In the wake of the George Floyd protests, like you, I started seeing calls to defund the police. Initially, I thought this was ludicrous. “Who's going to stop the burglars? The drunk drivers?” My understanding of the word “defund” was to remove funding, like defund Planned Parenthood or defund NPR. Shut them down.
Some activists do seem to want the police to be literally defunded and shut down, but most of the conversations surrounding Defund the Police are actually about redirecting police funding. I think it actually has some relevance to us in emergency medicine, and I'm all for it.
An example is New York City, with its $6 billion annual budget for its police department (the New York City Council just voted to slash the NYPD's budget by a whopping $1 billion at the time of this writing). Every jurisdiction's population, no matter how large or small, has individual and societal problems that require urgent, immediate, or emergent attention, and each jurisdiction decides how to address those problems. In most cases, that's through dialing 911, which then gets you fire, police, or EMS.
Address the Gap
Many cities are aware that this is a limited menu of options and have added semi-urgent but definitely not emergent services to address the gap. In San Francisco where I live, you can call 311 24/7 to report a pothole, a homeless encampment, a coyote sighting, or even just to ask a question about parking enforcement on the holidays. You can even report things and find information on the city's 311 phone app.
Cities are also wising up to the fact that many 911 medical calls don't actually require emergency services and that some issues could be safely and appropriately handled at an urgent care or even an alcohol sobering center like we have here. Alcohol-intoxicated patients without trauma who can walk with one-person assistance can sober up in a recliner under the supervision of a nurse practitioner, who can refer them to city resources and even look for and treat mild alcohol withdrawal. All on the city's dime.
It makes sense. We're all going to end up paying for it one way or another: The intoxicated patient on the street would get a 911 call, might be taken to the county hospital (taxpayer-funded), and would sober up in the ED instead. Not the best use of an ED bed, a precious and expensive resource.
When a 911 call is deemed not to be medical or fire-related, the police department is left with everything else. They respond to issues for which they're not formally trained. Police officers in New York State, for example, must complete a minimum of 700 hours of training. Cosmetology requires at least 1000 hours. (New York Times. June 19, 2020; https://nyti.ms/2VYbQP3.) Often mental illness is at play, with some estimating that 10 percent of 911 calls involve mental illness. (Governing. May 2016; https://bit.ly/2ALbkww.) Just as we're expected to be a urologist, cardiologist, pediatrician, and primary care doc, police officers are expected to be a therapist, marriage counselor, enforcer, and safety officer with even less training.
A 2009 National Association of Counties study found that “15 percent of male jail inmates and 31 percent of female jail inmates have a serious mental illness, which includes depressive disorders, bipolar disorders, schizophrenia, delusional disorders, and psychotic disorders.” (NACo.September 2015; https://bit.ly/2AJq2Ec; Psychiatr Serv. 2009;60:761; https://bit.ly/2ALi6SY.)
Other data suggest that these numbers have gotten even worse in the past decade. In 44 states, “a jail or prison holds more mentally ill individuals than the largest remaining state psychiatric hospital; in every county in the United States with both a county jail and a county psychiatric facility, more seriously mentally ill individuals are incarcerated than hospitalized,” according to the Treatment Advocacy Center. “A 2004-2005 survey found there were more than three times more seriously mentally ill persons in jails and prisons than in hospitals.” (September 2016; https://bit.ly/38DXhFm.)
So back to defunding the police: Imagine a world where New York City takes that $1 billion from the NYPD and spends it differently. It hires therapists instead of buying bulletproof vests and police cars. It hires social workers. It buys mental health crisis vans. And sobering centers. And drug treatment teams. I can only imagine this would help us in the ED as well. If our patients had resources they could access other than just the ED, I bet they'd take advantage of them. Imagine if there were more options than just fire, police, or EMS.
Dr. Walkeris an emergency physician at Kaiser San Francisco. He is the developer and co-creator of MDCalc (www.mdcalc.com), a medical calculator for clinical scores, equations, and risk stratifications, which also has an app (http://apps.mdcalc.com/), and The NNT (www.thennt.com), a number-needed-to-treat tool to communicate benefit and harm. Follow him on Twitter@grahamwalker, and read his past columns athttp://bit.ly/EMN-Emergentology.