The following is an excerpt adapted from Excessive Force: Toronto’s Fight to Reform City Policing, out March 31.

It’s a macabre roll call stretching back more than three decades.

Albert Johnson, a 35-year-old Jamaican immigrant with mental health issues, shot and killed in his home by Toronto police in August 1979.

Lester Donaldson, 45, who suffered from paranoid schizophrenia, produced a knife in a standoff with police, shot and killed in August 1988.

Albert Moses, 41, with a history of mental illness, shot and killed by police in his rooming house in September 1994 after attacking an officer with a hammer.

Tommy Barnett, 22, shot and killed by police in January 1996 after threatening an officer with a sword. His family said he had a history of mental illness.

Wayne Williams, a 24-year-old with schizophrenia, shot and killed by Toronto police in June 1996 after he advanced, with two knives in his hands, on five officers who were confronting him.

Edmund Yu, 35, shot and killed by police in February 1997 as he waved a small hammer on an empty bus.

Jeffrey Reodica, 17, allegedly brandishing a knife, shot three times in the back and killed by police responding to a report of a fight involving teenagers in May 2004.

O’Brien Christopher-Reid, 26, who had paranoid schizophrenia and was brandishing a knife in Edwards Gardens in June 2004, shot and killed by Toronto police.

Byron Debassige, 28, shot and killed by Toronto police in February 2008, described by the 911 dispatcher as armed and dangerous when he took two lemons from a store and pulled a three-inch knife as he was chased by the store owner.

Reyal Jardine-Douglas, 25, shot and killed by a Toronto police officer on a streetcar after he charged at the officer with a knife in August 2010.

Michael Eligon, 29, wearing a hospital gown and carrying two pairs of scissors, shot and killed by police in February 2012.

Andrew Loku, 45, holding a hammer in the hallway of his apartment building, which housed people with mental health problems, shot and killed by Toronto police in July 2015.

And, of course, Sammy Yatim in July 2013.

Each tragedy had the following in common: All were male. None of them was carrying a gun. All had mental health problems. None of them was white. No officer ever tried to de-escalate the confrontation.

And until James Forcillo, no police officer had been criminally convicted for any of these deaths.

This is the state-sanctioned culling of the inferior “other,” particularly the other of colour. It is the often-deadly intersection of police who are ill-equipped to deal with those who have a mental illness reacting to a perceived threat from someone who looks different. There have been more than 40 fatal police shootings of people with mental illness in Ontario since 2000. Coroners’ inquests have returned more than 550 recommendations for improvement and change since 1989. An Ontario government review of recommendations across the province between 1989 and 2011 counted 109 different calls for better police training, including better de-escalation techniques.

In the summer of 2017, back-to-back inquests—dealing with the death of Loku and the Durham police incident involving Michael MacIsaac, 47, shot while running naked through his Ajax, Ontario, neighbourhood on a frigid December morning in 2013—called once again for better de-escalation training for police. “I’m sure there have been lots of good recommendations from the inquests that have been had,” MacIsaac’s mother, Yvonne MacIsaac, told the Toronto Star. “My son would be alive if even a few of them had been followed.”

After the shooting of Yatim, retired Supreme Court Justice Frank Iacobucci looked into the question of police response to people in mental health crisis. But his review did not include the broader issues related to the use of force by police, or policing and racial bias, especially anti-black racism. The report was comprehensive, but it did not deal with the question of why so many of those with mental health problems killed by police were racialized people, particularly black people. The question of what goes through a police officer’s mind—what thoughts, ideas, stereotypes and prejudices an officer may have—when he or she is dealing with someone who is acting up and who is non-white was left unexamined. Justice Iacobucci stayed away from the question, although he was asked about it at the press conference where he released his report. His answer? “It was not in my terms of reference.”

He did, however, acknowledge that it was an important question. The question of implicit, or unconscious, bias was raised at the Loku inquest. Nicholas Rule, an associate professor of psychology at the University of Toronto, told the inquest about a study he had done with two American academics that showed when photos of the faces of white and black men with identical heights and weights were shown to subjects, the black men were perceived to be taller, heavier, more muscular and more physically threatening than white men. People’s stereotypes literally distort their vision, his study found. That perception held regardless of the race of the person who was asked to evaluate a set of photographs. “Black men tend to be stereotyped as threatening and, as a result, may be disproportionately targeted by police even when unarmed,” he said.

The study did not introduce the question of a person possessing a weapon, nor did it study police officers, but the inaccurate perception of the size of a black assailant has been cited in a number of US police shootings. Tamir Rice, who was shot and killed on a Cleveland playground in 2014, was described by a police union spokesperson as menacing. “He’s five-feet-seven, 191 pounds. He wasn’t that little kid you’re seeing in pictures. He’s a twelve-year-old in an adult body,” Steve Loomis, president of Cleveland’s police union, told Politico in 2015. It bears repeating: Tamir Rice was twelve. Police shot him two seconds after their patrol car pulled up to the recreation centre playground after they had received a report about someone with a gun. The caller had told dispatch it was “probably fake.” The officers were not charged.

There are two sets of complicating factors leading to these deaths. First, we have police dealing with people in mental health crisis; these officers may lack knowledge about how to handle these situations, and they may harbour stereotypes and prejudices about such people. And second, we have people who are black, brown or Indigenous. What assumptions and ideas affect how officers respond to these people? Beyond these factors, there is the big question of why a medical or health issue has become a police issue.

Despite the deficiencies noted earlier, Iacobucci’s report is one of the few comprehensive, systematic explorations of police engagement with people in mental health crisis. One of its strengths is Iacobucci’s view on police culture and the kind of people police should be recruiting. He talks about attracting people with a high level of education and a compassionate bent. Most of all, however, I subscribe to his philosophy of doing no harm when dealing with people in crisis. As he says, even one death is too many. The report calls for a different way of thinking about and approaching these situations.

As Ontario ombudsman Paul Dubé concluded in his June 2016 report, A Matter of Life and Death, police officers receive a disproportionately large amount of training in the use of their firearms and very little training in the use of negotiation, reasoning, empathy and de-escalation. (Toronto police officers now receive bias-free training, but the course is only a day long. The Loku inquest recommended officers receive annual anti-racism training focusing on the equitable treatment of blacks, but this has not yet been implemented.) They know how to use their guns, Dubé said. They must learn to use their mouths. Once their firearm is drawn, too often it becomes the only way to resolve the situation. This fact exacerbates an aspect of police culture that these days plays a prominent role in police interactions with the public—officer safety.

Today, it appears every encounter is seen through the prism of officer safety, not community safety. This is reinforced by the proclivity of investigators, be they from the SIU or the police service, to accept uncritically an officer’s actions in the name of personal safety. Why did Forcillo shoot? According to his testimony, he was fearful for his own safety. He did not talk about danger to the public or the community, but about his own safety. What is the threshold of officer safety? I am not aware of any objective standard or measure to determine the validity of an officer’s claim of imminent threat. It is subjective, residing in the officer’s mind. In fact, I would argue that the threshold of officer safety has consistently been lowered over the years. When I look at incidents that involve police use of violence, I ask myself, “What was the risk to the officer?”

The shooting of Michael Eligon in 2012 is a case in point. One man holding two pairs of scissors; a sick man, faced by a bevy of officers. He was at a distance, but as officers backed away from him, one inadvertently backed into a parked pickup truck. Then Constable Louie Cerqua shot and killed Eligon. Two of the three rounds missed Eligon, endangering bystanders. Writing in The Walrus, journalist John Lorinc quoted a bystander who witnessed the encounter. Doug Pritchard, who was out for a jog, watched the scene. “It’s a cold winter day,” he would later recall. “The guy is standing there in a hospital gown, with bare legs. My first thought: this guy is in a mental health crisis.”

Eligon had spent two sleepless nights in the emergency room at Toronto East General. There were no beds available. He had been taken there by police after he became unable to take care of himself at a mental health facility. He stole two pairs of scissors from a convenience store after walking out of the hospital and gave the store owner a minor cut in a tussle (the owner did not even bother to attend to his cut until the end of the day, after Eligon was dead). None of the ten officers who confronted Eligon attempted to engage him verbally. There were conflicting strategies from the officers at the scene. At least one yelled at a colleague to fire, while another called on his fellow officers to back away from the troubled man. Again, who was in charge? And on what basis did the SIU and the police service investigators conclude that any of the officers had been in such mortal danger that killing Eligon was justified?

Look at the case of Otto Vass. He was a big man, and when officers scuffled with him, one put him in a chokehold and he died. An inquest jury determined Vass had died of a rare medical condition called “excited delirium.” Other experts believed he had died from a fat embolism released by blows delivered by the officers. Four officers were ultimately found not guilty of manslaughter. Did they use excessive force? Was anyone else at risk from Vass? When I questioned the circumstances of Vass’s death, I was told by a senior officer working in the chief’s office, “Chair, you don’t understand how much demonic strength a person who is having a mental health crisis can gather.” I will never forget his use of that term.

An SIU investigation absolved Andrew Doyle, the officer who shot Loku, on the basis that imminent threat to officer safety justified the use of lethal force. As with every SIU investigation, the scope was narrow and the troubling issues I’ve identified here were not examined. Nor did the investigation scrutinize the validity of the claim of imminent threat, which appears to be the pattern with SIU investigations. The police chief’s mandatory internal administrative review did not consider it either, consistent with the pro forma nature of these reviews. “The threat that he presented to me was immediate grievous bodily harm or death,” Doyle told the inquest. “I was afraid for my life.”

I am aware that it may seem like I am generalizing and discounting police danger. There are cases I can understand. Sylvia Klibingaitis, killed in 2011, was by every account on a rampage. She called police from her house and said she was going to kill her mother, whom she lived with. She told them, “Somebody come and stop me.” When she lunged out the front door of her house, the police officers facing her had no room to move because they would have backed into a shrub. Constable Henry Tang was backpedalling as Klibingaitis charged at him with a butcher’s knife, a chilling scene caught on the officer’s dashboard camera. “I knew that she was trying to kill me,” Tang told an inquest. “The ferocity of her attack and the speed that she was coming towards me, I knew I had no choice but to fire my firearm.”

However, I cannot understand the case of Byron Debassige, an Indigenous man killed in 2008. It is inconceivable to me that the two police officers involved could not have backed off. There was nothing behind them. They could have called for reinforcements. Again, they made the same argument: he came too close to us. He could have done us serious harm. I think about the icy condition of the path on which he approached them, and I think about a man who was very drunk. Maybe there was a misunderstanding: he was staggering and they thought he was being aggressive.

I discussed this with a retired police superintendent and he told me, “You don’t let somebody get that close to you.” He emphasized the importance of planning before entering a scene, having clear objectives, gathering information and taking one’s time. He wondered why containment was not considered, with officers backing off and calling for reinforcements. “What was the hurry? Debassige was not going anywhere,” he said. Instead, constables John Tanner and Bradley Coutts shot and killed Debassige, a 28-year-old schizophrenic man who also suffered from alcoholism and drug addiction, when he allegedly lunged at them in Oriole Park that February day.

Debassige had taken two lemons from a corner store. As he left, the owner gave chase while his daughter called 911 and reported a “robbery.” To ward off the owner, Debassige brandished a pocket knife as he ran away. He was described as armed and dangerous by the call dispatcher. He was said to have charged at the officers from a distance of about six metres (19.5 feet). “I’ve never second-guessed anything I did that night,” Tanner told an inquest. Again, we are talking about officer safety above all else.

Even as I was tabulating this awful list and looking back on the circumstances, it happened again, this time in Ottawa. On the morning of July 24, 2016, police were called to deal with a man alleged to be groping a woman in a coffee shop just west of Parliament Hill.

Abdirahman Abdi, a 37-year-old Somali-Canadian with mental health issues, tried to flee to his nearby apartment when he saw police. He didn’t make it. Officers tackled him, pepper-sprayed him, beat him with a baton and punched him in the head, killing him. The events were witnessed and caught on smartphone camera amid screams for police to let him go. Abdi was armed with a piece of foam. In this case, the SIU charged Ottawa police constable Daniel Montsion with manslaughter, aggravated assault and assault with a weapon. The weapon, in this case, was allegedly reinforced gloves—that is, gloves with brass knuckles, worn by Montsion. In an example of how tone-deaf police culture can be, Ottawa officers began wearing black-and-blue wristbands in support of Montsion. The wristbands bore the words “United we stand” on the outside and “Divided we fall” on the inside, which also featured Montsion’s badge number. Ottawa police chief Charles Bordeleau, citing the perception of the community and pushback from its leaders, refused to let officers wear the wristbands while on duty.

Mental health is a global societal issue. But why is it a policing issue? The fact is that people suffering from mental health problems are not criminals. They are not violent people in the criminal sense of the word; some can be violent at times as part of their illness. They can be paranoid and that can cause them to be violent. They may have anxiety or a chemical imbalance, sparking a violent response. But those are all medical conditions. In many cases when they are in a state of crisis, these people are not able to engage in normal communication. They may not comprehend what is being said; they are often not even able to hear what is being said. They are responding from a different space.

Police are not diagnosticians, nor should they be. They are not knowledgeable in mental health issues. They have the same biases and lack of understanding as ordinary people. They use words like crazy to refer to those with mental illnesses. They are trained to take charge, to take control. Their first words tend to be words of control—“Don’t do that” or “Don’t move” or “Drop the knife”—not words that might defuse a situation or establish a relationship based on communication. They have been trained to treat knives and other edged weapons as they would guns—as just as dangerous and just as lethal.

As Paul Dubé’s research showed, between 1995 and 2000, Ontario police officers were assaulted 315 times with edged weapons compared to 51 times with firearms. But they are trained to deal with behaviour rather than the cause of the behaviour, so when a person’s response is “No, I won’t do that,” or the person ignores the command, the confrontation escalates. The police officer may quickly elevate the response to lethal force even though the use-of-force model they are trained on claims to provide for a graduated response and the option to dial down. Too often, an officer will not pull back and realize the person is clearly not engaged.

The ultimate result of this is that we are saying, “Okay, police officer, you can kill some of these people.” The police culture tells them that such deaths are unfortunate but unavoidable. And because they are unavoidable, the officer who kills or does serious injury to someone in crisis—whose behaviour is caused by an illness and who is not a criminal in the common meaning of that term—shall not be considered guilty of a criminal act. A person suffering from mental illness is society’s “other”—not normal—and history is full of examples where those in power have responded to “the other” with similar acts of control. People called “mad” were incarcerated; people considered unfit to bear children were forcibly sterilized; people considered “retarded” were lobotomized.

Have societies in the age of neo-liberal economic policies pushed these boundaries and accepted that it is all right to kill this new “other”? This, to me, is the defining moral, ethical and political question that we who call ourselves civilized must face. If not, people will continue to die, and those who kill them because they feel an “imminent threat” to their safety will continue to go free, perhaps with a slap on the wrist. What else can society expect when it turns a matter of social responsibility into a matter of “law and order” and “public safety”?