Social Medicine for Social Justice: Perspectives on Violence Prevention

Abstract

Social medicine is the application of social science research to address health, inequities in access to health care, and structural violence. Foundational to this work is to bring about social justice for marginalized and underserved populations. Drawing on several case studies from developed and developing countries, we apply ideas and practices from social medicine to explore how the advancement of social justice can help prevent interpersonal violence. Several themes offer fresh perspectives on inculcating social justice principles and practices in violence prevention, including recognizing the impacts of structural violence, fostering equity in the distribution of resources, expanding accompaniment, and overcoming a socialized acceptance of scarcity. We conclude with observations on the indistinct and dynamic boundaries between medicine and criminology.

A growing body of research evidence on the efficacy and effectiveness of a range of social interventions to prevent interpersonal violence focuses on mentoring, social-cognitive skills training, school-based programs, and after-school programs (Gottfredson et al. 2014; Taheri and Welsh 2016; Tolan et al. 2014; Welsh et al. 2024, ch. 23). Often missing from the literature are efforts to foster social justice among the populations and within the communities that are the targets of these interventions (Fishbein 2021). Criminal justice interventions have long faced the criticism that they are inadequate to promote, let alone achieve, some basic level of social justice (Mears 2017; Welsh et al. 2024, ch. 26). But among social interventions that operate outside of the formal justice system, which is the focus of this article, social justice needs to be intentional and prioritized alongside social impact.

The field of medicine provides any number of examples of how standardized solutions—even standardized solutions motivated by lofty altruism—have failed to distribute equally through a society. Since the commitment made by Hippocrates, that “into whatsoever houses I enter, I will enter to help the sick,” medicine has aspired to a humanitarianism so universal as to appear almost suprasocial. As the prevailing logic went, if individual physicians were willing to vow that they would not provide preferential treatment to some of their patients, then disparities in which some of these patients became sicker and others improved would then seem to result from something inherent in those individual patients. Yet while the story of “modern medicine” is one of stunning breakthroughs that have expanded the pharmacopeia and vanquished once-fatal diseases, that triumphalism is complicated by the reality that its delivery to low-income and marginalized populations has never been able to keep pace with its bureaucratization. ¹

Such inequities have shaped health outcomes. These disparities remain a central concern of social medicine, but the field also intervenes earlier by critically investigating the notions and causes of “sickness” and “health” themselves. Several (though still a minority of all) medical schools have implemented mandatory “social medicine” coursework in their curricula (Kasper et al. 2016), while far more incorporate teaching that concerns the social determinants of health (Solomon et al. 2025). Prominent medical journals have brought such principles to practicing clinicians more generally (Stonington et al. 2018). As perhaps the most explicit example of how that mindset gets applied, implementation scientists—those bridging the world of academia, nongovernmental organizations, and local populations and their burden of disease and social contexts—continue to innovate around the role that community health workers play in improving health outcomes (Palazuelos et al. 2021). To advocates for social medicine, such principles should be incorporated into all medical care. By attending to real-world conditions, social medicine draws upon the same pragmatism inherent in violence prevention efforts by acknowledging that people are actors within a complicated world, that acts that are antisocial (armed robbery) or self-hindering (nonadherence to a prescribed list of medications) are shaped by structural factors, that there are congruities among these factors, and that the response to consequent burdens of disease requires attending to these structural factors.

Drawing on several social medicine case studies from developed and developing countries, the purpose of this article is to explore how social justice can be advanced as part of a strategy to prevent interpersonal violence. Several factors motivated our interest in applying the concept of social medicine to violence prevention. First, as noted above, foundational to the work of social medicine is to bring about social justice for marginalized and underserved populations (Farmer et al. 2013). Second, a long-standing tradition within criminology is to engage perspectives from medicine and public health to inform the epidemiology, prevention, and treatment of violent behavior (Reiss and Roth 1993); for example, the public health approach has been a cornerstone of strategies to prevent interpersonal violence in the U.S. (Moore 1995; Rosenberg and Fenley 1991; Welsh et al. 2014). Third, we have personal and professional interest: One of us (Welsh) is a criminologist, and the other two (Beazer and Podolsky) are physicians who were trained and work in social medicine. Our collaboration across adjacent (and potentially allied) disciplines and professional communities has afforded us new perspectives and practices.

A Short History of Social Medicine in the United States

As examined in detail elsewhere (Greene et al. 2025), the history of social medicine in the U.S. in particular is a complicated historiographic question. Not everything that we would retrospectively consider social medicine was labeled as such at the time, especially given the enduring stigma attached to its sound-alike, “socialized medicine,” in red-baiting twentieth-century America.

Taking an admittedly hybrid approach, we can certainly recognize the contributions in the first half of the twentieth century of early academic pioneers like Henry Sigerist, who both advocated for the role of history and an appreciation for social context in medical education (and became the director of the Institute of the History of Medicine at Johns Hopkins University in 1932) and, among other things, played a key role in the advent of state-sponsored health insurance in Canada. At the same time, in the first half of the twentieth century, the Rockefeller Foundation played a crucial institutional role in promoting (and funding) progressive health efforts, both in the U.S. and globally. And pioneering, yet historically marginalized, scholars like W. E. B. Du Bois performed novel sociological work examining the social and economic forces that shaped racial inequalities in particular. Such varied actors all drew attention to the social forces shaping health outcomes.

In the post–World War II era (indeed, the Cold War era), individuals and organizations continued to advocate for engaging with such social forces. At Montefiore Hospital, Ephraim Bluestone founded the nation’s first hospital-based program in social medicine, hoping to influence medical care and education alike. By the 1960s, physicians Kurt Deuschle, H. Jack Geiger, and Count Gibson innovated around “community medicine” and “community health centers” focused on empowering communities and ensuring their members received the benefits of modern medicine. And in that decade, members of the Black Panthers established their own medical clinics in an effort to confront what they called “medical apartheid” and as a direct attempt to offset the impacts of what we would today consider forms of structural violence—individual- and group-based harms caused by social structures and institutions, including poverty, racism, and gender-based violence.

By the 1970s, social medicine in the U.S. would begin to assume its modern academic form, in places like Harvard Medical School and the University of North Carolina, where interpretative social sciences like history, anthropology, and sociology were applied to examine the contexts in which people became sick and in which health care was delivered (or not). By the 1980s, amid the HIV pandemic (and the related multidrug-resistant tuberculosis pandemic), physicians like Harvard clinician-anthropologists Paul Farmer and Jim Kim could link such understandings of health outcomes and inequities to attempts to fundamentally improve care among those most impacted by structural violence, including through the use of community health workers reconceptualized as “accompagnateurs.” Since then, a number of programs in social medicine have been developed across the country, as health equity and social justice (as well as their application to global health efforts) have assumed more prominent positions at medical schools nationwide. This is a process that has especially accelerated in recent years, amid the COVID-19 pandemic and the murder of George Floyd, as organized medicine engages with the many impacts of structural violence and with its own complicated history.

Case Studies in Social Medicine and Social Justice

If social justice envisions a fair balance of opportunity and services to all members of a society, “social medicine” can then be understood as the provision of medical care in accordance with these egalitarian principles. In practice, this provision often requires a departure from the usual arenas of the hospital and clinic. The innovativeness of social medicine exists in its delivery—that is, when clinicians are flexible enough to think outside of their accustomed systems to mitigate the illnesses that are wrought by poverty, trauma, and discrimination and to provide care to those who are unable to obtain it otherwise.

The three case studies that follow consider some nontraditional models of care delivery that sought to address the needs of a marginalized or underserved population. Within this context, and specific to the aims of our work, these case studies were also chosen because they focus on important themes that have come to embody the work of social medicine for social justice—some of the very themes that we believe can offer valuable insights for advancing social justice in the prevention of interpersonal violence (the focus of the next section). Key themes include recognizing the impacts of structural violence on disease burden and care delivery, committing to equity, acknowledging the role of accompaniment, and overcoming “socialization for scarcity” (Farmer et al. 2013).

From PACT to PACT: Support and accompaniment for vulnerable patients

In 1972, clinicians in Madison, Wisconsin, developed a program that would attempt to mitigate the relapse of psychiatric illness by meeting regularly with patients after they had been discharged from acute hospital stays (Rochefort 2019). Instead of relying upon outpatient office visits to maintain recovery, these clinicians recognized the practical benefits that could arise from meeting patients in their homes or in community settings. These check-ins presented a real-world, “in situ” opportunity to assess patients and intervene early when their illnesses posed barriers to independent functioning. Indeed, while patients were still in the hospital, psychiatrists began to pragmatically foreground conversations about patients’ day-to-day activities and whether they felt capable of functioning in the community. The subsequent extra-hospital contact represented a sustained investment, one that could both strengthen the clinician-patient alliance and promote treatment even as an acute mental health crisis waned. Avoiding rehospitalization was named explicitly as one of the program’s goals, and clinicians consequently strengthened their ties with the social service organizations and existing community treatment programs that would support patients upon discharge (Thompson et al. 1990, 626). As part of the community program’s core services, clinicians offered pharmacotherapy, individual therapy, peer services, case management, crisis intervention, employment services, housing services, and co-occurring disorder services (e.g., treatment for substance use disorders).

The first trial that compared the Program for Assertive Community Treatment (or PACT) with brief hospitalization and standard aftercare determined that PACT patients “were living and working in more autonomous situations than control patients” at the end of a five-month intervention (Marx et al. 1973, 510). Impressively, in subsequent trials, the provision of PACT resources was not shown to increase family or community burden, and though the intervention necessitated significant up-front investment, investigators determined that treatment costs were similar over time between the two groups (Thompson et al. 1990). These studies’ early consensus that PACT demonstrated superiority to traditional hospital-based treatment, where follow-up occurred exclusively in clinical settings, was named as “a critical force behind the program’s take-off and rapid rise in stature within the field of public psychiatry” (Rochefort 2019, 1156). The clinical benefits of PACT represented a success story with wide appeal—“a medical and social intervention in which . . . professional expertise and moral impulse seemed to coincide” (Rochefort 2019, 1169). Revealingly, in 1998, the patient advocacy group National Alliance for the Mentally Ill announced a “PACT Across America” campaign that sought to disseminate the program to all 50 states by 2002 (Rochefort 2019, 1159). As adoption became more widespread, the approach of PACT altered somewhat; hospitalization was acknowledged as a sometimes-necessary step, “the site of dramatic but limited interventions,” and universalized trajectories of “cure” or “healing” for patients were modified to recognize the chronicity of many mental illnesses and the value of maintenance (Thompson et al. 1990, 629).

Despite the positive outcomes seen in community treatment programs with assertive postdischarge follow-up care, maintaining continuity with patients who have chronic mental illness requires significant investment, and clinicians and case workers can be stymied by resource limitations. In one nationwide survey, only 13.4 percent of mental health treatment facilities in the U.S. reported offering variations of PACT, and only 19.2 percent from this subset provided all of PACT’s defined “core services” (Spivak et al. 2019).

A second story of PACT—in the world of tuberculosis and HIV care—yields additional insights. While the cognitive disruptions engendered by certain psychiatric illnesses facilitated the (admittedly still contested) adoption of assertive community treatment, the advantages of proactively providing treatment outside the walls of the clinic had first been espoused in the 1950s by Wallace Fox, a physician in Madras, India (McMillen 2015). In the years after the development of successful pharmacologic treatments for tuberculosis, Fox was discouraged by the low rates of cure among his ambulatory patients. The regimen for tuberculosis required several months of daily administration of a foul-tasting oral medication to achieve cure, and high transmissibility and the possibility of developing microbial resistance to existing therapies heightened the stakes of consistent treatment. Fox recognized that imperfect adherence to medical therapies was not unique to his tubercular patients but resembled patterns of antibiotic usage for streptococcal pharyngitis. More broadly, he saw the trend as “in keeping with the common experience that the continued treatment of many conditions just lapses when the patient feels better” (Fox 1958, 270).

Fox (1958, 271) suggested that this tendency could be mitigated by educating patients more intentionally on the importance of adherence, making visits to the patient’s home during the therapy course, and recruiting “another member of the family actually to watch the patient swallow the [medication].” Ultimately, directly observed therapy (DOT) was incorporated into tuberculosis treatment in the United States, again placing beneficence and autonomy in conflict. The debate over DOT grew warmest over claims that already marginalized members of society would most often be subject to this initial surveillance, but the significant public health threat of unchecked tuberculosis transmission was seen to outweigh an individual patient’s preference to decline medication (Bayer and Wilkinson 1995, 1548).

In the 1990s, infectious disease doctors at the vanguard of HIV/AIDS treatment were faced with the same vexing paradigm: A communicable disease once believed to be uniformly fatal was no longer a death sentence thanks to a breakthrough multidrug treatment, but mortality rates remained high among already disadvantaged patients—the unhoused, the substance-dependent, and the impoverished. Partners In Health (PIH), a nonprofit public health organization that began providing services in Haiti in 1987, responded to the devastation of the HIV/AIDS epidemic in that country by adapting a DOT model that had already been successful for patients with tuberculosis. PIH hired “accompagnateurs,” or health promoters, to administer highly active antiretroviral therapy to patients with HIV/AIDS. This “accompaniment” went beyond DOT, both logistically and morally. The accompagnateurs’ efforts prevented the development of resistant strains of HIV, and beyond this, the publicized successes of the accompagnateurs “constituted more than a humanitarian gesture” by widely demonstrating the feasibility of such treatment models in resource-limited settings (Schwartz 2016, 79).

Accompagnateurs were typically respected, middle-aged women who came from the same community as the patient receiving therapy (Behforouz et al. 2004, S431). PIH provided the accompagnateurs with education on HIV and basic training in emotionally supporting patients while respecting confidentiality. They made daily visits to the patients’ homes and observed them taking a dose of highly active antiretroviral therapy. PIH physicians described the subsequent investment of the accompagnateurs as a “virtuous social cycle,” recalling how the psychosocial support provided by these workers strengthened the sense of community cohesion in treating HIV/AIDS and reduced disease-related social stigma. Accordingly, the reliable administration of antiretroviral therapy reduced hospitalizations and opportunistic infections and lowered mortality in the accompaniment cohort (Behforouz et al. 2004, S432).

The successes of accompagnateurs in Haiti prompted PIH’s leadership, many of whom held faculty positions at Harvard Medical School, to consider whether a similar model of care might improve outcomes for Boston’s HIV-positive population. Through this implementation of PACT (now known as Prevention and Access to Care and Treatment), jointly administered by PIH and Brigham and Women’s Hospital, a subset of HIV-positive patients considered to be at high risk for failure of standard unobserved treatment—owing to structural factors like poverty and racism—were offered accompaniment (Behforouz et al. 2004). The PACT team recognized early on that differences in the patient populations of Haiti and Boston necessitated different rationales for accompaniment. ² The investigators outlined existing obstacles to viral suppression in these Boston patients as including “institutional racism, inability to negotiate the complex maze of medical and social services, depression, and isolation due to the deterioration of support networks” (Behforouz et al. 2004, S433). As in Haiti, health promoters in Boston were drawn from the patients’ communities and often had firsthand knowledge of patients’ social circumstances. Some of them were HIV positive themselves and could speak directly to the patients’ frustrations and “health care fatigue.” In the 15 high-risk patients selected for the accompaniment project, 11 would achieve viral suppression and experienced an increase in their CD4+ cell counts (a type of immune cell important for fighting infection) at one year postinitiation. More holistically, patients reported improved quality of life and an ability to return to valued activities (Behforouz et al. 2004, S434).

Despite the promising outcomes of accompaniment in these two disparate contexts, PACT at Brigham and Women’s Hospital closed in July 2013, when the program was determined to be no longer financially solvent. Because Medicare and Medicaid billing regulations in Massachusetts did not allow health promoters to be reimbursed for their work, funding for PACT was dependent on the vagaries of charitable donation, a model that proved unsustainable in the long run (Behforouz 2014, 2066).

Embracing community health workers as key components of a health system with a vested interest in patient advocacy should be a priority for health systems with a sincere commitment toward reaching society’s most vulnerable. The barriers to wider deployment of community health workers in the U.S. are multifold: some are economic (alterations to pay structures that have historically reimbursed for individual services rather than outcomes); some are driven by accountability (assuming liability for health care provided by those with limited formal training); and others are cultural (an objection to “global health,” in the context of conviction that laypeople should be deputized in places with limited national infrastructure only as a stopgap measure [Kangovi et al. 2015; Singh and Chokshi 2013]).

Community health workers amid COVID-19

Such concerns over funding—especially for the care of the most vulnerable—pertain to programs across the globe. When India experienced its COVID-19 surge in the spring of 2021, reporting as many as 414,000 new cases in a single day, the enormity of its crisis was perhaps most viscerally experienced by its Accredited Social Health Activists (ASHAs), a cohort of women hired in 2005 by the government’s National Rural Health Mission as health workers in rural communities. In a typical pandemic day, ASHAs made door-to-door visits to the homes of COVID-positive residents, monitored their symptoms and oxygen levels, assessed whether transport to a hospital was necessary, performed contact tracing, and ensured adherence to principles of quarantine (Jain 2022).

The National Rural Health Mission, an initiative of India’s Ministry of Health and Family Welfare, had founded the ASHA program in 2005 as a means of promoting population health in the nation’s rural provinces. Initially, the role had been designed as a volunteer position—policymakers cited past experiments with nurse midwives in which guaranteeing a salary had been seen as compromising performance (Ved et al. 2019, 5). Thus, ASHAs received no formal salary, but they were offered variable payments through an incentive-based system. For registering a pregnant woman and performing three antenatal visits and two postpartum visits to her home, an ASHA could expect to receive a capitated payment of INR 200, or USD 2.95 (Agarwal et al. 2019, 2).

Prior to the pandemic, India’s ASHA cohort (which numbered more than one million) had important roles in promoting maternal-fetal health, dispensing contraception, making home visits to the chronically ill, and providing health education to members of their communities. One ASHA was expected to serve as the primary intermediary between a population of one thousand rural villagers and the larger Indian health infrastructure. Their contributions to improving maternal-fetal outcomes were particularly striking. ASHAs were instructed to register every pregnant woman in the village and make home visits prior to and following childbirth. Between 1990 and 2016, India’s maternal mortality ratio declined by 77 percent, and the percentage of women giving birth in a health care facility doubled. Women from the poorest income quintile, those who lived in India’s rural northeastern states, and women from disadvantaged castes were more likely than wealthier, urban, higher-caste women to receive services from ASHAs during pregnancy (Agarwal et al. 2019).

In April 2020, ASHAs began to be paid a standardized rate—33 rupees, or 42 cents, each day (Jain 2022). The same press release that announced this standardized compensation for ASHAs also announced they were entitled to life insurance in the sum of 50 lakh rupees (roughly USD 60,000) in the case of death due to COVID-19 (Ministry of Health and Family Welfare 2021). Overburdened and underpaid, often forced into debt when their marginal stipends were delayed, ASHAs mobilized their frustrations by organizing a strike in 2021 that called for a guaranteed minimum wage. After nine days, the Indian government agreed to provide each ASHA with a smartphone and a USD 19 raise in their monthly salary, and the ASHAs returned to work.

Nearly three years later, this promise has remained unfulfilled (Tribune News Service 2024). As ASHAs continue to strike intermittently and agitate for higher wages, their organizing has inspired similar movements among cohorts of female community health workers in Bangladesh, Kenya, and Ethiopia, signaling that although their gender, limited formal education, and poverty may cheapen the value placed on their work, they do not diminish the power of their collectivism (Nolen 2023). That these essential health workers have had to agitate for the wages that will keep them out of poverty makes evident that programs within social medicine are perhaps especially subject to devaluation. The ASHAs’ strike should serve as an important caveat to the narrative of the successful community health workers in the prior vignette and demonstrates that pay structures that assume volunteerism and reimburse only for heroic efforts are unjust and unsustainable.

School-based health centers

Where the community health worker model exemplified by ASHAs was necessitated by the distance of India’s rural communities from hospitals and clinics, the development of school-based health centers (SBHCs) plays out in the context of urbanism. In this case, with the American inner city the site of worsened health care outcomes and differential access, the history of SBHCs traces the impact of attempts to improve such outcomes. SBHCs were first established in the U.S. in the early 1970s, through philanthropic funding from the Robert Wood Johnson Foundation, to meet the needs of youth living in inner cities. In general, SBHCs are located on or near school grounds, attended by midlevel practitioners, counselors, and social workers, and sponsored by a local hospital or community health center. Local and state agreements often guide how SBHCs engage with other school personnel, including school resource officers. Because of their convenience and their capacity to both perform routine screenings and address urgent concerns, SBHCs could provide continuity of care to young people who lack access to the idealized “medical home” primary care model (Desai and Romano 2017).

Though their scope quickly broadened, SBHCs were instituted with the primary goal of preventing adolescent pregnancy (Brindis et al. 2003, 99). SBHCs recognized that adolescents represented a distinct group that deserved dignity and confidentiality as they navigated sexual health and that they often encountered obstacles accessing contraception. Even if they did have an established primary care provider, adolescents faced a murky confluence of parental consent, medical documentation, and insurance status that threatened their ability to receive truly confidential care (Council on Scientific Affairs 1990). Early on, proponents of SBHCs recognized that “to overcome traditional barriers, services must be provided in a manner that was culturally sensitive, confidential, comfortable, and safe” (Brindis et al. 2003, 99). While “traditional barriers” refer to the logistical quagmire that teenagers encountered, it also aptly addresses the consequent political and religious opposition SBHCs faced as they thwarted a presumed sole parental right to the sexual education and oversight of adolescent children (Council on Scientific Affairs 1990).

Mental health is another major focus of SBHC services. One systematic review found that students who experienced mental health difficulties (like poor sleep, depression, or past suicide attempts) were more likely to use SBHCs than their peers without these difficulties (Mason-Jones et al. 2012, 8). The same review found that across studies, students who received care in SBHCs exhibited more “high-risk behaviors” than nonusers of the services, suggesting that youth with the greatest need use their schools’ clinics. While another study found that attending a school with a SBHC had a relatively modest effect on students’ self-reported mental health, attendance was associated with substantial reductions in emergency department visits and hospital utilizations for all conditions (Knopf et al. 2016, 118).

SBHCs are also promising for the benefits they may confer on outcomes broader than those traditionally linked to health—for example, students’ academic performance. In a study conducted in Dallas, students who received mental health services through their SBHCs had an 85 percent decline in school discipline referrals (Barnett and Allison 2012, 389). It is important to note that we are not aware of any research that suggests that youth who participate in SBHCs are at heightened risk for contact with the justice system (i.e., as a sole function of their participation in the centers).

In the first decades of the twenty-first century, the number of SBHCs across the country has more than doubled, numbering roughly 3,900 in 2022 (Soleimanpour et al. 2023). Importantly, this broad uptake has not altered their accessibility for students in disenfranchised communities. Data collected from the National School-Based Health Care Census in 2022 validated that 8 in 10 schools served by SBHCs were Title 1 schools (a federal funding designation given to public schools where students from low-income families make up at least 40 percent of enrollees). About 70 percent of students enrolled at schools with access to SBHCs were Hispanic or Black, whereas these students make up around one-third of the enrollment at schools without SBHCs (Love et al. 2019, 759; Soleimanpour et al. 2023). Because of these demographic factors and the persistence of positive educational and health outcomes across settings, the Centers for Disease Control and Prevention’s Community Preventive Services Task Force heralded that SBHCs “may be a prominent means of advancing health equity” (Knopf et al. 2016, 123). By sensibly integrating needed resources into an extant community hub (the public school), SBHCs provided reinvestment in neighborhoods that had experienced disproportionate interpersonal violence.

Perspectives on Violence Prevention

It is important to reiterate that, in keeping with the thrust of this volume, we are concerned with prevention interventions that operate outside of the formal justice system—what can be described as alternative or non-criminal-justice strategies. Irrespective of context, social justice needs to be intentional, and even among community-driven, alternative violence prevention strategies—where one might expect that social justice is a priority—we cannot presume that social justice is being advanced. Simply put, there is no default setting for social justice.

Several themes from the social medicine case studies detailed above offer fresh perspectives for advancing social justice as part of strategies to prevent interpersonal violence. First, each of the case studies draws attention to the impacts of structural violence—used here to denote the constraints on individual agency that are wrought by poverty, racism, gender discrimination, and similar, historically engendered forces (Farmer et al. 2006)—on disease burden and care delivery. Recognition of these impacts is the starting point for bringing about social justice. In the context of violence prevention, historical and structural injustices need to inform the development and implementation of programs and policies (see NASEM 2024a). In a recent review of evidence-based practices for preventing youth violence in urban settings, Ross and colleagues (Welsh et al. 2024, 459) describe how certain communities “face unique challenges, such as resource deprivation (e.g., food deserts) and service access (e.g., transportation), as a result of historic systemic issues (e.g., redlining, poverty).” In this vein, the authors emphasize the need to consider structural influences over the experiences of certain groups when thinking about risk factors. For example, in defining poverty as a monolithic “risk factor,” we can too easily ignore specific conditions, such as barriers to resources and overall systemic marginalization, facing young people identified as at risk for engaging in antisocial and violent behavior.

Second, another way to think about how to advance social justice in the context of violence prevention strategies involves a deep and unwavering commitment to equity in the distribution of funding. It has long been understood that, compared to low-crime communities, communities suffering from high rates of violent crime and crime in general are highly underresourced, receiving inadequate public funds to support violence prevention programs (Sherman 1997). ³ Lower levels of violence prevention funding in these communities can mean fewer summer jobs for teens; less access to after-school programs or even a loss of key activities as part of these programs (e.g., mentoring, tutoring, sports); unsafe public parks; and the absence of school-based violence prevention curricula, which can include a focus on healthy relationships, conflict resolution, anger management, and other key issues. SBHCs may serve as a model for how to avoid some of these deficiencies and provide a comprehensive array of violence prevention programs in communities with the greatest needs—in addition to meeting young people where they live.

Third, the important role of accompaniment also stands out from the case studies. Accompaniment holds special meaning in social medicine for health care delivery and advancing social justice. Haitian accompagnateurs (health promoters who were community members hired to administer highly active antiretroviral therapy to patients with HIV/AIDS) can serve as a powerful model to augment or reinforce some existing efforts in promoting social justice in violence prevention. One example is the Nurse-Family Partnership, a national home visitation program for first-time, disadvantaged mothers whose children are at heightened risk for abuse and neglect (Eckenrode et al. 2010). During the home visits, which begin in the final trimester of pregnancy and continue through the child’s second birthday, nurses give advice about prenatal and postnatal care, infant development, and the importance of proper nutrition and avoiding smoking and drinking during pregnancy. Over and above their professional skills, the nurses often hold deep ties to the communities they serve, allowing for genuine understanding of the needs of its members, and they are trained to encourage informal social support among the mothers’ partners, other family members, and friends and to help mothers make use of other community services to reduce situational stressors (Olds et al. 1997).

Mentoring could be considered another example of accompaniment in the context of violence prevention. Typically, mentoring involves nonprofessional adult volunteers spending time with young people at risk for delinquency, school dropout, school failure, or other social problems. Acting in a supportive and nonjudgmental manner and serving as a role model, mentors usually work one on one with young people and form strong bonds with them (Tolan et al. 2014). ⁴ Often viewed as a stand-alone intervention, mentoring can be one component of a larger, more comprehensive intervention, with mentors playing an additional role not unlike a case manager. This model could provide the young person with formative guidance as well as a greater sense of stability over a longer duration, beyond what most interventions offer. Defined in this way, mentoring could serve as a vehicle for expanding accompaniment as part of a range of violence prevention interventions.

Fourth, looming over much of the prior discussion is the pressing question of funding: Where will the money come from to pay for new strategy X or new program Y to advance social justice? Can the city government afford to hire one hundred new mentors (or train and support one hundred new volunteer mentors) to work with young people? Can government at any level afford to provide sufficient and sustained violence prevention funding to underresourced communities suffering from high rates of violent crime? These can be difficult choices in the traditional budgetary model, wherein any new spending—however important for society—needs to be weighed against other spending priorities and needs. Central to this model is the principle of economics known as scarcity; that is, some finite level of financial resources is available to government to provide for its citizens, including those in greatest need.

A contrasting view holds that this way of thinking is based on a fallacy and that citizens have been socialized to accept scarcity—what Farmer et al. (2013) call “socialization for scarcity”—especially for those who have been othered and marginalized. Expanding on this, Farmer describes how seemingly pragmatic analyses of “feasibility” tend to regard conditions of scarcity as evident and fixed—and in their own way, reinscribe the top-down logic of structural violence (Powell 2018). Writing in the context of strategies to reduce poverty and bring economic justice to poor and working-class families in the U.S., Desmond (2023, 172) notes that “our institutions have socialized us to scarcity, creating artificial resource shortages and then normalizing them.”

Overcoming the scarcity mindset begins with recognizing that we live at a time of an abundance of resources. This condition holds true both at an international level, with the likes of the World Bank and the International Monetary Fund, and among the richest countries like the United States. In fact, Desmond (2023, 175) argues that it is more a matter of “choosing abundance,” which provides for a “perspective and a legislative platform, a shift in vision and in policy design.” In making recommendations for increased violence prevention funding for individuals and communities denied justice, practitioners, researchers, and advocates should consider adopting an abundance mindset and engaging the practical levers to effect change. For the workforce of violence prevention practitioners—for whom recognition of their work is hardly enough—this effort should include supporting actions to increase pay and expand benefits, improve working conditions, prioritize self-care, and improve access to child care. For the resources needed to implement and run prevention interventions, it should begin with identifying more sustainable forms of funding and maintaining strong community and political support.

Conclusions

In this article, we have engaged ideas and practices from social medicine to explore the advancement of social justice in violence prevention. To do so, we selected several case studies, drawn from developed and developing countries, that focus on important themes that have come to embody the work of social medicine for social justice. These themes offer fresh perspectives for inculcating social justice principles and practices into violence prevention strategies. They include recognizing the impacts of structural violence, fostering equity in the distribution of resources, expanding accompaniment, and overcoming “socialization for scarcity.” Our use of the wording “fresh perspectives” is deliberate. Advancing social justice in violence prevention has long been a mission of practitioners, as well as a subject of some interest by researchers and policymakers (see Welsh and Kleemans 2015). By examining social justice through a different lens, we hope that our work can contribute to ongoing efforts in violence prevention.

We are mindful that this work has some limitations. For one, our selection of the social medicine case studies was guided more by their prominence in the field, in addition to their diversity, rather than through a systematic search of the literature. That decision had implications for the number of social justice themes that we highlighted here. Our interest was not to be exhaustive in the coverage of social medicine but rather to narrow in on some of the most important themes that define the work of social medicine for social justice. It was also the case that our focus on violence prevention was limited to social interventions that operate outside of the formal justice system. We did so to remain consistent with the volume, but to be clear, we see a dire need for work to advance social justice as part of criminal justice interventions (Tonry 2020; Welsh et al. 2024, ch. 26).

It may also be the case that some will view our efforts to engage social medicine for violence prevention as more theoretical than practical. We think otherwise. Indeed, there seems to be considerable merit in putting medicine and criminology, not to mention medicine and social sciences more broadly, in direct conversation with one another. And, in fact, the relationship between medicine and criminology is long-standing. For example, in our historical research on the social and intellectual contexts of the development of the Cambridge-Somerville Youth Study, beginning in the 1920s, there are clear indications that the boundaries between these disciplines were indistinct and dynamic on many fronts (Welsh et al. 2025). In more recent times, we can see an expanded role of medicine and public health in research and practice on the epidemiology, prevention, and treatment of interpersonal violence. Some of this work has taken place at the practical interface of medicine/public health and criminology, as with the medical profession’s response to victims of violent crime (see, e.g., Harris et al. 2002).

Indeed, the connections between social medicine and the social sciences are deep. Social science research serves to undergird social medicine’s approach to addressing social determinants of health, inequities in access to health care and medical treatment, and structural violence more generally. Anthropology, history, sociology, political science, economics, international development, and criminology are among the disciplines engaged. By advancing social justice in the context of violence prevention (and crime and justice more broadly), we expect that the interrelationships of social medicine and criminology will only strengthen in the years to come.