Law enforcement is difficult, stressful, demanding work. There is evidence that much of the work is sedentary, but the small part of the work which is not sedentary is physically demanding. This is also the part of the work which is often the most critical. In this respect, police work has been likened to the work of a lifeguard at a swimming pool. Most of the time, the lifeguard is watching from the water’s edge, but when it is necessary to intervene the emotional and physical demands are extreme and there is usually no warning. Unlike the lifeguard, the police officer may be exposed to attack with a knife or a gun, and may be exposed to intentional violence from some members of the public. Routine activities include patrolling streets, subways, country roads, parks and many other areas. Patrols may be carried out on foot, in vehicles (such as automobiles, helicopters or snowmobiles) and sometimes on horseback. There is a need for constant vigilance and, in many parts of the world, there is the constant threat of violence. Police officers may be called upon to provide assistance to the public in cases of robbery, riot, assault or domestic disputes. They may be involved in crowd control, search and rescue, or assistance to the public in the event of natural disaster. There is an episodic need to chase criminals on foot or in a vehicle, to grapple with, tackle and control criminals and, occasionally, to resort to the use of a lethal weapon. Routine activities can escalate to life-threatening violence with little or no warning. Some police officers work undercover, sometimes for prolonged periods. Others, particularly forensic specialists, are exposed to toxic chemicals. Almost all are exposed to biohazard risk from blood and body fluids. Police officers usually work shifts. Often their shifts are extended by administrative work or court appearances. The actual physical demands of police work and the physical tasks of policing have been extensively studied and are remarkably similar in different police forces and different geographical locations. The question of whether any specific medical condition may be attributable to the occupation of policing is controversial.
Violence is, unfortunately, a reality of police work. In the United States the homicide rate for police is more than double that for the general population. Work-related violent assault is common among police officers. The particular activities that are likely to result in violent conflict have been the subject of much recent research. The notion that domestic dispute calls were particularly dangerous has been seriously questioned (Violanti, Vena and Marshall 1986). More recently, the activities most likely to result in the assault of a police officer were ranked as follows: First, arresting/controlling suspects; second, robbery in progress; and third, domestic dispute.
The type of violence to which police officers are exposed varies from one country to another. Firearms are more common in the United States than Britain or Western Europe. Countries where political unrest is recent may see police officers exposed to attack from large-calibre or automatic-fire weaponry of a military type. Knife wounds are encountered everywhere, but large-blade knives, particularly machetes, seem more common in tropical countries.
Police officers must maintain a high level of physical fitness. Police training must include training in the physical control of suspects where necessary, as well as training in the use of firearms and other types of tools such as CS gas, pepper spray or hand-held batons. Personal protective equipment such as the “bullet proof” vest is necessary in some communities. Similarly, a communication system that allows the police officer to summon assistance is often important. The most important training, however, must be in the prevention of violence. Current police theory underscores the idea of community policing, with the police officer an integral part of the community. It is to be hoped that as this approach replaces the philosophy of armed military incursion into the community, the need for weaponry and for armour will be reduced.
The sequelae of violence need not be physical. Violent encounters are exceedingly stressful. This stress is particularly likely if the incident has resulted in serious injury, bloodshed or death. Particularly important is the assessment for post-traumatic stress disorder (PTSD) after such incidents.
Emotional and Psychological Stress
It is apparent that police work is stressful. For many police officers the excess of paperwork, as opposed to active law enforcement, is seen as a major stressor. The combination of shiftwork and the uncertainty about what may happen during the shift provides a powerfully stressful situation. In times of fiscal restraint, these stressors are often dramatically amplified by inadequate staffing and inadequate equipment. Situations where there is a potential for violence are stressful in themselves; the stress is dramatically increased where staffing is such that there is inadequate back-up, or when the police officer is seriously overworked.
In addition, the high stress levels which may result from police work have been blamed for marital difficulties, alcohol abuse and suicides among police officers. Much of the data supporting such associations are variable from one geographic region to another. Nevertheless, these problems may well result from the occupation of police work in some cases.
The need for constant vigilance for evidence of stress-related problems or post-traumatic stress disorder cannot be overemphasized. Stress-related disease may manifest as behavioural problems, marital or family problems or, sometimes, as alcohol or substance abuse.
Atherosclerotic Heart Disease
There have been numerous studies suggesting that atherosclerotic disease is more common among police officers (Vena et al. 1986; Sparrow, Thomas and Weiss 1983); there are also studies suggesting that this is not the case. It has been suggested that the increase in the prevalence of heart disease among police officers was almost entirely due to the increased risk of acute myocardial infarction.
This is intuitively satisfying since it is well known that sudden exertion, in the face of underlying heart disease, is an important risk factor for sudden death. The functional job analysis for a general-duty constable clearly indicates that a police officer may be expected, in the course of duty, to go from the sedentary state to maximal exertion with little or no warning and with no preparation. Indeed, much police work is sedentary, but, when required, the police officer is expected to run and chase, to grapple and tackle, and to forcibly subdue a suspect. It is therefore not unexpected that even if the rate of underlying coronary disease is not much different among police officers than the rest of the population, the risk of suffering an acute myocardial infarction, because of the nature of the work, may well be higher (Franke and Anderson 1994).
The demographics of the police population must be considered when assessing the risks for heart disease. Heart disease is most commonly found among middle-aged men, and this group makes up a very large proportion of police officers. Women, who have a significantly lower rate of heart disease during their premenopausal years, are significantly under-represented in the demographics of most police forces.
If one is to effectively reduce the risk of cardiac disease in police officers, the regular assessment of the police officer, by a physician knowledgeable about police work and the potential cardiac risks that are associated with police work, is essential (Brown and Trottier 1995). The periodic health assessment must include health education and counselling about cardiac risk factors. There is good evidence that work-based health promotion programmes have a salutary effect on employee health and that the modification of cardiac risk factors reduces the risks of cardiac death. Smoking cessation programmes, nutritional advice, hypertension awareness and cholesterol monitoring and modification are all appropriate activities that will help modify risk factors for cardiac disease among police officers. Regular exercise may be particularly important in police work. The generation of a work environment that educates the worker about positive nutritional and lifestyle choices and that encourages such choices is likely to be beneficial.
Lung Disease in Police Work
The evidence suggests that the prevalence of lung disease in police work is lower than in the general population. There is, however, evidence of an increased rate of cancer of the respiratory system. The majority of police officers are not routinely exposed to inhaled toxins at a rate any greater than other residents of the communities they police. There are exceptions to this general rule, however, the most notable exception being police officers working in forensic identification. There is good evidence that these individuals may suffer from an increased prevalence of respiratory symptoms and, possibly, occupational asthma (Souter, van Netten and Brands 1992; Trottier, Brown and Wells 1994). Cyanoacrylate, used in uncovering latent fingerprints, is a known respiratory sensitizer. In addition to this, there are a large number of chemical carcinogens routinely used in this type of work. For these reasons it is recommended that police officers who work in forensic identification, particularly those who do fingerprint work, should undergo annual chest x ray and spirometry. Similarly, periodic health assessment of these officers must include a careful assessment of the respiratory system.
Even though the practice of smoking cigarettes is becoming less common, a significant number of police officers continue to smoke. This may be the reason why some studies have shown an increased risk of lung and laryngeal cancers among police officers. Smoking is, of course, a major risk factor for cardiac disease. It is also the leading cause of lung cancer. When a police officer gets lung cancer the question frequently asked is whether the cancer is due to occupational exposure, in particular to the carcinogens known to be present in fingerprint powders. If the police officer smokes, it will be impossible to confidently assign blame to any occupational exposure. In summary, respiratory disease is not normally an occupational hazard of police work except for forensic identification workers.
There is some evidence that police officers suffer a somewhat higher risk of cancer than expected in the general population. In particular, the risk of digestive tract cancers such as cancer of the oesophagus, cancer of the stomach and cancer of the large bowel is reported to be elevated among police officers. There may be an increased risk of cancer of the lung and larynx. The risk of cancer among police officers working in forensic identification and forensic laboratory work has been briefly discussed above. The controversial issue of testicular cancer associated with the use of police “radar” to detect speeders must also be addressed.
The data suggesting an increase in the risk of cancer of the digestive tract among police officers is scant, but it is a question that must be seriously examined. In the case of lung and oesophageal cancer, it is difficult to see how the activities of police work would be expected to increase the risk. Smoking, of course, is known to increase the risk of both lung and oesophageal cancer, and significant numbers of police officers are known to continue to smoke cigarettes. Another substance known to increase the risk of oesophageal cancer is alcohol, particularly whisky. Police work is known to be exceedingly stressful, and there have been some studies that suggest police officers may sometimes use alcohol to relieve the tension and stress of their work.
The same research that demonstrated an increased risk of cancers of the digestive tract also demonstrated a peculiar increase in the incidence of cancers of the lymphatic and haemopoietic systems in some police officers. The increased risk was restricted to one group and the overall risk was not elevated. Given this very peculiar distribution, and the small numbers, this finding may well turn out to be a statistical aberration.
The risk of cancer among police officers involved in forensic identification work and forensic laboratory work has been discussed. The expected toxicities of chronic low-level exposure to various chemicals are determined by the level of exposure and the use of personal protective equipment. Based on these exposures a periodic health examination has been developed, performed annually and tailored to risks specific for these exposures.
Recent work has suggested a possible increase in the risk of skin cancer, including melanoma, among police officers. Whether this is due to the amount of sun exposure experienced by some police officers who work out of doors is purely speculative.
The question of cancer resulting from exposure to microwaves from “police radar” units has created much controversy. There is certainly some evidence that there may be clustering of certain kinds of cancers among police officers exposed (Davis and Mostofi 1993). The particular concern is about exposure from hand-held units. Alternatively, recent work with large populations refutes any risk of carcinogenicity from exposure to these units. Testicular cancer, in particular, has been reported to be associated with such exposure. The circumstance said to pose the greatest risk is that where the hand-held unit is turned on and resting on the lap of the police officer. This could result in considerable cumulative exposure of the testes over the long term. Whether such exposure causes cancer remains unproven. In the meantime it is recommended that police radar units be mounted outside the police car, be directed away from the police officer, not be used inside the car, be turned off when not in use and be tested regularly for microwave leakage. In addition the periodic examination of police officers should include careful palpation of the testes.
Low-back pain is a major cause of absenteeism throughout the Western world. It is a condition most common among middle-aged males. The factors which predispose to chronic low-back pain are multiple and some, such as the correlation to smoking, seem intuitively difficult to comprehend.
With respect to the occupation of driving, there is ample evidence that individuals who drive for a living are at a dramatically increased risk of low-back pain. This observation includes police officers for whom driving plays a significant part in their daily work. The majority of police cars continue to be equipped with the seats that were installed at the time of their manufacture. Various back supports and prosthetic devices are available which may improve the support of the lumbar spine, but the problem remains.
There is evidence that physical confrontation may play a role in the development of back pain. Motor vehicle accidents, particularly in police vehicles, may play a part. Some police equipment, such as thick leather belts festooned with heavy equipment, may also play a role.
It is important to remember that stress may precipitate or exacerbate back pain and that back pain, as a reason for sick-leave, may be perceived by some police officers as more acceptable than the need to recover from emotional trauma.
There is no doubt that specific exercises designed to maintain flexibility and strengthen the muscles of the back can significantly improve function and symptoms. Numerous classification systems of back pain have been promulgated. These different patterns of pain have distinct approaches of active intervention through specific muscle strengthening programmes. It is important that specific symptom patterns be sought out among police officers and that appropriate intervention and treatment be initiated. This requires periodic assessment by physicians knowledgeable in this clinical syndrome and capable of early effective intervention. It is equally important that a good level of overall fitness be maintained in order to avoid disability from this common chronic, costly syndrome.
There are reports of police officers said to have contracted AIDS from their work. In May 1993 the US Federal Bureau of Investigations reported that there had been seven cases of police officers contacting AIDS through their work over 10 years (Bigbee 1993). Let us begin by noting that this is a surprisingly small number of cases over a 10-year period in the entire United States. Let us next observe that there was some controversy about whether these cases were all to be considered job-related. Nevertheless, it is clearly possible to become infected with HIV as a result of police work.
Since there is no cure for AIDS, and no vaccine that prevents the disease, the best defence a police officer has against this infection is prevention. Latex gloves should be worn, whenever possible, any time that contact with blood or blood-contaminated evidence is foreseen. This is especially important if there are any skin breaks on the hands.
Any open sores or cuts that a police officer has sustained must be kept covered with an occlusive dressing while on duty. Needles should be handled with extreme care, and needles or syringes must be transported in a sharps container that can effectively prevent the needle from penetrating through the container. Sharp edges must be avoided and sharp exhibits handled with extreme care, particularly when contaminated with fresh blood. Where possible, such exhibits should be picked up with instruments rather than by hand.
Latex gloves and a barrier mask should be used if resuscitation attempts are undertaken, and latex gloves must always be worn when rendering first aid. It is important to bear in mind, however, that the risk of becoming infected with HIV from resuscitation procedures is very remote.
There are also some traditional techniques in policing that must be avoided. “Pat down” searches are dangerous to the police officer. There are numerous cases of police officers suffering needle stick injuries from this type of procedure. Also dangerous is searching containers, bags or even pockets by rummaging through them. All containers must be emptied into a flat surface and their contents examined in plain view. Similarly sweep searches under car seats and between seats and backs of couches and chairs must not be performed. It is preferable to dismantle furniture rather than have police officers putting their hands blindly in places where needles and syringes may be hidden. Latex gloves do not protect from needlestick injury.
Eye protection and face masks may be appropriate in circumstances where spatter of body fluid such as saliva or blood can reasonably be foreseen. There must be a system in place for the safe disposal of personal protective equipment. There must be a facility for police officers to wash their hands. Given the fact that few patrol cars have running water and sinks, prepackaged washing solutions for cleaning skin should be provided. Lastly, the question of what should be done for a police officer who, in spite of all the best precautions, suffers a percutaneous exposure to HIV should be asked. After appropriate wound care the first step is to try to determine whether the source of the exposure is truly HIV positive. This is not always possible. Secondly, it is imperative that the police officer be educated about the true risks of infection. Many non-medical personnel assume that the risk is much higher than it really is. Thirdly, the police officer must be informed of the need to retest for at least six months and possibly nine months in order to ensure that the officer has not been infected. Steps must be taken to prevent potential infection of the officer’s sexual partner(s) for at least six months. Lastly, the question of post-exposure prophylaxis must be discussed. There is increasing evidence that prophylaxis with antiviral drugs may be helpful in reducing the risk of seroconversion after percutaneous exposure. These are discussed elsewhere in the Encyclopaedia. In addition, the area of prophylaxis is under intense research scrutiny so that current references must be consulted to assure the most appropriate approach.
There are numerous case reports of occupationally acquired hepatitis among law enforcement personnel. The quantitative risk is not dramatically high when compared to other occupations. Nevertheless it is a real risk and must be seen as a possible occupational disease. The preventive approach to HIV infection that was outlined above applies equally well to the blood-borne disease hepatitis B. Given the fact that hepatitis B is so much more contagious than AIDS, and more likely to cause disease or death in the short term, this disease ought to be an even more compelling reason for following universal precautions.
There is an effective vaccine against hepatitis B. All police officers regardless of whether they are involved in forensics or general-duty policing, should be vaccinated against hepatitis B. Other conditions, including hepatitis C, tuberculosis and airborne pathogens, may also be encountered by police officers.