Addressing Law Enforcement Violence as a Public Health Issue

The 2018 Statement

This version of the statement was formally adopted by the American Public Health Association (APHA) at their annual conference in San Diego, CA on November 13, 2018 with majority support from Governing Council members (87% to 13%). The statement was written by the End Police Violence Collective--a growing group of public health researchers, teachers, graduate students, non-profit leaders, and community organizers--and is rooted in the work of grassroots organizing against state-mediated violence.

Read our reflection on the statement’s passage and a thank you message to our supporters by clicking here.

III. Sponsorships

Black Caucus of Health Workers; Medical Care Section; International Health; Student Assembly; Socialist Caucus, Sexual and Reproductive Health

 IV. Collaborating Units

This statement was reviewed by all sponsoring and endorsing units listed

V. Endorsements

Organizations within APHA Endorsing:

Community Health Planning and Policy Development Section; LGBT Caucus; Human Rights Forum; American Indian, Alaska Native, Native Hawaiian Caucus; Family Violence Prevention Caucus; Mental Health Section; Public Health Nursing Section, Maternal and Child Health Section, Community-Based Public Health Caucus; Latino Caucus, Physical Activity Section, Immigrant and Refugee Health Section, Peace Caucus, Occupational Health Section; Environment Section

Organizations Outside of APHA Endorsing:

Drug Policy Alliance; Public Health Justice Collective; HOMEY SF; Freedom Archives; On Earth Peace, Jewish Voices for Peace-Bay Area, California Coalition for Women Prisoners, Out Now, Stop Urban Shield Coalition, Anti-Police Terror Project; Critical Resistance Oakland, Public Health Justice Collective; Human Impacts Partners; Psychologists for Social Responsibility; CURYJ (Communities United for Restorative Youth Justice); CAYCJ (California Alliance for Youth and Community Justice); Planting Justice; The People’s Table; Equity And Transformation; Men and Women in Prison Ministries; Gray Panthers of San Francisco; Coalition on Homelessness;  Do No Harm; Racial Justice Action Center; End Solitary Santa Cruz County, CA; Californians United for a Responsible Budget (CURB); Penal Abolition Collective at the American Society of Criminology; The Sunnyside Longevity Project (Flagstaff, Arizona)

VI. Summary

Keywords: Violence, gun violence, minorities, injury prevention, racism, law enforcement, public safety

**Note: Language that is both bold and italicized has been explicitly defined in Appendix A**

Physical and psychological violence that is structurally-mediated by the system of law enforcement results in deaths, injuries, trauma, and stress which disproportionately affect marginalized populations (e.g., people of color, immigrants, individuals experiencing houselessness, people with disabilities, the Lesbian Gay Bisexual Trans and Queer (LGBTQ) community, individuals with mental illness, people who use drugs, and sex workers). Among other factors, the misuse of policies intended to protect law enforcement agencies have enabled limited accountability for these harms. Further, certain regulations (e.g., anti-immigrant legislation, policies associated with the war on drugs, and the criminalization of sex work and activities associated with houselessness) have promoted and intensified violence by law enforcement toward marginalized populations. While interventions for improving policing quality to reduce violence (e.g., community-oriented policing, training, body/dashboard-mounted cameras, and conducted electrical weapons) have been implemented, empirical evidence suggests notable limitations. Importantly, these approaches also lack an upstream, primary prevention public health frame. A public health strategy that centers community safety and prevents law enforcement violence should favor community-built and community-based solutions. The American Public Health Association (APHA) recommends the following actions by federal, state, tribal, and local authorities: (1) eliminate policies and practices that facilitate disproportionate violence against specific populations (including laws criminalizing these populations); (2) institute robust law enforcement accountability measures; (3) increase investment in promoting racial and economic equity to address social determinants of health; (4) implement community-based alternatives to addressing harms and preventing trauma; and (5) work with public health officials to comprehensively document law enforcement contact, violence, and injuries.

VII. Relationship to Existing APHA Policy Statements

The following APHA policy statements are relevant to the current statement:

-APHA Policy Statement 7120: Substance Abuse as a Public Health Problem

-APHA Policy Statement 8817(PP): A Public Health Response to the War on Drugs: Reducing Alcohol, Tobacco and Other Drug Problems among the Nation’s Youth

-APHA Policy Statement 9123: Social Practice of Mass Imprisonment

-APHA Policy Statement 9926: Support for Research on the Socioeconomic Causes of Violence

-APHA Policy Statement 9929: Diversion from Jail for Non-Violent Arrestees with Serious Mental Illness

-APHA Policy Statement 20128: Opposing the DHS-ICE Secure Communities Program

-APHA Policy Statement 200914: Building Public Health Infrastructure for Youth Violence Prevention

-APHA Policy Statement 201311: Public Health Support for People Reentering Communities from Prisons and Jails

-APHA Policy Statement 201312:  Defining and Implementing a Public Health Response to Drug Use and Misuse

VIII. Rationale for Consideration

This document establishes a policy statement focused on structurally-mediated law enforcement violence as a public health issue with public health and system-based strategies to reduce law enforcement violence and increases public safety for marginalized communities. This is necessary due to the archival of APHA Policy Statement 9815 Impact of Police Violence on Public Health and APHA Policy Statement LB-16-02 Law Enforcement Violence as a Public Health Issue.

IX. Problem Statement

Prevalence, impacts, and inequities

Law enforcement violence is a critical public health issue. Consistent with domains of violence defined by the World Health Organization (WHO), law enforcement violence has been conceptualized to include physical, psychological, and sexual violence as well as neglect (i.e., failure to aid) [1-3]. While all forms of violence are important to consider and have been shown to correlate with poor mental health outcomes in at least one study [1], this statement focuses on physical and psychological violence.

According to The Counted (a UK-based website, which operated from 2015 to 2016 and provided the most timely, comprehensive source of U.S. data at the time) [4-6], at least 1,091 individuals were killed by law enforcement officers in the United States in 2016 [7]. These deaths in 2016 amounted to 54,754 years of life lost [8]. Based on data from the Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control, there were 76,440 non-fatal injuries due to legal intervention in 2016 [9]. At least 28 serious injuries were inflicted on students between 2010 and 2015 by school-based law enforcement officers [10]. The CDC estimates that the overall cost of  fatal and non-fatal injuries by law enforcement reported in 2010, including medical costs and work lost, was $1.8 billion [11]. Legal scholars describe a clear connection between increased exposure to stops and an elevated risk of death or physical harm by law enforcement officers [12].

Inappropriate stops by law enforcement are one form of psychological violence with serious implications for public health [1, 2].  Even in the absence of physical violence, several studies have found that stops perceived as unfair, discriminatory, or intrusive are associated with adverse mental health outcomes, including symptoms of anxiety, depression and posttraumatic stress disorder [1, 13, 14]. Additionally, one study found neighborhood-level frisk and use of force was linked with elevated levels of psychological distress among men who live in these neighborhoods [15]. In two large surveys, Black individuals were more likely than white individuals to report stress as a result of encounters with police [13, 14] – a concern given evidence of an association between stress due to perceived racial discrimination and risk factors for chronic disease and early mortality [16]. A nationally representative study found an association between death of Black individuals due to legal intervention with subsequent poor mental health among Black adults living in the same state [17]. 

The impacts of physical violence likewise extend beyond injuries and death, affecting individuals’ and communities’ ability to achieve positive health outcomes in the short- and long-term, and compounding extant health inequities. For example, one study found residents of neighborhoods with high rates of law enforcement use of force were at increased risk for diabetes and obesity [18]. Among youth, exposure to violence from school-based law enforcement officers is linked to "denial of educational and social growth"[19] – both key determinants of health [20] – and ethnographic research indicates that current policing practices alter key developmental processes among Black male adolescents [21].  In summary, aggressive policing is “a threat to physical and mental health,” which may be exacerbated among marginalized populations [13].

Marginalized populations are inequitably affected by law enforcement action and violence. People of color comprised more than 50% of years of life lost due to legal intervention in 2016, but account for just under 40% of the U.S. population [8]. Native Americans have been killed by law enforcement, per capita, at a higher rate than any other group in the U.S. (3.5 times higher than white Americans), with these mortality data likely to be an undercount [7, 22]. In 2016, Black and Native American individuals were over 2 and 3 times (respectively) more likely to be killed by law enforcement than white individuals [7]. When stratified by sex and age, Black and Native American males ages 15-34 were 9 and 6 times (respectively) more likely to be killed than other Americans in their age group [7]. Similarly, Black women are disproportionately represented among women killed by police [23]. Black and Latino individuals are more likely to be stopped, arrested, and experience non-fatal violence by law enforcement [1, 24-27]. Of the 4,400 persons shot by officers from the 50 largest police departments from 2010 to 2016, 55% were Black, more than double the proportion of Black population in these departments’ jurisdictions [28]. In 2012, Black and Native American individuals made up admissions to emergency departments for injury due to legal intervention at 3 and 6 times (respectively) their representation in the general population [29]; and in a nationally representative sample of emergency departments from 2001-2014, Black individuals age 15-34 were treated for legal intervention injury at almost 5 times the rate of their white counterparts [30]. Students most at risk for violence by school-based law enforcement officers include children with disabilities, students of color, and poor students [31].

Other marginalized populations also experience inequitable exposure to law enforcement violence. Among recorded U.S. deaths attributed to law enforcement in 2015, an estimated 27 percent were individuals with mental illness [32]. Other groups highly affected by law enforcement violence include, people who identify as transgender, lesbian, gay, and/or bisexual [1, 33]; individuals experiencing houselessness [34]; low-income individuals [1, 35]; sex workers [36, 37]; and people who use drugs [2]. Women also experience sexual violence by police officers, particularly women of color. In a 2003 study in New York City, 38% of Black women, 39% of Latinx women, and 13% of Asian or Pacific Islander women reported being sexually harassed by police officers [38]. Immigrant communities are subject to policing from local, state, and federal immigration authorities, such as the Department of Homeland Security Bureau of Immigration and Customs Enforcement. Immigration raids result in “immigration enforcement stress,” and fear of interacting with government agents and informal social networks [26]. Policies that increase law enforcement contact, or fear of contact, create barriers to health care and other health-supportive services – including Medicaid, WIC, HIV prevention, harm reduction programs, and domestic violence services – for undocumented individuals and their U.S. citizen family members. [39-43] The disproportionate impact of policing on these communities has been documented since at least the 1960s [44].

Insufficient Monitoring and Surveillance of Law Enforcement Violence

Data presented above likely underestimate the magnitude of law enforcement violence given that comprehensive information on deaths, mental and physical injuries, and frequency of encounters is limited (e.g., there is no systematic public health data on sexual assaults committed by police)[45]. While the Federal Bureau of Investigation’s (FBI) Uniform Crime Reporting System and CDC’s National Violent Death Report System (NVDRS) generate some data on injuries and fatalities by law enforcement, they neglect indicators vital to understanding the magnitude and scope of the issue, such as type of injury, death on federal property (e.g., federal prisons, tribal lands, military bases), and type of law enforcement officer(s) involved [46-48]. Most concerning, reporting occurs on a voluntary basis. As a result, even NDRS – the most reliable of the official reporting systems [48]– notably underestimates deaths by law enforcement [6]. The U.S. National Vital Statistics System (NVSS) failed to capture 55% of such deaths in 2015 due to misclassification [4]. The magnitude of disparities in violence by school-based law enforcement officers is likely underestimated as well, given communication challenges and unreliable mechanisms for reporting abuse [31]. Given this, public health practitioners and researchers must rely on non-governmental, web-based social media data sources, such as The Guardian’s The Counted, which captured 93% of deaths by law enforcement in 2015 [4, 5]. Yet, it is feasible to gather reliable, real-time data on law enforcement-related deaths via existing public health reporting mechanisms [6].

Policing as a mechanism of social control that exacerbates social inequity

Ecosocial theory of disease distribution holds that to meaningfully analyze and interpret the population distribution of a health exposure, a grounding in the historical context from which the exposure emerged is necessary [49]. Namely, U.S. policing was historically deployed for the social control of communities deemed socially marginal (i.e., in the 19th century, it evolved from ruling-class efforts to control the immigrant working class in the North and slave patrols in the South) [50]. Policies and practices continue to implement and sustain this historical intent. For example, the War on Drugs assigned drug use intervention to law enforcement in lieu of formulating a public health approach. Scholars suggest that the associated “tough on crime” rhetoric was a racially coded appeal to white populations across class lines, aimed at legitimating targeted policing in communities of color [51, 52]. By encouraging drug arrests with cash incentives, loosening restrictions on searches, and creating a culture that encouraged law enforcement to repeatedly stop and search people of color without reasonable cause, the federal government disproportionately subjected marginalized communities to increased contact with the law enforcement system [51]. Data-driven policing is another example of a structural and targeted policing practice that links crime with place and race, and facilitates increased contact with law enforcement among marginalized communities [53, 54].

Policies and practices that facilitate a system of discriminatory policing are particularly problematic given the weakening of the Posse Comitatus Act, the enactment of the National Defense Authorization Act, and the 1033 program, which distribute surplus military equipment to local and state law enforcement agencies [24, 55, 56]. Delivery of military equipment to law enforcement agencies precipitates military-style training, allows military weapons to become the tools of law enforcement, and increases the use of Special Weapons and Tactics (SWAT) techniques resulting in increasing rates of use of force and extrajudicial murders by law enforcement - disproportionately among marginalized communities [24, 57]. The observed militarization and extensive purview of domestic law enforcement is facilitated by mounting investments of federal funds in police departments, and financial enticements [51].

Research on predictors of police force size conclude that the system of law enforcement upholds existing racial and class hierarchies by targeting socially marginalized groups - often low-income communities of color. Key predictors, which maintain an association with police force size after controlling for crime rates, include (1) size and growth of populations of color, (2) racial economic inequality, and (3) poverty [58, 59]. These findings suggest that these populations are perceived as a threat to the social order and that policing is used as a mechanism of control [58, 60]. Upholding social hierarchies perpetuates and exacerbates adverse health outcomes among those who are already disproportionately affected by inequities in key social determinants of health - or those underlying factors that “affect a wide range of health, functioning, and quality-of-life outcomes and risks,” and are widely understood in the field of public health to be the primary contributors of persistent health inequities.[61]  These include: access to education and economic opportunities; perceptions of public safety and exposure to violence; quality of housing and transportation; social norms and attitudes (e.g., discrimination, racism, and distrust of government); and availability of community-based resources. [20, 61]

Ineffective response to social problems

The concentration of policing in socially marginalized communities - and the associated public health threats - stems from a framework that crime originates from inherently “bad” individuals and communities - or a “thin blue line” ideology [44, 50, 60, 62]. Yet, the social determinants of health framework indicates that efforts to promote physical, mental, economic, and social wellbeing are more effective if premised on an assessment of the social conditions underlying the behaviors that are typically addressed through the criminal justice system. With this framework, the range of interpersonal harms and behaviors deemed “criminal” can be understood from a social determinants of health perspective as emerging from social inequities. Theft, as just one example, can be understood as a behavior to meet material survival needs in the context of poverty due to long-standing, systematic economic disinvestment from low-income communities of color, and intra-community violence has been shown to be linked to the chronic stress of poverty [61].

Criminalization of houselessness, sex work, and drug abuse exemplifies how law enforcement is deployed to rectify social inequities [34]. However, laws that criminalize houselessness (e.g., local and state laws prohibiting loitering and sleeping in public spaces) are costly to enforce, perpetuate houselessness, and violate basic human rights, among other harms to public health [63, 64]. The National Law Center on Homelessness and Poverty finds that criminalizing behaviors associated with houselessness violates the United Nations’ Convention Against Torture, and recommends that federal agencies take active steps toward decriminalization while funding constructive alternatives [65]. Police officers have also indicated that criminalization of houselessness is an ineffective response to the root cause, and that responsibility for addressing houselessness should lie outside of law enforcement’s purview [66]. Criminalization of sex work likewise results in high rates of law enforcement violence toward sex workers and those assumed to be sex workers, such as transgender women of color [33]. Similarly, punitive strategies of addressing drug abuse shows little evidence of reducing substance abuse and has proven harmful to working-class communities of color [67].

Though the need to invest in addressing the social determinants of health is clear, government spending on social services such as housing assistance and education has decreased since the 1980s. The Center for Budget and Policy Priorities documents a median budget reduction of 26% among 11 of the 13 largest health, housing, and social service block-grant programs between their inception in the 1980s and 2016, and a $13 billion reduction in these funding streams between 2000 to 2016 [68]. Yet, spending on policing increased 445% between 1982 and 2007, including a 729% increase in federal funding [34]. The Center for Population Democracy found that in 9 out of 10 cities it examined, over one-quarter of general funds were committed to local police departments. For instance, in Oakland, California, 41% of the general fund went to the police department, which had a 19% budget increase between 2013-2017, while total city expenditures increased by just under 8% [3].

Barriers to accountability and reform

Between 2005 and 2011, only 47 police officers across the U.S. were charged by prosecutors with a crime for their involvement in civilian deaths, with 11 out of those 47 convicted [69]. Multiple barriers impede accountability and obstruct meaningful reform. Cultural barriers, such as efforts to “protect one’s own,” can manifest in a “code of silence,” or a norm of not reporting other officers’ misconduct and protecting them during investigations [26, 70, 71].

Laws and policies— such as state-based police bills of rights (generally referred to as Law Enforcement Officers’ Bill of Rights or LEOBORs) and police union contracts—provide law enforcement officers accused of excessive use of force or murder with protections from investigation and disciplinary action, known as “super due process” [72, 73], including suppression of law enforcement data related to deaths [74]. LEOBORs are found in 14 states and first emerged in the 1970s when law enforcement officers pursued unionizing efforts in reaction to grassroots mobilizations demanding democratic accountability and transparency over police (e.g. civilian review boards) given experiences of officer misconduct, corruption, and brutality [75, 76]. LEOBOR provisions can generally be broken into two categories: those which should be eliminated due to their ability to hinder efforts to hold law enforcement officers accountable (e.g., investigative delays) [76, 77], and some protections that should be extended to everyone, including civilians suspected of a crime (e.g., limits on the duration of interrogation) [78]. Rights and protections present in some LEOBORs that protect law enforcement officers from merited accountability include: unreasonable limitations on reporting time that disqualify civilian complaints; restriction of interrogation of officers to other sworn officers; preventing civilians investigators from interviewing or investigating officers; and restrictions of public access to disciplinary records [76]. In addition, investigative delays, coupled with notifications of who will interrogate an officer, and unrestricted access to all the evidence brought against an officer, allow officers to prepare the most-exculpatory and/or least-inculpatory narrative [75-77].

Structural racism embedded within “legal, social, and political systems...enable[s] police officers to disproportionately stop people of color, often without cause...with greater use of force [and] without any repercussions” [79]. Protective laws and policies, obstruction from oversight, and cultural norms inhibit accountability, confound reform, and lead to harm, especially among marginalized communities.

X. Evidence-Based Strategies to Address the Problem

Improving Surveillance and Reporting of Law Enforcement Violence

Improvements to existing public health monitoring systems, such as expanding NVDRS to include all states, and moving to more timely processing and release of data at the local level - not just the state level - could prove highly effective [6, 48, 80]. To leverage the success of The Counted in capturing and classifying death by law enforcement, state and local public health agencies could collect additional data beyond what are typically reported by using validated, existing social-media sources. In addition to these data already being publicly available, they capture real-time reports that include data on age, gender, race/ethnicity, and census tracts of residence and death; and serve to correct misclassification in vital statistics [4, 5]. With regard to reporting, transparency can help identify appropriate policy and programmatic intervention; evidence indicates success of transparency measures such as: making health inequities visible by presenting data stratified in relation to categories of race/ethnicity, nativity, gender identity, sexual identity, and socioeconomic position; including housing tenure (as a proxy for houselessness); and presenting type of law enforcement official, mechanism of death (firearm, Taser, chokehold, etc.), and locale of death (e.g., on the street, in the decedent’s home, at a school, at border crossing, etc.) [3, 6, 81]. Further, a mechanism for state and local public health agencies to share data with various entities can encourage appropriate prevention and intervention measures, such as sharing with state attorney generals for further investigation [82].

Decriminalization of activities shaped by the experience of marginalization

As criminal justice scholars have argued, mass criminalization is a key mechanism through which communities of color experience heightened rates of law enforcement violence [12]. Others have concluded that disparities in contact with law enforcement may be a root cause of differential exposure to physical violence by law enforcement, and that “reducing inequality in police stops can simultaneously reduce inequalities in exposure to violence” [1]. Therefore, a critical step in reducing both structurally-mediated physiological and psychological violence by law enforcement is to repeal laws that promote or justify increased scrutiny of specific populations. Such laws include those relating to drug use or possession, sex work, houselessness, and immigration. By removing justification for law enforcement intervention, this will reduce encounters between law enforcement officers and individuals whose activities are presently criminalized. Crimes should not simply be downgraded to lower-level offenses; for example, research shows that marijuana-related arrest rates remained stable or increased when possession was reclassified as a lesser offense but was still considered against the law [83]. By contrast, in Massachusetts courts ruled to limit police enforcement of marijuana possession, and arrests fell by 86% [83]. Not only can drug decriminalization reduce arrests and incarceration, it also has the public health benefit of increasing uptake of drug treatment, with cost savings due to redirecting resources from criminal justice to the health system [84]. Regarding sex work, one meta-synthesis of qualitative studies concluded that New Zealand’s full decriminalization of sex work was associated with reductions in law enforcement contact and improvements in HIV prevention among sex workers [85]. These findings may be generalizable to the U.S. context and serve as a model for structural intervention. Decriminalization is consistent with the WHO recommendations for structural interventions that address social determinants of health for marginalized groups [61].

Under certain legislation, criminalization extends to protesting and mass mobilizations - which are vital means by which marginalized communities voice concerns. In 2017, several states passed anti-protest legislation; among them were North Dakota and South Dakota, where, in 2016, protestors against the Dakota Access Pipeline at the Standing Rock Indian Reservation - including many Native Americans - were met with violent force by local law enforcement and the North Dakota National Guard, leading the United Nations (UN) to declare human rights violations [86, 87]. Advocating against such laws is critical to protect free speech, human rights, and reduce unnecessary contact with law enforcement.

Reallocation of funds from policing to the social determinants of health

As described above, policing reproduces inequitable social and economic conditions that precipitate intervention by law enforcement. This places both law enforcement officers and marginalized community members at risk of injury, death, and adverse health outcomes. By contrast, a public health approach targets the structural inequities that manifest in criminalized behaviors by addressing the social determinants of health. [88, 89]. Such approaches include increasing access to housing, expanding educational and employment opportunities, increasing access to mental health and substance use treatment, and restoring a sense of safety by addressing interpersonal and institutional factors contributing to perceptions of safety and experiences of discrimination [61]. The social determinants of health approach is associated with reduced community trauma and interpersonal harm, improved community health and safety [88], and is the basis of the CDC’s recommendations for data-driven, community-level, prevention-focused interventions [90]. This approach is a key element of the Movement for Black Lives platform, a policy agenda that calls for “reallocation of funds at the federal, state, and local level from policing and incarceration...to long-term safety strategies such as education, local restorative justice services, and employment programs” [91].

Evidence demonstrates the benefits of shifting from criminalization to a framework grounded in social determinants and primary prevention. For example, there is a well-established link between improving educational attainment and positive outcomes in employment and socioeconomic outcomes, and subsequent positive short- and long-term health outcomes [92]. More evidence is found in houselessness services. The U.S. Interagency Council on Homelessness recommends providing permanent housing as a proven approach to improve health among those experiencing houselessness, as such efforts have been associated with higher housing retention rates, reductions in use of crisis services and institutions, and improvements in health and social outcomes [93], and have been cost effective [94, 95]. Similarly, because exposure to violence is a critical determinant of health, and can lead to further violence by trauma survivors and later contact with law enforcement [96], “trauma-informed” approaches to care and policy are recommended across sectors [97]. Reinvestment in community resources can also occur in tertiary prevention by using a health model for crisis response. For example, health workers in Oakland are training community members to respond to mental health crises and suspected overdoses in ways that minimize law enforcement involvement [87].

The above evidence, combined with the decreasing crime rates [34], suggests that funds disproportionately allocated to policing could be more effectively invested in social services to improve health, particularly in communities where historically-rooted endemic disinvestment has negatively contributed to health disparities.

Strategies to ensure community safety without reliance on armed law enforcement

Although greater social and economic equity is likely to lead to higher quality of life for marginalized communities, interpersonal harm will still exist, and strategies to ensure community safety will still be necessary. Alternative approaches can improve public safety without the harms associated with the system of policing. For instance, community-based violence intervention programs that detect and interrupt potentially violent conflicts, identify and treat high-risk situations, and mobilize the community to change norms have significantly reduced homicides and nonfatal shootings in the urban neighborhoods with the highest numbers of incidents [98]. These programs have had success employing violence interrupters and culturally appropriate unarmed street outreach workers; these interrupters have been able to defuse potentially harmful or violent situations with no, or minimal, intervention by police [98].

Similarly, restorative justice is a non-punitive approach to resolving interpersonal harm through dialogue between perpetrators, victims, and others affected without reliance on law enforcement. Its implementation in school settings has been associated with reduced suspensions, expulsions, and referrals to law enforcement [99]. Future programs might increase efficacy by ensuring the populations most affected by law enforcement violence lead program design and implementation, which is widely acknowledged as best practice [100].

XI. Opposing Arguments and Evidence

Arguments against reducing law enforcement presence and ensuring accountability as mechanisms to address law enforcement violence assert that these strategies will increase crime, decrease public safety, and harm public health. Others propose to address law enforcement violence through tactics such as community-oriented policing, use of body-mounted cameras and Tasers, and increases in officer training. This section presents these arguments along with research that suggests the former strategies are aligned with a public health approach and have a negligible impact on increasing crime or decreasing public safety, while the latter tactics do not address the structural predictors of law enforcement violence nor its health implications.

Opposing Argument #1: Decriminalization harms the public’s health

Proposals to decriminalize drug possession and sex work are often met with concern that doing so will negatively affect the public’s health. For example, opponents suggest decriminalization of drugs leads to an increase in drug use and higher rates of traffic accidents. Initial research on decriminalization has yielded mixed findings [101, 102], and studies show that the legitimate concern about negative health effects of drug use is better addressed with health service approaches. Data from Portugal, which decriminalized all drug use in 2001, when compared with Spain and Italy – which maintained criminal penalties for drug use – showed increased uptake of drug treatment, reductions in opiate-related deaths and infectious diseases, and increases in the quantity of drugs seized by the authorities due to shifting law enforcement resources from minor possession crimes to a focus on traffickers [103]. Many organizations support drug decriminalization to improve human rights and public health, such as the Office of the UN High Commissioner for Humans Rights [104], The Joint United Nations Programme on HIV/AIDS (UNAIDS) [105], and the UN Office on Drugs and Crime [106]. Existing APHA policy supports a public health strategy on drug use, marked by recommendations for an end to criminalization of personal drug possession and use (APHA 7121, 8817, 201312), and prioritization of treatment and harm reduction strategies, such as ensuring access to sterile syringes [107]. WHO recommends that countries work towards decriminalization of drug use and sex work as a means of reducing known barriers to health services and treatment [107].

Regarding sex work, there are concerns that decriminalizing sex work could facilitate human trafficking, exploitation, and other forms of violence. Sex workers and advocates note that sex work is not synonymous with “sex trafficking,” and distinguish between various forms of sex work (sex work, survival sex work, and forced sexual labor aka “sex trafficking”; see glossary for expanded definitions) as it relates to the nuances of sex workers’ experiences (including interactions with police) [108]. As noted above, an environment of fully decriminalized sex work can improve health outcomes and reduce interactions with police [107]. Decriminalization and/or full legalization of all forms of sex work have been overwhelmingly recommended by sex worker study participants and by human rights organizations, including Amnesty International and WHO, citing these approaches as means to remove harms caused by disproportionate psychological and physical law enforcement violence, and to eliminate punitive laws that inhibit sex workers’ abilities to report human trafficking, forced sexual labor, and other forms of violence and exploitation [36, 108, 109].

 Opposing Argument #2: Increased law enforcement funding protects the public’s health

Because of the current structure of civil society, institutions of law enforcement are perceived as necessary to protect the public from harm and violence either through direct intervention or as a crime deterrent vis-a-vis increasing perceived risk of arrest. The argument follows that reducing law enforcement budgets will adversely affect communities. However, an incremental increase in quantity of law enforcement officers has not been linked to decreased violent or property crime. In fact, a meta-analysis of studies published between 1973 and 2013 found no statistically significant association between police force size and combined violent and property crime rates, and that violent crime remained stable when law enforcement abruptly withdrew from neighborhoods [110]. A nationally representative survey of urban areas found that police force size did not act as a crime deterrent for violent or property crimes vis-a-vis increasing perception of arrest risk [111]. In school settings, there is no evidence that school crime or mass shootings have been reduced by increasing campus presence of law officers (known as school resource officers) [112]. Ultimately, research suggests that law enforcement presence has not been shown to consistently reduce crime – especially violent crime – and its adverse impacts on people’s lives. Nonetheless, spending on municipal policing has increased substantially over the last few decades [34]. Proponents of increases in law enforcement funding argue that decreasing crime trends are a result of this increased investment. However, the Congressional Budget Office and others researchers note that multiple drivers can explain this reduction, including demographic and economic changes, and social investments [3, 113].

Opposing Argument #3: Interventions should implement novel policing strategies (e.g., community-oriented policing, body-cameras, Tasers, training), not reduce law enforcement presence.

3a: Community Oriented Policing

Some have argued that specific policing strategies, such as community-oriented policing (COPS), will reduce law enforcement violence. COPS was designed to increase policing effectiveness by building relationships between law enforcement and community to address the crisis of legitimacy police departments experienced after the urban rebellions of the 1960s [114]. Seventy percent of police departments across the United States report COPS activities [115]. COPS strategies have changed over time and are inconsistent across departments, but may include assigning specific patrol officers to a single neighborhood, encouraging partnerships with community organizations and other city agencies, and emphasizing problem solving in conjunction with the community [34], arguably “significantly broaden[ing] the reach of the police, perhaps giving them even more discretion” [114].

Numerous investigations of COPS —including a 2014 meta-analysis— show little impact on crime prevention or community members’ feelings of safety; however, COPS appears to be associated with increases in citizen satisfaction and perceived police legitimacy, and decreases in perceived disorder [34, 116]. Historically, government agencies have recommended community-oriented policing strategies as a means of improving relationships between community members and law enforcement officers, especially after high-profile deaths by law enforcement, rather than as a mechanism for reducing law enforcement violence [44, 62]. For example, the Chicago Alternative Policing Strategy (CAPS) at the Chicago Police Department, which was lauded as effective and helped pave the way for the national COPS program, has been under continued scrutiny for police brutality and killings [26]. If the goal of public health is to reduce violence due to underlying structural and social determinants of health, strategies should aim to reduce the violence of the system of law enforcement, rather than be designed primarily to improve relationships between law enforcement officers and members of marginalized communities.[82]

Few studies of community-oriented policing critically assess the nature of partnerships that police develop with communities and who is included in – or excluded from –the “community.” An important exception is a grassroots research project conducted by a community group that visited meetings of CAPS in neighborhoods across the city, focusing on neighborhoods affected by gentrification [116]. The group reported that police officers encouraged the mostly white, property-owning residents who attended CAPS meetings to surveil their neighbors, report minor infractions such as loitering and public drinking, and report anyone who seemed “out of place,” turning to law enforcement interventions more frequently and quickly,” which results in increasing “surveillance of a community’s most vulnerable residents or visitors” [116]. This pattern of increased surveillance has been observed in other cities, and has been posited by legal scholars as one pathway that promotes law enforcement violence against African Americans, raising important questions about perpetuation of social and racial discrimination through COPS [52]. Finally, community policing coexists in many departments alongside more aggressive policing styles, including increased surveillance and racial profiling, which may be employed to address issues identified in community contexts, even as departments publicly emphasize community-oriented activities [117].

3b: Use of Tasers and other conducted electrical weapons

Another tactic argued to address law enforcement violence is technological tools, such as conducted electrical weapons (known as CEWs or Tasers). While CEWs may be less lethal than handguns, they were associated with more than 500 deaths from 2001 to 2014, 90% of which occurred when the victim was unarmed [118]. Risk of adverse effects from Taser shocks is higher in people who suffer from pre-existing cardiac conditions or other medical conditions - such as being prone to epilepsy, or who are experiencing drug intoxication [118]. Adverse consequences of CEW shocks are also higher after a struggle [118]. Amnesty International and the UN Committee on Torture recommend restricting use of CEWs to situations in which police would otherwise use lethal force [118, 119].

3c: Body- and dashboard-mounted cameras

Increased funding for body-mounted cameras is often put forth as a measure to reduce law enforcement violence because of the presumed increase in transparency and accountability offered by these devices. An oft-cited example of body cameras’ success is in Rialto, California, where reports of use of force by law enforcement dropped by 50% in the first year of body camera implementation, and citizen complaints dropped by 88% [120]. However, more representative studies have found harmful associations of use of force with body camera use, or no association at all. A national study of more than 2,000 departments revealed a statistically significant association of wearable body cameras with a 3.6% increase in fatal police shootings of civilians, and no significant association with use of dash cameras [121]. The largest and most rigorous randomized control trial on the use of body cameras by Washington D.C.’s Metropolitan Police Department (MPD) found that wearing body cameras had no statistically significant effect on use of force, civilian complaints, officer discretion, whether a case was prosecuted, or disposition [122].

Issues of policy, protocol, and intentional sabotage raise additional questions about the efficacy of body and dashboard-mounted cameras in decreasing law enforcement violence or increasing accountability for perpetrated violence. One third of police departments using body cameras do so without written policies, which may give officers discretion over their use and lead to selective recording [123]. Most existing policy on body cameras does not guarantee that law enforcement agencies must make footage publicly accessible, and many other policies are inconsistent or unclear [123]. Recordings may also be deleted by police; in Chicago, 80% of dash-camera video footage was missing sound due to error and “intentional destruction” [124]. Even when key events are recorded, these videos do not necessarily increase accountability because of cultural, institutional, and structural barriers described above.

3d: Training in implicit bias and crisis intervention 

Another oft-touted reform is mandatory training to reduce implicit bias of law enforcement officers against communities of color. This training is predicated on the understanding that officers’ decisions to use (or restrain from) force are influenced by unconscious biases, such as associations between Black individuals and criminality [125]. However, little is known about these biases effects on behavior, and no experimental studies have measured the impact of implicit bias reduction interventions among law enforcement officers [126].

Other methods of proposed training to improve community experiences with law enforcement include Crisis Intervention Team (CIT) training, generalized de-escalation training, and mental health training - which can include interagency collaboration. For example, CIT-trained officers are taught to recognize people suffering from mental illness and crises, de-escalate the situation, and link individuals with mental health care rather than arrest. A systematic review of interagency collaboration models for contact with police for mentally ill people finds that evidence regarding the efficacy of such training and collaboration models is limited, that there have been no robust evaluations, and that existing evidence rarely examines the impact on community experience with police or police use of force - focusing instead on organizational outcomes such as arrest rates - which occur after initial contact with police [127]. In the example of CIT, existing studies are based on data collected from surveys of officers in classroom settings and not actual outcomes with citizens [128]. Public health scholars and organizations including the International Association of Chiefs of Police and National Research Council acknowledge that only very limited evaluation of law enforcement training has occurred, and extant evaluations have focused on officers' attitudes rather than one-the-job performance [129-131]. Officers generally receive limited de-escalation training [132], and national efforts to increase de-escalation training have been met with resistance from police chiefs and the national Fraternal Order of Police [133]. Leaders from these groups have expressed fear that hesitation to use force may put officers’ lives at risk. In this context, it remains to be seen whether de-escalation training will lead to less law enforcement violence, and more rigorous evaluation would be necessary to warrant any scalable implementation.

While it does not address the root causes of law enforcement violence discussed above, CIT and other de-escalation training could function as harm reduction for law enforcement violence. In keeping with this statement’s other recommendations, if additional training of law enforcement officers is used as a harm reduction strategy, then one must consider the investment of funds and other resources required to do so as restitution, ideally using re-allocations from existing law enforcement budgets and savings from eliminating enforcement of laws that do not promote public safety. Further, as previously stated, such programs would require rigorous evaluation to maintain funding. 

To sum up Opposing Argument #3, efforts to improve law enforcement officer behavior are at best unsupported and at worst, perpetuate harm. The notion that escalating law enforcement presence is the antidote to inequality is inherent in these opposing arguments. Even if some strategies demonstrate some benefit, they fall short of addressing the fundamental causes of the issues law enforcement agencies are deployed to address. Moreover, they obscure the fact that law enforcement presence in marginalized communities has historically served to maintain state control over said communities. While President Obama’s Task Force Report on 21st Century Policing recommended training, COPS, and body and dash cameras [62], it did not incorporate upstream, public health strategies to address root causes of law enforcement violence. Though it acknowledged unrealistic roles delegated to police officers, and that policies related to drug use and sentencing affect policing, it deemed these policies “beyond the scope of a review of police practices” [62]. This acknowledgement lends support for an upstream, public health approach to mitigate law enforcement violence, focus on community-based alternatives, and reducing contact with law enforcement. Such upstream approaches will prove even more critical in the context of federal administrations that promote aggressive policing policies and practices.

Opposing Argument #4: LEOBORs protect law enforcement officers from unfair administrators & false accusations.

As described above, LEOBORs were intended as law enforcement protections from aggressive, coercive administrators and false accusations. However, as Jonathan Smith, former chief of special litigation in the Civil Rights Division of the U.S. Department of Justice, stated, LEOBORs and collective bargaining agreements create “barriers to actual accountability that don't serve the public good,” given that law enforcement officers can accumulate multiple complaints and remain employed (and even see upward career mobility) [78]. Provisions in LEOBORs that rightfully protect officers from coercive interrogations when they are suspects of crime – such as conducting interrogations at reasonable times and guarantees they can attend to their biological needs – would better serve public health if extended to all suspects [78].

Conclusion

While public safety is essential for public health, as a society we have delegated this important function almost exclusively to law enforcement. Evidence of continued law enforcement violence shows that U.S. policing has failed to equitably deliver safety, placing an inequitable burden of mental and physical harm on socially and economically marginalized populations [134]. Indeed, as argued by Geller et al., “any benefits achieved by aggressive proactive policing tactics may be offset by serious costs to individual and community health” [13]. Community-centered strategies for addressing harm and violence can increase public safety without the violence associated with policing. Investment in these strategies, as well as comprehensively documenting and intervening in cases of law enforcement violence, is a promising way forward.

XII. Action Steps

Therefore, APHA:     

1.     Urges federal agencies, localities, and states to add death or injury by legal intervention to their list of reportable conditions - including the CDC adding legal interventions to their list of Nationally Notifiable Conditions. APHA further urges CDC to expand the NVDRS to include all states and move to more timely processing and release of data at the local level. APHA urges CDC and the National Center for Health Statistics (NCHS) to create surveillance protocols informed by research on causes of misclassification and underreporting of deaths due to legal intervention, and to provide technical assistance to states to rectify problems.

2.     Urges that Congress fund the National Institute of Justice and the CDC to conduct research on the health consequences, both individual and community-wide, of law enforcement violence, particularly exploring the disproportionate burden of morbidity and mortality among people of color; people with disabilities or mental illness; people who are experiencing houselessness; poor people; LGBTQ populations; and immigrant populations. Funds should also support research to determine how to generate valid estimates of injuries due to police violence.

3.     Urges that Congress also fund the National Institutes of Health to study the effectiveness of interventions that may decrease the reliance on law enforcement, including decriminalization, increased investment in social determinants of health, and community-based alternatives that promote public safety, such as violence intervention and restorative justice.

4.     Urges federal, state, tribal, and municipal governments to fund programs that meet human need, promote healthy and strong communities, and reduce structural inequities (economic, racial, and social) – such as employment initiatives, educational opportunities, and affordable housing – including by using resources currently devoted to law enforcement.

5.     Urges federal, state, tribal, and municipal governments to advance equity and justice by decriminalizing activities shaped by the experience of marginalization, and eliminating officer enforcement of regulations designed to control marginalized people, including, but not limited to, substance use and possession, sex work, loitering, sleeping in public, minor traffic violations (e.g., expired registrations, jaywalking, not signaling a lane change, broken taillights), and targeting undocumented immigrants; and to also ensure that decriminalized offenses are removed from the purview of law enforcement. An existing precedent is the Massachusetts’ Decriminalization of Misdemeanors Law.

6.     Urges federal, state, tribal, and municipal governments and law enforcement agencies to engage in a review of law enforcement agencies’ formal and informal policies and practices in order to eliminate those that lead to disproportionate violence against specific populations – contracting with non-governmental organizations to do so in order to encourage objectivity. Examples of such policies and practices may include racial and identity profiling, stop and frisk, gang injunctions, and enforcement of laws that criminalize houselessness.

7.     Urges federal, state, tribal, and municipal governments to allocate funding from law enforcement agencies to community-based programs that address violence and harm without criminalizing communities, including mental health intervention and violence prevention and intervention, and restorative justice programs, particularly in the communities currently most affected by law enforcement violence. In the development and scaling of newer modalities for addressing and preventing harm, careful consideration should be given to constructing protections for privacy, dignity, and legal rights.

8.     Urges federal, state, tribal, and municipal governments and law enforcement agencies to reverse the militarization of law enforcement, including by eliminating the acquisition and use of military equipment and reducing the number of SWAT teams and the frequency of their deployment.

9.     Urges state legislative bodies to eliminate legislative provisions that shield law enforcement officers from investigation and accountability and urges municipal governments (both executive and legislative branches) to negotiate police union contracts to eliminate barriers to identifying, investigating, and addressing possible law enforcement officer misconduct.

10.  Urges law enforcement agencies and oversight bodies to provide full public disclosure of all investigations of law enforcement officer brutality and excessive use of force as well as access to recordings of any incidents in question, which should be deemed public property. These materials could be made public through an online database.

Appendix A: Glossary Terms

Decriminalization:

Decriminalization refers to the repeal or narrowing of criminal statutes, to remove all or portions of a conduct from the purview of the criminal law. It can also refer to the codification of decriminalization practices, in which a criminal offense remains a part of criminal law, but is no longer enforced [135]. This process differs from legalization, which refers to a legislative regime characterized by significant regulations—many of which can limit rights and protections, create mechanisms for abuse by authorities, and have other negative impacts. While the specific ways in which a jurisdiction enacts decriminalization may differ, there are a variety of examples to learn from. New Zealand and New South Wales, Australia are two jurisdictions known for their decriminalized sex industries [136] while Portugal acts as a model of drug use decriminalization [103]. APHA Policy Statement 7121 explicitly calls for ending criminalization of the use of “alcohol, marijuana, or other substances when no other illegal act has been committed” (7121). Policy Statement 201312 (2013) recommended the removal of “criminal penalties and collateral sanctions for personal drug use and possession offenses” while recognizing that “proportionate criminal penalties may be appropriate—consistent with principles of public health and human rights—for behavior that occurs in conjunction with drug use if that behavior causes or seriously risks harm to others, such as driving under the influence; however, such penalties should not be imposed solely for personal drug possession and use.” (Policy Statement 2012, 2013)

 Sex work: Sex workers and advocates generally classify the sex trade into three categories, with the understanding that there is more nuance within and crossover between these categories: 

• Sex Workers: people who exchange sexual labor for money or goods

• Survival Sex: is by choice, but under circumstances of economic duress, and is often a symptom of intersectional issues of poverty, houselessness, lack of economic options, racism, and transphobia

• Forced sexual labor: (often referred to as “sex trafficking”) people who have been forced, coerced or manipulated into the sex trade.

The Counted: draws from official US databases, media outlets, social media, and crowdsourced websites (such as Fatal Encounters and Killed by Police) to deaths attributable to direct encounters with law enforcement, including, “people who were shot, tasered and struck by police vehicles as well as those who died in police custody” [7].

The Department of Homeland Security Bureau of Immigration and Customs Enforcement (ICE): the largest investigative unit under DHS; it works with other federal and local law enforcement agencies—including local police departments—to enforce immigration policy [138].

Thin blue line ideology: according to Chicano historian Edward J. Escobar, “Chief of Police William H. Parker Described the LAPD as ‘the thin blue line’ that stood between civilization and chaos” [53]. This idea assumes that social problems are due to concentrations of ‘pathological’ people in certain areas and require police to keep 'those' people from harming others. This ideology takes people-with-problems and represents them as problems to be suppressed, detained, or deported, and fails to examine fundamental social-structural issues that linked with unwanted behaviors, and, as such, fails to consider complex strategies to resolve these issues. Moreover, this way of viewing people and issues of safety is countered by a public health approach of addressing social and structural determinants of health.

War on drugs: “President Reagan officially declared the current drug war in 1982, when drug crime was declining, not rising. From the outset, the war had little to do with drug crime and nearly everything to do with racial politics. The drug war was part of a grand and highly successful Republican Party strategy of using racially coded political appeals on issues of crime and welfare to attract poor and working-class white voters who were resentful of, and threatened by, desegregation, busing, and affirmative action. In the words of HR Haldeman, President Richard Nixon’s White House Chief of Staff, ‘[T]he whole problem is really the blacks. They key is to devise a system that recognizes this while not appearing to” [49].

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