Black Americans experience nonfatal firearm assault at a rate more than 20 times that of White Americans. For Black men, this epidemic runs even deeper. It reflects a pattern that has held for decades: firearm assault rates are highest among Black Americans, while rates of firearm suicide are highest among White Americans. Black Americans bear the heaviest burden of gun assaults and are the primary population that hospital-based violence intervention programs (HVIPs) are designed to serve. The question is whether HVIPs are built to meet the compounding harm survivors carry or whether the frameworks guiding them fall short of the justice they claim to pursue.
Designed to break the cycle of violent injury, HVIPs are multidisciplinary programs that bring together medical staff and trusted, community-based partners to provide safety planning and wraparound services to individuals who survive violent injuries. Central to HVIPs are Violence Prevention Professionals (VPPs), individuals with lived experience who work directly with survivors at the bedside during what is called the “golden hour”, the critical window where a survivor may be most receptive to support and imagining a different future. Today, more than 100 HVIPs are operating across the United States.
Typically run by trauma surgeons and housed within trauma centers, HVIPs bring valuable clinical grounding but also a particular set of assumptions about what healing should look like and whose expertise counts. When physician-led HVIPs crowd out community knowledge, they risk treating symptoms while leaving root causes poorly understood or untouched. Research conducted with CVI frontline workers confirms what many already know: community violence is driven by structural inequities such as unemployment, failed education systems, criminal legal system involvement, and over policing or de-policing. HVIPs created without centering community voice reproduce the problem they claim to address.
Public health developed “social determinants of health” to move medicine toward structural explanations of illness, but as Braveman and colleagues have shown, the concept is more often named than acted on. HVIPs risk the same pattern: using structural language (equity, lived experience, community-based) without structural change, naming inequity without reorganizing who defines care or who benefits from it. They remain embedded in bioethical traditions built around individualized, transactional care never designed to ask who holds power or who bears its costs. In this framework, the survivor becomes a case to be managed rather than a person whose injury tells a more complex story of decades of intentional disinvestment and displacement. Wraparound services can connect a survivor to housing resources without addressing the policies that produced housing instability. Crisis intervention can interrupt a cycle of retaliation without addressing the conditions that made retaliation feel like the only viable response. This is not a failure of individual programs or practitioners, many of whom carry their own lived experience of these systems. It is a structural problem that requires a structural answer.
In healthcare, the dominant definition of justice traces back to John Rawls’s 1971 A Theory of Justice, which established fairness and equal basic rights as the foundation for a just society, with scarce resources flowing to those with the greatest need. Applied to HVIPs, this framing is not wrong, but it is radically insufficient. As Charles Mills argued, Rawls’s framework assumes historical social conditions were relatively fair to begin with, an assumption that collapses when confronted with the actual history of disinvestment, criminalization, and structural exclusion shaping HVIP participants’ lives. If the starting point was never fair, principles designed to ensure fair distribution cannot produce justice, only redistribution within a system already organized around racial hierarchy. An HVIP built on Rawlsian principles will ask whether survivors receive equitable access to services, not why they are disproportionately Black, why they live in disinvested neighborhoods, or who created those conditions. Procedural fairness cannot repair historical harm. It can only manage its consequences.
We write this critique from different vantage points. One of us is embedded inside an HVIP as a researcher and program leader, and the other is examining these programs from the outside as a scholar. That combination of proximity and distance shapes what we see and what we are able to say. We offer this not to dismiss the work but to sharpen it.
What HVIPs need is a framework of structural justice: one that names the cumulative harm of intentionally unjust systems and refuses to reproduce those hierarchies internally. HVIPs cannot dismantle structural violence on their own, but they can choose to be part of the ecosystem working toward that end rather than operating as if individual intervention is enough. This means VPPs are compensated and included in leadership rather than subordinated to clinical authority, and program success is measured by survivor-defined outcomes rather than institutional metrics. When VPPs hold genuine authority over how care is defined and delivered, programs become more responsive to the actual conditions survivors face. When success is measured by survivor-defined outcomes rather than institutional metrics, programs are held accountable to the people they serve rather than the systems that fund them. That shift from managing individuals to transforming conditions is what structural justice makes possible. How VPPs are paid and positioned reflects what Miranda Fricker called epistemic injustice, the systematic discounting of community knowledge in favor of clinical authority. When VPPs are treated as program staff rather than expert knowledge-holders, the program reproduces the very hierarchy it claims to challenge.
Some programs are already leading the way. Yale New Haven Hospital’s HVIP now offers unconditional direct cash transfers to survivors. This practice implicitly acknowledges what a structural justice framework makes explicit: that it is not enough to ration scarce medical resources when the needs of survivors arise from social inequality itself. Doing justice to survivors means acknowledging the systems that made them vulnerable in the first place and building programs accountable to that history, not just to clinical outcomes.
But justice cannot stop at the bedside. Most survivors do not recover in isolation; they return to households that absorb much of the weight of recovery. Primary caregivers manage medications, navigate insurance, provide emotional support, and absorb economic hardship, frequently without support, recognition, or any voice in how programs define success. Research has documented the significant challenges caregivers face, yet HVIPs have largely continued to treat the survivor as an individual rather than a person embedded in an ecosystem. A structural justice framework demands that we ask not only what survivors need, but what those who care for them need. Their unmet needs and definitions of success are not secondary data.
HVIPs were built to break cycles of violence. But cycles are not broken by managing their endpoints. They are broken by naming what produces them, refusing to reproduce those conditions internally, and building programs honest enough to measure themselves against the full weight of what their patients have survived. That is what structural justice demands. And it is the least that survivors and their loved ones are owed by the society that has harmed them.
William Wical, PhD, MA is a postdoctoral fellow at the Johns Hopkins Bloomberg School of Public Health in the Center for Gun Violence Solutions
Nazsa S. Baker, PhD, MA is the Research Director and Program Manager at the University of California, San Francisco, The Wraparound Project