unemployment rate reached a peak of 27.8% in July 2009 and averaged 24.6% from January 2009 to June 2010 [29].

#### Crime in Caracas

Venezuela's violent crime epidemic appears to be escalating into a full-blown humanitarian crisis. As seen in Figure 9, Venezuela has the top homicide rate in 2016, comparing to the other surrounding Latin American and Caribbean countries. Although the Venezuelan government stopped publishing comprehensive crime data more than a decade ago, the Venezuelan Violence Observatory, a nongovernmental group, reported that Venezuela's homicide rate one of the highest in the world (Table 4) [47]. According to a UNICEF report published in late 2014, homicide is the leading cause of death among young people in Venezuela. As one resident notes,

"The violence has got worse and worse. It is a devastating situation. There are killers everywhere. It has gotten dangerous to just be on the street. Many of us stay indoors at night, imposing a curfew on ourselves" [48].

The capital of Venezuela, Caracas has replaced San Pedro Sula in Honduras as the most dangerous city in the world with the highest per capita murder rate in the world, (Table 4). Behind the increasing statistics, homicide rate for male adolescents is extremely high in Caracas, as seen from Table 5. Impunity is rife and legal consequences for murder are minimal or unenforceable, with an estimated 92% of homicides not resulting in a conviction and 98% of the crime unsolved [49].

Historically, Venezuela is a key transit country for drug shipments leaving Colombia for the United States and Europe [50]. Foreign groups, particularly Colombians, have traditionally controlled Venezuela's drug trade, being attracted by poor rule of law and corruption [50]. Beginning in the mid-2000s, corrupt elements in the security forces stepped up their role in the business, forming a loose network dubbed the "Cartel de los Soles" (Cartel of the Suns) [50]. In fact, the rising murder rate in Caracas appears to be the symptom of nationwide political and economic chaos, such as poorly paid, poorly trained, under-equipped, and often corrupt police force, an inefficient and politicized judicial system, a system of violent and largely overcrowded prisons that are under the control of prison gang leaders; and country-wide availability of millions of illegal weapons [50]. Political and economic crises have undermined the legitimacy of institutions [47]. As one resident noted,

"There has been a destruction of the institutions, a breaking of social rules. There are armed groups the police know they can't touch" [48].

Venezuela has seen the growth of criminal gangs including drug cartels with links to the security forces, several leftist guerrilla groups, right wing paramilitary forces opposed to the socialist government, and heavily-armed street mega-gangs [48]. With the nation suffering from both hyperinflation and food shortages, looting of supermarkets and food trucks has become almost a regular occurrence [50]. The poorest areas (barrios, ranchos) frequently provide safe havens for criminal gangs [51]. A majority of violent crimes occur in these areas, but criminal "ownership" of some of these neighborhoods by mega-gangs often prevents police from entering [51]. "Mega-gangs" terrorizes wathes of Venezuela in the latest indication the country's criminal chaos may be converging around more organized structures [48]. Each gang consists of around 50 core members but can call on a network of up to 200 criminals through connections with local street gangs with extortion, kidnapping, hijackings, robbery, murder-for-hire and petty drug trafficking as their principal criminal activities [51]. The gangs are much more heavily armed than common street gangs, and use weaponry such assault rifles and fragmentation grenades [51]. Unlike the cartel armies of Mexico, the Venezuelan gangs often have just a few dozen members and control a few blocks. But they possess potent weaponry including fragmentation grenades, automatic rifles and even anti-tank guns [48]. Mega-gangs are not an evolution of smaller street gangs, but instead are based on the criminal model developed in Venezuela's prisons, where leaders known as "pranes" hold sway over hierarchically organized structures [51]. Several of the gangs are controlled from within prison by such figures [51].

The turmoil faced by the country's longstanding socialist regime -- including recent National Assembly elections in which the opposition won a majority, a shortage of goods, and the imminent risk of hyperinflation -- appears to have detracted attention from effectively tackling crime [50]. Many poor barrios (neighborhoods) in Caracas and across Venezuela have seen an expansion of street gangs, who sell drugs, carry out armed robberies and commit heinous amounts of murders [48]. Two state policies in particular have facilitated their growth. The first of these is the "peace zones", where security forces have no permanent presence, allowing criminal structures to flourish. The second is the militarization of security, which has weakened the police and helped criminal source heavy weapons after coming into contact with corrupt military officials [51]. Ever more organized structures have been emerging to capitalize on the gaps left by corrupt and incapable security and justice institutions [51]. These range from the drug trafficking network of corrupt military officials known as the "Cartel of the Suns", to the armed radical political collectives that hold sway in urban slums [51]. The coup against Chavez and opponents of the current government break down the law and order in Venezuela [48]. Also, long-standing corruption has made police reform meaningless. The police force and collective mega gangs combine to ensure future violence.

### Acapulco, Mexico

"It was so different: It was Acapulco. People were out in the streets. We all lived from tourism". Guillermo Perez, as cited in Partlow, 2017 [52].

Acapulco, is a city, municipality and major seaport in the state of Guerrero on the Pacific coast of Mexico, 240 miles south of Mexico City. Acapulco is located on a deep, semicircular bay and has been a port of call for shipping and cruise lines running between Panama and San Francisco, California, United States (Figure 10). Tourism is the main economic activity of the municipality and most of this is centered on Acapulco Bay. About seventy-three percent of the municipality's population is involved in commerce, most of it related to tourism and the port [53]. Although Mexico's economy has become increasingly oriented toward manufacturing since the North American Free Trade Agreement (NAFTA) entered into force in 1994, mining and manufacturing employ less than twenty percent in Acapulco and only about five percent is dedicated to agriculture [53]. Industrial production is limited mostly to bottling, milk products, cement products, and ice and energy production.

#### Acapulco's economy

Mexico, as a country, is one of the developing nations with vast infrastructure development, large exports, and large amounts of foreign investments. But national economic growth is predicted to remain below potential given falling oil production, weak oil prices, structural issues such as low productivity, high inequality, a large informal sector employing over half of the workforce, weak rule of law, and corruption [53]. The economy is vulnerable to global economic pressures, such as lower external demand, rising interest rates, and low oil prices with approximately 10% of government revenue derived from the state-owned oil company, PEMEX [53]. After the drug crackdown in Colombia, many of its cocaine operations simply moved to Mexico. Without stringent drug controls, the drug cartels took over local governments. Rising drug-related crime has resulted in homicides, and widespread corruption has increased public dissatisfaction about the effectiveness of anticorruption efforts by weak government institutions.

#### Crime in Acapulco

In the 1950s, Acapulco was a refuge for A-list celebrities from California. In the late 1990s and early 2000s Acapulco could still attract international tourists and thousands of Mexican visitors from the nearby cities of Cuernavaca and Mexico City. However, for each of the past five years, Acapulco has been the deadliest city in Mexico [49]. The violent crime rate in Acapulco, along with some Northern states, is well above the national average since 2012, according to Figure 11. Between 2007 and the middle of 2010 Acapulco reported an average of ten homicides per month. By mid 2010 that rate jumped 72 murders a month. In 2013 Acapulco was the most violent city in Mexico and the murders have continued in 2016 [54]. As Christian Hernandez suggests

"There were killings and people were scared to go out-they thought we were at war. But as the years pass you learn to live this way. You learn to live with fear" [54].

President Felipe Calderón declared war on organized crime since he official took office. Mexican security forces and their U.S. allies arrested cartel bosses and kingpins, splintering their organizations [52]. In Acapulco, after the killing of a powerful Beltran Leyva brother, the head of the Beltran-Leyva Organization (BLO), in 2009, rival factions emerged, with names like the Independent Cartel of Acapulco, the South Pacific Cartel and La Barredora [52]. Acapulco turned into a major battleground for cartel in-fighting. During Calderon's presidency the police detained other BLO leaders and further disrupted the stability in the criminal hierarchy [54]. Contenders joined the fray from ascendant heroin-trafficking groups and crime organizations from other cities.

For the residents of Acapulco, the result of these arrests was the fragmentation of established criminal groups and an explosion of violence as warring factions fought for control of the city and street gangs brazenly increased their activities [54]. With the loss of all-powerful cartel bosses who had tightly controlled their criminal empires, drug gangs moved increasingly into other crimes, such as kidnapping and extortion [52]. The losses of cartel leaders enable Mexico's crime gangs to proliferate differently in past decades. The newer generations of criminal gangs can operate independently or can be allied with other members at times [52]. If these quasi-independent cells get disrupted, the larger network can still function, causing significant difficulties for law enforcement and authorities. The dominant drug cartel in Acapulco and the state of Guerrero broke up, so that the criminals now in charge resemble neighborhood gangs-with names like 221 or Los Locos [52]. An estimated 20 or more of these groups operate in Acapulco, intermixed with representatives from larger drug cartels who contract them for jobs [52]. The gang members are young men who often become specialists-extortionists, kidnappers, car thieves, assassins-and prey on a largely defenseless population [52].

Cumulatively, the foregoing exemplifies the Acapulco's decline. For decades, tourism has been one of Acapulco's most important industries. Now, tourism and its associated businesses, such as famed local spots El Alebrije night club and Plaza Las Peroglas, closed in the past few years, driven away by crime and a withering economy [52]. The frozen economy and the lack of security have given the residents mass anxiety, resulting in a disintegration of order across growing swaths of the city. Poverty and unemployment lure more youngsters to make money by dealing drugs or joining gangs. As Fr Reyna relates,

"I feel unable to do anything to make it better. There's a sense of shock and despair. Organized crime has grown so much. It's easy money, especially for poor kids, who have few options. They are the recruits who end up as cannon fodder" [55].

The spike in violence in Guerrero, as in other states on Mexico's west coast, is in large part related to drugs and organized crime. Guerrero is not only a major producer of opium, but its location also makes it a prime transshipment point [55]. Moreover, the integration of, the competition for the domain of captured kingpins, the breakdown of secret agreements between criminals and politicians, a failing judicial reform, a corrupted police system, and the growing American demand for heroin, meth and synthetic opiates, combine to worsen the interrelated problems of poverty, violence and drugs [52]. The US State Department claims that 90 per cent of the cocaine coming into the U.S. is through Mexico [52]. In the meantime, police forces have been largely ineffective as residents believe that law enforcement is either powerless to stop the killings, the violence, or actually complicit in it [55]. Mexican law enforcement have been hobbled by corruption for decades, and Acapulco has been no exception. Half the 1,500 municipal officers had failed federal vetting and background checks [52]. The municipal police had spent much of 2014 on strike to protest salaries and benefits, with little training, low pay, poor equipment and little capacity to conduct investigations. Federal police and the army often lack street-level knowledge of cities and their crime gangs. Most of the on-duty federal, state and municipal policy forces are around the tourist strip, leaving the vast majority of the city exposed [52]. With the lack of law enforcement, many residents refuse to press charges out of concern the information will leak back to their tormentors, making investigating crimes all the more difficult [52].

## Results

The analyses of each city's historical, geographic, economic, political and social contexts reinforce the fact that violence is an multifaceted issue resulting from and complicated by post-urbanization, de-industrialization, unemployment, income inequality, poverty, welfare system ineffectiveness, political instability, racial segregation, social acceptability of violence and firearm availability. Poverty, economic deterioration and wage and income gaps are found in all four cities, though with different historical or current root causes. Violence is higher in the former industrial blue-collar communities in Detroit and St. Louis. In both former rustbelt cities, there are diminished economic opportunities, with high concentrations of poor and unemployed, with high levels of residential instability along with fewer institutional resources, and with limited public welfare services (i.e. health and education) available to residents. It should come as no surprise that there are fewer civic and voluntary associations as well.

People living in impoverished neighborhoods and communities with a diminished opportunity structure often experience social isolation and exhibit lower levels of trust and attachment to the community. Weak family environments, such as homelessness, or families with poor family management and parenting practices, low emotional bonding and support, divorce, separation and family conflict and violence can also generate antisocial sentiments and behaviors. In all four cities, we can see gangs become the first choice of social affiliation for the youth and young adult males, rather than family, school or church. Importantly, alcohol and drug use are associated with all types of violence both as an individual factor influencing a person's propensity to commit violence as well as a factor influencing relationships and family environments [1]. Drug cartels, largely run by adult males, play a more prominent role in international cities such as Caracas and Acapulco.

The damages of violence are also multifaceted and in turn impede human and economic development. To individuals, victims usually face immediate injuries or even death, which impact short-term and long-term physical conditions. They are more likely to be involved in mental illnesses, such as depression, anxiety, post-traumatic stress disorder, attempted suicide, and psychosomatic complaints (eg, headache, stomachache, and sleeping problems) [1]. To adolescents, long-term health effects are more evident: Violent victimization in adolescence associated with an increased risk for mental health problems and substance use in adulthood; youth who commit violence are also at increased risk for health problems, including alcohol and drug use, high-risk sexual behavior, and psychological disorders. Violence can dissuade individuals from investing time and money in education; deter persons from attending night school out of fear of becoming a victim of violent crime, or it may even induce some individuals to turn to a life of crime instead of completing their education. The foregoing results in the lower high school graduation rate and higher teenage pregnancy rates for both males and females [56].

From a macroeconomic point of view, violence reduces foreign and domestic investment as well as domestic savings, thus hindering prospects for long term growth [56]. Also, the costs exacted by violence on law enforcement, the judicial system and social services for the purpose of alleviating the effects of violence cuts into the scarce resources available to society, which could otherwise be earmarked for more productive purposes [56]. Collective and organized violent crime can particularly generate a number of significant consequences on the economy such as lower accumulation of human capital, a lower rate of participation in the labor market, lower on-the-job productivity, higher rates of absenteeism from work, lower incomes and an intergenerational impact on the future productivity of children [56].

## Discussion and Implications for the Future

As the foregoing study has shown, violence is one of the most important threats to public health. Psychological and behavioral characteristics such as antisocial beliefs and attitudes, social cognitive deficits (i.e., difficulty interpreting social situations), poor emotional and behavioral control (i.e., anger/hostility, impulsiveness), previous victimization, a history of engaging in aggressive behavior, and involvement with drugs and alcohol have been linked to multiple types of violence [1]. Relationships, such as those with peers, intimate partners, and family, also influence risk for violence. Violence is also greatly associated with the broader community and societal context within which people live. Places that register severe social and economic inequalities typically face a greater probability of armed conflict. These risks are amplified in contexts affected by low levels of economic development and religious polarization [57]. Communities with these characteristics also lack cohesion or collective efficacy to develop social norms, informal ties and support networks, but a subculture supportive of violence [16].

Hence, the crucial stage, early identification and interventions, requires a holistic, multi-systems approach. Macdonald [58] furthers the approach by developing an epidemiological triangle that addresses the time, place and person of the violent episode. At the primary prevention level, approaches involve: Violence risk education; parenting education; targeting communities where violence is more endemic with strategies such as street lighting, surveillance cameras and poverty reduction strategies. At the secondary prevention level, approaches involve: Support counseling or post-traumatic counseling; peer mediation to resolve disputes; home visits to high risk families; and violence prevention coalitions targeted to highrisk neighborhoods. At the tertiary prevention level, approaches involve: Treatment/rehabilitation for violent offenders; promoting parent management strategies and child bonding techniques; training and strategies for health and social care professionals; and increasing the penalties for perpetrators of violent crime [58].

In all four cities, we found that if adults, the media and society, in general, accept the subculture of violence and teach children and youth that violence is a quick way to accumulate wealth, then young people, especially males, are more likely to adopt violent behavior. In Caracas and Acapulco, we found that structural violence in which police forces or paramilitary groups become agents of violence further undermines democracy and breeds more violence [56]. From a policy perspective, successful efforts to reduce violence in marginalized neighborhoods will produce benefits not just for safety, emotional wellbeing and health, but also potentially in other domains.

Actual violent crime is only one facet of the relationship between violence and health. Fear of crime as demonstrated by the quotes in this paper also has deleterious effect on health and well-being. More research is needed on the causal factors of violence and their broader ecologies, to create a greater understanding of the causes and effects of violence, along multiple dimensions. Based on our analyses, violent crime is not just an individual choice, but is driven by broader social, political and economic inequalities in the given society. Violence should therefore be seen as a social problem which cannot be solved by policing along. Rather, any solution to violence must involve a study of the broader ecologies and social and political policies which create, sustain and normalize violence. However, the prevalence of guns and gun violence and its human toll in America, the most developed nation in the world, must be addressed in the broader political arena. The growing social acceptance of violence, the availability of weapons and the exposure of violence in mass media leads to political instability in any geographical context. Those most marginalized in society are the most vulnerable. Only informed social policy to alleviate poverty and growing inequality, in both developed and developing nations, will serve to reduce the health challenges of all forms of violence in global society.

## Abstract

With the pace of rapid urbanization, people not only live in cities, but in increasingly larger cities, resulting in major changes in daily living and public health conditions. Nation states have made enormous strides in their efforts to improve their population's health conditions, from prenatal care and immunization to hospital care, extending life spans previously thought unimaginable. Unfortunately, interpersonal violence has become one of the major public health issues in major cities in nations with high homicide rates across the globe, with consequences for both direct and indirect victims. Violence is a complex, multifaceted problem, and the result of the complex interplay of individual, relationship, social, cultural and environmental factors. Its damage goes beyond the intangible suffering and impacts on quality of life and well-being, violence impedes human and economic development. For decades, research has demonstrated that public safety, or the lack thereof, is a public health issue. This study focuses on the World's most dangerous cities: Caracas Venezuela, Acapulco Mexico, Detroit Michigan and St. Louis Missouri in the U.S. Building upon the Bronfenbrenner ecological model, this study investigates the risk factors of violence in these four cities through the lenses of their historical, political, economic and social contexts. The study concludes with an analysis of the multi-faceted collateral damage done by the increase in urban violence in each city and with a multilevel intervention approach to mitigate urban violence, from the perspective of public health.