Proceedings of a Workshop—in Brief

Community Safety as a Social Determinant of Health

Proceedings of a Workshop—in Brief

On December 6 and 7, 2023, the Roundtable on Population Health Improvement and the Forum on Mental Health and Substance Use Disorders cohosted a workshop on community safety as a social determinant of health. Roundtable cochair Ana Diez Roux, Distinguished University Professor of Epidemiology, director of the Drexel Urban Health Collaborative, and dean emerita of the Dornsife School of Public Health at Drexel University, offered context for the workshop.¹ Community safety, Diez Roux said, is more than the absence of violence; it is directly linked with fairness and justice, with systems of inequality and racism—“systems we create and [that] we can change.”

Therese Richmond, Andrea B. Laporte Professor of Nursing at the University of Pennsylvania, added that the workshop would examine safety and violence through the socioecological model of health (i.e., at the individual, family, neighborhood, and societal level), along the life course, and considering intergenerational effects. She shared statistics that indicate violence is not equally distributed by gender, race and ethnicity, age, or geography:

• Black males ages 15 to 34 account for just 2 percent of the U.S. population but 36 percent of firearm homicide victims.
• Indigenous communities experience the highest rate of suicide, of which 45 percent are associated with firearms.
• Since 2019 more children from 1 to 19 years of age have died due to firearm-related injuries than from any other cause.
• Homicide is a major cause of maternal mortality; and
• Sexual and gender minority groups bear a disproportionate burden of firearm injury.

Richmond shared that in Philadelphia firearm violence is concentrated in communities that were redlined² in the 1930s and remain stricken with generational poverty and limited resources, an example of a racist policy whose ramifications persist decades later. A growing body of science, she added, shows how communities can be safer from firearm violence, including via safe storage of firearms, “lethal means” counseling, identification of at-risk adolescents, and place-based interventions such as reclaiming abandoned buildings and greening blighted lots.

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HISTORY OF VIOLENCE IN AMERICA AND DEFINING SAFETY TODAY

Hedwig Lee, professor of sociology at Duke University, presented the historical legacies of racial violence and the relationship with contemporary patterns of conflict and inequality.³ Racial violence is foundational in U.S. history, Lee shared, with colonization and slavery operating as pillars of economic growth. Lee quoted Claudia Rankine’s article on racial violence, “The Condition of Black Life Is One of Mourning”:

There really is no mode of empathy that can replicate the daily strain of knowing that as a Black person you can be killed for simply being Black: no hands in your pockets, no playing music, no sudden movements, no driving your car, no walking at night, no walking in the day, no turning onto this street, no entering this building, no standing your ground, no standing here, no standing there, no talking back, no playing with toy guns, no living while Black.⁴

Lynching, or extrajudicial mob killings, represents the most extreme form of racialized interpersonal violence in the post-Emancipation South, Lee stated. Between the Civil War and World War II, 4,000 Black Americans died by lynching.⁵ Lynching reinforced white supremacist hostility toward Black communities and discouraged Black people’s participation in politics. Lee summarized modern-day consequences of historical racial violence: white supremacist mobilization, residential segregation, infant mortality, and decreased voter turnout.⁶ Although the nation’s racial history shapes the present, “there are possibilities to intervene on those legacies” and “mitigate the harms,” Lee stated.

Thomas Simon, senior director for scientific programs in the Division of Violence Prevention at the Centers for Disease Control and Prevention (CDC), shared that CDC envisions a “violence-free society in which all people and communities are safe, healthy, and thriving.” This vision is guided by the principle of economic, gender, and racial equity and informed by a focus on the social determinants of health.

Violence across the lifespan ranges from domestic violence to sexual violence to community violence, and CDC uses a public health approach for violence prevention.⁷ Simon highlighted key data points, including a nearly 35 percent increase in firearm homicide rates between 2019 and 2020, and an additional 8 percent in 2021, resulting in the highest firearm homicide rate since 1993.⁸ Simon discussed how systemic inequities in housing, education, and employment contribute to health disparities and how the COVID-19 pandemic could have worsened these conditions, particularly in some racial and ethnic communities. He shared data showing the association between firearm homicide rates and county poverty rates.⁹

CDC is developing a Community Violence Prevention Resource for Action¹⁰ that will foster community safety through three categories of preventive policies and programs:

1. Improving underlying economic and social conditions and outcomes, including housing assistance, tax credits, and livable wages.
2. Improving the physical conditions through revitalizing vacant lots and ensuring safe routes to and from schools (e.g., the Safe Passages program in Chicago).
3. Helping people who experience the greatest risk through outreach and hospital-based violence prevention programming.

The current evidence, while important, is not enough, noted Simon. A well-supported violence prevention

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workforce is needed to put the evidence into practice and sustain it over time.

Discussion

Richmond asked Lee to consider why people of privilege, usually white, should see this as relevant to them. Lee responded that stereotypes and racialized patterns of how Black people die are informed by concepts of Black inferiority. She underscored the importance of thinking about how the past affects the present and how the histories of slavery and Jim Crow (i.e., legalized racial segregation) reverberate today. She added that the well-being of other groups, including white populations of lower socioeconomic status, is also affected by historical policies that limit access to opportunities and hamper social reintegration of people who interact with the criminal legal system.

Panelist Annita Lucchesi, founder and director of the Sovereign Bodies Institute (SBI), asked Simon for examples of interventions in rural and tribal communities. Simon said CDC’s exploration of a range of policy interventions (including low-income housing tax credits) is relevant to both urban and rural populations. Suzanne Bakken from Columbia University asked about the usefulness of data sources and interactive tools in violence prevention. Simon shared that CDC uses multiple data systems, including mortality data from death certificates and the National Violent Death Reporting System (NVDRS), which integrates coroner and medical examiner data with law enforcement data to provide more complete information on violent deaths. CDC also conducts syndromic surveillance to provide timely data on violence-related injuries treated in emergency departments (e.g., the FASTER initiative¹¹) and to provide communities with data to inform prevention activities over time. Lee spoke about surveys that shed light on social and health outcomes of violence exposure and innovations both in survey design and modes of data collection (e.g., through smartphones). Challenges in the use of administrative data, Simon said, include ambiguity in data from death certificates, systematic bias, and underreporting in law enforcement data. Simon added that each data source is characterized by strengths and limitations. For example, NVDRS data have been shown to provide comprehensive estimates of deaths from law enforcement use of force than law enforcement data alone. Some data sources on violence outcomes may be further linked; for example, with County Health Rankings or with the Social Vulnerability Index, to help provide a clearer picture of the conditions that influence violence. Lee said that it is important to understand links between the criminal legal system and the health care or school system.

Margarita Alegría, chief of the Disparities Research Unit at Massachusetts General Hospital and the Mongan Institute, asked how data sets may reflect feelings of hopelessness or dislocation that shape violent incidents and related outcomes. Lee said that factors such as residential segregation and overpolicing affect well-being because they may hamper people’s ability to inhabit public spaces and interact socially, due to being hassled or feeling devalued. Simon shared that research indicates that young people report carrying guns because they feel a need to protect themselves and other forms of protection do not operate in their communities or work for them. After mass casualty events, individual experiences of hopelessness and grief are reflected in crisis helpline data. These incidents also influence behavior. Data collected before and after the Columbine school shooting, Simon added, indicated that a high proportion of students felt too unsafe to attend school in the event’s aftermath.

Participant Yessica Amezquita asked if storytelling can play a role in violence prevention. Simon said personal stories can help strengthen quantitative information, elevate lived experiences, and raise awareness about the impacts of violence and the effects of prevention strategies. Lee mentioned research techniques that center community narratives, such as the use of Photovoice. Panelist Tyrique Glasgow, executive director and founder of Young Chances Foundation, asked if historical data about redlining and its lasting effects, such as lack of access to fresh fruits and vegetables, are integrated with other data sources. Simon said that CDC’s new Community Violence Prevention Resource for Action describes redlining as a factor in the structural conditions that affect community violence. Lee said that the effects of redlining have been modeled to clarify its contributions to modern-

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day disparities and consideration of the history of places is helpful in avoiding blaming individuals or communities for their experiences.

A participant asked if the relationship between historical lynching and modern-day homicides has been mitigated by acknowledgment of that history. Lee said the findings are preliminary, but the study of acts of resistance to historical symbols shows promising evidence. It also is hard, she added, to measure the effects on community sentiment and orientation in places where people are contending with the legacies of Jim Crow and other racist practices.

Bobby Milstein of ReThink Health asked about strategies to build public support for sound policies on community safety. Simon said that the CDC Youth Violence Prevention Centers are academic–community partnerships that support the implementation and evaluation of a range of community initiatives to prevent violence, such as the Center for Youth Equity at Tulane University and the University of Louisville’s Youth Violence Prevention Research Center.

Lee shared the artist collective Story Stitchers, which promotes community safety by involving youth in musical performance, and the work of LJ Punch, a former Saint Louis trauma surgeon who popularized the Stop the Bleed program, which incorporates elements of community care. Monica Valdes Lupi from The Kresge Foundation asked Simon about resources for the public health workforce. Simon shared information about tools and resources on CDC’s VetoViolence website, and the PREVAYL initiative, which works to prevent violence affecting young people.

INTIMATE PARTNER VIOLENCE AND DOMESTIC VIOLENCE

Debbie Chang, president and CEO of the Blue Shield of California Foundation, introduced the panel by outlining the drivers of interpersonal safety: racism, economic insecurity, and gender inequity. She said there are unique opportunities for interventions along the life course, including opportunities for prevention, and intimate partner violence (IPV) is “healable and preventable.”

Chang introduced speakers Anita Raj, executive director of the Newcomb Institute at Tulane University, principal investigator of its VEX (violent experiences) survey, and Nancy Reeves Dreux Endowed Chair in the Tulane University School of Public Health and Tropical Medicine, and Arnold Chandler, president and CEO of Forward Change.

Raj spoke about the VEX surveys conducted in California and Louisiana by NORC at the University of Chicago. Findings include a growing discrepancy between women (47 percent) and men (7 percent) who have experienced IPV, with more life-threatening forms of violence affecting women, particularly during pregnancy and postpartum. Among the 3,560 California and 1,081 Louisiana survey respondents, higher rates of IPV were found in people ages 18–24, women, and nonbinary individuals. The surveys, Raj added, found that 3 percent of respondents in California and Louisiana reported experiencing physical or sexual IPV in the past year, with social, economic, and health effects.

The 2023 VEX surveys found the following risk factors and community-level predictors of IPV: guns in the community, abusive policing (in California), policing, everyday discrimination, and viewing the neighborhood as unsafe (in Louisiana, which has the second-highest homicide rate in the United States).

Raj stated that “IPV is at an epidemic level in the United States, but lack of timely data impedes our ability to act and track change.” The VEX surveys “offer timely data on IPV and document ecological factors affecting IPV and mental health outcomes.” Although the surveys did not show significant racial or ethnic differences in IPV, there was a strong finding of Black femicide risk, as well as higher risk for minoritized sexual orientation groups, youth, and those experiencing economic distress and everyday discrimination. Given that IPV starts in youth, the timing of interventions is key, Raj noted.

Chandler focused on prevention of domestic violence (DV, referring to family violence more broadly) and its consequences on health and well-being, and contrasted the short-view approach (i.e., mandatory arrest) with a long-view approach—a life-course perspective on prevention. A study in Milwaukee showed positive evidence of mandatory arrest on IPV recidivism, or revictimization, at 6-month follow-up. However,

long-term (23-year) follow-up showed increased death rates of victims, especially if they were Black women, compared to women whose abusers were warned but not incarcerated.¹² Chandler asserted that this indicates negative side effects of engagement with law enforcement. Further research across states with mandatory arrest laws shows that arrest is associated with a 60 percent increase in IPV homicide.¹³

The four types of IPV are psychological aggression, coercive control, physical violence, and sexual violence. Research shows a critical window to emphasize prevention between parental exposures and their children’s exposures. Employing a dual-generation approach to IPV prevention offers an opportunity to intervene in parallel with young children and their parents, Chandler shared, because the cycle of violence that begins with exposure to and experience of abuse in childhood often continues with IPV perpetration in young adulthood.

Most families with children in a nationally representative sample experiencing IPV had never interacted with one of the systems designed to prevent or respond to DV. Only 25.2 percent of families experiencing IPV have police contact, and 14.9 percent of incidents led to contact with a DV advocate. Chandler outlined promising programs intended to prevent IPV and DV in health care and school settings, home visitation, law enforcement strategies, and community-based services (see Figure 1).

Chandler explained that there is an assumption that women who have been victimized want to or should leave their partners, but the systems currently in place do not support those women who want to remain with their partners. He listed several domains where more research and services for families experiencing DV are needed, including restorative justice diversion programs and substance abuse–targeted DV prevention for adults with children.

Discussion

Asked about solutions to IPV, Raj said that policy solutions that avoid evictions, improve food security, and preserve the safety net can help. In Louisiana, there are no red flag laws that aim to prevent people who show signs of being a danger to themselves or others from having access to firearms. Such laws are critical protections needed for households experiencing DV.

Chang asked Chandler where he sees opportunities for prevention and innovation. Chandler responded that law enforcement is a blunt instrument, mass incarceration has harmful effects, and including restorative justice in batterer intervention programs is more likely to mitigate DV risk. Chang added that the Violence Against Women Act includes funding for restorative justice efforts.

Participant Dara Blachman-Demner asked how DV programming could be integrated into violence interrupter work and street outreach programs. Raj agreed with the importance of integrating such interventions. For example, the bystander and interrupter programs could inform one another; the latter could integrate awareness of gender dynamics and homophobic and transphobic biases.

Lucchesi observed that communities of color are more likely to have intergenerational households, and some experience historic and structural factors that shape DV, such as the trauma associated with boarding schools for Indigenous people. Also, victims of trafficking are often survivors of child abuse. Chandler shared that the domain of interventions is nascent and underdeveloped but agreed that broader ecological factors are at play and prioritizing the parental dyad is insufficient. Chandler

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and Raj acknowledged the importance of adopting a perspective that is inter- or multi-generationally focused. Raj noted that understanding cultural variations in definitions of family can better inform responding to a family’s needs (e.g., policies that deny fathers access to their families are counterproductive).

Phillip Alberti of the Association of American Medical Colleges asked if any interventions Chandler outlined have been studied in LGBTQIA+ populations, given their increased risk of IPV. Chandler admitted that not much is known about IPV in this population. Chang responded that this illustrates gaps in science and research funding.

Stacy Skelly from the Reis Group asked Chandler about how the knowledge gaps can be closed, given the need for a long-term approach. Chandler acknowledged that short-term follow-up is a challenge. He also commented on patterns he noticed in the existing evidence, such as that punitive interventions are likely to have poor long-term outcomes.

Chang asked a viewer’s question about mandatory reporting as a form of child maltreatment. Raj said that mandated reporting can compromise disclosure, prevent bringing a child forward, and lead to negative outcomes.

Steven Hargarten from the Medical College of Wisconsin said that victims of DV come to emergency rooms every day, but it is not clear what the health care system should do. Chang replied that Futures Without Violence has developed a toolkit for health care providers.¹⁴

LEARNING FROM RESEARCH

Ruth Thomas-Squance, co–executive director of the Build Healthy Places Network, moderated a discussion highlighting evidence-based research and effective interventions at the interface of physical spaces and social structures that create safe and healthy communities. She said that “safety” is a term used in multiple contexts, such as for clean air and water, but also for living in a community with access to safe transportation and free from crime, injury, violence, and traumatic stress. Safety also includes freedom from stigma, discrimination, and oppression, she added.

Tha Thai, assistant director of Roca Boston, gave an overview of Roca’s intervention model, a 4-year program for people ages 15 to 24 experiencing violence in Baltimore and Boston. The program includes four components:

1. “Relentless outreach” because “most of the young persons that we service are not ready, willing, or able [and] we can’t wait for them to show up.”
2. Roca’s Rewire cognitive behavioral therapy (CBT) approach, which trains staff to teach skills such as emotion regulation.
3. Building relapse into the program to allow growth in “a place that is safe from judgment”; and
4. Fostering meaningful partnerships with police departments, youth services, courts, local hospitals, and public schools to improve outcomes for people experiencing urban violence.

Thai said the objective is for participants to go back to their communities and feel productive and valued enough to refrain from past behaviors, making the community safer for themselves and others.

Joseph Richardson, MPower Professor of African American studies, medical anthropology, and epidemiology at the University of Maryland, discussed the hospital violence intervention program (HVIP) in the trauma unit at the University of Maryland Prince George’s Hospital Center as an example of community-engaged research that elevates community voices.¹⁵ In this work, Richardson recruited 25 young Black men to understand what led to their violent injury and what social factors would lead them back to the hospital for a repeat injury, noting the high trauma recidivism rate for Black men. Richardson emphasized the importance of establishing trust and rapport. One of the participants, Che Bullock, became the first person he hired as a violence intervention specialist. Richardson and Bullock produced a documentary, Life After the Gunshot, which made these data and resources more accessible to

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community members without financial barriers such as journal paywalls. The documentary recounted the experiences of 10 HVIP participants in a humanizing, relatable way. Richardson concluded by emphasizing the need for narrative change around young Black men and the communities they come from.

Sonali Rajan, associate professor at Teachers College, Columbia University, described adverse childhood experiences, or ACEs,¹⁶ as “stressful or traumatic events that impact the healthy development of kids through adolescence and into adulthood” by disrupting a child’s sense of safety and stability. Currently, exposure to gun violence is not explicitly considered an ACE. In her work, Rajan found that exposure to gun violence should be included in prevention and intervention efforts designed to mitigate the impact of ACEs on child health, learning, and development. According to data, 100,000 Americans are injured with a firearm every year,¹⁷ more than 17,000 of whom are children; firearms are currently the leading cause of death among all children in the United States; Black children disproportionately experience firearm violence in comparison to white children;¹⁸ and more than 360,000 K-12 students have experienced gun violence at school since the Columbine shooting in 1999.¹⁹ Rajan noted that even indirect gun violence exposures negatively impact children. The current reactive approach to gun violence prevention in schools has little to no evidence base, and some of these strategies have been shown to have a negative impact on student learning, mental health, and teacher well-being, Rajan explained. U.S. K-12 schools are structured to anticipate violence through active shooter drills, arming teachers with firearms and increased police presence instead of preventing and curing the root cause, she said. Rajan suggested investing in evidence-based interventions that are known to reduce gun violence, such as affordable housing, improving street lighting in neighborhoods, green spaces, equitable early childhood education, caregiver support, community-based programming, public libraries, restorative justice efforts in schools, and connecting education research to public health efforts.

Discussion

Thomas-Squance asked how policies have been helpful or harmful to panelists’ work. Thai said the housing crisis and homelessness need to be addressed. Barriers to homeownership include credit checks and having a criminal record. “How can we say it’s a community where maybe 70 percent of the people that live there don’t even own homes?” He asserted that homeowners would take care of the community they have invested in. Richardson identified mass incarceration as the biggest issue in his work, explaining that the number one risk factor for repeat violent injuries in young Black men is a previous history of incarceration. He suggested that while in clinical care, patients need to be protected from law enforcement practices such as interrogation and confiscation of possessions. Richardson also highlighted how structural racism directly affects Washington, DC, by giving examples of unfair housing policies that led to redlining and gentrification. Rajan added that when children feel safe in schools, they are more motivated to learn and display less aggressive behaviors, and by extension, teachers experience less burnout. Furthermore, poor mental health is often used to rationalize gun violence without any investment in accessible mental health care. Investment is needed to hire more school counselors, psychologists, and other qualified school-based mental health professionals, said Rajan.

Thomas-Squance asked panelists to give the audience an example of what they can do to advance community solutions. Richardson said engaging communities as equitable partners will enable them to determine their own outcomes. Thai underscored the value of compassion. Rajan called for reshaping the public narrative to encompass a broader range of solutions and pushing elected officials to support scientific investment.

Brian Wade from the University of Pennsylvania asked about the implications of and necessary responses to frequent gun violence exposure, such as gunshots in the neighborhood or videos on social media. Richardson

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reiterated the importance of training community residents to engage in CBT and trauma-informed care with other community residents. He also mentioned sharing university resources with all community residents. Thai reiterated that Roca’s goal is to lead participants to a mental health professional to heal their trauma, noting that many people “translate their trauma through survival. In order for me to survive, this is how I have to react.” Rajan emphasized the need to reallocate resources toward effective interventions to prevent ACEs and gun violence.

A participant asked Richardson for examples of tools and data to uplift and engage communities. He said each community has different needs and “communities can heal themselves if we provide the space and opportunity for them to do it.” Viewer Abigail Sobotka-Briner asked how to move away from punitive policies in a culture that is resistant to reimagining how to approach public safety. The current approach is not enough, Rajan said, and “we have a collective commitment to do better by this younger generation.” Reducing class sizes and hiring more teachers and mental health counselors have produced positive outcomes quickly, noted Rajan.

SAFETY AND IDENTITY

Alegría introduced panelists Lucchesi; Theo Greene, associate professor of sociology at Bowdoin College; and George Nicholas, CEO of the Buffalo Center for Health Equity and senior pastor of Lincoln Memorial Methodist Church. Alegría asked the speakers to share their work and lived experiences related to safety and identity.

Lucchesi first shared the realities of living in a rural community—the Northern Cheyenne Indian Reservation on the northern plains of southeastern Montana, 2 hours from the nearest city. In addition to experiencing isolation and violence, this community struggles to provide basic needs like clean drinking water and utilities. “Ultimately, our ancestors fought and died for us to have the ability to stay connected across great distances . . . but it’s also a hardship in trying to address violence.” Lucchesi shared her experiences of survivorship from many forms of violence, which led her to create SBI. Lucchesi added that research on violence often excludes urban and rural Native communities. SBI conducts research to fill these gaps with experts focused on violence against Indigenous people. “We have had to figure out how to survive the apocalypse . . . and we are really good at it,” Lucchesi said. SBI also responds to missing and murdered cases, serves as family advocates, and offers healing solutions. Lucchesi concluded by reiterating that culture specificity, community sovereignty, and self-determination matter.

Greene said his research has found that for LGBT people, living in and participating in a neighborhood “has been much more vital and critical to the formation of identity.” Greene referenced the Stonewall riots of the 1960s, which led to an increase in gay neighborhoods and provided discreet places to build political mobilization. Over time the LGBT community’s increase in political engagement led to gaining more rights and opportunities but also to the decline of gay neighborhoods, said Greene. Gentrification also added to the disappearance of institutions that supported LGBT people, such as gay bars, bookstores, and community centers, places that have value especially for LGBT seniors and queer youth of color. Greene found that Black and Latino queer youth often experience violence at home, family rejection, bullying, sexual violence, homelessness, and increased police surveillance. Greene added that youth have been lifting their voices to advocate for their right to be in neighborhoods that make them feel safe on social media platforms, through protests, and in press conferences and local meetings. He also acknowledged that more organizations are trying to provide services for queer youth, but these services often do not provide the kind of support queer youth need to feel safe. Greene concluded by emphasizing the importance of the notion of place in LGBT communities’ ability to feel safe and healthy and to thrive.

The purpose of the Buffalo Center for Health Equity is to “eliminate race-based health disparities,” specifically in the Black community, said Nicholas. In Buffalo 80 percent of Black people live on the East Side and have a life expectancy that is 10–12 years less than white counterparts living outside of that community. “Systemic racism is an act of violence that creates trauma and dysfunctional communities,” Nicholas said. He recently

conducted funerals for two young people from the same community, who were both random victims of gun violence. He argued that “there is no place in America where a Black person is safe.” He explained that health disparities are a byproduct of other disparities within our society, noting the education system as the most pronounced. Black children are often placed in school systems without fair opportunities to thrive, said Nicholas. “Educational outcomes are a great predictor of your economic opportunities, which is a great predictor of where you’re going to live,” he added. Nicholas offered steps to address violence through equity, beginning with the importance of truth-telling and understanding the causes of violence. Accountability should be prioritized, and advocates should not be discouraged to bring change. “The reason why we have these issues around violence . . . is not because of resources. Stop that language. It’s about priorities. . . . It’s that we make a choice not to spend that money in order to bring the change,” Nicholas concluded.

Discussion

Viewer Jewel Crawford asked if reparation funds from entities that benefited from slavery could be used to address damage from enslavement and other historical injustices. Lucchesi agreed and said reparations for Indigenous people would mean receiving jurisdiction and landownership. “This country was built off of stealing land from Indigenous people . . . and by enslaving African bodies” and redress is needed, said Nicholas. Glasgow commented on the need for resources such as libraries and schools rather than individual reparations. Nicholas clarified that reparation funds should be used to make systemic investments in communities that have been oppressed and marginalized to bring them to a place of equity. Diez Roux asked panelists how to reframe conversations around violence and identify root causes, and what society can do to advance a different way of thinking about safety. Greene restated that violence comes from a system that works inherently to inflict violence on historically marginalized populations. Lucchesi agreed and added, “If we are going to fix these issues, we’re going to have to invest in tribal sovereignty, in Black self-determination, in our own self-governance and our own right, especially for Black and Indigenous people.” Alina Baciu, National Academies staff, referenced a National Academies report on federal policy to advance racial, ethnic, and tribal health equity.²⁰

Richmond underscored the need to confront racism and other structural drivers of violence and the value of truth-telling, equitable partnerships, utilizing accurate data to scale into community, and centering the community voice. “We have to find safe spaces to find joy, not just to survive but to also thrive,” she said.

REGAINING SAFETY IN PUBLIC SPACES

Ruth Shim, professor of cultural psychiatry and clinical psychiatry at the University of California, Davis, introduced this panel focused on key ingredients for safety in schools, neighborhoods, and in interactions with law enforcement. She noted that her work considers how social determinants of mental health are driven by social injustice and explained that the panel would focus on the intersection of public norms and policies that offer advantages to some and not others, leaving some vulnerable to violence, including structural violence. She introduced Rashawn Ray, vice president and executive director of the American Institutes for Research (AIR) Equity Initiative; Ashley Monterrosa, youth advocate with the California Children’s Trust; Glasgow; and Samantha Holquist, senior research scientist at Child Trends.

Ray, as a researcher and a funder, asked what does it mean to be safe and what does it mean to thrive? One of his main research findings is that Black men are less likely to be physically active in white neighborhoods, and often change their attire and behavior in ways they hope deflect the danger presented by policing. Virtual reality training simulation research he conducted at the University of Maryland varied the race and gender of the people police officers encountered and showed that Black people were more likely to experience physical violence, more aggressive language, and less respectful body language. As a funder, Ray said, he works to elevate community assets such as co-responder programs (New Jersey ARRIVE Together program) and the need to think deeply about police accountability. For example, civil settlements for

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police misconduct might be paid out of police department insurance policies, not with taxpayer funds.

Monterrosa introduced herself as a youth advocate with California Children’s Trust and a person with lived experience of police violence, as the sister of Sean Monterrosa, who on June 2, 2020, was killed—while kneeling and with his hands up—by Vallejo, California, police officer Jarrett Tonn. She spoke about how she and her sister harnessed their pain into advocacy for police decertification at a time when California was one of three states that lacked a policy for decertification. Monterrosa shared that officers of the Vallejo Police Department have killed 37 Black and Brown men, and the department still employs some officers who have each killed five people or more. In 2021, California enacted Senate Bill 2, which established decertification procedures for serious law enforcement officer misconduct.

Holquist is investigating community violence in Wards 7 and 8 in Washington, DC, and working with youth in Minneapolis to ensure that schools are safe for Black and Brown students. She emphasized the importance of helping students, especially those not traditionally served by educational systems, to voice their needs and engaging young people in effecting change, including how to use data. The key questions that inform her work are, “What does it look like when structural violence comes into the classroom? How are teachers trained and how do they interact with students? and What relationships are needed in classrooms to help students feel safe?”

Glasgow framed his talk by sharing three photos: a baby photo of himself; a photo of his grandmother, Roberta Chance; and a Philadelphia County Prison System booking photo of himself. Glasgow spoke of being raised with love and underlying intergenerational trauma and of a life in which dealing drugs and handling guns felt normal. “When you go to memorials more than you go to graduations,” Glasgow said, “you grow up with a sense that death is going to be your life.” He shared that when he returned to his community, he decided he wanted to lead in a positive direction. His organization provides after-school programming, sports, a range of learning opportunities, meals, and a community garden.

Discussion

Shim shared her reflections, drawing on Richardson’s remarks and insights from panelists, that communities can heal themselves with the right support. She asked Monterrosa and Holquist what is needed to help communities feel safe. Monterrosa said that credible messenger programs and investment in community youth are two approaches that help people thrive. Holquist said that the goal of scaling evidence-based programming must be checked by a recognition that an evidence-based program from one community will not necessarily fit another. She added that it is important to follow the money available to improve community safety and change the way it is invested. Shim underscored the value of asking, “Whose evidence are we talking about?”

Glasgow shared an analogy of someone going to the hospital and providers pulling that patient’s chart. Similarly, responses to a community’s violence problem need to be tailored to the community’s needs.

Ray said that his work at AIR is designed to engage communities in conversations about mobilizing their assets, in contrast with an academic focus on studying deficits. Reflecting on Ray’s remark about how academic priorities diverge from those of communities, Glasgow shared that the University of Pennsylvania offers the Community Scholars Program, which enabled Glasgow to understand the effects of the environment on health and engaged him and other community leaders in true conversations. Glasgow underscored the value of relationships with “academics who are not going to poverty pimp, or play the data game, or use community members as numbers, because they are people.” Shim said that those who generate the billions of dollars of research funding in academia are not people of color coming from underserved communities, so there must be a path from communities to academic and research workforce roles so that researchers originate in the communities they serve.

In his research, Ray found that police often surveil the very people who need safety, that they work to keep specific types of people safe, and that those are less likely to be people in Black and Brown communities. To

illustrate the meaning of “overpoliced and underserved,” Ray said it may be helpful to reflect on how long it would take first responders to arrive if somebody’s grandmother had a heart attack.

Shim asked Monterrosa if there is a difference between community safety and public safety. Monterrosa said that public safety includes safety from barriers like environmental racism or food deserts. Community safety is not about institutions but about “keeping each other safe.” Many people do not have safe places to go, she said. Glasgow said public safety has never benefited the Black and Brown community—it has always been about overpolicing and stripping funds, not about communicating with communities. Public safety originated as slave catching, to return enslaved people to their owners, Glasgow said. Community safety is about helping someone cross the street safely, helping someone pay for something, staying around to make sure someone is okay. It is about setting the table for everyone and building intergenerational resources.

Returning to the role of academia, Ray said credible messengers from academia to community are essential, as is paying community leaders and trustees for their labor. Timeliness matters too, and Ray said that when he worked as a researcher with communities, it took so long to get the necessary resources that by the time the approval came through, project priorities had changed. Shim agreed that researchers tend to prioritize p-values and numbers, not people.

Holquist asked what it means for decision-makers to partner with communities and noted that major government and philanthropic funders are recognizing the importance of working with communities, including conducting research. In her research, she said, she pays young people to contribute, and at Child Trends there is discussion about whether young people need a college degree to do research. She emphasized the importance of moving from a “power over” mode of engaging with communities toward a “power with” model. Lucchesi spoke about her community-led work and said, “We do not need the academy for anything.”

Ray said that many current policies are disruptive; for example, the status quo where considerable taxpayer funds go to law enforcement agencies. He shared that data can inform decision-makers about the resources needed for a given city’s law enforcement, and more precise allocation would allow shifting unneeded resources to workforce development, infrastructure, health, or education. Data also inform policy and provide accountability to taxpayers. Ray shared that less than 40 percent of law enforcement agencies submit use-of-force data to the federal government. That data could help show where policing systems are working and where they need change, but change requires a community role. In an example highlighting the importance of voter engagement, he shared that the community oversight board in Nashville once had the ability to vote on police misconduct issues, but the state legislature banned the board.

Glasgow added that the federal policy of redlining is often cited, but it is important to remember the 1996 U.S. Department of Defense authorization that spurred police militarization, reflecting a continuation of harmful federal policies. Glasgow also underscored the need to reconcile the goal of affordable housing with the reality that banks will not lend to certain communities, and said real progress requires addressing “yesterday’s hurt and trauma.”

Monterrosa spoke about the state-level bureaucratic challenges facing victims of police violence. Using California Senate Bill 838 to compensate victims of police violence requires a police report, but how does one obtain a police report for a murder committed by police, she asked, adding that survivors of state violence need systems and policies that remove barriers to accountability and compensation.

Shim asked the panelists about the levers for change. Ray said it is important to start with police officer standards and training committees, and to relocate some responsibilities to other kinds of professionals, away from law enforcement. He added that it is crucial for people researching or designing policy to visit affected

communities. Holquist shared that students are taught to meet an assessment-based system that perpetuates violence on young people, and when community violence flows into schools, school violence flows into communities. Rethinking is needed on policies around the country that do not allow youth to serve on school boards.

For Monterrosa, regaining public safety is at the intersection of philanthropy, community-based organizations, and other sectors, including policymaking. Glasgow shared that his program teaches youth to establish themselves by getting state-issued identification cards, learning about finances, and local government resources (with their families, as appropriate).

CHANGING PUBLIC PERCEPTIONS OF VIOLENCE AND SAFETY

During the last session, speakers considered the importance of shifting the narrative, messaging, and the public perception of violence; what it means to be safe; and how conversations can empower building healthy communities. To frame the discussion, Abigail Henson, assistant professor at Arizona State University and the host of the podcast Whatsjust Presents Critical Conversations, shared her observations from the workshop and discussed how themes like defining community, framing safety, research, and the power of conversation incorporate narratives.

Eduardo Bocanegra, senior adviser of community violence intervention in the Office of the Assistant Attorney General, shared his lived experience as “someone who has been a victim of violence, but also as someone who was sentenced to 29 years for a violent offense.” He shared his personal experience with violence and how he dedicated his life to building community safety. He mentioned community programs he has worked with, like READI Chicago, Bridging the Divide, and Urban Warriors. Bocanegra witnessed through his personal and professional experience that the root cause of violence is enforcing outdated policies. He referenced the Bipartisan Safer Communities Act, passed into law in 2022, which provided states with additional funding for community violence intervention and prevention efforts and support to establish safer, healthier environments. Bocanegra said he is honored to shape funding and to lead efforts to improve public safety.

Moira O’Neil, senior vice president of research interpretation at the FrameWorks Institute, shared themes related to community safety identified in her organization’s work on narrative change. For example, the word “safety” was commonly associated with the absence of crime or violence, but a broader definition is needed. There is a false narrative that punishment is an effective way to change human behavior. FrameWorks Institute has developed effective strategies to create narrative change. First, she emphasized the negative impact on any population or community to be described as “vulnerable.” Evidence shows that label limits support for progressive and positive systemic changes. FrameWorks Institute advises partners, movements, and thought leaders to use a responsible narrative and to take accountability. For example, it is more effective to talk about a vulnerable society that is not designed to meet basic needs than to tell stories about vulnerable populations. Another strategy to shape messaging is to have a complete narrative. For example, data can often be misinterpreted without a complete story. Explain more and describe less, said O’Neil. Finally, people with lived experience offer powerful messages that can move others to see the need for systemic change, she said.

Henson asked Bocanegra how he is perceived by his colleagues, given his lived experience. “When I make myself vulnerable about the fact that I have been in prison, it’s simply because I want people to understand what a convicted felon looks like. . . . What people don’t see is the weight I have to carry in certain rooms to prove that people like [me] are worthy of a second, third, or fourth chance,” he said. He noted that although celebrating people with lived experience is important, it can also be harmful. Allowing people with lived experience to create their own narratives and public perceptions is critical. Henson asked O’Neil about accountability and who should be held responsible for shaping perceptions. O’Neil said the media is a big source of public understanding, which is why it is important

that the media capture consistent conversations about accountability and restorative justice. Also, having an alternate vision or approach often makes a difference when changing the narrative. “We can fundamentally redesign the system,” she said.

Henson reiterated that the outcome of structural violence is community violence and asked who is responsible to provide safety in community violence interventions. Bocanegra said, “We are all coproducers of public safety or community safety. . . . We all have ownership in that.” To improve public safety, he added, “we need to start building bridges across sectors, connecting law enforcement, communities, education, mental health, and wellness with community violence interventions.”

CLOSING REMARKS

Diez Roux offered her reflections on the workshop:

• Generations have been impacted by structural and historical violence, which are “things of our own making, and therefore we can change them.”
• Community voices need to be elevated by shifting power and the allocation of resources.
• Science and evidence shed light on the problem, but researchers need to engage communities as equitable partners in change.
• Narratives about safety need to shift to change public mindsets and perceptions and to create opportunities for new solutions.

Chang pointed out the need to align current efforts used to address racism, economic insecurity, and gender inequity. Milstein applauded the community leaders present and said, “Punishment doesn’t stop violence, love stops violence.”

DISCLAIMER This Proceedings of a Workshop—in Brief was prepared by Alexandra Andrada and Alina Baciu as a factual summary of what occurred at the workshop. The statements made are those of the rapporteurs or individual workshop participants and do not necessarily represent the views of all workshop participants; the planning committee; or the National Academies of Sciences, Engineering, and Medicine.

*The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop—in Brief rests with the institution. The workshop was planned by Therese Richmond (Chair), University of Pennsylvania; Margarita Alegría, Mongan Institute, Massachusetts General Hospital, Harvard Medical School; Debbie Chang, Blue Shield of California Foundation; Milton Little, United Way of Greater Atlanta; Ruth Shim, University of California, Davis; and Monica Valdes Lupi, The Kresge Foundation Health Program.

REVIEWERS To ensure that it meets institutional standards for quality and objectivity, this Proceedings of a Workshop—in Brief was reviewed by Suzanne Bakken, Columbia University; Nancy Connolly, University of Washington; and Eboni Drummond, Health Education Specialist. Leslie Sim, National Academies of Sciences, Engineering, and Medicine, served as the review coordinator.

SPONSORS This workshop was partially supported by Association of American Medical Colleges, Atrium, Blue Shield of California Foundation, The California Endowment, Fannie E. Rippel Foundation, The Kresge Foundation, Nemours, NYU Langone School of Medicine, Robert Wood Johnson Foundation, Samueli Foundation, and St. David’s Foundation.

STAFF Maggie Anderson, Research Assistant; Alexandra Andrada, Program Officer; Alina B. Baciu, Roundtable Director; Stephanie Puwalski, Research Associate.

For additional information regarding the workshop, visit https://www.nationalacademies.org/event/41148_12-2023_community-safety-as-a-social-determinant-of-health-a-workshop.

Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2024. Community safety as a social determinant of health: Proceedings of a workshop—in brief. Washington, DC: The National Academies Press. https://doi.org/10.17226/27741.

Health and Medicine Division Copyright 2024 by the National Academy of Sciences. All rights reserved.