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A 5-Year Retrospective Analysis of Legal Intervention Injuries and Mortality in Illinois
- 1. Original Article A 5-Year Retrospective Analysis of Legal Intervention Injuries and Mortality in Illinois Alfreda Holloway-Beth1 , Rachel Rubin1,2 , Kiran Joshi3 , Linda Rae Murray4 , and Lee Friedman1 Abstract There has been a public outcry for the accountability of law enforcement agents who kill and injure citizens. Epidemiological surveillance can underscore the magnitude of morbidity and mortality of citizens at the hands of law enforcement. We used hos- pital outpatient and inpatient databases to conduct a retrospective analysis of legal interventions in Illinois between 2010 and 2015. We calculated injury and mortality rates based on demographics, spatial distribution, and cause of injury. During the study period, 8,384 patients were treated for injuries caused during contact with law enforcement personnel. Most were male, the mean age was 32.7, and those injured were disproportionately black. Nearly all patients were treated as outpatients, and those who were admitted to the hospital had a mean of length of stay of 6 days. Most patients were discharged home or to an acute or long-term care facility (83.7%). It is unclear if those discharged home or to a different medical facility were arrested, accidentally injured, injured when no crime was committed, or injured when a crime was committed. Surveillance of law enforcement–related 1 School of Public Health, Environmental and Occupational Health Sciences, University of Illinois at Chicago, Chicago, Illinois, USA 2 Cook County Department of Public Health, Forest Park, Illinois, USA 3 Cook County Department of Public Health, Oak Forest Health Center, Oak Forest, Illinois, USA 4 Health & Medicine Policy Health Group, Chicago, Illinois, USA Corresponding Author: Alfreda Holloway-Beth, School of Public Health, Environmental and Occupational Health Sciences, University of Illinois at Chicago, 2121 West Taylor Ave. MC 922, Chicago, IL 60612, USA. Email: ahollo2@uic.edu International Journal of Health Services 0(0) 1–17 ! The Author(s) 2019 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/0020731419836080 journals.sagepub.com/home/joh
- 2. injuries and deaths should be implemented, and injuries caused during legal inter- ventions should be recognized as a public health issue rather than a criminal jus- tice issue. Keywords legal interventions, injury epidemiology, police killings, surveillance Perhaps due to the use of social media, live streaming, and the public demon- strations of social justice groups, there has been an outcry for the surveillance and accountability of law enforcement agents who kill and injure citizens in the United States. Public health researchers and policymakers have taken up this charge by trying to use what is in their social medical toolkit to address this controversial issue. To have a solution to a problem, there must be an acceptance that the problem exists. Epidemiological surveillance systems help to underscore the exis- tence and magnitude of the diseases that plague our society. Coinciding with the increase in public awareness of this serious public health problem, data collected by the U.S. Centers for Disease Control and Prevention (CDC), based on hospital and death records, show that the number of both fatal and nonfatal injuries caused by law enforcement personnel has risen sharply during the last 15 years, with a more precipitous increase occurring since 2010.1 However, even CDC numbers are likely limited. According to the Bureau of Justice Statistics data, approximately 15% of civilians who have force used or threatened during their encounter with police are injured, but only about 37% of them seek medical care and would be captured by CDC data.2–4 Although the CDC and Bureau of Justice Statistics collect law enforcement–associated morbid- ity and mortality data, the reporting of such data is infrequent and limited to basic demographic factors. These latter data sources lack additional information regarding the sociodemographics, injury severity, medical costs, pre-existing con- ditions, geographic information, and hospital resources needed to treat these injuries and to build on the growing legal intervention literature. Furthermore, data from the CDC Web-based Injury Statistics Query and Reporting System show that, while the growing number of injuries has raised concerns for the safety and well-being of citizens nationwide, year after year data clearly show that African Americans are 5 times more likely to be injured and twice as likely to be killed by law enforcement personnel than white non-Hispanics.1 We currently have comprehensive public health data that detail the morbidity and mortality of citizens at the hands of law enforcement. In the article, we discuss how the use of the International Disease Classification code for injuries caused during legal intervention can help us establish a surveillance system in the state of Illinois and nationwide as well as provide more comprehensive 2 International Journal of Health Services 0(0)
- 3. information about the individuals injured in these events. In this study, we address sociodemographic characteristics of the injured persons, comorbidities, health outcomes, health resources used, and geographic distribution related to legal intervention injury. Materials and Methods We conducted a retrospective analysis of legal intervention injuries in the state of Illinois occurring between 2010 and September of 2015 using the outpatient and inpatient hospital databases. Both databases are derived from billing records and represent a census of cases treated in Illinois hospitals. The outpa- tient database includes patients treated in emergency rooms for less than 24 hours who were not admitted to the hospital. The inpatient database includes patients treated for 24 hours or more. Both datasets include information on patient demographics, exposure information, health outcomes, and economic outcomes. Based on the annual state audit of hospitals, the hospitals included in the datasets comprise 96.5% of all patient admissions statewide. All patients with an ICD-9-CM cause of injury code for legal intervention were included in the analysis (ECODES 970-977). The ICD-9 category for inju- ries caused by legal intervention include “injuries inflicted by the police or other law-enforcing agents, including military on duty, in the course of arresting or attempting to arrest lawbreakers, suppressing disturbances, maintaining order, and other legal action.” Under the ICD-9 definition, the cause of injury codes should only be used when suspects or bystanders are injured. Injuries to law enforcement officers are excluded from these series of codes in the ICD-9. However, it should be noted that nearly all medical providers in the United States transitioned to the ICD-10 coding system in October 2015. The new ICD-10 coding system differentiates between injuries caused to suspects, bystanders, and officers. All statistical analyses were conducted using SAS software (v.9.4; SAS Institute Inc., Cary, NC). As part of the descriptive analysis we compared demo- graphic characteristics, geospatial trends, temporal trends, injury severity, and hospital course of treatment measures. Publicly available data tables were cre- ated showing average 5-year incidence rates by zip code. We also mapped trends in injuries by residential zip code using ArcGIS software. Results Demographics and Clinical Outcomes We identified 8,384 patients treated for injuries caused during contact with law enforcement personnel from 2010 to 2015. The majority of patients were male (82.8%) with a mean age of 32.7 years. The patients were disproportionately Holloway-Beth et al. 3
- 4. black or African American (42.9%); this is in stark contrast to general popula- tion demographics, where only 14.7% of the Illinois population identifies as black or African American as of 2015 (Table 1). Almost all the patients were treated as outpatients (n ¼ 8,000, 95.4%), but less than half were treated in hospitals with trauma units (n ¼ 3,834, 45.7%). As seen in our previous work, some of the most commonly report comorbidities in this group of patients were alcohol abuse and dependence (n ¼ 744), drug abuse and dependence (n ¼ 423), and paralysis and other neurological disorders (n ¼ 202). Among those admitted to a hospital, the mean length of hospitalization was 6 days. Only 561 (6.7%) of the patients suffered penetrating injuries, of which 98 were admitted as inpa- tients. In addition, an even smaller number of patients required surgery for their injuries (n ¼ 222, 2.7%) or mechanical ventilation (n ¼ 36, 0.4%). Mental Health Disorders Among Legal Intervention Cases A little more than 5% (n ¼ 455) of legal intervention cases had diagnoses for mental health disorders in the medical records. The greatest proportion of patients with mental health diagnoses were ages 15 to 24 (28.98%), ages 25 to 34 (34.74%), and ages 35 to 44 (18.94%). Of the cases with mental disorders, the largest proportion were diagnosed with a nondependent alcohol disorder, 7.69% were diagnosed with a dependent alcohol disorder, 16.70% had affective psy- choses, and 7.91% were diagnosed with schizophrenia. Types of Injuries and Body Parts Affected The most common types of injuries suffered by these patients were contusions (n ¼ 5,054), sprains or strains (n ¼ 1,592), open wounds (n ¼ 1,542), fractures (n ¼ 704), internal injuries (n ¼ 195), burns (n ¼ 46) and nerve injuries (n ¼ 32). An additional 340 patients suffered injuries caused from excessive heat or cold. Injuries were spread across the body as follows: head (n ¼ 3,131), arms (n ¼ 3,115), torso (n ¼ 1,525), legs (n ¼ 1,392), and back (n ¼ 459). Most frac- tures occurred to the upper extremities (n ¼ 302), face and head (n ¼ 244) and torso (n ¼ 93). Internal injuries to the brain (n ¼ 140) were more common than injuries to the internal organs of the torso (n ¼ 55). Open wounds predominately occurred on the face and head (n ¼ 820), upper extremities (n ¼ 367) and torso (n ¼ 308). Spatial Distribution of Injuries Injuries occurred among residents living across the entire state of Illinois and were not isolated to major urban centers. In fact, the largest number of patients were residents of areas outside of Cook County (n ¼ 4,169, 49.73%), followed by residents of Chicago (n ¼ 2,766, 32.99% of all cases), and the remainder of Cook County (n ¼ 1,449, 17.28%; Figures 1 and 2). 4 International Journal of Health Services 0(0)
- 7. When we analyzed the region in which the patients were treated, we found that two-thirds of the patients were treated in the greater Chicago area in Emergency Medical Services (EMS) regions 7 through 11 (n ¼ 5,648, 67.36%). These EMS regions cover Cook County and the collar counties around Chicago. There were no observable temporal trends. Most Common Cause of Injury The most common cause of injury came from blows or manhandling, not from firearms (Table 2). Firearms were the cause of 2.95% of all nonfatal injuries (n ¼ 247) and 86.67% of all deaths (n ¼ 13). The category for “blows or man- handling” excludes injuries caused by commonly used blunt objects, such as batons and flashlights. The category for “blows or manhandling” typically involves injuries resulting from pushing or throwing the civilian against objects, including the ground (tackling, throws, insertion into vehicles); submission holds, including sitting on the civilian or choke holds; maneuvers used to shack- le citizen (arm twisting, bending); blows to the civilian’s body using officer extremities; and falling and tripping. Most Common Cause of Death The hospital data system captured 15 deaths resulting from legal interventions from 2010 to 2015. The most common cause of death was due to firearm (86.67%), while being manhandled was the cause for the rest. Of those injuries caused by the use of firearm, 5.26% died, whereas of the 6,531 injured by being manhandled, 0.03% died. One hundred percent of deaths occurred among men, 46.67% among white men, 40.0% among black men, and 13.33% among those who racially identify as “other.” Only 13.33% of these deaths occurred in the city of Chicago. Crude Average Annual Incidence Rates The average annualized crude incidence rates were 19.2 per 100,000 residents of Chicago, 11.4 per 100,000 residents of Cook County (excluding Chicago), and 6.8 per 100,000 residents of the remainder of the state of Illinois. In addition to a regional disparity, black or African American patients had the highest incidence rates regardless of region (Table 3). The data show that civilian injuries caused by law enforcement impacts all citizens in the state. Discharge to the Court or Law Enforcement Among those injured by law enforcement personnel, 80.36% (n ¼ 6,737) had routine discharges home or to self-care, while 1,038 legal intervention cases were discharged to the court or law enforcement (12.38%). Men accounted for Holloway-Beth et al. 7
- 8. Figure 1. Crude rate ratios of average annual incidence rates from January 2010 through September 2015 by zip codes: rate ratio black versus white non-Hispanic. 8 International Journal of Health Services 0(0)
- 9. Figure 2. Crude rate ratios of average annual incidence rates from January 2010 through September 2015 by zip codes: rate ratio white Hispanic versus white non-Hispanic. Holloway-Beth et al. 9
- 12. 90.37% of those placed in the criminal justice system, and about 24.28% of these occurred in the city of Chicago. The highest proportion of those jailed occurred among those between the ages of 25 and 34 (33.91%), followed closely by people between 15 and 24 (29.09%), while those 35 to 44 accounted for 18.98%, 45 to 54 had 13.49%, those 55 and older had 4.14%, and those younger than 15 accounted for less than 1% of deaths. Blacks (39.31%) had the highest proportion discharged to the court or law enforcement after experiencing a legal intervention in Illinois, whites had the second highest at 36.99%, while Latinos had 9.15%, unknown race had 8.19%, and both Asian/Pacific Islanders and American Indian/American Native accounted for less than 1%. Discussion The very idea of an acceptable level of force is unclear. According to the Fourth Amendment of the U.S. Constitution, police must be “reasonable” in the level of force they use in an arrest and only use deadly force in “defense of life or when necessary” to make a difficult arrest. The language used in the Constitution leaves a substantial area of interpretation. Thus the acceptable levels of force used and tolerated can vary greatly from state to state, from one police district to the next, and certainly between individuals. It is important that scientific and statistical analyses aid in the development of a more precise definition of an acceptable level of force. An important finding from the analysis was that non- fatal injuries are very common and in many cases result in serious injuries. Blows and manhandling are the predominate causes of these injuries, not includ- ing injuries caused by blunt objects such as batons and flashlights. Our data show that any long-term surveillance program should not be restricted to firearm-related injuries alone. Furthermore, while the common narrative is that these injuries are an “urban problem,” we found that civilian injuries caused by law enforcement occur across the state of Illinois and are not isolated to major urban centers. However, our data confirm that, while all major socio- demographic groups are represented in the data, clearly black men are consis- tently and disproportionately the victims of both fatal and nonfatal injuries caused by law enforcement throughout the state. In our analysis, the vast majority of patients were discharged home or to an acute or long-term care facility (83.7%). It is unclear if those discharged home or to a different medical facility were (1) arrested during the legal intervention and arraigned while in the hospital, (2) accidentally injured through an indirect action during a legal intervention (e.g., motor vehicle crash), (3) involved in the use of force when no crime was committed, or (4) involved in a crime that justified the use of force but did not result in charges filed. However, it is rare to arraign a person not present in the courtroom, and if charges were pressed, a greater proportion of these individuals would likely be transferred to a jail with an infirmary after they were stabilized in a community-based hospital. In 12 International Journal of Health Services 0(0)
- 13. addition, a preliminary analysis of ICD-10 codes shows that less than 2% of legal intervention injuries involve bystanders. Our data show that any long-term surveillance program should not be restricted to firearm-related injuries alone. Unarmed blows, firearms, or strikes with a blunt object caused nearly all the civilian injuries by law enforcement agents – not activities such as motor vehicle crashes. According to Meyer and colleagues, this is consistent with the most commonly reported methods of force used by law enforcement – grabbing, tackling, pushing and shoving, striking (with flashlight or baton), and control holds.5,6 Normally, individuals involved in a police assault that do not remain in police custody have paid a bond to be released pending further charges or may have been released without charges. Confusion and distrust of law enforcement personnel by civilians and the daily hazards and general stresses faced by law enforcement personnel while on the job exacerbate the probability of physical or lethal force. Reports by law enforcement personnel and civilians differ starkly. Perceived threat to an officer is the most commonly reported reason for use of force by law enforce- ment personnel. In contrast, the Bureau of Justice Statistics 2008 survey, con- ducted by Durose and colleagues, shows that, of the civilians who were involved in contact with law enforcement personnel in which force was used, only 28.4% behaved in 1 or more of the following ways: argued, insulted, disobeyed, resisted arrest, fled, or assaulted the officer.4 The 2008 PPCS shows that only 0.6% of the civilians who had force used against them reported that they “pushed, grabbed, or hit the officer(s).” In addition, 80% felt the law enforcement person- nel’s use of force was excessive, and 83.9% of civilians who experienced force or the threat of force reported that the law enforcement personnel “acted improp- erly.” There is a clear divide between the perceptions of law enforcement per- sonnel and civilians. A key issue is that statistics that rely on complaint data severely underesti- mate civilian concerns about excessive use of force. In the same BJS study cited above, only 13.7% of civilians who felt the officers “acted improperly” filed a complaint. In Illinois, some evidence in the literature suggests that excessive use of force by law enforcement personnel is not an infrequent event. In the past, the Chicago Police Department (CPD) in particular has had problems with allega- tions of excessive force. Based on a major report from the University of Chicago School of Law conducted by Futterman and colleagues, 1,774 claims of police brutality were filed against officers of the CPD alone between 1999 and 2004.7 However, this issue is difficult to research because of the lack of adequate data. In Illinois and more broadly across the United States, no policy directives require publicly accessible repositories for such information as seen with other types of violent injuries, such as mandated reporting of child or elder abuse. While other countries have registries for injuries caused during contact with law enforcement personnel, in the United States the public is largely left to search through media reports and court documents for information on the subject. Holloway-Beth et al. 13
- 14. Since it is mandatory for police to report civilian injuries to their departments, these data should be compiled, analyzed, and publicly distributed on an annual basis in an effort to identify ways to reduce these types of injuries, as is done in Australia. Conclusions There is a need for (1) a surveillance system documenting law enforcement- related deaths; (2) a paradigm shift identifying injuries caused during legal inter- vention as a public health issue, rather than exclusively as a criminal justice issue; and (3) improved accountability and training of officers. Media reports seem to show that law-enforcement-related deaths are occur- ring at an alarming rate. However, these incidents are frequently dismissed, because they are anecdotal. The lack of data exacerbates the common view that the problem does not exist, is exaggerated, or simply being used as a polit- ical tool by “anti-police” constituents. Before we can define policy on reporting requirements, accountability, and training, we need to define the problem. Researchers who understand that this is a public health issue rather than solely a criminal justice problem have called for a paradigm shift. In turn, these researchers have called for the collection and reporting of law enforce- ment–related injuries and deaths by public health entities, to augment current criminal justice sources. Law enforcement–related violence has proven to be in alignment with the issues that public health strives to deal with, such as social and structural determinants of health, especially the correlation between vio- lence, socioeconomic status, and race in the United States. Nancy Krieger and others believe that we could use the existing public health system to implement mandatory reporting seamlessly.8 Injuries caused through legal intervention impact the individual and the com- munity as a whole. The public health model can provide new insights that can be used to prevent these injuries from ever occurring. A statement by the Public Health and the Policing of Black Lives calls for recognition that certain police activities cause harm to the public, and, in fact, add to existing racial dispar- ities.9 The persistent disparity observed in the data may be attributable to polic- ing activities that encourage profiling, harassment, and aggressive behavior toward U.S. citizens, especially African Americans. According to Geller, these injuries and deaths create mental trauma in families, in communities, and espe- cially among young men in urban communities. The hope is that by implement- ing public health policies for active surveillance of law-enforcement-related injuries and deaths, the data can inform policymakers on how to best reduce or eliminate unwarranted injury.10 Police violence is a public health issue and requires policies and safeguards to be put in place to reduce the rates of fatal and nonfatal injuries. The surveillance data should inform several key policy issues, including mandatory reporting; 14 International Journal of Health Services 0(0)
- 15. evaluation of nonlethal tactics; transparency and accountability, especially in egregious cases and repeat offenders, which entails public release of data and regular reviews by independent review boards with the power to discipline, fire, and indict officers; recruitment strategies for screening new cadets; and development of ongoing training programs for officers, including training on unconscious bias and how to interact with the disabled, intoxicated, and men- tally ill persons. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The authors received no financial support for the research, authorship, and/or publica- tion of this article. ORCID iD Alfreda Holloway-Beth http://orcid.org/0000-0002-3690-4277 References 1. U.S. Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System. Fatal Injury and Nonfatal Injury Data. https://www.cdc.gov/ injury/wisqars/. Accessed February 23, 2019. 2. Langan PA, Greenfeld LA, Smith S, Durose M, Levin DJ. Contacts Between Police and the Public, 1999. Bureau of Justice Statistics. http://www.bjs.gov/content/pub/ pdf/cpp99.pdf. Published 2001. Accessed February 23, 2019. 3. Durose M, Smith E, Langan PA. Contacts Between Police and the Public, 2002. Bureau of Justice Statistics. http://www.bjs.gov/content/pub/pdf/cpp02.pdf. Published 2005. Accessed February 23, 2019. 4. Durose M, Eith C. Contacts Between Police and the Public, 2008. Bureau of Justice Statistics. http://www.bjs.gov/content/pub/pdf/cpp08.pdf. Published 2011. Accessed February 23, 2019. 5. Meyer, G. Nonlethal weapons versus conventional police tactics: assessing injuries and liabilities. The Police Chief. 1992;59:10–17. 6. Garner J, Maxwell C. Measuring the amount of force used by and against the police in six jurisdictions. In: Greenfield LA, Langan PA, Smith SK, eds. Use of Force by Police: Overview of National and Local Data. Washington, DC: National Institute of Justice and Bureau of Justice Statistics; 1999:25–44. 7. Futterman CB, Mather HM, Miles, M. The use of statistical evidence to address police supervisory and disciplinary practices: the Chicago police department’s broke system. DePaul J Soc Justice. 2008;251:289. 8. Krieger N, Chen JT, Waterman PD, Kiang MV, Feldman J. Police killings and police deaths are public health data and can be counted. PLoS Med. 2015;12(12):e1001915. Holloway-Beth et al. 15
- 16. 9. Feldman J. Public health and the policing of black lives. Harvard Public Health Review. Vol. 7; 2015. http://harvardpublichealthreview.org/public-health-and-the- policing-of-black-lives/ 10. Geller A, Fagan J, Tyler T, Link BG. Aggressive policing and the mental health of young urban men. Am J Public Health. 2014;104(12):2321–2327. Author Biographies Alfreda Holloway-Beth, PhD, MS, is a research assistant professor at the University of Illinois at Chicago School of Public Health in the Environmental and Occupational Health Sciences Division. She has a PhD in environmental and occupational health sciences and a master of science in epi- demiology. She has published on legal interventions and law enforce- ment injuries. Rachel Rubin, MD, MPH, FACP, is a senior public health medical officer with the Cook County Department of Public Health and holds faculty appointments at the University of Illinois at Chicago School of Public Health and Rush University Medical College. Rubin’s area of responsibility within the health department includes oversight for the communicable diseases and environmental health serv- ices units. She is also a practicing internist and specialist in occupational medicine. Rubin trained at Cook County Hospital in Chicago and has worked for the Cook County Health system for most of her career. In addition, she spent 2 years in Mozambique working as a public health specialist and the district medical chief. Kiran Joshi, MD, MPH, currently serves as senior medical officer at the Cook County Department of Public Health, where he oversees the department’s emer- gency preparedness, chronic disease, and epidemiology units. Joshi is also cur- rently an assistant professor of clinical family medicine at the Northwestern University Feinberg School of Medicine. Prior to this, he was a faculty attending physician at the Northwestern McGaw Family Medicine Residency Program, where he supervised family medicine residents in the inpatient setting; engaged residents in numerous hospital quality improvement and patient safety activi- ties; and oversaw the hospital’s electronic health record deployment. Joshi has also worked as a consultant to the World Health Organization, where he pro- vided technical assistance in the development of trainings for health workers in sub-Saharan Africa. He completed medical school at the University of Illinois at Chicago and trained in preventive medicine at the Johns Hopkins School of Public Health and Family Medicine at Illinois Masonic Medical Center. He is committed to advancing health equity in suburban Cook County. Linda Rae Murray, MD, MPH, FACP, practiced as an occupational medicine physician at a workers clinic in Canada, residency director for occupational 16 International Journal of Health Services 0(0)
- 17. medicine at Meharry Medical College, and bureau chief for the Chicago Department of Health. She served as medical director of a federally funded health center. Murray has served as a member of the Board of Scientific Counselors for the Agency for Toxic Substances and Disease Registry, the Board of Scientific Counselors for the National Institute of Occupational Safety and Health, the Board of Directors of Trinity Health, and the National Advisory Committee on Occupational Safety and Health. She has served as the chief medical officer for primary care for the 23 primary care and community health centers that make up the Ambulatory and Community Health Network of the Cook County Bureau of Health Services. She practices as a general internist at Woodlawn Health Center and is an attending physician in the Division of Occupational and Environmental Medicine at Cook County Hospital. Murray is a past president of the American Public Health Association. She has been a voice for social justice and health care as a basic human right for over 40 years. Lee Friedman, PhD, MS, is an environmental and occupational epidemiologist with a focus on injury epidemiology. He is an associate professor at the University of Illinois at Chicago School of Public Health in the Environmental and Occupational Health Sciences Division. He received his PhD in environmental and occupational health in 2006. His research interests include injury epidemiology, occupational injury, violence across the lifespan, alcohol and injury, road injury prevention, non-ionizing radiation, community health, and conflicts of interest in biomedical research. He has published on legal interventions and law enforcement injuries. Holloway-Beth et al. 17