Faculty in Focus: Charting a New Course

I went back to my mayor and I said, “There’s this drug called buprenorphine and if you really increased its availability, it would start to save lives.” And the mayor said, “That can’t be right. If it was that simple, we wouldn’t have this crisis.” I went back to folks like Jody and said, “Am I missing something?” And they said, “It really is that simple, but the systems are not in place.”

My public health moment was when I realized that public health is about two things: it’s about science and about systems.

You can get all the science right and do it very diligently, but if you don’t have the right systems of public administration, if you don’t have the right public/private partnerships, if you don’t have the right way to operationalize the science in government and in communities, you’re leaving critical public health value on the table.

My career working in very big and smaller government systems has shown me the acute need we have to turn these systems toward public health.

What’s an example of a law enforcement system that could be turned in the direction of public health?

From the mountains of Idaho to Atwells Avenue, if you have broken a law, there’s a system in place for the police to bring you in front of a judge, in a matter of hours, 24/7. That’s the main system that police have at their disposal—the other things are either pilot projects or add-ons that are competing with this super well-established system.

We get frustrated with the police in their instinct to take that system and apply it to everything: You’re unhoused, you’re trespassing, let’s go in front of the judge. You have drugs in your pocket, let’s go in front of the judge. You have a mental illness and you’re waving a baseball bat around, well, you know what? That seems like menacing, which is a crime, so let’s go in front of the judge.

But Chicago and Tucson, Arizona, for example, have really promising programs where, citywide, if you commit a minor crime related to drugs or addiction, and there’s nothing more serious looming over you, you get brought to the precinct, but then instead of being charged, you are directly connected with treatment if you want it. These are not pilots. They are citywide, 24/7 systems that link people who are up for drug possession, or up for a minor offense related to addiction, directly to social workers working in the precincts. That system genuinely competes with prosecution.

Diverting people away from criminal justice and toward health care sounds like an effective intervention, but it also sounds expensive. What is your response to the “defund the police” movement?

If you’re unhappy with the ship you’re on, you don’t scuttle it while you’re at sea. A better analogy is that we need to chart a new course and repair this ship while we’re in a storm. You don’t do that through destroying or hobbling the institution—you need to turn it. And understanding bureaucracies is one of the keys to understanding how to change and improve them. Even the most agile bureaucracies take years to change.

Politicians might say that’s the problem with these government agencies, that they move at the speed of… bureaucracy, but what you get along with that slow pace is resilience. Once something is working well, you want it to be resilient and you want it to have its own momentum. When something is not working well, it’s frustrating that it has resilience and momentum, but you can’t have it both ways.

What we don’t need more of are one- to two-year, limited scale pilot projects that show a good idea works in one neighborhood but don’t get expanded and funded, and then peter out. We need to bake good practices and science into bureaucracies that will give them the momentum and the resilience to carry that forward for years. That takes time.

I worry that when you tear down institutions and let people sort things out for themselves, number one, it’s overwhelming for people who are already facing serious challenges, and number two, it’s going to end up being unfair and illiberal in some surprising ways.

Tell us about your current research funded by a K award with Dr. Jody Rich.

Police have contact with 65 million people a year, and so many of them are dealing with substance use disorders. Instead of turning those encounters into punitive or prosecutorial encounters, there’s a big opportunity to turn a lot of those encounters toward linkage to treatment and linkage to harm reduction. My goal is to take that idea, which has evidence behind it, and get police to embrace it.

Policing is eminently about decision-making. At the lowest levels, in the darkest hours of the night, in the worst weather, in the most far-flung places, police are making decisions about whether to arrest or not arrest, to charge or not charge, what to do with the person in need who may have some criminal behavior. My research is about the individual officer and his or her supervisor out there doing police work on a daily basis, far from public view, making decisions at two in the morning. How to get them to understand the power of linkage to treatment and harm reduction, not only to save lives, but also to enhance public safety.

If we can steer police encounters toward health instead of punishment, I think it would help us tremendously, but it requires really getting into the mind of police and into police systems. That’s what my work is about—why officers do or don’t use discretion, how to direct that discretion toward improving health outcomes, how to understand that linkage to effective treatment is both a health outcome and a justice outcome; and finally how to build not only big department-wide systems, but lower, precinct- and officer-level systems that officers find acceptable, that they find feasible.

The moonshot of my K award is for officers to go out there and think: “Tonight, if I find somebody who’s breaking into a car because they’re addicted to opioids, I know what I can do to get them to treatment. I think it’s a good outcome. I think it’s a fair outcome. I think it’s as appealing and as effective and feasible as arrest. And I accept it as part of my routine work.”

There are people who use a health lens to expose the problems with criminal justice. It’s very important work. For my part, I’m interested in using a health lens to improve the way we deliver justice. The justice system is hurtling down its path with so much momentum behind it, and public health is trying to reduce its harms. I’m trying to link health and justice, to bring them into congruence.

People working in health are wishing for more progress in the government space and in the criminal justice space. And criminal justice practitioners are tired of having an existential crisis in their profession every five years. Countless leaders in the field know that there are better ways to do things. I think there’s that appetite on both sides. It’s about bringing these disciplines together and putting evidence behind their practices.