Document 9: Statement of Dr. Robert McAfee, President-elect, American Medical Association. Senate Hearing 103-878, 12 November 1993. Hearing before the Committee on the Judiciary, United States Senate, 103rd Congress, First Session on Examining the Rise of Violence Against Women in the State of Maine and in Other Rural Areas, South Portland, Maine. Serial No. J-103-36.

Introduction

       Dr. Robert McAfee was a practicing general surgeon in Portland, Maine, and president-elect of the American Medical Association. In his testimony, McAfee discussed domestic violence as an epidemic and a major public health problem in America. He highlighted its broad-reaching negative effect on all Americans and the need for Congress to remedy the problem. In his discussion of the strain that care for the victims of domestic violence takes on the health care system, McAfee's statements showed that this violence placed a heavy toll on the economy by disabling the productivity and mobility of women. This negative effect on the nation's economy costs billions of dollars annually.

STATEMENT OF DR. ROBERT McAFEE

       Dr. MCAFEE. Thank you. Good morning, Senator. My name is Bob McAfee, and I am a practicing general surgeon in Portland, ME, and president-elect of the American Medical Association. It is with a great sense of personal pride and not the least of any humility that I realize I am the first Maine physician to occupy that post in the 150-year history of the American Medical Association.

       Senator COHEN. Could I interrupt you just for a moment? There are a number of people who are standing, and I am told there is a room downstairs with seats and a TV screen where you could all sit down comfortably if you prefer to do that, or you may stay here. If it is possible, we may be able to accommodate the people who are standing by putting some seats up that do not block the television cameras.

        Dr. McAfee, please continue.

       Dr. MCAFEE. I merely wanted to say Senator, that in my role as president, I intend to use family violence as my theme in this country and internationally representing my association.

       We certainly are very pleased to have the opportunity to testify regarding this very serious problem of violence against women and family violence in general in this country, and we offer our support, indeed, for S. 11.

       We the people of the United States of America, in order to form a more perfect union, will manage to kill 26,500 people by homicide in this country this year, 12,500 of those by handgun homicide. The next nearest country is Great Britain in which we kill 95.

       We the people of the United States of America, in order to form a more perfect union and assure our right to bear arms, will allow tomorrow in this country 100,000 children to go to school with a gun.

       And we the people of the United States of America, in order to form a more perfect union and assure domestic tranquility, will allow more women to be killed in their homes during an 8- to 9- year period by their husbands or boyfriends than men died in the Vietnam War. Envision, if you will, the President of the United States addressing us on Memorial Day standing in front of the Vietnam Memorial 9 years from now with a second wall behind that and 18 years from now with a third wall behind that with the names of women killed in this country by those who are closest and theoretically dearest to them in an environment that should be nurturing their safety.

       If we are going to have any real success in addressing this epidemic, which is a major public health problem in this country, we have to realize that violence is far more than carnage in the streets of urban America and images on our television screen, it has a broad-reaching negative effect on all Americans; and if we look to Congress to reform the health care system, we hope to address the excess that is caused by violence. Violence results in a huge number of encounters within the health care system. Care of the victims of violence strains the health care system in many communities and adds very significantly to our health care bill. In this regard, it has been estimated that over 500,000 emergency visits annually are due to violent injuries and, furthermore, 2/3 of crime victims who are treated in hospitals are uninsured. And it is been estimated that the direct medical costs alone of all violent injuries are more than $5.3 billion to U.S. health expenditures. Now these are largely preventable costs, and we are pleased that this committee is addressing the massive problem and focusing on the particularly insidious and troubling issue of violence against women.

       When one asks victims of violence whom you would have rather told of this repetitive behavior, as you have just heard, the family physician is named 87 percent of the time. That is more than what they tell their priest, their pastor, or their rabbi; it is considerably more than what they tell the police. And with that ominous responsibility, we have had every right to go to our membership and say when we look at our accuracy in detecting those victims, who are probably less than 10 percent of the time accurate, or ask those special screening questions that are necessary to make us break the cycle of violence. These are preventable costs, and we are pleased the committee is addressing this massive problem.

       The AMA and physicians are very active in efforts to address the issues of family violence in general and violence against women in particular. In the past several years, we have undertaken a substantial number of activities to recognize and address family violence prevention. We have gone out to the medical community to sensitize them to the needs of victims of violence. I had 1/2 of the requests with my schedule of roughly 250 days a year is now based on requests to appear on behalf of family violence issues at a time when we have health system reform as a major, major problem.

       Our commitment is an ongoing one. We are pleased to be sponsoring, and I am very excited about this, Senator, a national invitational conference on family violence to be held March 11-13, 1994, in Washington, DC. This conference will be entitled "Family Violence: Health and Justice." It is cosponsored by the American Medical Association and the American Bar Association. There are 43 other sponsoring organizations both from the health side and the justice side, including the American Nurses Association, the Hospital Association and specialty societies, the Trial Bar, the Judges Association, the Chiefs of Police, and everyone involved in the justice side. It is our hope that this invitational conference, a working conference, will hammer out a series of five to six public policy statements regarding issues such as guns, such as reporting, such as application of stalking laws, such as other elements that we as a society must grapple with. In using the influence and perhaps clout of the organizations sponsoring this, with the presence of the White House and Congress, we can come to a conclusion on some of these issues that will allow us to move on as a society.

       The AMA has organized a National Coalition of Physicians Against Violence. We now number close to 5,000 physicians who are throughout the country in providing a focus for the development of violence prevention committees through local medical societies. This is already occurring in 16 States. And, further, our National Advisory Council on Family Violence, consisting of representatives from the National Medical Specialty Society numbering now 42, has been formed and is actively functioning. In addition to these outreach activities, we are working to help the practicing physicians better address those situations where violence is the cause behind a patient's encounter. We recognize the need to be even more proactive, and physicians and others in the health care sector must operate with a full knowledge of the extent of this epidemic, especially as it relates to women.

       The AMA's diagnostic and treatment guidelines on child physical abuse, child sexual abuse, domestic violence, and elderly abuse have been widely distributed, and I will leave copies of this for the committee.

       At the same time it was 3 years ago we went to the editor of JAMA, Dr. Lundberg, and said, "It is time for you to consider a theme issue on violence."

       Senator COHEN: JAMA being the Journal of the American Medical Association.

       Dr. MCAFEE. The most widely read weekly medical journal in the world, distributed in 47 countries and 7 languages.

       Dr. Lundberg said, "In order to have a theme issue, I have to have 8-10 manuscripts of a peer review to make a them issue." I said, "You are not going to know if you do not ask, George." He asked and he received 122 manuscripts within a 2-month period of time. So not only one but two issues of JAMA were totally devoted to violence and, in addition, every single specialty journal--seven specialty journals that the AMA had for the month of June 1992 were totally devoted to violence. This compendium, which I will also leave with the committee, is the culmination of all those papers put together in a single volume, indicating at this time such things as television impact on children, women's violence and prevention programs, child abuse, elderly abuse. Put together in one package, it gives one a beginning understanding of the horrible problem that this public health menace creates in this country.

       Studies now indicate that at least 20 percent of adult women and 15 percent of college women and 12 percent of adolescent girls have experienced sexual abuse and assault in their lifetime. It is disturbing but true that young adult women and adolescents are most at risk with acquaintance and date rape and at least risk from someone unknown to them. Studies now document that women in the United States are more likely to be assaulted and injured, raped or killed by a current or ex-male partner than by all other type of assailants combined. It is also true that these surveys or studies, especially estimates of intimate violence, are marked underestimates. Researchers on family violence agree that the true incidence of partner violence is probably double the published statistics.

       There are both human and health care costs associated with violence against women. There are, of course, direct costs to the health care system. Beyond the dollars spent to provide the physical and mental health treatment to women against whom violence is perpetrated, there are additional health care and societal costs: one, the cost of psychological treatment for traumatized children who innocently stand by and witness abuse on their mother; the cost of the social service system, and the cost incurred in the legal and judicial system; and the cost incurred in the future in response to the fact that violence breeds violence. Children who witness domestic violence are 5 times more likely to be batterers or victims as adults. For the future well-being of our society this cycle of violence must be curtailed. The human costs are especially tragic and immeasurable, and they cannot be ignored. In addition to the psychological pain and sorrow incurred by those who are victims of violence, there is a loss of self-confidence, self-respect, and personal dignity. And who knows how many women's lives have been devastated because of violence perpetrated against them?

       We commend you, Senator Cohen and Senator Biden, for introducing S. 11, The Violence Against Women Act of 1993. We view this as a strong step forward in recognizing and treating domestic violence as the public health epidemic that it truly is. We support S. 11 as being consistent with our major initiative to declare violence as a major public health issue, to support research and educational programs and appropriate interventions to increase public awareness of domestic and other types of violence and to reduce harmful behaviors and work towards the goal of achieving a violence-free society. We would be pleased to work with the committee to provide our expertise on any of the issues contained in the bill.

       For example, we feel that the bill could be improved by adding stronger provisions based upon your model law on stalking to this particular bill as well and also including verbal threats of violence which are a significant method in which this violence is carried out. I also would point out that gender-neutral language should be incorporated where appropriate to recognize males as well as females can be victimized by sexual and domestic violence. It is our estimate that between 5 and 10 percent of our victims are men. I have done two national call-in television shows, and the first two callers both times were men who were complaining of this problem.

       So in conclusion, the issue of family violence in general and violence against women in particular has direct relevance to practicing physicians. It is the practicing physicians who treats the results of family violence, who must diagnose that an injury is a result of violence and refer cases of abuse to the appropriate authorities for protection against prosecution. The AMA belives that we must dramatically reduce violence and must do so now before countless more lives are devastated by the brutality of continuing abuse, and I am here today, Senator Cohen, to pledge to you that the American Medical Association's intent to help amputate the rule of thumb from our lexicon.

       Thank you.

       Senator COHEN. Thank you very much.

       I have just been told we have a technical problem with the television monitoring in the other room and we're working to correct it as soon as possible.

       Ms. Hodgdon?

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