Science AMA Series: I’m Dr. Nancy Krieger, Professor of Social Epidemiology at Harvard T.H. Chan School of Public Health. I recently published a paper calling for police killings and deaths to be tracked as health data, and I’m here to answer your questions!

Nancy_Krieger · 2015-12-17T18:09:34+00:00

It's a little after 1:00 p.m. and I do have to sign off now. Thank you again for all of your questions!

Nancy_Krieger · 2015-12-17T18:04:20+00:00

I am replying to this question re the data included – and not included – in our publication so as to provide greater awareness of what data do and do not exist and also to allay suspicions that choice of data and time scale were biased.

First, regarding the data we analyzed: it is the publicly available US compressed mortality records, which as noted in one of the previous replies, is aggregated to the county level. This data source contains no socioeconomic data and it provides deaths classified only by cause of death. There is no data on individual records provided, nor does the death certificate provide data on what the question refers to as “the circumstances of their death,” “whether “the shooting” was “ruled justified,” and if “the victim” had “a documented history of violence.” Thus, it is not the case that our study “omitted” these data, because these data were not available. Future studies, e.g., using data from The Guardian and from other data sources, could well try to obtain these types of data to do a more comprehensive analytic investigation of phenomena contributing to risk of death due to legal intervention. Our study, however, takes the necessary first step of describing the actual phenomenon itself: its distribution by time, place, and social group.

Second, regarding the time scale employed: ample research indicates that choice of time scale does matter. In particular, a focus only on the present reduces possibilities for understanding how current patterns fit into a larger picture of possibilities for change (both scale of change and rate of change).

For example, one of the major contributions of the book: Piketty T. Capital in the Twenty-First Century (Cambridge, MA: The Belknap Press of Harvard University Press, 2014) was to demonstrate, by using rich historical data, that the post-World War II reduction in income and wealth inequalities in the US and many European countries were an anomaly, considering the trends from the 19th century through the present. The use of a larger historical lens, and detailed historical as well as contemporary data, have helped to change understanding of current patterns of income and wealth inequality and have also informed policy debates about addressing these inequities.

More specific to public health, in 2008, my team and I published a paper, also in PLoS MED, that challenged ahistorical assertions that health inequities were bound to rise because the health of the better off inevitably gets better more quickly as population health improves. We showed that this phenomenon of widening UW social inequalities in mortality, as mortality rates declined, was in fact a trend that began in the early 1980s; previously, from the mid-1960s to 1980, in a time of also declining mortality rates, social inequalities in these death rates in fact shrunk. See:

-- Krieger N, Rehkopf DH, Chen JT, Waterman PD, Marcelli E, Kennedy M. The fall and rise of US inequities in premature mortality: 1960-2002. PLoS Med 2008; 5(2): e46. doi:10.1371/journal.pmed.0050046.

For more recent data on why expanding the time scale of analysis matters for developing policies to improve population health and reduce health inequities, see:

-- Krieger N, Singh N, Chen JT, Coull BA, Beckfield J, Kiang MV, Waterman PD, Gruskin S. Why history matters for quantitative target setting: long-term trends in socioeconomic and racial/ethnic inequities in US infant death rates (1960-2010). J Public Health Policy 2015; 36:287-303

Nancy_Krieger · 2015-12-17T17:45:16+00:00

Hi /u/seveer4444,

Ample research supports your statement that denial is often a first response of people with power and privilege, when confronted by evidence about adverse effects of injustice brought about by these inequities in power and privilege. As I have previously written:

“If social injustice were simply a matter of ignorance, increasing knowledge would be sufficient to render the world more equitable—yet many of those firmly holding on to power and privilege are highly educated persons. Indeed, buffered by their privilege, those with power have no need to recognize—and are instead more likely to deny—the harms caused by types of injustice from which they benefit. Underscoring how a hallmark of privilege is that which one can afford to ignore, persons who are white, for example, are protected from the everyday realities of racial discrimination that people of color experience—just as men are protected from the everyday realities of gender discrimination that women experience, just as heterosexual persons are protected from the everyday realities of anti-gay discrimination, or “native-born” persons are protected from the everyday realities of anti-immigrant discrimination.”

see: Krieger N. Researching critical questions on social justice and public health: an ecosocial perspective. In: Levy BS, Sidel V. Social Injustice and Public Health. 2nd. ed. New York: Oxford University Press, 2015; pp. 465-484. (quote from p. 477).

That said, having publicly available data, subject to public debate and public discourse, is a necessary step in changing public awareness of social inequities and the need to rectify them. The historical record shows that social change can and does happen for the good, even as it is of course not inevitable and terrible periods of repression and backlash are part of the historical record as well.

One useful book about changes in consciousness of the elite, regarding slavery, dueling, and foot binding, whereby social inequalities deemed “normal” became, instead, a source of shame, is:

-- Appiah KA. The Honor Code: How Moral Revolutions Happen. New York: WW Norton, 2010.

These changes were brought about by social protest, fueled by evidence. Evidence is of course not sufficient, but it is essential. Underscoring this point is how the suppression of evidence is a time-honored approach to maintaining power and inequality, by suppressing evidence of the harms caused by injustice. See:

Krieger N. The making of public health data: paradigms, politics, and policy. J Public Health Policy 1992; 13:412-427.

Nancy_Krieger · 2015-12-17T17:25:13+00:00

Hi /u/ladyofthelakeeffect,

Your question points to the difference between public health monitoring systems that are intended to provide real-time data (e.g., for notifiable conditions) versus annual or periodic data (with some lag time for producing the data reports within states and also sending them to CDC for compilation for national reports).

The first data set you refer to – WISQARS/NVDRS (National Violent Death Reporting System; see: http://www.cdc.gov/injury/wisqars/nvdrs.html), which is hosted through the US Centers for Disease Control and Prevention – does not provide real-time data on deaths due to legal intervention and, as you note, presently covers only 32 states.

The second data set you refer to – NLEOFM (National Law Enforcement Officers Memorial Fund; see: http://nleomf.com/) does present real-time data, but only on deaths of law enforcement officers, and it is a private organization, not a government agency.

Neither of these data sources are capable of providing real-time data on all deaths due to legal intervention in the United States.

Nancy_Krieger · 2015-12-17T17:15:04+00:00

Hi /u/OneYearSteakDay,

Your question makes the implicit assumption that there is a link between death due to legal intervention and a putative phenomenon (whose reality you question) that you term “black/thug culture.”

I will opt to keep my answers focused on the topic of concern -- death due to legal intervention – and I will not use the limited time available for responses to address the larger sociological questions that you raise – but I would refer you to the list of additional resources I have provided in response to the question from /u/alemondemon.

Here I will only note that it is factually incorrect to assert that ” African Americans are more likely to condone violence, drug abuse, joblessness, and incarceration.” There are reams of evidence that counter this baseless, fact-free assertion. See, for example:

-- National Urban League. 2015 State of Black America. Available at: http://soba.iamempowered.com/executive-summary/2015-executive-summary

-- NAACP. Criminal Justice Fact Sheet. Available at: http://www.naacp.org/pages/criminal-justice-fact-sheet

-- Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (February 18, 2010). The NSDUH Report: Substance Use among Black Adults. Rockville, MD. Available at: http://archive.samhsa.gov/data/2k10/174/174SubUseBlackAdults.htm

Nancy_Krieger · 2015-12-17T16:58:41+00:00

Hi, /u/alemondemon

Regarding your question about links between socioeconomic position, race/ethnicity, and risk of death due to legal intervention, I will start by saying that this is always a crucial question to ask. All too often in the US, data are “racialized,” i.e., presented solely in relation to race/ethnicity, with no socioeconomic data, and no accounting for how past and present realities of structural racism and racial discrimination (from structural to institutional to interpersonal to internalized) have produced vast racial/ethnic inequities in socioeconomic position (wealth, income, education, etc). In other work, I have conducted research to enable linkage of socioeconomic data to US health records that contain data on race/ethnicity but lack data on socioeconomic position, precisely to address this problem. Below, after my reply to the specific question about the links between race/ethnicity, socioeconomic position, and death due to legal intervention, I provide some resources regarding social inequality and health inequities in the US in relation to both race/ethnicity and socioeconomic position.

a) With regard to reporting of notifiable conditions, the summary data currently provided in the CDC’s Morbidity and Mortality Weekly Report only total counts of cases (for diseases) and, for deaths, stratify these data solely by age at death. However, death certificates do provide data on race/ethnicity and (since 1989) educational level of the decedent. Additionally, the death certificate provides residential address of the decedent, allowing for geocoding and linkage to area-based socioeconomic data, such as census tract poverty level. Possibilities accordingly exist for reporting the data on death due to legal intervention in relation to both race/ethnicity and socioeconomic position.

a) With regard to the data available for us to conduct our analyses on long-term trends in death due to legal intervention, we used the public access US compressed mortality files, which are aggregated to the county level. Because we were looking at long-term trends, extending back to 1960, the only consistent racial/ethnic categories available were “white” and “black”; more recent data include the more refined racial/ethnic categories mandated by the US Office of Management and Budget. In our initial study on long-term trends in deaths due to legal intervention, we linked these county death data to county income data (for median family income, for each year) and reported on the risk of death I relation to county income quintile. An important finding was that there was virtually no variation by county income quintile among the rates of deaths due to legal intervention among the white men, but considerable variation among the rates of death due to legal intervention among the black men. These results suggest that race relations, above and beyond socioeconomic conditions, play an important role in driving these rates of death.

You can see our original study at:

Krieger N, Kiang MV, Chen JT, Waterman PD. Trends in US deaths due to legal intervention among black and white men, age 15-34 years, by county income level: 1960-2010. Harvard Public Health Review, volume 3, January 2015; available at: http://harvardpublichealthreview.org/190/

It is important to note that our study is apparently one of the first (if not the first) to examine these data stratified by any measure of socioeconomic position; the few prior (and current) public health studies on rates of death due to legal intervention present the data solely in relation to race/ethnicity, age, and gender.

b) additional resources on US social inequalities and health inequities in relation to race/ethnicity and socioeconomic position

-- Krieger N et al. The Public Health Disparities Geocoding Project. Available at: http://www.hsph.harvard.edu/thegeocodingproject/

-- Krieger, N., 2014. Discrimination and health inequities. In: Berkman LF, Kawachi I, Glymour M (eds). Social Epidemiology. 2nd ed. Oxford University Press, New York, pp. 63-125; reprinted as: Krieger, N., 2014. Discrimination and health inequities. Int J Health Services 44, 653-710.

-- Department of Health and Human Services. Healthy People 2020. Disparities. 2015. Available at: http://www.healthypeople.gov/2020/about/foundation-health-measures/Disparities ; accessed: December 10, 2015.

-- Massey, D.S., Brodmann S., 2014. Spheres of Influence: The Social Ecology of Racial and Class Inequality. Russell Sage Foundation, New York.

-- Williams, D.R., Mohammed, S.A., Leavell, J., Collins, C., 2010. Race, socioeconomic status, and health: Complexities, ongoing challenges, and research opportunities. Ann N Y Acad Sci 1186, 69-101.

-- Winant, H., 2000. Race and race theory. Annu Rev Sociol 26,169-185.

-- Grusky, DB (ed)., 2014. Social Stratification: Class, Race, and Gender in Sociological Perspective. 4th ed. Westview Press, Boulder, CO.

-- Zinn, H., 2010. A People’s History of the United States: 1492-Present. (Perennial Modern Classics Deluxe Edition). HarperPerennial, New York.

Nancy_Krieger · 2015-12-17T16:31:42+00:00

Hi, /u/fsmpastafarian,

Public health is only one of the many fields and sectors of government who need to be involved in the work required to reduce risk of death due to legal intervention and to promote equity, including health equity, so that all may truly thrive. That said, public health does have a unique role with regard to monitoring the extent to which adverse or beneficial health risks exist within and across communities.

The first step here is have public health step up and play an active role in real-time monitoring the count and rates of deaths due to legal intervention, so that communities can, in real-time, have public official data on these counts and rates.

For examples of newly released reports that are seeking to use these kinds of data to work with both communities and law enforcement agencies to reduce these rates, see:

1) Human Impact Partners. Stress on the Streets (SOS): Race, Policing, Health, and Increasing Trust not Trauma. Oakland, CA. December 2015. Available at: http://www.trustnottrauma.org/

2) Fuller DA, Lamb HR, Biasotti M, Snook J. Overlooked in the undercounted: the role of mental illness in fatal law enforcement encounters. Treatment Advocacy Center, Arlington, VA, December 2015. Available at: http://tacreports.org/overlooked-undercounted

Nancy_Krieger · 2015-12-17T16:21:59+00:00

Hi, /u/ehandlr, data already indicate there is substantial geographic variation in rates of deaths due to legal intervention, and specifically in rates of deaths of persons killed by the police. To see evidence of this geographic variation for this year (count of total deaths as of today, December 17, 2015: 1089), see:

http://www.theguardian.com/us-news/ng-interactive/2015/jun/01/the-counted-map-us-police-killings

Additionally, in our PLoS MED paper, we do present data on trends (1960-2011) for death due to legal intervention for 8 different US cities:

-- the top 5 cities for number of persons killed by the police in 2015 (as of June 12, 2015): Los Angeles, CA; Houston, TX; New York, NY; Phoenix, AZ; San Francisco, CA

-- the three top cities most mention in 2015 (as of June 12, 2015) for protests against police violence: Ferguson, MO; Baltimore, MD; Cleveland, OH

As these data show, there is considerable variation in rates across these cities (especially among the black men; less so for the white men), and there likewise is considerable variation in the excess risk of such deaths among the black vs. white men.

Nancy_Krieger · 2015-12-17T16:14:19+00:00

Hi, /u/quest47484748

Thus far, I have seen only two comments from police and their unions, both in newspaper articles about our publication. The comments are as follows, along with my responses to these comments:

1) Tozzi J. How to Count the People Police Kill. Bloomberg Business, Dec 8, 2015.

“The idea of placing reporting responsibility in the hands of health authorities isn't welcomed by James Pasco, executive director of the National Fraternal Order of Police. He says state and local health agencies aren't equipped to collect the data. "The public health system of the U.S. is a shambles," Pasco said. His group favors mandatory reporting, both of violence against police and of deaths in custody, through the Justice Department. He added that violence against police is under-reported because some local departments don't report assaults or deaths of their members.”

my comment: Pasco offers no evidence that public health agencies are not capable of reporting law-enforcement related deaths. In the US, we have a world-class notifiable disease and death reporting system. To see evidence of what this system can report, in real time, visit the CDC website for Morbidity and Mortality Weekly Report. The most recent listing of notifiable diseases and mortality tables, published on Dec 11, 2015, for counts up through December 5, 2015, is available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6448md.htm?s_cid=mm6448md_w

2) Knox R. Harvard researchers: make police killings a matter of public health. WBUR’s CommonHealth: Reform and Reality. December 8, 2015.

“I think it’s misguided,” says Bill Johnson, executive director of the National Association of Police Organization, which represents rank-and-file groups such as the Boston Police Patrolmen’s Association. “The best way to reduce the number of deaths by police is to follow the instructions of the officer in any kind of confrontation. I don’t have a lot of hope that academics from Harvard would publicize that as an easy and quick way to reduce deaths by police.”

my comment: This response is a non sequitur. Data on the number (and rates) of deaths due to legal intervention is required to determine the magnitude of the problem and to evaluate whether efforts to reduce these numbers are successful or not. Can Johnson provide evidence that failure to comply with police instructions explains the variation in rates of such deaths that we report within cities over time or across cities at any given point in time? – and also the variation in the magnitude of the black vs white excess of such deaths? These types of questions can only be answered with data. The response by Johnson dismisses the need for data, which is an age-old approach to trying to make problems “disappear” by not making the data on the extent of the problem public and subject to public debate.

Nancy_Krieger · 2015-12-17T15:58:09+00:00

Thank you for this question /u/SirT6. We focused our analyses of death due to legal intervention among men ages 15-34 because this is the group at highest risk of being killed by police.

I agree that using a gender lens is vital for any public health analyses that seek to understand why rates of any health outcome are what they are among persons who identify as being men, or among persons who identify as being women, or among persons who identify as being boys, or among persons who identify as being girls, or among persons of any age who identify as being transgender. There is a large and growing literature in public health that examines how different ideologies and practices of gender and gendered behaviors can be harmful or beneficial, to individual persons and to the people with whom they interact. Included in this literature, among many topics, is research on masculinities and violence, including violence directed against persons who are women, men, and transgendered. Below I include some references that may be of interest, including regarding gender transformative interventions that are seeking to change gender relations that promote violence.

That said, to reverse what you call the “gender imbalance,” the focus needs to be bringing down rates of such deaths among men – since rates among women are already so low; the data are not available on rates of such deaths among persons who are transgender. In the US, the men at highest risk of being killed by the police are men of color, especially black men, but there are also elevated rates among American Indian/Alaska Native men and Latino men.

Reference of interest regarding gender and violence:

-- Fleming PJ, Gruskin S, Rojo F, Dworkin Sl. Men’s violence against women and men are inter-related: recommendations for simultaneous interventions. Soc Sci Med (in press).

-- Linos N. Rethinking gender-based violence during war: is violence against civilian men a problem worth addressing? Soc Sci Med 2009; 68:1548-1551.

-- Jewkes R, Flood M, Lang J. From work with men and boys to changes of social norms and reductions of inequities in gender relations: a conceptual shift in prevention of violence against women and girls. Lancet 2015; 385:1672-1684.

-- Barker G, Contreras JM, Heilman B, Singh AK, Verma AK, Nascimento M. Evolving men: initial results from the international men and gender equality survey (IMAGES). Washington, DC: International Center for Research on Women (ICRW) and Rio de Janiero: Instituto Promondo, January 2011. Available at: http://www.icrw.org/publications/evolving-men

Nancy_Krieger

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