Policing, health care, and institutional racism: Connecting history and heuristics

1. INTRODUCTION

Alang et al.'s article in this issue of Health Services Research, “Police Brutality and Unmet Need for Mental Health Care,” ¹ identifies an important association between negative police encounters and self‐reported unmet need for mental health care. While the authors are careful not to make any causal attributions, the paper—implicitly and, at times, explicitly—postulates that people who experience police brutality may additionally hold heuristics regarding their reception and treatment across institutional settings. Heuristics, which involve mental shortcuts used to reduce cognitive load, can function unconsciously and in response to a variety of triggers, influencing how people understand and make sense of the world around them. Further, the authors present how these particular heuristics may be associated with additional adverse mental health outcomes, particularly for people of color.

Their analysis contributes to an important and growing body of literature connecting police brutality to adverse health outcomes, both mental and physical, and the role these experiences may play in exacerbating racial health inequities. Additionally, this article adds to a related but often overlooked body of work examining the complex relationships between individual experiences, historical and contemporary racism, interpersonal and institutional trust, and clinical outcomes. Increasingly, this literature is essential for clinicians and researchers to integrate into their work, particularly at a time when COVID‐19 vaccine hesitancy has raised national awareness about the impact of mistrust between racially minoritized populations and the US health care system.

2. THE PAPER'S KEY FINDINGS

Alang et al.'s article begins with the observation that a growing body of research connects police brutality with mental health issues—from psychological distress to post‐traumatic stress disorder and suicidal ideation. The authors add to this research by investigating how experiences of police brutality may be associated with relational dimensions of accessing care, and subsequently, with unmet need for mental health care. Specifically, Alang et al. explore the connection between experiences of police brutality and feelings of mistrust and disrespect in health care. Further, they evaluate whether any rupture of trust or perception of disrespect appears to reduce the likelihood of seeking and receiving mental health care. As hypothesized, they find that those who report exposure to negative police encounters are also more likely to (a) report being treated with less respect in health care settings, (b) convey higher levels of medical mistrust, and (c) have higher odds of unmet need for mental health care. Unmet need was additionally associated with higher odds of depressed mood, generalized anxiety, and activity limitation.

Especially notable is their analysis highlighting the role of race in connections between experiences of police brutality and unmet need for mental health care. In this subgroup analysis, the authors first examine individuals who report no negative police encounters, finding no association between levels of trust/perceived respect in health care and unmet need for mental health care. In fact, Black respondents and respondents who reported multiple races or “other race” within this subgroup were less likely than White respondents to report unmet need. However, in a subgroup of individuals who report “negative and unnecessary” encounters with police, the opposite is true: mistrust and perceived disrespect in health care are associated with a higher odds of unmet need, with Black respondents having higher odds of unmet need for mental health compared with White respondents. These findings suggest that Black individuals who experience police brutality may have a fundamentally different relationship with health care than those who do not. As the authors write in their discussion, “this pattern highlights the salience of police encounters as indicators of racism that shape relationships between Black people and medical institutions.” While their analysis is cross‐sectional and does not specifically interrogate causal relationships between experiences of police brutality and perceptions of mental health care, these findings are nonetheless instructive and warrant further review of the potential mechanisms that underlie this association.

3. THE ROLE OF RACE IN INTERPERSONAL AND INSTITUTIONAL TRUST

This study's findings align with a body of literature demonstrating that race frequently influences the interdependence between interpersonal and institutional trust. Campos‐Castillo et al. write that for “minority, female, and low‐income patients, who may be more likely to experience discrimination … a lack of trust may not necessarily be focused on a single provider. Rather, negative experiences with one provider may lead to lower trust of the healthcare sector in general.” ² As an example, in a widely cited study of 1784 patients with cardiovascular disease, both Black and White patients endorsed the existence of racism in health care; however, Black patients reported higher mistrust and lower satisfaction with health care. ³ Another study of 776 Black and White patients found that while societal mistrust was higher among Black patients, this variation could not be completely explained by health care factors, including trust in one's physician, previous discrimination, or awareness of the Tuskegee Syphilis Study. ⁴ Yet another example involves empiric data from 504 adults in Chicago, suggesting Black individuals are significantly more likely than White to experience police violence, which additionally predicts hypervigilance—a state of heightened sensitivity to one's surroundings. High levels of hypervigilance were also associated with an increase in systolic blood pressure by 8.6 mm Hg, a magnitude that correlates with nearly 50% higher risk in cardiovascular events in the Framingham Heart Study. ⁵ Taken together, these prior findings raise concern that—particularly for racialized minorities—negative experiences in institutional settings likely reinforce the notion that institutions in general are not intended for them and cannot be trusted, and that they need to be hypervigilant or “on‐guard” in these surroundings. The origins of this dynamic appear deep‐seated and embedded within the larger framework of structural racism, which has differentially restricted Black peoples' access to goods, services, and opportunities (e.g., education, housing, health care) for generations and likely has profound heuristic implications.

4. HISTORY, TRUST, AND THE DEVELOPMENT OF BLACK AND WHITE SPACES

The role of race in connections between interpersonal and institutional trust likely reaches far beyond present‐day encounters to the extensive history of racialized violence in the United States. In his influential 2015 publication, “The White Space,” Yale sociologist Elijah Anderson points to how historic forces have shaped the way race influences peoples' experiences of everyday institutions and settings. Anderson traces the emergence of informal Black and White spaces in contemporary American society, recounting the impact of slavery and state‐sanctioned racial segregation, leading to both de jure and de facto spatial segregation in American cities and towns. He explicates how “police officers, taxi drivers, small business owners, and other members of the general public often treat Blackness in a person as a ‘master status’ that supersedes their identities as ordinary law‐abiding citizens.” ⁶ As a result of these processes, Anderson noted that when Black Americans are present in “the White Space” and determine that a setting is “too White,” Black people “can feel uneasy and consider it to be informally ‘off limits’. For Whites, however, the same settings are generally regarded as unremarkable, or as normal, taken‐for‐granted reflections of civil society.” ⁶ As Anderson notes, because of their different experiences across the arc of American history, Black and White people frequently experience settings and institutions differently—as foreign and hostile on the one hand versus commonplace and welcoming on the other. As a result of these variations, the ways in which they interpret and negotiate these spaces differ accordingly. The notion of “the White Space” may partially explain Alang et al.'s finding that Black peoples' experiences of police brutality were associated with higher odds of health care mistrust/disrespect compared with White peoples' experiences—because health care institutions may be frequently perceived as “White Spaces.”

In unpacking Alang et al.'s finding that police brutality appears to have particular salience in distinguishing racial minorities' experiences in health care, we, like Anderson, feel that it is instructive to state explicitly the historical dimensions of these institutions, which may serve to contextualize present health disparities. These histories encode and explicate structural forces by which experiences of interpersonal or institutional racism in one setting may readily influence expectations and experiences in others, particularly policing and health care.

5. RACISM AND POLICING: A HISTORICAL PERSPECTIVE

In the wake of recent high‐profile killings of unarmed Black people, captured on video and disseminated across media platforms, much attention has been paid to the racialized history of policing and criminal justice in the United States. Scholars across disciplines have documented the centrality of race in policing and criminal justice in the United States. Numerous studies find that legislative and enforcement tactics, which have “the desire to regulate and subjugate the behavior of [Black people]” as a “primary impetus,” have roots that stretch beyond the founding of the country. ⁷ These studies chronicle how the country's first semiformal, organized policing forces emerged to combat the perceived threat of slave insurrection and the “recurrent problem of slaves fleeing captivity.” While these “slave controls” were initially informal and voluntary, the passage of the 1850 Fugitive Slave Act gave the states broad authority to compel individuals to join more formal iterations of these early police forces, which had legal authority to physically punish runaway slaves. ⁷ , ⁸ , ⁹

Following the formal emancipation of slaves, Black Codes emerged as a way to exert economic and social control, with enforcement by law officers. ⁷ These laws required free Black people to provide documentary evidence of employment while also preventing them from seeking employment outside of farming and domestic labor. Violations were punished with a wide range of control tactics from fines to service on chain gangs and involuntary labor. As these Black Codes came under attack, Jim Crow laws emerged to enforce racialized segregation. In the North, racial redlining, combined with tactics of intimidation and systemic harassment by law enforcement, ensured informal structures of racialized segregation and the concentration of poverty in Black neighborhoods. Such spatial and economic segregation facilitated the differential distribution of public goods and police practices. ⁷

Following the Civil Rights Movement of the 1950s and 1960s, many have convincingly argued that the War on Drugs also arose as a tool of enforcing historic patterns of discrimination, leading to immense racial disparities in incarceration. ⁷ , ¹⁰ As a result of this centuries‐long history, police have become an interpersonal face to the institutional and systemic racism frequently, persistently, and disproportionally experienced by Black people in the United States. Given this history, police brutality against racialized minorities can be frequently and correctly understood by those who experience it as what Professor Anderson would call a “most dramatic” interpersonal manifestation of institutional racism. ⁶

6. RACISM AND HEALTH CARE

Though perhaps less recent attention has been paid to the history and ongoing presence of interpersonal as well as institutional racism in health care, there are many reasons to view health care settings as a “White Space.” The 1932 Tuskegee Syphilis Study is likely the most well‐known example of racialized violence in medical research, but experimentation on and poor treatment of racial and ethnic minorities has been ubiquitous and pervasive. ¹¹ In 2003, the Institute of Medicine released its landmark report that evidence of institutional, interpersonal, and implicit forms of racial bias exists throughout the health care delivery continuum, across multiple specialties, and in every region of the United States. ¹² , ¹³ For example, pain has been shown to be assessed and treated differently among White and Black patients for common conditions such as long bone fractures and postoperative care. Goddu et al. used clinical vignettes to examine the impact of stigmatizing language among physician trainees (medical students and residents) and found that exposure to stigmatizing language in hypothetical medical records was associated with more negative attitudes toward patients and less aggressive pain management. ¹⁴ In addition, many of our decision tools and risk calculators embed race in a way that produces unequal outcomes. ¹⁵ Zelnick and colleagues analyzed 1658 self‐identified Black participants and found that the use of Black race in the estimation of kidney function (glomerular filtration rate), a common practice, was associated with a 1.9‐year delay in achieving transplant eligibility. ¹⁶

Specific to mental health care, Black people have been historically and presently burdened by overdiagnosis and disproportionate institutionalization for mental health disorders. For instance, Black people are about four times more likely to be diagnosed and hospitalized for schizophrenia than White people, even though there are no racial differences in the prevalence of schizophrenia after controlling for socioeconomic status. ¹⁷ , ¹⁸ Moreover, Black people are less likely than White people to receive regular care for probable mental illness, more likely to require acute care, ¹⁹ and far more likely to be arrested for substance use disorders. ²⁰ These factors, along with underrepresentation of racial and ethnic minorities in the health care workforce, as well as the historical legacy and ongoing experience of interpersonal and institutional racism, likely contribute to perceptions of health care as a “White Space.”

7. SUMMARY AND CONCLUSIONS

In ending their discussion, Alang et al. conclude that, despite the limitations of a cross‐sectional analysis, which curtails causal inferences, their findings have significant implications. They assert that while substantial prior research has examined more proximate barriers to mental health care among racial/ethnic minorities, such as cost, stigma, and accessibility of services, their analysis reaches beyond these barriers to examine institutional experiences of racism. As a result, they conclude that not only are interactions between patients and providers associated with medical mistrust and perceptions of disrespect, but also interactions between patients and police.

We agree that it is not only the interaction of patients and providers that circumscribe perceptions of trust and respect in health care settings. After all, trust is not a compartmentalized construct; and in an age of social media, digital connection, and polarization along racial, economic, and political divides, people have and will likely continue to have myriad inputs that influence the way they form heuristics, develop trust, and make sense of the world around them. These processes will not only vary across demographics and populations but will also influence peoples' likelihood and ability to access care. What erodes interpersonal and institutional trust in one space can have invariable implications in other settings—in effect, no single input will ever control the narrative. Going forward, it is imperative that health services researchers and clinicians be mindful of the specific histories that underlie and perpetuate narratives of trust and respect, while recognizing that trust is not compartmentalized for many minoritized communities that have experienced “brutality” across settings, institutions, geographies, and generations. As Rabbi Jonathan Sacks explains: Greater are the blessings of those who remember the past and future of which we are a part. ²¹

Glasser NJ, Tung EL, Peek ME. Policing, health care, and institutional racism: Connecting history and heuristics. Health Serv Res. 2021;56(6):1100‐1103. doi: 10.1111/1475-6773.13888