SCCM Resource Library-The Impact of Gun Violence on Public Health

Video Transcription

It is my distinct pleasure to introduce Dr. Therese Richman, who will present this year's William Shoemaker Honorary Lecture.  Dr. Richman is the Andrea B. Laporte Professor at the University of Pennsylvania School of Nursing and serves as its Associate Dean for Research and Innovation.  She has an extensive program of research aimed at improving recovery from serious injury by addressing the interaction between physical injury and its psychological repercussions.  Her science also focuses on prevention of violence and firearm violence. The National Institutes of Mental Health, the National Institutes of Nursing Research,  the Centers for Disease Control, and the Pennsylvania Department of Health have supported her research.  Dr. Richman serves on the Executive Committee of the CDC-funded Penn Injury Science Center and on the Executive Committee of the Leonard Davis Institute of Health Economics.  She is a fellow at the American Academy of Nursing and an elected member at the National Academy of Medicine.  Dr. Richman serves on the Federal Advisory Committee to the Secretary for National Health Promotion and Disease Prevention Objectives for 2030.  Please join me in warmly welcoming Dr. Richman as she presents the William Shoemaker Honorary Lecture titled, The Impact of Gun Violence on Public Health.  Hi, everybody. Hello. Say hello. Thank you so much for having me. I'm absolutely thrilled to have been invited by SCCM to talk about the public health burden  of gun violence, and especially with the William Shoemaker Award. When I was on the board of the American Association of Critical Care Nurses decades ago, he was  our plenary speaker. So it's very nice to have the tables turned and to be here. So thank you very much.  I'm not going to talk about blood and guts, critical care, vasoactive agents, managing patients in the critical care unit for gun violence.  All of us probably do that many days a week, every day of the week. I would like us to sit back and think about what's our role, what's our responsibility  as citizens, as providers, to deal with the issue of gun violence and the impact of gun violence in this country. So for disclosures, I'll be talking about decades of research.  These are all the funding groups that have funded the research I'll be talking about today. I have no other financial disclosures other than funding for the studies I'll be talking  about. I would like to acknowledge some really important people. First is Eleanor Kauffman. I invited Eleanor, who's a trauma fellow at Penn, to co-write the paper that will come  out in critical care medicine from this session. And it's a catchier title, actually, Beyond Band-Aids for Bullet Holes. She did a wonderful job, and she's a star.  She will be a rising star, so keep your eyes on her. My colleagues at the Penn Injury Science Center, we've been around for a long time.  I co-founded the Firearm and Injury Center at Penn maybe 1995, and it's now a CDC-funded Penn Injury Science Center. We do interdisciplinary team science.  I'll talk in the global we, because it's a complex problem, and we all work together. And then finally, for the thousands of patients who've entered my research studies over the  years at very, very, very vulnerable points in their lives that were generous enough to  be in longitudinal follow-up studies so that we could really understand the impact of violence on their lives. We live in a purple America.  We really live in a red and blue America, but in purple America, where we have different political views and multiple lenses, what do we see?  We see about 100,000 people shot every year. About 39,000 people are shot to death. CDC just yesterday released the 2018 statistics. Maybe 40 less deaths than 2017.  We have a far way to go. About $100 billion is lost to gun violence from a cost perspective, and about 19 children die every, or shot every day. About nine die every day.  We're killing our children in this country. We need to think about that for the pediatric providers in the audience, it's a pediatric  disease, it's an adult disease, it is indeed a biopsychosocial disease. So in red and blue America each year, we know that guns are a contentious issue.  Not surprising to anybody in this room. We know the dialogue is nasty and polarized. We argue Second Amendment rights, and we have few viable solutions. That's the world we live in.  I want you to walk out of here today and say, as a healthcare provider, as a critical care clinician, as a pharmacist, as a nurse, as a physician, I can change that dialogue.  I can bring people together, and we can attack this problem as a health problem. When I say that it's nasty and polarized, that's an understatement. And I will give you an example.  Published a paper, and you know how you get emails, and this is a good example from before the Twitter world, you would get emails about your paper.  I get an email one day that says, anonymous, dear Dr. Richmond, please take your head out of your ass, after one of our papers was published.  And it was like, well, okay, I can do that. I can try to do that. And because it was just, they had such a problem with the nature of the paper, where we were  making the case that knowing the kind of gun, the number of bullets that could be discharged, et cetera, was important from a clinical perspective, and those data were important.  So when we say nasty and polarized, it is. We have to get past that, and we have to change that.  If we recast the conversation as providers, we think about, you're shot with a gun, kinetic energy is released, the bullet goes into the body, where do you come?  You come to emergency department. You come to a resuscitation. You come to your critical care unit. That makes it, by definition, a health problem.  And it's no different than when we think about infectious diseases, right? Whether tick-borne or insect-borne, et cetera, we deal with it as a disease. And we need to do that.  And if we deal with it as a disease, it opens up possibilities, and we'll talk about that. So it's not just, I'm not just taking care of you after you're infected, I'm going to  take care of you by changing the environment where the mosquitoes thrive, by having you put on bug spray, by having you cover up your limbs when you're in high-risk areas.  We can do the same when we think about gun violence as a disease. So that is central to what we have to think about.  So I'm going to start with the public health burden by talking about mass shootings. And I'll do it for a couple reasons. That's what we see in the media.  That's what hits the press. And we're in Florida, the Parkland shooting, the Orlando nightclub shooting. They are absolutely terrible, terrible events.  This is what we hear, and hence I'll start with this. Mass shootings are not new. So you don't even need to know the details of this slide.  This is, for the past 70 years, the top mass shootings in this country in terms of number of people killed. You can see we go back all the way to 1949. So it's not new.  It's not different. We hear about it more because of all the media, the 24-hour news cycle, the social media that we're exposed to. It's not new.  In red, I've circled the Sandy Hook shooting. Because for many of us, that was a seminal event. It was an elementary school.  Like how could this happen when we're sending our children to school? And we thought, it's going to change. Life will change. We're going to make progress.  But these mass shootings, this is only the tip of the iceberg. I come from Philadelphia. And outside Philadelphia is Amish country.  And we had a mass shooting, you may remember the Amish schoolhouse shooting, where 10 little Amish girls were lined up and shot, eight were shot in the back of the head, five died,  three were badly injured.  This doesn't even rise to the level of making it to the chart I just showed you. And yet, can you imagine a more asynchronous, asynchronous experience than in an Amish schoolhouse  that this could happen? Mass shootings are egregious. The Parkland, Marjorie Stoneman Douglas mass shooting was terrible. We saw students mobilized.  It was absolutely a fabulous thing. And in no way do I want to minimize the importance and the impact of mass shootings and school  shootings, but they account for only 1% of all gun deaths in this country every year. Only 1%. The reality is we're killing people every single day.  On the day of the Parkland shooting, this is the trauma alert from Penn Presbyterian in the same 24-hour period.  And you can see gunshot wound, gunshot wound, gunshot wound, gunshot wound. And that's one trauma center of many trauma centers in one city.  So we need to recognize that while the media pay phenomenal attention to mass shootings, 1%, and we are dealing with shootings and deaths every single day.  So let's think about the daily toll of the burden of gun violence. So we hear a lot about tornadoes and having tornado cellars and having warning systems.  Over 300 years, there were maybe 20,000 deaths from tornadoes. Over 30 years, right, 300 versus 30, over a million deaths from guns. Last year, 10 deaths from tornadoes.  Last year, 39,740 deaths from gun violence. So we need to really put in perspective the impact of what we're dealing with. This is a health issue that we have to deal with.  The majority of gun deaths are suicides. Most people don't realize that. Even those of us in healthcare who are clinicians, 61.5% last year were due to self-inflicted  suicide attempts. 35% were interpersonal violent attacks. Everything else was unintentional, et cetera, very small parts of that pie.  It's important to know firearm suicide is the biggest killer when we think about gun deaths, and it's important for us as clinicians in particular to understand that because we  often don't see these patients in our hospitals because the case fatality rate is so high in self-inflicted firearm injury. It's so high.  These people go right to the medical examiner or the coroner. We don't see them.  So out of sight, out of mind. But we need to know this because in some ways as we think about what are palatable things  that we can start doing as healthcare providers protecting impulsive teens from killing themselves is something most people can rally around and take care of.  Taking care of older men who are a big risk group, that's something that we can rally around.  So when we talk about firearm violence, think broadly and understand the different components of this pie chart.  So this is a little busy slide, but it almost doesn't matter what the numbers are. And I do thank Eleanor Kaufman, my co-author on this, because I could not make the slide  of my life dependent on it. So this, if you look at your left, right, that's men. If you look at the right, that's women. Who has the biggest burden? The guys, right?  So it's very unequal from a gender perspective. Then if you look at the top left, that's male, broken down by race.  Who takes the biggest hit for interpersonal firearm violence, firearm homicide is young black men.  In fact, young black men are 17 times more likely to be killed in an interpersonal gun violence event than young white men.  So we know it's not disproportionately spread, but the story changes when you look at self-inflicted.  So the bottom left is the self-inflicted, and the two groups that are high risk, these are people in your community, younger, young adult, and middle-aged adult Native Americans,  and older white men. No offense, folks, but I'm looking at older white men in the audience here.  So I'm just saying, right, like I'm not pointing to anybody in particular, but I have gray hair here, but I'm a woman, is older white men are really at high risk.  What can we do about that? How do we target? What kind of social services do we provide? So the disparate impact of gun violence is important to understand.  I had the, one of the joys of being a research director in an injury center is I get to give out money, right, for pilot studies.  And one of the things we wanted to do at Penn, we have our business school's warden, if you haven't heard of it. We think, of course, think everybody's heard of it.  And went to a wonderful man, John Lemire, who's a world-class actuarial scientist, and said, John, you don't know that you want to be a violence researcher, but if we give you  money, would you like to figure out what's the impact on life expectancy in this country because we choose to live in a world with guns? And he said, okay, I'll do that.  So he did a paper, and then he and I did a paper together. And what we found was, overall, we lose, as a society, 106 days of life expectancy.  And that's accounting for all the other reasons you could die if you didn't die. It's a very sophisticated analysis.  Black males lose more than a year of life from living in a world with guns. So the impact is huge.  And if you don't think in terms of life expectancy, the older you get, the more you do, I will say.  But if you don't think in terms of life expectancy, let's put this in perspective. So the big red bar are black men, loss of life expectancy in terms of days.  But if we look at the blue bars in the front, which is all men, lung cancer, colon cancer, prostate cancer.  So again, I want to contextualize the impact of gun injury in relation to the other things that we deal with on a daily basis in health care.  So it's important to understand gun violence affects us all. How many people in here personally know somebody who was shot, who was injured, who killed themselves with a gun?  There are a lot of hands up in this room. And then if I said as clinicians, how many of you had interacted with people who were shot? Probably all the hands would go up, right?  It affects us all. It's an important point to make. So here we have a beautiful picture of urban America. This is Philadelphia.  It's sort of cool looking, actually, and rural America. And I bring this up specifically because in a state like Pennsylvania, we have, I guess  if this is East, we have Philadelphia and we have Pittsburgh. And we think of Pennsylvania as urban, but the reality is Pennsylvania is a rural state.  And I bring up states because most policy is going to have biggest impact at the state level.  So if I live in rural Pennsylvania and I don't believe I have a problem in my community, right, because all I hear in the media is all the gun deaths in Philadelphia or Pittsburgh,  then I don't have a problem. And if I don't have a problem, I don't have to solve a problem, right? There's no obligation to solve it.  So how do we help people understand that this is everybody's problem? So this is a paper we published in the American Journal of Public Health.  And we looked at big cities to small towns using a very well-accepted gradation from urbanicity to rurality.  And if you look at the blue line, firearm suicide is lowest in big cities, and the more rural you get, the higher it goes. And this is rate, 100,000, so this is controlled.  And if you look at the red line, we know firearm homicide is highest in urban areas, and it goes down the more rural you get, right? So it's different.  But when we pull it together, if you look at the top right with the little red box, in adjusted analysis, it essentially says wherever you are in the urban-rural continuum,  you have a firearm injury problem. You have deaths in your community from firearm injury. It's both an urban problem, it's a suburban problem, and it's a rural problem.  And if it's everybody's problem, then we're obligated to step up to the plate and do something. This is a paper by Sandra Galea's group.  He's up at BU right now, looking at the social network. And essentially what this says is 90 to 100% of people in this country will at some point  in their lifetime be involved with somebody in their social network who dies from a gun. So we've done the urban-rural thing. We understand the social network aspect.  We are all going to be touched. It affects resource distribution. This is a picture of a Philadelphia high school, and you know in Philadelphia high schools  now we have metal detectors to come into the school. And I love this quote. At the entrance of the West Philadelphia high school, an armed officer asked the poet Denise  Froman if she had a weapon. And standing before the metal detector, she held up her weapon, a book. So think about how our resources are being distributed.  In Philadelphia, we're closing schools because of asbestos exposure. That's very hot right now.  We don't have enough books for all the students, but we're investing in metal detectors and security guards as kids come in and out of school.  So the impact on where we spend our money is significant. So what might be the long-term consequences?  And this is really one of the components of what is sort of central to my research. So I want to talk a little bit about mental health consequences of people who are shot.  So this is a paper that we just published last year in JAMA Surgery. It's a prospective study where we consecutively enrolled 623 seriously injured urban black men.  Fifty-five percent were violently injured, the majority were gun violence. Three months out, 45% had significant, significant symptoms of depression and PTSD.  In fact, on screening instruments, they met diagnostic criteria. One of the big drivers was violence in terms of that. Childhood adversity, neighborhood adversity.  So we have people who are traumatized over life, who now have been injured, who are violently injured, who have poor mental health outcomes.  This study was, I mean, it's a strong design as a prospective cohort study. We retained 82% of the men in the study, and this is a tough group to follow over time, but really 45%.  And you could sit there and say, three months, that's not a long-term outcome. Okay, it's not a long-term outcome, but it certainly gives us a glimpse.  A subsequent paper that came out from a different team at Penn looked at, they contacted about 10% of all gunshot wounds who have been treated at Penn.  So it's a relatively small sample, right? So you're going to have sampling bias issues there, et cetera. But the median time from gunshot wound was almost six years.  And lo and behold, almost six years post-injury, 48% screen positive for PTSD. So when you put that together with my prospective study, we're hearing the same story.  And these mental health consequences are significant, they're important, and they feed cycles of violence.  One of the trauma fellows who's now at Emory, Randy Smith, came to me at one point and said, well, don't you think if we leave a bullet in the body that maybe they'll have worse  psych outcomes? And I thought, I never thought of that. That's an interesting question. And it's probably because I'm not a surgeon.  I'm not there either deciding whether to take a bullet out or not. And I'm not there talking to the patient in follow-up clinic about the bullet.  But it was an interesting question, so we asked the question. We had the data to answer it.  And indeed, if patients had retained bullet, they had significantly more severe depression symptoms over time. Not PTSD, but certainly depression.  We see a loss of trust in people who have been shot. And the loss of trust is in other people around them. And we should care about this. So a little advertisement stop here.  We need to incorporate into our critical care units, into our trauma services, behavioral health, psych support, to help people deal with the mental health consequences of what  has happened to them. These men lose trust. I don't know if it's somebody who's right next to me who did this to me. And I withdraw from people.  So we see them withdrawing from people at the time that they need the most social support. So this is a huge issue. I'm going to skip this. Why don't they seek help?  We found that even though I had symptoms, I didn't go seek help. And why not? Well, I don't want to end up in a straitjacket.  That's the cultural view of what it means to seek mental health services. I don't know who to talk to. I don't even know how to get counseling.  Well, if our patients are discharged from our hospitals, and they don't know how to connect with a healthcare provider, and they don't know how to get counseling, somebody's  missed a step in terms of preparing patients when they go home, when all of this psych stuff is going to fall out.  The saddest statement up here is they would look at me just like I'm crazy, stupid, or just like I don't matter. So we're seeing huge psych fallout. Why do we care?  This is a wonderful, almost algorithmic kind of thing, if we think about algorithmic medicine,  from my colleague John Rich, who looked at men who had been shot and people who had symptoms of psych distress.  And essentially, if we don't meet those needs, we see self-medication, using of illicit substances. We see a lack of trust in police.  So if I'm having issues when I go back on the street, I don't trust the police to help me. Therefore, I may carry a weapon and retaliate, and it's just a huge problem.  So what we see is the outcome are two things. One is, I'm at risk for being injured yet again, or I'm at risk for getting connected  with the criminal justice system, when in reality, they need mental health services, but we're not meeting those needs. So it's a very, very bad and vicious cycle.  But what happens, and I want the pediatric people, we have pediatric people in here? Okay. For the pediatric people in here, for all of us who are parents, for all of us who work  with kids or have grandkids, we see children injured every day, and you don't have to be shot to be injured.  We're seeing children injured every day from exposure to firearm violence in their neighborhoods, and you don't need to have a bullet in your body to be injured.  That's hard for us maybe as critical care clinicians to think about, because we're used to seeing people in our units who have the bullet buried in their body.  But I'm making the case that these children are injured by the very exposure to gun violence in their communities.  There's a consortium called the FACTS Consortium, I'll talk more about it at the very end, that's  run out of University of Michigan that many of us in the violence research world are involved with.  They just published a scoping study, a scoping review of 31 studies, and this is specific for children and adolescents.  And what they found is most of the papers had a disproportionate focus on mass shootings, and you've already heard me say most children are not injured in mass shootings.  They're injured every single day in their daily lives. And they found that the study designs were relatively weak, right, so we have a way to  go in terms of the quality of the science, but essentially, exposure to firearm injury, high rates of PTSD, and also high rates of future injury. So it's problematic.  And limited evidence on how do we best provide care for these children and adolescents. We published from Philadelphia a study with community partners where we surveyed 10- to  16-year-olds living in neighborhoods in Philadelphia with a youth homicide rate five times the national norm, okay, so that's not a place you probably grew up.  It's not a place your families probably live. But it's a place where these children are growing up. The vast majority, 95%, heard about somebody being victimized.  87% directly witnessed victimization. Over half have been directly victimized. And of that, a significant number, half of that, a significant number had been victimized  more than once. Now this wasn't all firearm injury, but when we looked at the qualitative data from these children, 10- to 16-year-olds, this is what they said.  Yes, they're actually shooting past me. I was standing down the street, and the other one was standing down the street, and they actually are firing back and forth. I was shocked.  I had the trash in my hand because his mother had asked him to put the trash out, and he's in the middle of a shooting experience.  That's being injured without having a bullet in your body. Or the swimming pool area is fine in the summertime, but gosh, if the basketball court, sometimes  that's fine, and sometimes that's not fine. And this kid is talking about the city-run recreation center, the safe place that we  can send kids to spend their time and be safe and productive. Well sometimes it's safe, but you know, sometimes, sometimes a couple shootings happen.  This is our city-run recreation center, and if we don't think that's real, here it is. So this is King-Sussing Rec Center.  This is where I go for all my community meetings with my partners, and indeed, six are injured in a Philadelphia Rec League basketball game.  This is where we're sending our children to hang out because it's a safe place. So these children are exposed to firearm injury. They're exposed to trauma.  It's very difficult for them to process, and they are indeed injured. The impact we know of all of this is children who have this kind of exposure are more likely  to violently offend. They have poor academic performance, increased risk of depression and suicidal thoughts,  allostatic loathe, sort of that chronic stress that the popular press calls toxic stress. And Cat Thiel down in New Orleans just really was able to show exposure to firearm violence  and community violence. Children have shorter telomeres. Normally we associate shorter telomeres with aging. These are children who are living in high violent neighborhoods.  So the impact is on adults. The impact is on children. The impact can happen whether a bullet is in your body or not. We have to move upstream.  So we talk about this in public health all the time. Our injury center motto is stop it, fix it, and live on.  We do research in all three areas, but to stop it we have to move upstream. How do we change this from happening to begin with? What is our responsibility for doing that?  Is that my job as a critical care provider to think about moving upstream? I would say yes. And I would say if you're not doing it, I don't think you're doing your job.  And I was trying to think of a, I talked to a reporter recently, I was in the Oprah magazine in the January issue, and I was trying to get the reporter to understand why firearm  violence or gun violence is a health issue and why we have to prevent it. And I said, and she finally got it, I finally said, you know, when a patient comes in with  a heart attack, I'm sure we have some CCU people in here, yeah? Like cardiovascular people.  When a patient comes in with a heart attack, we don't just treat the heart attack, we counsel  people on nutrition, weight loss, we put people on statins, you know, we do all the things to prevent the heart attack from happening.  And if you didn't do that, I think maybe that might be considered malpractice, actually.  So why is it, when we think about gun violence, if we don't do that, it's like, okay, we don't have to do it. So I'm suggesting we move upstream.  But upstream is not this calm, little upstream, it is turbulent out there. And it's turbulent out there because it's political and it's policy.  But we are in the best position as providers to navigate that turbulence. By moving upstream, this is a, I use this all the time because it's a way I think.  For that injury to happen, for that gunshot injury to happen, things have to come together. The potential victim, the gun, the potential instigator, right, have to come together for  that to happen. And it comes together in a variety of environments, economic environments, social environments, racial discrimination environments, legal environments.  Essentially, all you have to do is stop one of those paths or change the environment to help prevent that firearm injury.  So by moving upstream with the health mindset in your head, it takes us totally away from the cruel gun, anti-gun.  It allows us to think more broadly in terms of what are the potential paths that we can take. To do that, we need money, right? You need money to do research.  This is, we published this now several years ago, but the story is pretty much the same. If we look at the major NIH research awards from 1973 to 2002 for things like cholera,  diphtheria, polio, and rabies, so like 2,000-some cases, right, or like 320 cases, no, like 2,000 cases, more than, you know, a whole lot of millions of dollars. Think about that.  For firearm violence, three awards, three awards. It's just unbelievable. So we need funding to do the science.  After Sandy Hook with the Biden Commission and President Obama, they issued the Now is the Time report. We were hopeful that things would change.  Part of this report was ending the freeze on gun violence research, and hope was borne out pretty nicely for a while.  NIH put out a call for proposals specific to firearm violence in 2013, but it went to bed in 2017, so it didn't last very long.  In 2014, we saw legislative mandates come back in a language that said none of the funding used available from NIH can be used to promote or advocate for gun control.  Now those of us who work in this space don't do that. We build science. We get data. We find what are effective interventions.  But the interpretation of this has had a chilling effect on funding for research. So what does the future hold for this? Well, foundations have sustained the field.  The Joyce Foundation in Chicago, we're seeing other groups come in. They have consistently provided financial support.  In this new federal budget, in this unbelievably contentious political world we live in, they  actually agreed to put $25 million to CDC and NIH specifically, specifically for firearm violence research.  And for the first time a week ago, we saw a call out from CDC that is actually looking for both K and R mechanisms focused on firearm violence. We'll see that coming from the NIH.  We have the National Consortium for Gun Violence Research, which is a group spearheaded by the Arnold Foundation, who are bringing in other foundations, rigorously managed through  the RAND Corporation in terms of peer review to fund gun violence research. I think there's hope.  I think maybe we've turned a bit of a corner and we can build science and develop the next generation of violence researchers, because we've lost generations of potential superb  violence researchers because of the funding climate. So we have a model we can follow. Remember FDR? Remember FDR?  I don't really, but even though I have gray hair, but you know, maybe some of you do. I don't know. How old would you have? You'd have to be pretty old. All right.  So FDR, in 1936, he wrote in the Reader's Digest. Maybe that was the Twitter of the time. I don't know.  But he called on the American people to make motor vehicle safety priority a social duty. We are going to stop cars from killing people. FDR did that.  And indeed, one of the top 10 public health successes in the 20th century was decreased death by car. I don't think we have any fewer cars on the road, right?  In fact, we drive more miles than we ever did, but we have decreased death. So this is a model. We have no fewer cars on the road, but we decreased death by car.  We've chosen to live in a world with guns. So we've chosen that. How do we decrease death by gun? How do we do that? This is the model. What did it take?  A surveillance system, the fatal analysis reporting system, a lead agency, NHTSA, stable funding, lots of funding in NIH and CDC, data accessible to researchers.  Researchers can tap in to the fatal analysis reporting system, interdisciplinary approaches, research all possible points of intervention.  You drive down the road right now and you go off to the right, you hit a rump strip, right? You have reflectors in the middle of the road. We changed car design and road design.  We've made passive protections in cars. We know how to do this. We can do this with firearm violence. So I'm going to tell you a story. It's 1990s. You say, this is too long ago.  Important story. Steve Hargarten, then chair of emergency medicine at Medical College of Wisconsin, starts the  firearm injury reporting system, modeled after the fatal analysis reporting system from car crash.  In 1997, Bill Schwab and I ran a study called the Trauma Center Community Partnership Study.  How could we get local data from medical examiners, coroners, police, healthcare systems, to paint the picture of firearm violence in your community in Ohio, Iowa, and Pennsylvania?  1999, the same decade, David Hemingway, an economist at Harvard, said, let's take FERS,  which he called the National Violent Injury Surveillance System, and put it in the Departments of Health. 2001, so tenacity and teamwork. We know teamwork in critical care.  This is teamwork. Bill and I go down to meet with Arlen Specter's chief of staff to say, we want you to put  $10 million in the federal budget to start the National Violent Death Reporting System. The CDC, it wasn't for us, it wasn't for Penn, it wasn't for my research, it was do this.  The first thing out of the chief of staff's mouth was, it's all about gun control, isn't it? And I said something that I never say, because I love being a nurse.  I said, you know what, I am only a nurse. I'm not a Second Amendment scholar. I'm not here to talk about that. All I want to do is keep people safe.  Don't you want to keep people safe? Now how can a politician say no? Of course I want to keep my constituents safe. We can change the dialogue.  2002, we started piloting National Violent Death Surveillance System in six states. All right, so this is decade two. Let's go into decade three.  In 2014, Pennsylvania finally becomes a National Violent Death Reporting State. And in 2018, all 50 states finally have National Violent Death Reporting System and a CDC.  So it was a team. It was all the researchers across the country coming together and saying, we're going to make this happen. This is how we're going to make it happen.  And it happened. So what do we have when we think about gun violence? We have a fledgling surveillance system. We have interdisciplinary approaches.  We have research in all points of intervention. We still have to crack lead agencies, stable funding, data accessible to researchers. But we're getting there.  So I want to finish in talking about what can we do now and today. This is a report from a workshop that we held at the National Academy of Medicine last  year on what's the role of health systems interventions to reduce firearm injuries and death. Health systems are starting to step up to the plate.  Kaiser Permanente has dedicated $2 million to take this on. Northwell Health System, which is the largest integrated health system in New York State, has pledged $1 million.  I'm having lots of conversations at Penn Medicine as we think, what are health systems' roles? And you're the health system, right? This is our house.  We have to commit to reducing gun injury. Identify who's at risk. Pick a focus. Maybe it's teen suicide.  Maybe it's urban black men who were shot and we're going to work with law enforcement to look at hot zones. Maybe it's older white men in the community who are killing themselves.  Pick a focus and run with it and evaluate it and iteratively improve. The rape opportunities, if you walk away with nothing else, we tend to be somewhat judgmental  in the healthcare world and we sometimes stigmatize gun owners in terms of putting people at risk. We can't do that.  We have to start where people are and say, if you choose to own a gun, how do you do it more safely? How do you do it more safely in your house?  How do you do it more safely when you travel? And let's not stigmatize. We need to get past that. Multiple things that we can do here. We can look at patients at risk for suicide.  My gerontology friends, we have a lot of increasingly large numbers of older adults with dementia.  Many of them have guns in their homes. And many of them have grandchildren coming to visit them. That's a problem. Are we counseling them? Are we talking to them? So many things.  I encourage you to go to the National Academy of Medicine report. And the final thing I'll say, and I will end here. We live in a world of precision medicine, right?  Precision medicine. Let's think about how do I get the right intervention to the right person at the right time and the right place?  We're sitting on piles of data in our health systems. We can start identifying and risk stratifying patients who are at risk for firearm injury.  One simple example is the safety score that came out of the University of Michigan. Very simple clinical screener. Identify high-risk adolescents.  Provide them with wraparound case management services. We can do this. It's data-driven. We know how to do this. We do this a million times with other things.  We should be doing it with firearm violence. So on that note, I'm going to stop and say there's lots of things out there.  A positive call out for Society of Critical Care Medicine, who signed on to the Medical Summit for Firearm Injury Prevention, in terms of nine elements that these societies  could come together and support, much of which I've talked about. Pull that paper. Take a look at it. Pull the National Academy of Medicine report and take a look.  So on that note, I would say thank you so very much. I hope I've given you some food for thought. Ben Franklin, who founded Penn, said you build knowledge for societal good.  This is the problem that we need to build knowledge on for societal good. So thank you so much. Thank you.

Video Summary

Dr. Therese Richman, Associate Dean for Research and Innovation at the University of Pennsylvania School of Nursing, delivered the William Shoemaker Honorary Lecture titled "The Impact of Gun Violence on Public Health." Dr. Richman highlighted the importance of addressing the public health burden of gun violence and emphasized the need for healthcare providers to play a role in preventing and addressing this issue. She discussed the various consequences of gun violence, including the physical and psychological impacts on individuals who have been injured, as well as the effects on children who are exposed to firearm violence in their communities. Dr. Richman emphasized the importance of moving upstream and addressing the root causes of gun violence through research, policy changes, and community interventions. She also discussed the need for increased funding for research on gun violence and the role of health systems in preventing and addressing this issue. Dr. Richman concluded by calling on healthcare providers to take action and advocate for change in order to reduce gun injuries and deaths.

Asset Subtitle

Worldwide Data, Crisis Management, 2020

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2020 Critical Care Congress held February 16-19, 2020, in Orlando, Florida, USA.

The Impact of Gun Violence on Public Health

Therese S. Richmond

Learning Objectives

Describe the burden of gun violence on the public’s health and well-being.

Employ a multifaceted, public health approach to reduce the burden of gun violence on individuals, families, and communities.

Explain the important role of health care providers and health care systems in reducing gun violence and mitigating its impact.

Meta Tag

Content Type Presentation

Knowledge Area Crisis Management

Knowledge Area Worldwide Data

Knowledge Level Foundational

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Membership Level Professional

Membership Level Associate

Tag Trauma

Tag Resource Allocation

Year 2020

Keywords

Gun Violence

Public Health

Healthcare Providers

Consequences

Children

Research

Policy Changes

Advocate

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