Saturday 9 March 2019

Not a sticking plaster

  • Violent crime in Britain has been rising. The increase in the number of stabbings, particularly of young, black men, is causing enormous concern
  • The policy response has been to call for medical techniques to understand the spread of violence
  • The approach is not well understood. And there are risks to treating people like a disease

By Matthew Ryder

Britain is gripped by concern about a rise in knife crime. A problem which first surfaced in London is now front page news everywhere, and the country is identifiably in “something must be done” territory. It is a moment of risk for politicians but there is a degree of consensus about the solution, expressed again this week by the Home Secretary Sajid Javid: “I want serious violence to be treated by all parts of government, all parts of the public sector, like a disease and I want us to tackle it the same way – everyone would come together.” He was talking about what has become known as the “public health approach” to policing violence.


In September 2018, the Mayor of London Sadiq Khan, announced a new strategy to tackle rising knife crime. The news was greeted positively by virtually everyone, including his opponents. A month later, the Home Secretary indicated that the Government would follow suit. The problem was that many were praising a policy they didn’t fully understand.

At the time, I was London’s deputy mayor for social integration and a strong supporter of a public health approach to reducing violence, particularly as London was facing a worrying increase in knife crime. But the universal, uncritical approval of the concept had started to trouble me. Many groups with whom I spoke supported a public health approach but, when pushed, struggled to define it. Others held contradictory views as to what it meant. More worryingly, some were keen advocates of it without appreciating that some of its key features – strong enforcement measures, increased data gathering – were things they frequently opposed.

What is the public health approach?

A public health approach to violent crime borrows medical techniques to tackle a social problem. Primarily, the lessons from the treatment of disease are to do with the importance of co-ordinating activity by different parts of the state, including police, social services, and housing. In practice, the public health approach to crime involves pre-emptive policing, which means closer involvement with the community (not easy or, often, welcome) and data tracking of individuals and groups (not, so far, a success). Its advocates cite success in Glasgow (a small city) and Chicago (a big one, where violent crime is back up). We need to be honest about what a public health approach can – and can’t – achieve.

Glasgow paramedics treat a young man who has been badly beaten and stabbed in an unprovoked attack


The idea of approaching serious violence as a public health issue originated with Dr Gary Slutkin, an epidemiologist with the World Health Organisation. During the 1990s, he noticed parallels between his work combating Aids in Uganda, and the way violent incidents clustered and spread in Chicago. He sought to apply similar methods to tackling violence as had been applied to tackling disease – and it worked. The World Health Organisation advocated his approach in a seminal document in 2002 and cities across the US have adopted it.

In practice it means police working closely with other agencies and public bodies so that the underlying causes of violent behaviour are addressed, rather than just apprehending and punishing those who have committed violent crimes. It also means involving communities in changing the behaviours that may allow violence to be tolerated and to spread. The US model focused significantly on tackling gun violence and the particular problems that are entrenched in US cities. In the UK, we have relied heavily on the success of the public health approach somewhere closer to home – Glasgow – which has been using a public health approach for over ten years. If it has worked in reducing youth violence and knife crime in Glasgow, why not in London? There are two reasons why that appealing proposition needs closer examination.

Stabbed in a fight between rival gangs, a man is treated in the Glasgow Royal Infirmary


First, as cities, London and Glasgow are dissimilar in many ways. Their respective problems with knife crime may have very different causes, requiring different solutions. Glasgow’s population is about 500,000 – not much larger than one or two of London’s 32 boroughs, which make up London’s total population of about eight million. Glasgow’s homicide rate has now halved from a peak of 40 per annum 15 years ago, but it has always been well below the 100-200 per year that London has experienced over the same period.

This reflects not merely a difference in scale but in the nature of the problem. For example, Glasgow’s initiative to reduce knife crime among youth gangs in the early 2000s saw this as distinct from problems of organised crime. It focused on the established culture of rivalries among young people in the East End of Glasgow and the violence that erupted when they came into contact. In contrast, there is a growing acceptance that London’s current knife crime problem is a symptom of the wider prevalence of young people exploited by organised crime. It begins with local networks and extends to “county lines” activity (drug running by urban gangs to areas far outside their patch). London seems to have a distinctly different problem causing knife crime than that which Glasgow had.

Second, there are significant demographic differences between the two cities. This is important because the current discourse around London’s knife crime has a distinctly racialised ingredient – black boys are heavily overrepresented as both victims and perpetrators – which was not present in Glasgow. It means that the success of a public health approach to reducing knife crime in London will depend on police and other public authorities successfully engaging with the wider black community. That is a substantial additional challenge, given the long history of structural racism black Londoners have faced. It is even more problematic when you appreciate that there are some aspects of a public health approach which rely on the very areas that have caused friction between the police and the black community in the past.

An arrest in Glasgow's notorious East End


One clear example is the heavier use of police enforcement measures, particularly stop and search. In Glasgow the public health approach addressed the causes of violence by supporting young people by engaging with public services. But it also promoted a very explicit message of tougher enforcement and harsher penalties. Community groups I have spoken to invariably focus on “addressing causes” as the key feature of a public health approach, thinking that enforcement measures like widespread stop and search, which have caused so much community friction with the police, will be reduced.

Conversely, police officers were always keen to mention that strong, increased, even intimidating enforcement measures were a major component of the public health approach in Glasgow, and should be part of the solution in London. If London’s black community starts to realise that increasing stop and search and harsher police enforcement against young men in their communities is positively encouraged as part of a public health approach, many may feel troubled or even misled.

Strathclyde Police arrest a man for beating another with his belt outside a nightclub


A similar problem arises with the way a public health approach increases reliance on data. It depends on making assessments of young people – through information from schools and other services – to intervene at early stages in their lives. Those most likely to fit the profile of becoming involved in gang activity are identified and information about them is shared across multiple agencies. The precautionary nature of such activity means definitions and categorisations of people are often relatively fluid. The assessments of a young person who is at risk and one who poses a risk start to merge.

For example, in Glasgow a “gang” could include “loosely knit social networks of individuals” who may engage in violence or weapon carrying. The terms “gang” and “group” were used interchangeably. If a community has confidence in public services, they may welcome early engagement in the lives of their children as a way of protecting them and be unconcerned if a potential offender and a potential victim are treated in a similar way. But for London’s black community, with longstanding experience of discrimination by police, social services, health services and education, there may be deep mistrust of young people being assessed negatively and having information about them shared, based not so much on any criminal activity but on loosely defined social networks.

Glasgow paramedics transport a young man attacked with machetes and crowbars to hospital

We have already seen that mistrust played out in the flawed use of the Metropolitan Police Gangs Matrix, which gathers and shares information about potential “gang members” across multiple agencies. The Gangs Matrix has been heavily criticised by organisations as varied as Amnesty International and the London Mayor’s own Office of Policing and Crime (Tortoise reported on the Gangs Matrix on 22 January). I have heard community activists praising the introduction of a public health approach while powerfully decrying the use of the kind of data gathering tools on which such an approach will almost certainly rely – and not connecting the two. If a public health approach is to be successful in London, it will need to go a long way to win back the confidence of communities who currently do not trust how the data about their young people is gathered, processed and stored.

Perhaps most striking for me is how the terminology that surrounds a public health approach can become misleading and unhelpful when not properly understood. I have been present at numerous meetings and talks when, under the rubric of “public health” the problem of youth violence turns into the medicalisation of what is, in reality, a social problem. That has a particularly unpleasant flavour when it hints at a pathological or innate inadequacy among those most likely to be affected by youth violence, ie, young black men. Seeing black offending as a form of pathology has a long, ugly history among both conservatives and liberals, as the celebrated author Ta-Nehisi Coates has famously explained. In this regard, the language we use in coping with the problem is important.

In many ways the term “public health approach” has been helpful. It encourages agencies to approach the problem in a concerted way as they would the outbreak of an illness or disease. The phrase almost depoliticises the issue by lending a quasi-scientific approach to what was previously seen as an economic or political issue.

However, at its most unhelpful “public health” approach gives the impression that youth violence is something akin to a disease or illness in the communities in which it occurs . It conflates health – in the way most people understand it – with social violence, as if the underlying social problems are a disease that can be cured. If the term is not properly understood, a young man carrying a knife in fear of being attacked in his housing estate in London, begins to be viewed as someone with a deep-rooted, quasi-medical problem that needs medical treatment, rather than someone in social or economic circumstances that need to be changed.

Despite all of the above, a “public health” approach is by far the best way forward and evidence from across the world over two decades confirms that. The London mayor and the home secretary are right to have adopted it. It must be properly funded and both its limits and its potential dangers must be understood by all who work with it – from police to community groups. And anyone who is tempted to think it may be a panacea need only look to Chicago. Violent crime fell there after the public health approach was adopted. More recently? It has been rising sharply.

Matthew Ryder QC is a barrister at Matrix Chambers and former London Deputy Mayor for Social Integration

All photographs are part of an extensive project by David Gillanders, taken in Glasgow over many years

Further reading

  • Ta-Nehisi Coates’s celebrated 2014 essay in The Atlantic on Black Pathology and the Closing of the Progressive Mind: the role of white supremacy in America’s history and present
  • The seminal World Health Organisation report into the public health approach to violent crime
  • Reports by Amnesty International and by the London Mayor’s office into the Gangs Matrix, a controversial database used by the Metropolitan Police in London to identify current and prospective gang members