Applications of the American Public Health Association’s Statement on Addressing Law Enforcement Violence as a Public Health Issue

In 2018, the American Public Health Association (APHA) adopted a policy statement recognizing law enforcement violence as a public health issue. The statement was informed, in part, by a public health literature that documents consistent associations between law enforcement violence and adverse health outcomes, including physical health (e.g., injury), mental health (e.g., posttraumatic stress disorder), and death.¹ This literature also finds inequitable distributions of law enforcement violence that disproportionately target Black, Latinx, and Native American communities; immigrants; people who identify as transgender; people who identify as lesbian, gay, bisexual, or queer; those experiencing houselessness; low-income individuals; sex workers; and people who use drugs.¹ Rooted in an understanding of how structural racism and institutional oppression shape population patterns of law enforcement violence, the statement proposes a public health alternative for ensuring public safety and well-being.

For this editorial, we examined the extent to which the statement’s recommendations have been implemented. A summary of our findings, including illustrative examples as well as further opportunities to leverage the statement in support of upstream, public health approaches to intervening on law enforcement violence, follows.

ACTION STEPS

Supported by evidence suggesting that deploying the criminal legal system to address activities precipitated by inequitable distributions of resources is costly, ineffective, and health harming, the statement instead recommends a public health–centered approach. Based on existing, multigenerational work by grassroots, antiracist organizing campaigns against state-mediated violence and community members most directly affected by such violence, the statement’s 10 action steps for understanding and addressing law enforcement violence comprise four broad categories: (1) improvements to data collection and research; (2) reallocation of resources, including reversal of militarization; (3) decriminalization; and (4) structural changes to law enforcement policies and procedures (see the box on page S31). For a comprehensive list of each action step, see the full policy statement.¹

ADDRESSING LAW ENFORCEMENT VIOLENCE AS A PUBLIC HEALTH ISSUE STATEMENT ACTION STEPS AND EVIDENCE.

Summary	Evidence	APHA Action Step No.
Improvements to data collection and research	In the United States, data on deaths and injury caused by legal intervention are not reliably or comprehensively collected. As with the CDC’s National Violent Death Reporting System, this is partly attributable to the voluntary nature of agency reporting. This approach poses a challenge for estimating the prevalence of law enforcement violence and related health outcomes. For example, in 2015, the US National Vital Statistics System underestimated deaths by law enforcement by as much as 55%. By contrast, nongovernmental, Web-based social media data sources, such as The Guardian’s The Counted, captured 93% of deaths by law enforcement in 2015, demonstrating that a comprehensive data collection mechanism is feasible.	1–3
Reallocation of resources and reversal of militarization	Government spending on social services has decreased since the 1980s while spending on policing has increased. By contrast, the literature suggests that increasing access to housing, education, employment, mental health, and substance use treatment; addressing structural factors that contribute to experiences of discrimination; and facilitating community-based, trauma-informed approaches to interpersonal harm and crisis response are associated with reduced community trauma and interpersonal harm, improved health, and cost savings. Similarly, implementation of a health-in-all-policies approach, inclusive of rolling back legislation promoting militarization, has been linked to harm reduction.	4, 7, 8
Decriminalization	Mass criminalization is a mechanism through which structurally marginalized communities experience increased risk of law enforcement violence. Notably, law enforcement intervention has not been shown to reduce criminalized activities. Decriminalizing stigmatized activities, such as drug use, and investing in public health alternatives have been linked to reductions in encounters with law enforcement and improvements in health outcomes.	5
Structural changes to law enforcement policies and procedures	Structural components of the law enforcement system may impede meaningful action toward accountability or reform. For example, local police union contracts and state-based Law Enforcement Officers’ Bills of Rights enforce suppression of data related to deaths and disciplinary records and promote investigative delays. Furthermore, procedural guidelines, such as stop and frisk and gang injunctions, have been linked to increased surveillance of marginalized groups.	6, 9, 10

Note. APHA = American Public Health Association; CDC = Centers for Disease Control and Prevention.

Source. APHA.¹

APPLICATIONS OF THE STATEMENT

We present examples of how these action steps have been leveraged to advance cross-sector efforts to address law enforcement violence.

Education

Raising awareness of this public health framing is key to achieving the systemic change necessary to address law enforcement violence as a public health issue. To that end, the statement’s formal adoption generated multimedia coverage (e.g., mainstream press, social media, radio shows) across sectors, emphasizing its broad applicability and infusing the ongoing national conversation on law enforcement violence with a public health framing. Adapting the statement as an educational tool in academic settings has also increased its accessibility to learners in public health and beyond. For example, the statement has been used in a University of Michigan School of Public Health course (William Lopez’s “Health Impacts of Immigration Law Enforcement in the US”) in which students review literature on policing, draw connections between immigration enforcement violence and police violence, and examine the role of marginalized communities in resisting state violence.

Research

In addition to summarizing the existing literature, the statement has itself been cited in peer-reviewed publications to highlight the need for further research on systemic inequities in law enforcement violence.^2,3 It has also been used to inform ongoing efforts to fill existing data gaps. For example, The Justice Study, a project led by the University of California, San Francisco, and Santa Clara University used research gaps identified in the statement to inform their survey development, with preliminary findings forthcoming.⁴

Practice

The statement applies a public health framing to align existing efforts to understand and intervene on law enforcement violence across sectors and disciplines, including public health practice and grassroots organizing. For example, before its adoption by APHA, community organizers convened a multidisciplinary audience at a local community center for a learning session entitled “Health Equity Now: Ending Police Violence.” Using the statement as a resource, the session hosted local activists, scholars of sociology and criminal legal studies, medical providers, public health researchers, and surviving family members of Alfred Olango, a San Diego, California, resident killed by law enforcement. Once adopted, the national grassroots organization Critical Resistance and Bay Area–based Public Health Justice Collective gathered public health workers, clinicians, and advocates to discuss strategies and share resources for its implementation.⁵

Policy

Several of the statement’s action steps seek to inform federal, state, tribal, and municipal policies. As a result, policy research and advocacy organizations, grassroots activists, and others have cited the statement in public testimony and open letters against proposed state and local legislation to form private armed forces (Maryland), entrench gang databases (Cook County, IL), newly construct jails (Los Angeles, CA), criminalize houselessness (San Francisco, CA), and host Urban Shield’s militarized SWAT training—succeeding in diverting federal funding to demilitarized disaster preparedness trainings (Alameda County, CA).⁶ In several instances, copies of the policy statement were distributed as a resource for policymakers after testimony.

FUTURE DIRECTIONS

Altogether, these examples illustrate how the statement has been used to support a public health approach for intervening on law enforcement violence and improving health equity. Yet, more opportunities remain. For example, while crowd-sourced, open data sets such as The Counted have endeavored to document real-time US legal-intervention injuries and deaths, the need for a nationwide, mandatory-reporting database still remains.^1,7 Thus, researchers may leverage the statement to advocate establishing this database. Policymakers may also turn to its evidence sections to inform public health–oriented policy alternatives (e.g., divesting from youth jails and investing in school spaces). Furthermore, although the statement’s recommendations are tailored to a US context, they could also serve as a basis for new and ongoing efforts among those seeking to understand and address harm perpetrated by law enforcement and other expressions of militarized state violence as a public health issue internationally. Ultimately, the statement can serve as a unifying resource—using an upstream, community-based, community-led framework to align the efforts of public health educators, researchers, policy advocates, organizers, and activists to address law enforcement violence.

CONCLUSIONS

APHA has officially recognized law enforcement violence as a public health issue that warrants an orchestrated public health–centered intervention. A public health approach neither accepts harm as a given nor accepts punishment as prevention. Rather, a public health approach divests from a punishment framework and invests in a prevention framework, centering community-based and community-led efforts to public safety and well-being. This includes shifting the conditions in which people live, work, and go to school by committing financial and human resources to the social determinants of health (e.g., education, housing, economic opportunity). As such, the APHA policy statement proposes evidence-based, structural interventions for minimizing exposure to law enforcement violence and its health consequences. In this editorial, we have provided examples of how these action steps are indeed actionable. Specifically, we have highlighted instances in which the statement has been leveraged for public health action and noted opportunities for further application.

As the issue of law enforcement violence continues to feature in national conversations and garner energy around reform, public health has a key role to play. As researchers and practitioners, the public health workforce is well-positioned to contribute to the ongoing work of organizers and community members most affected by (1) documenting the structural determinants and health consequences of law enforcement violence and (2) informing structural interventions to address them. In short, to address law enforcement violence as a public health issue, it is critical that the public’s health and well-being be prioritized.