Policing and health: lessons from Minneapolis

On the south side of Minneapolis, a concrete wall separates the interstate from a row of century-old Queen Anne-style houses, all bearing similar messages written on cardboard taped to windows: “Black Lives Matter,” “Justice for George Floyd,” “I Can’t Breathe.”

A nearby street sign posted by the Minneapolis Community Crime Prevention Program warns, “If I don’t call the police, my neighbor will.”

“Abolition” is graffitied below it.

More than half of those who live in the surrounding neighborhoods are people of color, compared with 30% of Minneapolis at large. The area includes a diverse population of Somali and Latino immigrants, who make up 20% of the ward. These neighborhoods are plagued by poverty: Nearly 1 in 5 people live below the federal threshold, and housing and food insecurity are common.

And in the same ward where the murder of George Floyd took place, residents are acutely aware of the police presence there. “They don’t feel safe just by being someone of color, and the police definitely don’t make them feel safer,” said Heidi Titze, a nurse practitioner and the clinical director of Southside Community Health Services.

People living in American communities like these endure the legacies of slavery, segregation and racism daily. Among the consequences are well-documented disparities in health status, access to care and clinical practices. And emerging science suggests that exposure to heavy policing itself can have harmful health effects including higher risks for preterm births and heart disease.

Healthcare organizations have the power to ameliorate those health consequences if they choose to use it.

In 2020, the New England Journal of Medicine published a call to action co-written by Rachel Hardeman, a health policy researcher who leads a University of Minnesota program studying the relationship between racism and health.

“Healthcare systems must play a role in protecting and advocating for their patients. Victims of state-sanctioned brutality are also patients, who may present with injuries or disabilities or mental health impairments, and their interests must be defended,” Hardeman and her colleagues wrote. “Healthcare systems should also be on the forefront of advocating for an end to police brutality as a cause of preventable death in the United States.”

In Minneapolis, institutions including Blue Cross and Blue Shield of Minnesota are advancing research on the impacts of over-policing, creating tools to reduce tensions between officers and citizens, and advocating for new public safety policies.

The people who live near Southside Community Health Services have a complicated relationship with law enforcement, Titze said. Locals fear the growing prevalence of violent crime. Still, they hesitate to call the police, fearing that officers will only escalate situations, as they saw happen to Jamar Clark, Philando Castile, George Floyd and, most recently, Amir Locke.

Southside Community Health Services, a federally qualified health center, provides care to residents of an approximately 15-square-mile radius in the south-central section of Minneapolis. Its medical clinic sits less than a mile from where a police officer killed Floyd.
 

“After the murder of George Floyd, the pain was just so profound and intense and present like it never has been before,” said Cindy Nelson, the clinic’s director of behavioral health. “There were all these protests and all this social action, and it feels like we’re still ground zero in Minnesota for social justice. There’s a level of frustration that’s being built up.”

The Leadership Conference Education Fund, a human and civil rights advocacy foundation, surveyed community perceptions of policing in Minneapolis and the findings show a profound lack of trust among many city residents: 75% of Black residents, 55% of Latinos and 56% of Native Americans said they do not believe the Minneapolis Police Department faced accountability for past misconduct. Similar proportions found that the police were not helpful during mental health calls.

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“Folks are really clear about wanting another option,” said Corenia Smith, a nurse and local organizer for Reclaim the Block, a group that seeks to reallocate police funding to public health.

A review of all Minneapolis police incidents shows that most police interactions last year involved nonviolent offenses, including addiction and mental illness. Researchers continue to connect the dots between over-policing and the physiological effects of “weathering,” a term used to describe the cumulative health effects that living with racism can cause. There’s a scientific consensus that these are medical events but they aren’t always treated that way.

Over-policing and bad health outcomes

South central and northwest Minneapolis have something in common: They are predominantly Black in a highly segregated city, and they are disproportionately policed compared with their white counterparts, researchers from the University of Minnesota documented.

The study, which Hardeman and Bert Chantarat co-authored, also found that the women who lived there had a higher risk of preterm births linked to the higher police presence, and that U.S.-born Black women experienced worse health outcomes overall.

“Over-policing is bad for everybody, but the fact that over-policing is racialized—in that the neighborhood has a lot of Black people who receive over-policing—shows that what leads to birth inequities between Black and white women is likely to happen because of over-policing,” Chantarat said.

Studies about the effects of over-policing on health have been published since the 1960s during the era of the Civil Rights movement. Researchers are now exploring how specific patient populations are affected.

Outside of the obvious health implications for police violence against citizens—such as the fact that Black people are three times as likely to be killed by police as white people—the legacy of racism in policing also has a psychological impact associated with higher risk of preterm births, heart disease, anxiety and depression, recent studies reveal.

Every study has the same caveat: It’s unclear exactly how much policing plays a direct role in those adverse health events. Instead, these effects reverberate in an echo chamber of social factors concentrated within the same ZIP codes, disproportionately among communities of color.

“Experiencing or witnessing police brutality, hearing stories of friends who have experienced brutality, and having to worry about becoming a victim are all stressors,” Hardeman wrote with three others in an analysis published in the American Journal of Public Health.

That paper describes the process by which the body produces stress hormones that increase heart and respiratory rates. “When the threat becomes reoccurring and persistent—as is the case with police brutality—the survival process becomes dangerous and causes rapid wear and tear on body organs and elevated allostatic load,” the authors wrote.

The physiological toll that takes on a body can increase the risks for diabetes, stroke, ulcers, cognitive impairment, autoimmune disorder, accelerated aging and death. The healthcare system needs to take an active role in understanding and mitigating that harm, Hardeman said.

The areas most significantly affected by police violence are typically the most segregated and those with high levels of poverty. These locations also face compounding social issues in housing, nutrition, poverty and education that impact health. For example, researchers found a link between over-policing and predominantly Black districts that were historically redlined in New Orleans.

“This whole idea of weathering, it’s not just policing,” said Jocelyn Parker, senior director of communications and public relations for the Minnesota Council of Health Plans, a trade group for not-for-profit health insurance companies.

“It’s high unemployment, it’s stable housing. You think about inflation right now. You are kind of worried about how you’re going to make it. And if you’re pregnant and don’t have those basic needs …” Parker said. “You talk about a vicious cycle—that child is already starting behind. They’re already at a disadvantage upon getting here, and they’re playing catch-up. So that cycle keeps going over and over and over again. We have to think about: how do we get people the resources they need to help stop that cycle?”

Looking better

More research is needed. Hardeman and Chantarat believe their study is the first to link over-policing to a higher risk of preterm births. Recent papers call for exploration into what types of police interactions—if not all—impact health.

The Center for Antiracism Research for Health Equity at the University of Minnesota is looking to fill the gap. The college founded this research hub in February 2021 following civil unrest throughout Minneapolis. Blue Cross and Blue Shield of Minnesota provided a $5 million donation, which then-President and CEO Dr. Craig Samitt called an investment to “advance health equity and dismantle racism from the structure and fabric of our society.”

Hardeman, an associate professor at the U of M, leads the center, which is laying the groundwork for studying structural racism in healthcare. Historically, clinicians have looked to race as a risk factor, Chantarat said. Antiracist research posits that racism, not race, is the fundamental cause of health inequities.

In a New England Journal of Medicine article on the role of healthcare institutions in combating disparities associated with policing, Hardeman wrote: “We argue that police brutality is a social determinant of health, although it has not received sufficient attention from the public health community.” She calls for public health surveillance of police violence and additional funding for research to better understand the experiences and health needs of people confronted by police brutality.

Responding to nonviolent crime

Health systems can serve as alternative public safety options and provide services that help prevent situations that could devolve into police encounters, such as drug use or mental health crises.

Healthcare organizations can deploy response teams for mental and behavioral health services that don’t involve law enforcement personnel. They can also partner with violence prevention groups to better integrate with communities where tensions with police officers deter people from calling 911. By giving people options for whom to contact in emergencies, healthcare entities can limit the number of people who otherwise may avoid the healthcare system.

Preventive services such as needle-exchange programs, safe drug consumption sites, housing support, doula and midwife services, and other community partnerships are also needed, Reclaim the Block’s Smith said. Those programs—and all others across the healthcare system—should be staffed by workers who represent the diversity of their communities.

“There’s a lot of different ways that we can create harm reduction within the medical industry and within healthcare,” Smith said. “Healthcare has the innate ability to not be punitive and actually look at a person for who they are and treat them for all the aspects of what they’re experiencing, given their circumstances or environment.”

Other research shows that distrust in the police translates to distrust in healthcare. Undocumented immigrants may not seek hospital care if the police are present, fearing the focus may shift from their medical needs to their legal status, for example. In addition, Black patients may not trust white doctors due to racialized violence they’ve experienced with police.

“As we saw with George Floyd, not only was his life a loss, but a good family suffered a lot. He suffered a lot, and we all get pulled down by that,” Parker said. “When things like that happen, and you have a general violation of trust in the community, that spills over into everything. Not just policing, but education and into healthcare. Because you see that this happened over here, and this person’s life was so blatantly taken.”

Another recent incident underscores why the area’s Black residents may find the healthcare system and government services difficult to trust. In March, the Star Tribune published a photograph depicting the deputy chief of the county emergency medical services agency and two paramedics employed by Hennepin Healthcare, the local safety-net health system, in blackface.

Legal aid and policy

In January, Blue Cross and Blue Shield of Minnesota announced a partnership with Minneapolis-based TurnSignl. The company offers a smartphone app of the same name that provides on-demand legal services during traffic stops. The insurer is piloting a program as an element of its benefits package for 3,000 policyholders who live in suburban Brooklyn Center, where the high-profile manslaughter of Daunte Wright by a police officer took place in April 2021.

The app connects individuals involved in car crashes or traffic stops to attorneys who are trained in de-escalation and can advocate for citizens in real time. The tool serves as a proactive layer of accountability during police interactions, and can help mediate tensions, Parker said.

The not-for-profit insurer also declared racism to be a public health crisis, aligning itself with the American Medical Association and the American Public Health Association, which have called for policy reforms that would end racialized police practices and empower community accountability groups.

A month after Floyd’s murder, top executives from 87 firms, including local healthcare organizations such as the Mayo Clinic, HealthPartners, Fairview Health Services, Medtronic and Blue Cross and Blue Shield of Minnesota, delivered a letter to the Minnesota Legislature advocating new police policies. Among the companies’ asks were repealing a law that mandates binding arbitration for officers accused of misconduct, modifying union contracts that impede holding officers “who seriously betray the public trust” accountable and making admissions to law enforcement training programs more selective.

Over the past 60 years, improvements in racial health disparities have come in waves. Between 1968 and 1978, the Civil Rights movement catalyzed large economic gains for Black families in the U.S. that paralleled a decline in mortality rates. During the 1980s, the gap between Black and white adult and infant mortality widened once again as the median household income for Black people declined.

Looking ahead, experts on racism and public health emphasized that diversifying the healthcare workforce is the first and most critical step toward reducing health disparities.

You can’t have health equity if you don’t have diversity in your ranks to create an ecosystem of cultural competence and accountability, Parker said. “Now that we’re getting a couple of years away from George Floyd, the question really becomes sustaining that momentum and building that sustainable model,” she said. “That’s why we really need to be incorporating (diversity, equity and inclusion) and health equity into everything we do.”