• Policing Standards

    Introduction

    Negative interactions with law enforcement are associated with harmful impacts on individual and community health. They pose a serious risk, diminishing physical health and mental well-being. Moreover, systemic health inequities experienced by Black, Indigenous, and people of color (BIPOC) are further exacerbated when they have negative interactions with law enforcement.

    The American Academy of Family Physicians’ (AAFP’s) mission is to improve the health of patients, families, and communities by advancing family medicine. We can’t achieve our mission when current standards of policing do not adequately prioritize individual and community health; when the act of policing leads to death or injury of unarmed citizens; and when disparate harms caused by inadequate police training and discriminatory policing practices lead to frayed community bonds and entrenched mistrust.

    One of the core functions of policing is to enhance public health and safety by serving as first responders and providing protection from, and as a deterrent to, crime. The AAFP acknowledges that the responsibilities of police and law enforcement are often inherently dangerous, involving life-threatening circumstances and requiring expeditious intervention. However, this risk in no way excuses or explains the significant number of people killed or injured by police in the United States each year, the burden of which disproportionately affects Black Americans and other people of color.

    The AAFP urges police and law enforcement agencies to develop, implement, and practice policies and procedures that reduce the risk of harm to the public, with particular attention on impacts to BIPOC and other marginalized populations. As a specialty, family medicine must provide input into these reforms. Family physicians stand at the forefront of longitudinal care, serve as an arm of public health, and bear witness to the destructive impacts of the social determinants of health (SDoH). This collective insight can be harnessed to maximize public health and safety.

    Call to Action

    Physician Level

    • Understand health inequities in your community and raise awareness of these issues to the public and policymakers
    • Recognize risk factors for exposure to violence and traumatic stress and ask patients about their experiences with violence; this helps patients understand that violence is related to their health conditions and allows them to talk openly about its impact within the context of their health
    • Know the organizations working to improve equity and access to social support services in your community and have a process to refer community-based social services and other resources for care

    Practice Level

    • Create a practice culture that values health equity by addressing implicit bias in your practice and using cultural proficiency and health literacy standards
    • Promote trauma-informed care, which involves understanding sources of trauma and its interaction within and among individuals and how that relates to health and health care utilization
    • Ensure that office staff and other team members in the practice are trained to assess and recognize signs of trauma, chronic stress, and violence exposure and respond comprehensively

    Community-leadership Level

    • Advocate for diversion programs and community alternatives to incarceration
      • An individual’s first court appearance is an opportunity to divert their mental or behavioral health needs away from the traditional criminal justice system. Mental health courts coordinate the expertise of judges, prosecutors, defense attorneys, and treatment experts to address defendants’ mental health needs while still holding them accountable for their actions.
    • Advocate for Health in All Policies (HiAP), which includes racial impact statements in community and municipal regulations and policies, including policing standards
    • Support funding for evidence-based social support programs
    • Lead or participate in community-based participatory research to identify, implement, and evaluate community-based alternatives to policing

    State Level

    • Support legislation that improves access to health care upon release from prison or jail
      • Thirty-three states and Washington, DC, have legislation allowing Medicaid coverage to be suspended, rather than terminated, upon incarceration. Suspending coverage for those incarcerated (instead of terminating it) can reduce delays in access to benefits upon their release by months.1
    • Advocate for HiAP that includes racial impact statements in state laws and policies
    • Support efforts to reopen and sustainably fund state hospitals and other critical community health care, including eliminating Medicaid exclusions for hospitalization and long-term treatment and care

    National Level

    • Advocate for sustainable investment in comprehensive mental health services that include long-term treatment and care
    • Advocate for sustainable funding (such as the Crisis Stabilization and Community Reentry Act of 2020) for states, tribes, local governments, and community-based nonprofit organizations to provide clinical services for people with serious mental illnesses and substance use disorders who need mental health services upon release from a correctional facility2
    • Advocate for federal research funding to enable states and local communities to identify, implement, and evaluate community-based alternatives to policing
    • Advocate for HiAP that includes racial impact statements in laws and policies, including, where reasonable, federal guidelines in policing standards

     

    Racism as a Public Health Crisis

    A system of racism structures opportunity and assigns value to individuals within society based on how people look – this is the social perception of race. Racism unfairly disadvantages some individuals and communities and unfairly advantages other individuals and communities by establishing implicit and explicit practices, procedures, and policies that reinforce this imbalanced system of opportunity.3

    Explicit bias is the conscious beliefs, attitudes, and assumptions we have about groups of people that impact the way we interact with those groups. Implicit bias is the unconscious beliefs, attitudes, and assumptions we have about groups of people that impact the way we interact with those groups.4 Explicit and implicit bias both perpetuate systemic racism and lead to more significant inequities and increased disparities. Systemic racism has played a crucial role in decreasing access to health care for BIPOC by affecting the flow of human and financial resources into communities of color across generations, making it challenging to establish and maintain health care facilities in those communities.5 Understanding, recognizing, and addressing systemic racism as a root cause of health inequities is necessary to reduce health disparities.6

    The AAFP condemns racism in all forms and has encouraged leaders from federal, state, and local governments, as well as private, medical, and community organizations, to develop a national response to address systemic racism. The AAFP has also supported federal legislation to officially recognize racism as a public health issue and declare a public health emergency to address the negative impacts racism has on the physical and mental well-being of millions of people. The AAFP supports attaining the highest level of health care for all people and stands opposed to the systemic racism that persists in our society and many of our institutions, including health care and policing.

    Race and Policing

    Structural racism, bias, and the use of violence by police have long and complicated histories within BIPOC communities. In the United States, the modern policing system developed out of the slavery-era system of escaped slave patrols in the American South.7 Current policing practices are inextricably linked to a broader history of surveillance, intimidation, and use of violence.8

    The death of George Floyd while in police custody in Minneapolis, Minnesota, in May 2020, dramatically increased public awareness of the effects of racism in policing practices and the consequences on morbidity and mortality among BIPOC. Data show significant disparities in police-involved injuries and killings by race in the United States. For example, a Black American is five times more likely to experience an injury by police compared to a white American.9 The probability of a Black American of any age being shot and killed by the police is three times that of a white American.9 The probability of a Black teenager being shot and killed by the police is 21 times that of a white teenager.9 In fact, being killed by police is the sixth leading cause of death for young Black men.10

    Systemic racism, bias, and discriminatory policing have led to significant disparities throughout the criminal justice system, including incarceration rates among BIPOC and white Americans.11 An estimated 15% of Black men in the United States have been incarcerated.12 The health impacts of incarceration are wide-ranging. They include long-term physical and mental health implications and serious challenges to secure employment, housing, and financial stability.13 These outcomes are exacerbated in BIPOC communities, where economic inequities from generational poverty and low-wage jobs further increase the likelihood of housing insecurity, food insecurity, other racial disparities, and adverse health outcomes.14,15

    Negative encounters with law enforcement are also linked to heightened mistrust and avoidance of health care institutions.16 Therefore, an individual’s interactions with police can be detrimental to their health, even if the encounter does not result in injury, death, or incarceration.9 Data show an association between police violence and mental health conditions such as post-traumatic stress, anxiety, and depression for people of all races. The adverse health outcomes of racial bias in policing can affect BIPOC even if they do not have any direct interactions with police. Individuals who live in a neighborhood where lethal policing has occurred are more likely to have high blood pressure and other chronic disease risks.17 This is likely, in part, due to the potential threat of mistreatment by police.9,18 Given the significant impact on physical and mental health, it is imperative that medical and public health organizations work with policing and judicial systems to address racial bias and improve the health of BIPOC.

    Police-involved Killings

    Police accounted for 8% of all homicides of adult males between 2012 and 2018.19 That is 2.8 men killed per day. The racial breakdown of police-involved killings shows that Black men’s mortality risk is 3.2-3.5 times higher than white men. Latino men’s mortality risk is 1.4-1.7 times higher than white men.19 However, tracking race alone may not fully explain police-involved killings. For example, individuals who live in neighborhoods with the highest concentration of racial/ethnic minorities are at the highest risk of being killed by a police officer. However, data also shows that non-Hispanic Black individuals were at higher risk for death by police in neighborhoods with the highest concentration of non-Hispanic whites compared to certain neighborhoods with high concentrations of residents of color.20 This shows data on police-involved killings must also be rooted in a context beyond a breakdown by race or ethnicity. Racial composition and income breakdown of neighborhoods may significantly alter police officer behavior, and with expanded research, areas for intervention can be explored.

    Still, the number of police-involved killings is likely underreported each year due to the historical lack of a nationwide tracking and reporting system. The National Violent Death Reporting System (NVDRS), established by the Centers for Disease Control and Prevention (CDC) in 2018, is the first comprehensive national database for tracking violent deaths, including killings committed by police. While the NVDRS has some of the most complete data on police-involved killings compared to previous methods, it has only been collecting data on all states, Washington, DC, and Puerto Rico, since its inception in 2018. The NVDRS also does not track nonfatal injuries caused by police, which leaves significant gaps in the broader understanding of police violence. Consistent delays in reporting may also impede efforts to timely track and inform policymakers to implement public health interventions.21

    Youth Interaction with Police

    Youth 16-24 years have more frequent interactions with the police than any other age group.22 These interactions fall into four main categories: youth-initiated, including reporting a crime or seeking assistance; police-initiated, which is often involuntary and includes an officer stopping a youth on the street or while driving; contact resulting in arrest; and contact due to victimization, including youth being a victim of a crime, witnessing a crime, or being exposed to the victimization of others.22 These interactions can have long-lasting effects, including sleep deprivation and lower sleep quality,23 and worse long-term physical and mental health outcomes, including emotional distress and post-traumatic stress disorder symptoms.24

    During the past 30 years, there has been an increase in community-police interactions, particularly for youth and communities of color. Youth have especially had more interactions with police through zero-tolerance school discipline policies, the rise of school resource officers (SRO), stop-and-frisk policies, and other measures that increase police presence in neighborhoods.25 SROs are law enforcement officers trained to protect the safety of the school environment. In many schools, they mentor and counsel students and connect them to community resources. However, the increased presence of police in schools increases interaction with the criminal justice system. One study showed that while schools with SROs were less likely to have student arrests for weapons charges, they were five times more likely to have arrests for disorderly conduct than those without SROs. After accounting for school poverty, disorderly conduct arrests occur at similar rates.26 However, schools with SROs deferred punishment more often to the SRO than handling it within the school discipline protocols, increasing youth interaction with the criminal justice system. In addition, schools with 25-50% or more Black and Latinx students had a greater rate of SRO presence than those with 10% or less Black or Latinx youth, again increasing the opportunity for minority youth interaction with police and the criminal justice system.27 Another study similarly showed that SROs resulted in fewer student arrests for weapons and assault charges but an increase in arrests for minor infractions such as disorderly conduct.27

    The majority of youth typically age-out of delinquent behavior.25 While white and minority students self-report similar rates of participation in delinquent behavior, Black youths are 3 times more likely to be arrested for a drug offense, 2.5 times more likely to be arrested for a property crime, and 2.7 times more likely to be arrested for violating curfew laws when compared to white youth.28

    “Whether a youth is detained or not for minor delinquency has lasting ramifications for that youth’s future behavior and opportunities. Carnegie Mellon researchers have shown that incarcerating juveniles may actually interrupt and delay the normal pattern of ‘aging out’ since detention disrupts their natural engagement with families, school, and work.”29

    Increased interactions with police result in an increased rate of arrests and incarcerations. Between 2007 and 2017, the United States experienced a 50% reduction in youth incarceration.30 Despite the decrease, the racial disparity in incarceration has not only persisted but worsened. Black youth are 4.6 times more likely, American Indian youths are 3 times more likely, and Latinx youth are 42% more likely to be incarcerated than whites.30

    Reductions in disparity occur when states make overall system changes to reduce juvenile participation in the criminal justice system. Examples of changes include restorative justice programs, raise-the-age legislation, which protects minors from entering the adult prison system, and community-based programs in mental health counseling and violence prevention.30 Racial impact statements, or commitments to explore how changes to law and policy may diminish or exacerbate disparities, are essential in preventing and mitigating unintentional racial inequities.30

    Policing and Mental and Behavioral Health

    There was a significant shift toward deinstitutionalizing mental and behavioral health treatment during the latter half of the 20th century, with widespread closure of public and private asylums, mental health hospitals, and state-run inpatient care facilities.31 Scientific advances in psychiatric medications, greater acceptance and reduced stigma for individuals diagnosed with mental illness and behavioral health conditions, and federal funding for Medicaid and Medicare enabled many mental and behavioral health conditions to be treated in outpatient community mental health centers instead of mental health institutions or state-run inpatient care facilities.32,33 Between 1955 and 1994, there was a reduction in the nation’s public psychiatric hospitals of more than 487,000 patients who had a mental illness condition. States closed many of their psychiatric hospitals, which permanently reduced long-term inpatient care across the country.31

    Deinstitutionalization gave rights to many people with mental illness but also led to more of those individuals living in local communities than ever before.31 While there were obvious benefits to treating patients in community settings, one challenge was an increased reliance on first responders, including police, to respond to mental and behavioral health crises.34 The permanent closure of inpatient facilities also meant that many patients with severe mental illness, who were not good candidates for treatment in community settings, were left with no facilities for care. At the peak of institutionalization in 1955, more than 300 psychiatric beds were available per 100,00 people in the United States.35 By 2010, there were only 14 psychiatric beds per 100,00 people – equal to the number of psychiatric beds per 100,000 people in 1850.39 Without necessary treatment and care, individuals in acute or chronic psychiatric crises have direct altercations with police and/or are booked in jails or prisons.34,36

    Policing Practices Related to Mental Health Crises

    Police response to situations involving people with mental or behavioral health disorders has increased dramatically in recent years. In North America, mental and behavioral health crises account for between 1-20% of all service calls to police.37 Unfortunately, police officers are often not adequately trained to respond or deescalate situations involving individuals in a state of psychiatric crisis. Nearly one in four people shot and killed by police officers between 2015 and 2020 had a mental health condition.38 Uncertain policing practices related to mental health, combined with consistent shortages and underfunding of mental health services, have led to a significant overrepresentation of individuals with mental health conditions in jails and prisons across the country. In fact, 37% of people incarcerated in state and federal prisons and 44% of people held in local jails were informed by a medical health professional that they have a mental health disorder.36

    Community treatment and diversion programs, such as the Forensic Assertive Community Treatment (FACT) program, have been a success for adults with mental health disorders charged with a misdemeanor. Individuals in the FACT program experience fewer convictions and days spent in jail, and more days spent in outpatient mental health treatment.39 Some communities have success with specialized crisis intervention training (CIT) programs to help police identify and navigate situations involving mental or behavioral health crises. Although more research is needed, CIT programs improve police response to encounters with individuals with behavioral and mental health disorders. The program has the upstream benefit of decreased arrests rates and legal costs.40 Similar programs of police responding to individuals experiencing suicidal ideation increased feelings of officer preparedness. Likewise, programs increase the likelihood police officers will direct people to mental health treatment and community services rather than leaving them on the scene or bringing them to jail.41

    Policing Practices Related to Substance Use

    Substance use accounts for a sizeable number of arrests in the United States. In 2017, 10.5 million arrests were made, with 15% involving illicit drugs and 9% involving people driving while intoxicated with alcohol.42 Even in states that passed legislation to reduce the criminalization of substance use disorders and mental and behavioral health disorders and increase financial support for treating conditions, there were still racial disparities in arrest rates. For example, after Proposition 47 passed in California, there was a decline in felony drug arrests for all racial groups, and Blacks had the most significant decrease in felony drug arrests. However, when looking at the proportional reduction of felony drug arrests for each racial group, Blacks had the smallest proportional decrease, which led to a widening disparity in felony drug arrests between Blacks and whites. After Proposition 47 passed, Blacks were three times more likely to experience a felony drug arrest than whites, compared to two times more likely before its passage.43

    There are many possible explanations for differences in drug and alcohol arrests and incarcerations between racial groups. The war on drugs led to disproportionate policing and arrests for substances such as crack cocaine, which were more likely to be used by BIPOC.44 Public and semipublic sales of alcohol and drugs are more common in communities of color. The sale of alcohol and drugs is also more likely to occur between unfamiliar parties in communities of color. Policing crimes considered minor, such as drinking in public, also disproportionately affects communities of color.45 Despite racial disparities in drug and alcohol arrests in the United States, whites and BIPOC use and sell drugs at similar rates. Public and mental health experts and the criminal justice system must work together to address policies and institutional practices that mistreat certain groups when it comes to substance-related arrests and incarcerations.44

    Policy Implications and Models for Community Alternatives to Policing

    A growing body of evidence demonstrates the efficacy and sustainability of funding community alternatives to traditional policing models. The research has inspired public policy conversations about whether, and/or to what extent, to defund the police. The defund the police movement calls for reallocating funds from police departments to non-policing public safety and community support. Examples include social services, youth and senior services, housing assistance, adult

    education, health care, and other community resources. This paper does not intend to promote or support the defund the police movement but rather to examine a change in funding priorities and its potential impact on public health.

    Tracking specific police spending is difficult due to how funds are distributed across local, state, and federal governments. However, police funding accounts for more than 9% of local government spending (second only to education) for a total of $193 billion in 2017.46 Between 2000 and 2017, state and local police protection expenditures overall rose 26%.47 Reallocating police funding to professionals in other community support fields (e.g., mental and behavioral health crisis intervention specialists, social workers, community health workers) to respond to certain situations is a sensible step to empower communities to identify and solve issues.

    The AAFP supports reforms to policing practices that mitigate disparities caused by biased and discriminatory policing, reduce health disparities caused by traumatic stress and over-policing in communities of color, and reduce the risk of exposure to direct and indirect police-related violence to members of the public – with particular attention to the impact on BIPOC and other marginalized populations. Successful interventions should encompass system-wide, anti-racist strategies at the community and policy levels. Additional research and funding are needed to identify and evaluate scalable, evidence-based reforms to current policing practices. The following is a non-exhaustive list of best and promising alternative approaches to traditional policing:

    • Community-oriented policing, emphasizing partnerships and problem solving over violence and punishment
      • Training to emphasize de-escalation and making it clear in use-of-force policies that deadly force is the last option
      • Prioritizing diversity in police recruitment
      • Reforming community-oriented policing; efforts in Camden, New Jersey, have led to a 42% drop in violent crime during a seven-year period with an overall reduction in crime from 79 crimes per 1,000 people to 44 crimes per 1,000 people48
    • Routing calls from the police department to a community response department (staffed by medical, social work, and mental and behavioral health professionals) for situations involving medical, mental health, disability-related, or other behavioral or social needs49-51
    • Using a separate, unarmed force for all traffic enforcement and directing traffic officers to only issue citations and not make arrests or conduct searches50
    • Using sobering centers as an alternative to incarceration for individuals publicly intoxicated
      • Creating a safe environment for people to get sober and seek recovery services without legal consequences or entering the criminal justice system
      • Decreasing public intoxication jail admissions; Houston, Texas, decreased their public intoxication jail admissions by 95% during a five-year period52
    • Using mental health courts and other community diversion alternatives to incarceration, including critical connections to vocational and housing assistance services
    • Mental health courts reduce recidivism and may reduce the number of encounters with police.53,54

     

     

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    (January 2022 COD)

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