Public health and violence

In the twenty-first century, the public health model is increasingly taking centre-stage in global responses to violence. Based on impressive claims of success, interventions such as Cure Violence (CV) – originally a Chicago-based programme that treats violence as a disease – are being adopted and adapted in communities around the world. The World Bank unequivocally describes the public health approach as the most effective form of violence intervention, and the World Health Organisation has placed it at the centre of its global strategy for violence-prevention (World Bank, 2016; World Health Organization [WHO], 2002). As public health practitioners lead the way in providing an alternative to criminal-justice-centred responses to violence, this issue highlights the importance of maintaining flexibility in the way that the drivers of violence are conceptualised, engaging with multiple methods and levels of analysis that will help to avoid simplistic, even damaging diagnoses of causes, and by doing so, significantly improving the chances of arriving at effective solutions.

Violence lies at the juncture of many disciplines, intersecting analyses that traverse the micro and the macro, from individual psychosocial factors to structural societal dimensions. Fields such as criminology and psychology have provided invaluable insights into criminal and interpersonal violence; others, such as political science and economics, have explored the dynamics of collective and organised mass violence. Despite categorical distinctions, focus and insights from these fields are often interconnected and indivisible, and taken together they offer a sophisticated understanding of violence befitting its complexity. Regrettably, disciplinary rigidity has often impeded such exchange, and in the worst cases, commitment to a specialised methodology or interpretive framework has led to the blinkered exclusion of all others (Hazen & Rodgers, 2014; Kalyvas, 2015, p. 1518; Mitton, 2015; Whitehead, 2004). Through three very different contexts and methodological approaches, the articles in this issue caution against reductive analyses that follow exclusionary disciplinary lenses and methods. Most emphatically of all, they underline that to effectively understand violence at the individual level, a critical public health approach must engage with the structural.

In its most comprehensive, holistic formulation, the advantages of a public health approach to violence reduction are considerable. A reconceptualisation of the problem in health terms may help authorities avoid the damaging consequences of an almost reflexive default to securitised and draconian criminal justice responses, which at their extremes have tended to worsen rather than reduce violence (Lessing, 2018). In doing so, the public health model can help to mobilise greater community engagement to transform social norms and address educational and welfare needs. However, where an approach puts exclusive focus upon the individual or a specific community in isolation, to the degree that broader structural causes are marginalised or obscured, the picture of what drives violence (and therefore what may work to prevent it) is left drastically incomplete. If causes of violence are reduced to social norms and individual learned behaviour, arguably little space remains for understanding violence (or non-violence) as a rational decision made in response to structural inequalities (Stewart, 2001) or as a facet of the political economy of organised crime (Skarbek, 2014; Lessing, 2018). If violence is understood exclusively as a disease, we risk diminishing the agency of the violent, and by extension, entirely missing the expressive or socio-economic functions of aggression. Can the violent be ‘cured’ solely by an altering of social norms in communities, if social norms themselves are shaped by wider socio-economic and political conditions beyond ‘infected’ communities?

These questions naturally arise from Malte Reimann’s (2019) critical analysis in this issue, in which he problematises the ‘medicalization of violence’, drawing on the case study of CV. Through the language of epidemiology, Riemann charges that CV effectively marginalises the contributions made by fields such as criminology and sociology, and by extension, promotes treatment models that become ‘disentangled from socioeconomic inequalities and explained by reference to individual pathology alone’ (Riemann, 2019). Individual behaviour and community norms are thus the priority for change; broader structural factors that might drive violence are reduced to ‘modulating’ factors (Riemann, 2019). Kwon and Cabrera’s (2019) analysis of mass shootings in the US likewise identifies and addresses the side-lining of structural factors in explanations of violence. Accounts of mass shootings have invariably focused on individual motives, relying on societal stereotypes concerning mental health that have little support in the evidence (Kwon & Cabrera, 2019). Their study is an important departure then in seeking to locate explanations within a broader context of economic and social structures that may induce anger, frustration, and ultimately violence by those most severely affected in society. In another context, Huynh et al. (2019) similarly establish the critical importance of conceptualising interpersonal violence within these wider socio-economic structures. Drawing on extended ethnographic research in South India among sex workers and their intimate partners, they vividly reveal the relationship between local ideologies and practices of masculinity and the socio-economic structural realities that shape them. From this understanding, they demonstrate that practically tackling violence and seeking individual behavioural change necessarily directs us to address these broader structural realities (Huynh et al., 2019).

For policy-makers, a major appeal of public health interventions and programmes such as CV is precisely that they offer clear evidence-based steps to practically tackling violence. As Reimann (2019) notes in this issue, CV employs the language of medical science in emphasising the rigour of its data collection and analysis, and ‘presupposes the superiority of a quantitative, evidence-based epidemiology over other approaches’ (Reimann, 2019, p. 5). However, in this respect such programmes may fail to fully acknowledge or answer critical questions ill-suited to a quantitative methodology, and in the process, risk offering a misleading degree of certainty concerning their impact and effectiveness. Even where data are reliable, interpretation may well fall short. A recent paper based on the gold standard of evaluations, the RCT, concluded that parachute use did not reduce death when used by participants jumping from aircraft. This satirical study carried a cautionary lesson: ‘interpretation requires a complete and critical appraisal’ (Yeh et al., 2018, p. 5). For violence-interventions evidence of success is essential to the continuation of contracts, funding and local political support. This political economy is familiar to scholars and practitioners of development and public health: institutional survival of an important programme may depend upon the delivery of quantifiable and immediate success, even in situations where change may only be discernible in the long-term, or impossible to definitively identify against a background of numerous variables. Reimann’s analysis does not evaluate the effectiveness of CV, but it does draw attention to its fervent promotion of success that, perhaps understandably, may not fully reflect scientific evaluations that have found ‘mixed’ results, or in some instances, potential links to increases in violence (Butts, Gouvis Roman, Bostwick, & Porter, 2015). These evaluations do not undermine CV’s impressive body of positive results, but rather point to the challenge of securing reliable scientific data and definitive proof of impact where violence is concerned. Whether in terms of establishing causes or ‘cures’, the study of violence is one which demands caution and humility. The papers in this special section show that violence is a challenging, complex, and multifaceted phenomenon that proves resistant to certainty, scientific, or otherwise.