Public Health and Public Safety: Converging Upstream

Rarely have both health and public safety held such high priority for policymakers throughout the United States. The COVID-19 pandemic, in underscoring profound inequities in health outcomes, has refocused attention on structural approaches to achieving more equitable distribution of social determinants of health. In parallel, a separate yet related national debate has surfaced on how to improve public safety, spurred by police use of lethal force against Black Americans and other people of color, and also by high rates of violent crime and incarceration nationwide. Despite moving on different tracks, these two sets of issues share fundamental attributes that could prove mutually reinforcing in framing forward-facing policies.

First, consider health. In the words of the widely cited World Health Organization definition, health signifies more than the absence of disease—specifically, “a state of complete physical, mental and social well-being” (https://bit.ly/3Mv7dVn). Though aspirational, such framing sends a clear message: although medical care can blunt or reverse an individual’s physical and mental illness, only by addressing core upstream determinants of health—from fundamental (racism, poverty) to social and environmental (poor education and housing, air pollution) causes—is progress toward improved health at the population level achievable. Yet the United States continues to spend more on health care, and proportionally less on addressing underlying causes of ill health, than any other wealthy country.

Now consider public safety. Just as health signifies more than the absence of disease, public safety embodies far more than the absence of crime—rather, a sense of physical, emotional, social, and material security that fosters stability and is accompanied by support from community and society when needed. Fundamentally, safety is a core human need that comprises not only physical safety but also security in health, housing, education, and living-wage jobs.¹ As with health, the implication of such a framing is clear: although policing can contribute to key dimensions of safety, a deeper state of public safety and security can only emerge if essential needs—such as supportive conditions in early childhood, and safe and affordable housing—are met, and root causes like exposure to racism addressed. Just as it is preferable to prevent disease than treat it, so too must we prioritize preventing unsafety (crime being a pronounced example) rather than only responding to it.

As with health care, the United States is an outlier among Organisation for Economic Co-operation and Development countries in its high per capita spending on police and other law enforcement, and it maintains a higher rate of incarceration than any other country.² Also as with health care, much of our public safety system still follows a fee-for-service model, fostering incentives for some in continued downstream investment in measures like prison construction and bail bonds. It is perhaps not surprising, then, that the aggregate experience of safety in the United States, again as with health, is in the middle of the pack of other nations³, and falls disproportionately short in marginalized communities.

To improve public safety and enhance equity, as with health, we must focus more squarely on systemic, root causes—such as shortcomings and structurally racist inequities in our systems of education, housing, and health care, and entrenched gaps in income and employment. Yet as long as the links between these underlying and systemic drivers of unsafety, including crime, are not held up clearly to the public’s view, action by policymakers and community members is dampened. The result is a fundamental disconnect that stands uncorrected: although determinants are systemic, reaction and blame—in the form of arrests, convictions, and incarcerations that disproportionately affect people of color—are meted out at the individual level.

What is missing? First, purposeful efforts are needed to build widespread public understanding that poorer public safety outcomes have their roots in upstream drivers: exposure to racism, lack of employment opportunities at a living wage, unaffordable housing, exposure to lead and other toxins. Such understanding would help drive public sentiment that crucial police and other downstream reforms must be complemented by reversing chronic upstream disinvestment in communities across the nation. It would also support the growth of less intensive responses to threats to safety—from violence interrupters and restorative justice practices to integrating mental health and social service professionals into the responses to emergency calls. And it would spark needed conversation about which communities of “the public” need the greatest allocation and realignment of resources to improve their safety. Additionally, there is need for research that delineates the determinants of public safety (construed more broadly than crime alone)⁴ to the same degree as has been achieved for the social determinants of health.

Second, guided by local data and knowledge, resources must be allocated to catalyze measurable gains in public safety, broadly construed. Given the strong alignment between social and environmental determinants of health and of public safety, targeted upstream investments can be expected to yield dividends in both health and public safety realms.^5,6 To date, US spending in health and public safety has been disproportionately concentrated on the most resource- and technology-intensive end of the spectrum, with a focus on addressing rather than preventing harm. Allocating greater spending upstream will be essential to advancing goals of health, safety, and equity.

Fortunately, promising examples point the way. The Healthcare Anchor Network is working with health care systems across the country to lend the economic power of the hospital sector to strengthening community health through purposeful investment in social determinants of health. An initiative to restore blighted and vacant spaces in communities in Philadelphia, Pennsylvania significantly improved residents’ sense of safety while reducing police-reported crime.⁷ As recent federal investments in infrastructure, education, housing affordability, and reducing childhood poverty have demonstrated, spending on drivers of public safety need not be considered a zero-sum game.

To build public and policymaker support for apportioning greater resources upstream, a reframing of public safety is needed, accompanied by new metrics, programming, and funding. Four initiatives would advance this agenda:

• 1.Community-partnered redefinition of public safety, supported by community-partnered research to sharpen definition of its social and environmental drivers in diverse contexts and of the effectiveness and impact of dedicating greater resources to addressing these drivers;
• 2.A widely accessible data resource with metrics of key determinants of public safety for cities and communities across the country, to help broaden public understanding and catalyze local action (e.g., modeled after the City Health Dashboard⁸ for social determinants of health);
• 3.Funding for local initiatives to reframe health and public safety goals in specific cities and communities that achieve consensus on upstream determinants and metrics of success; and
• 4.Resource reallocation initiatives, at an ambitious (citywide or regional) scale, jointly funded by philanthropy, the business community, and the public sector.

We stand at a crossroads. We must now seize the historic opportunity, following the trail blazed by our evolving understanding of the social determinants of health, and shift public safety policy and practice from its narrow focus on policing and crime to a broader vision, inclusive of upstream drivers, that is at once more equitable and more effective.