Feature

Is crime a health issue?

The relationships between crime and health are complex and often hidden. While health services can’t tackle crime head on, neither can they ignore it, says Chris Ford

If you believe what you read in most newspapers then ‘riots’ — breakdowns in civil society of the type experienced on Tyneside in the early 1990s — are largely inexplicable, unpredictable, and unpreventable.

It is generally agreed that there are public health issues in such extreme situations. But in fact such breakdowns in civil society are at the end of a continuum of multiple deprivation and exclusion along which an increasing number of communities find themselves.

If this is true, then a preventative model of public health needs to engage with the issues thrown up by the relationships between health and crime. The relationships are complex and our thinking is often confused.

It is a feature of white liberal societies that there is a clear distinction between legal and moral judgements. We can think of something as both legally and morally wrong, but the two judgements are separate.

But the same language is often used for both. Saying ‘that action was wrong’ can mean both ‘it was illegal’ and ‘I morally disapprove of that action’. Judging the person rather than the action leads to different claims; ‘he is a criminal’ and/or ‘he is morally wrong’.

If, in a public health context, the confusion between legal and moral is transferred to communities, the results become part of the dynamic that leads to those communities being excluded from the mainstream of society, labelled as ‘other’ and blamed for their own situation.

One way of breaking out of this dangerous morass is to consider the issues in terms of the relationships between the formal and informal economies. The salaries (plus share options, pension contributions and so on) of top executives gives them huge power within the formal economy. This is not true of people dependent upon benefits. In the language of the day, the size of the stake they have in the formal economy, and hence the pull of the informal, is substantially different.

This is not to say that criminality is class-based — a cosy notion promoted by the Right — or to make any moral judgements on law breaking. It simply provides us with a more neutral language for description.

The rolling back of the welfare state and the destruction of the UK’s manufacturing base is leading to a significant shift in the relationships and relative strengths of the formal and informal economies in many communities. As the formal economy retreats, the informal gains power in the lives of individuals and communities. As the informal economy becomes more entrenched it becomes more organised.

Some of the relationships between crime and health can be seen depressingly clearly in an A&E department on any weekend evening: drunk driving, bar room brawls, the child who has swallowed the eye of a counterfeit teddy bear, and so on.

Criminal activity often affects the health of both victim and perpetrator. ‘You get a good kicking if you burgle the wrong house...quite a severe kicking in one or two cases.’¹

Beyond the visible, crime has many health effects that are more hidden. Domestic violence and sexual assault do not often grab the headlines and are frequently untouched by mainstream health services. Excluding such crimes from the debate makes the debate simpler. It also reinforces the silence within which one person (ab)uses their informal power against another. Given that assault is most commonly by a known aggressor, to focus the debate on street crime is to miss substantial aspects of the health agenda.

‘One woman stated that she had not drunk alcohol while in a violent domestic situation, needing all her wits about her to survive the return of a drunk partner. She had been frightened to go to sleep. Now in the refuge she is frightened of not sleeping and uses a combination of sleeping tablets and alcohol “seeking oblivion”.’¹

There are several health issues here: assault, drug use, and fear. One health services manager told me there was nothing the health services could do about crime, but the fear of crime was a recognisable mental health issue where intervention might be appropriate. A distinction between crime and the fear of crime can be useful; for some people fear is more debilitating than reality.

However, a strategy of target hardening — physical measures aimed at deterring crime and reassuring those perceived as vulnerable — can lead in strange directions. Locking out potential attackers involves locking yourself in.

Further, like many mental health issues, there is a danger of individualising a collective problem and blaming the victim. In this context risk assessment is useful. In some communities a high level of fear is a coherent reaction to a real situation. In some it is not. Interventions need to be developed that allow people to make informed assessments of the risks they face and to draw on a repertoire of responses that they can deploy.

If it is accepted, from the very brief outline above, that there are relationships between crime and health, there is a further question as to where health services ‘fit’ in addressing the impact of crime on individuals and communities.

‘Organised crime is one issue that health and social workers cannot tackle head on, but neither can they ignore it. Health workers can continue to play their part by supporting the residents of deprived communities through crises, and by working with them, and other agencies to tackle the deprivation and hardship that allows crime to flourish. Meanwhile, at a district and regional level, health services can develop their role as members of the partnerships concerned with urban regeneration.’²

This comes from the recent report of a local director of public health. At the end of the chapter on crime and health there are five ‘action points’. The lead authority for four of the points is identified as the local authority and for the fifth it is the police.

Primary health care teams will continue to patch up individuals whose health is affected by criminal activity. While the work undertaken by health professionals released from the burdens of caseloads is vital in supporting communities under pressure, the potency of the health services engaging in the debate around crime can be seen more clearly elsewhere.

There is a general agreement, following the Morgan report, that multi and interagency structures are the most effective mechanisms for addressing these issues.³

While the health services are established by statute, they are unusual among statutory agencies in that they have no role in interpretation, implementation or enforcement of the law. Forensic and analytical medical skills often inform the criminal justice system, but the structural relationship is different.

This means that, in a multi-agency context focused on crime, health professionals do not have to ‘protect their backs’ in the same way as those from other statutory agencies. If health professionals use the language of a broad definition of health, it allows the starting point of dialogue to be where it is needed: not on which agency is not doing what, but on those individuals and communities whose health is affected.