Police in America shot and killed at least 2,053 people between 2015 and 2024 who were in the middle of a mental health crisis. That’s 20% of all killings by police in the last decade.

Those numbers are helping to fuel a movement. Instead of sending armed police to most 911 calls, cities like Denver, Albuquerque, Houston, Louisville, and New York—more than 100 jurisdictions, all told — now send unarmed mental health workers to respond to 911 calls that involve mental illness, addiction, or suicidal thoughts.

As a reporter and producer for Tradeoffs, a national nonprofit news organization covering health policy, I spent more than a year reporting on these “alternative crisis response programs” to understand what early adopters have learned that may help other communities. We partnered with The Marshall Project, a nonprofit news organization covering criminal justice, to produce a three-part podcast series called The Fifth Branch. The series focused on one of the most respected programs in the country: Durham, North Carolina’s Community Safety Department and its Holistic Empathetic Assistance Response Team, known locally as HEART.

For decades, Durham had four branches of public safety — 911, police, fire, and EMS. Ryan Smith, who was tapped to lead HEART in 2021, saw his job as creating a fifth branch.

“Your house is on fire, we send fire. You’re having cardiac arrest, we send EMS. There are shots fired, there is violent crime or criminal activity, we need to send law enforcement,” Smith said. “But people call 911 for a whole bunch of other reasons. And most of those reasons, because we haven’t had another branch to sort them into, have gone to law enforcement.”

Tradeoffs watched HEART in action as its teams of social workers, EMTs, and peer support specialists responded to 911 calls. And we talked extensively with Durham city leaders, first responders, and program critics, as well as to the residents who had called HEART in a crisis.

Our reporting focused on some of the biggest questions that Durham—and any community interested in the alternative response approach—has to answer: How do you get buy-in to launch a new public safety branch? Is an unarmed response safe? How big should a program like HEART be?

Birth of Durham’s Fifth Branch

Durham, like many cities, erupted in protests in the summer of 2020, after the police killings of George Floyd and others. These protests led Wanda Page, Durham’s city manager at the time, to launch an independent review of her city’s 911 data, which found that violent crime represented less than 2% of all calls. Trespassing, verbal disturbances, and mental health crisis calls made up much of the rest.

“That research let us know that the majority of the time when folks are calling 911 … it is just a neighbor or a resident that needs assistance,” Page said in a documentary about HEART’s early days.

To respond to certain nonviolent calls, city leaders earmarked $2.8 million in June 2021 to create the Community Safety Department. Page told residents shortly before the department launched:

“We still need policing to help protect our community. But it is unfair to expect them to address every single issue our residents experience.” 

The new HEART team spent six months researching “unarmed response,” an approach that dates back to the 1980s. Their counterparts in early adopter cities like Denver, Albuquerque, and San Francisco shared lessons learned and data proving this work could be done safely for people in crisis and for the people responding to those calls.

Smith presented the research to the city council in January 2022 and proposed a four-part program:

1. A mental health worker inside 911 who can resolve calls over the phone.

2. Unarmed teams of social workers, EMTs, and peer support specialists to respond to nonviolent calls that involve mental illness and homelessness.

3. Pairing a mental health worker and police officer for crisis calls that involve the threat of violence.

4. Teams that connect people to longer-term support after a crisis call.

Smith believes Durham’s model is the most comprehensive in the nation. “If what we’re really doing is about sending the most appropriate response, then I want that to be available for as many people in as many moments as possible,” Smith said.

The city council greenlighted Smith’s proposal, giving him six months to build the city’s fifth branch of emergency response.

Resistance from Police

Smith had a problem: Police officers felt attacked. Durham police sergeant Dan Leeder said many officers saw HEART as an outgrowth of the “defund the police” protests.

“Nothing is ever 100%, but it was darn close [in the police department] that this was a bad idea,” Leeder said. 

“There was a lot of trepidation about what this is going to mean for us, how this is going to affect what we’ve been doing for years.” 

Most of the officers’ concerns came down to fear: fear for their jobs, fear for residents, fear for the safety of the new responders.

Ryan Smith didn’t need police to like HEART. With backing from city manager Page and the city council, HEART was happening. But Smith believed that getting cops’ support would give his fledgling department its best chance of success. “The inability to get law enforcement buy-in can lead to programs like ours being much smaller than they need to be,” Smith said.

Luckily, he had an important ally in Durham police chief Patrice Andrews. The city hired Andrews a few months after forming the Community Safety Department, in part, because of her support for alternative response. A quarter century as a cop—most of them in Durham—had given the new chief an intimate understanding of how difficult it can be for police officers to respond to people with mental illness.

She remembers early in her career responding to a call from a woman who insisted someone had broken into her home. It quickly became clear after Andrews arrived on scene that there were no intruders. “She’d point to a lamp and she’d say, ‘They’re behind the lamp.’ And so we’d go over there and say, ‘You can’t be here,’” Andrews said.

Andrews and her partner hoped humoring the woman, and being patient with her would mollify her concerns. But the woman continued to call 911. “We kept saying, ‘You can’t call us anymore for this. We’ve told the people to get out of your home, and they’re out. You can’t call us anymore. Don’t call us anymore.’”

The calls kept coming. “We didn’t know what to do. We didn’t have the professional knowledge on how to work with someone clearly going through a moment of crisis,” Andrews said. Eventually, Andrews and her partner arrested the woman for abuse of 911 and brought her to jail. “It felt so wrong,” Andrews said of the arrest. “I knew right from wrong, but I didn’t necessarily know how to change a system that had seemingly always done it the wrong way and had gotten away with it.”

To Andrews, HEART represented a way to change a system that too often failed people in the middle of a mental health crisis. Adding a new crisis response team, Andrews hoped, would also allow her officers to focus their efforts on what they did best — fight crime. “We can do both,” Andrews said. “We can have a wonderful professional police department. We can also have amazing public safety partners in HEART.”

How to Convince the Cops

“We can do both” became a rallying cry for Andrews and Smith. From their very first meeting, the pair agreed that HEART should be presented as a complement to good police work. “We’re not replacing you,” Andrews told officers. “You still have work that you need to do as a law enforcement officer.”

Durham’s current city manager, Bo Ferguson, echoed those sentiments. 

“It was always critically important for me that this not be perceived as something that we were taking away from the police department.” 

Ferguson directly oversaw HEART and the police department as the deputy city manager for public safety until taking over as city manager in early 2025.

Smith and his team met regularly with the police department. Andrews even invited Smith to answer patrol officers’ questions and address their concerns. Smith, as he did with the city council, presented officers with data that unarmed response could be done safely.

Smith’s campaign to win hearts and minds extended to community activists and 911, where front-line call-takers also questioned whether unarmed mental health workers should respond to crisis calls. “Every single one of our calls touches 911,” Smith said. “If this is about sending the right response, we need [911 workers] to feel really confident.”

HEART formally launched on June 28, 2022. During those early days, skeptical officers would swoop in and respond to calls meant for HEART. Others would ignore orders and engage before social workers arrived.

Sgt. Dan Leeder listened on the police radio as the new teams fanned out across the city responding to homeless people panhandling, to potential suicides, and to parents past their breaking point. He expected to hear the social workers screaming for police support. He guessed wrong. “I’ll hear these calls come out, the HEART team responding to it, and the call’s been handled,” he said. “Whatever it is they’re doing, they’re doing it right.”

Police support for the program has grown, according to an independent study. Initially, just 37% of officers thought HEART would be helpful on mental health calls; that number had risen to 67% last year.

Andrews said officers have started to come around to the idea that HEART can help them do their own jobs better. HEART estimates their responders saved Durham police officers more than 5,500 hours in the program’s first two years, leaving the short-handed department better able to respond to violent calls. Cops have even asked HEART to take over calls more than 450 times.

Seeing HEART’s work has transformed Sgt. Dan Leeder from a strident critic into one of the program’s biggest supporters. “When I’m wrong, I’m the first one to raise my hand and say, you know what? I was wrong,” Leeder said. “These people are going to help you. They’re going to make your job and your lives on this job easier.”

Unarmed Responders Feel Safe, Too

After every 911 call, HEART responders have to tell their bosses whether they felt safe. In nearly 25,000 calls answered as of March 24, 2025, HEART responders said they felt safe 99% of the time. Other cities (Eugene, Oregon; Denver, Colorado; and Albuquerque, New Mexico) report their responders can do this work safely, too.

This high rate is by design. Durham sends HEART to calls like trespassing, wellness checks, and intoxication, which city data show rarely end in violence for police. To mitigate the risks that exist with this work, HEART responds with a police officer to any call with a threat of violence. HEART also provides their responders with police radios to call for backup if necessary.

“Is there a level of risk in this job? There is,” said David Prater, one of the department’s unarmed responders. “Do I consider it an acceptable risk? I do.” 

Prater’s boss, Ryan Smith, said it’s important to acknowledge the risks involved in unarmed response, but adds that society has deemed those risks acceptable for firefighters and EMTs. As with the other branches of public safety, it’s worth putting HEART’s first responders in harm’s way, Smith argues, if that lowers the risk that someone in crisis is hurt by the police.

“I think that’s part of what being a public servant is,” Smith said. “I think government at its best is shifting burden and risk away from those that we serve to those who are signed up to be public servants.”

“Help Is on the Way.”

Yolanda is a 38-year-old Durham resident with depression, PTSD, and bipolar disorder. (We’ve agreed to not use Yolanda’s last name to protect her family’s privacy.) She has called 911 many times when her two teenage daughters’ mental health issues have escalated into yelling, punching doors, and suicide threats. Yolanda said those phone calls are always a last resort.

“I fear[ed] that an officer was going to show up and be having a bad day and decide that today’s the day that I’m going to use my badge to be able to do whatever it is that I want to do, and nobody’s going to be able to do anything about it because I have a badge,” she said.

Since HEART launched, Yolanda feels much safer calling 911. HEART units have responded several times, de-escalating the situation and offering Yolanda and her daughters coping tools to help them prevent future fights. “When you ask for the HEART team and they say help is on the way, to me that is the biggest sigh of relief that I could possibly take during an altercation,” Yolanda said.

In a 2023 survey of Durham residents, 57% said they were more likely to call 911 thanks to HEART. In the 2024 survey, more residents were satisfied with HEART than with any other public safety unit in the city. 

It’s unclear if physical safety has improved. Researchers in Durham and a handful of other cities are studying whether unarmed responses reduce arrests, police use of force, and involuntary hospitalizations.

Anecdotally, Chief Andrews believes that working with HEART has improved how her officers do their job—a sentiment shared by many officers we interviewed. Andrews recalls a particular call where a man was dancing on top of a squad car in downtown Durham. Before HEART, Andrews said, the man would’ve been handcuffed and taken to jail. Instead, her officers spoke with the man and then called HEART. “I was so damn proud of how those officers just allowed this man to just have his space,” Andrews said. “He wasn’t hurting himself. He wasn’t hurting the officers. HEART provides us the opportunity to be a part of a different face of public safety.”

HEART’s Biggest Challenge: Connecting People to Care After the 911 Call

HEART, in many ways, has exceeded expectations. The program has established and maintained deep support from elected leaders, law enforcement, and the community. It’s proven that unarmed mental health workers can safely respond to 911 calls that used to be answered by the police.

The challenge is what happens after HEART responds to a 911 call. Right now, the team refers residents to its Care Navigation unit. Staffed by social workers and peers with similar lived experience, navigators are responsible for connecting people to longer-term care such as housing, therapy, or addiction treatment.

“I knew that [part] would be hard,” said Ryan Smith. “I knew that it would be messy. But that it would be the hardest thing that we do? That’s the thing that surprised me.” Smith knew when he designed the program they would encounter people with problems bigger than anything social workers could solve out of a van. But he wanted to avoid his department sliding into delivering long-term care, so he limited Care Navigation to 30 days.

“We’re not there to provide all the services,” he said. “We’re there to try to make the most of our sometimes underfunded, fragmented system of support.” 

Yet in these first three years, HEART’s efforts have regularly failed to adequately address people’s long-term problems in a month. HEART has connected just 20% of people to follow-up care.

Part of the problem is structural, Smith said. Housing and mental health services are hard to come by in Durham. Programs across the country face similar challenges.

Absent a more robust social safety net, certain individuals cycle in and out of HEART’s care. John Warasila, a real estate developer in Durham, sees HEART as well-meaning, but is upset with the program as a handful of homeless or mentally ill people continue to present problems on city streets. “[HEART] will tell us, ‘We’re working on it.’ They tell us this list of things they’re doing,” Warasilla said. “At the end of the day, it’s not resolved. So at a certain point you’re like, I appreciate all the effort that’s going into this, but this is not functioning as a solution.”

Smith has met with Warasilla and other frustrated members of the business community. HEART now directs its care navigators to contact people as soon as possible. The department is also gathering data to inform city leaders what additional services could more meaningfully help people.

“It is a larger system-wide failure and HEART is put in a position that is a very difficult one without appropriate resources,” Smith said. “We’re continuing to take seriously the concerns of [business owners]. It is a long road that we’re not shying away from.”

City Manager Wary of Mission Creep, but Wants HEART to Grow

HEART’s inability to connect people to follow-up care has on occasion led the department to expand its role beyond first responder and care connector. HEART helped stand up an emergency cold weather shelter during one of the coldest weekends of 2024, for example. The department also has piloted a program that provides intensive ongoing support to a handful of people with significant needs.

Durham city manager Bo Ferguson appreciates that certain cases require HEART to provide what looks like more traditional social services, but he said the department must keep sight of its core function — responding to 911 calls. “I’m comfortable acknowledging the line is fuzzy and the line can move and has moved because we’re such a young program. We’re still learning how to operate in this space,” Ferguson said.

Ferguson is eager for HEART to expand operations to run 24/7. Having at least one unarmed unit on all day would push the program’s annual budget from $5 million to $6.5 million. Ferguson knows some elected officials and community advocates would like to see police funding diverted to beef up HEART.

“If the growth of alternative response takes a certain amount of workload off of police, and police no longer have the call volume that justifies a certain level of staffing, naturally, we’ll have a conversation about whether or not we need as many officers,” Ferguson said. “We haven’t seen that yet.”

Police chief Patrice Andrews also wants HEART to grow. But she, Ferguson, and Ryan Smith agree there’s a danger to pitting police against HEART. Andrews said cutting her budget would be difficult at a time when the city continues to grow and demand for police is only increasing.

She believes Durham — and any city doing this work — must balance responding to crisis and responding to lawlessness. “You need a level of law enforcement, but you also need that side of public safety that really is all about taking care of our populations of people that are most vulnerable,” she said. “We can do both.”

RYAN LEVI is a reporter and producer for Tradeoffs (tradeoffs.org).