February 5, 2019 — Each year in the U.S. more than 30,000 people are killed by guns—with two-thirds of those deaths being suicides. And there are tens of thousands non-fatal injuries. Yet research into preventing firearm violence remains limited and under funded. In a special collaborative episode with Review of Systems we’re taking an in-depth look at gun violence in America: why we know so little about the toll of firearm injuries and deaths, what researchers want to know, and how they are engaging gun owners and enthusiasts as key stakeholders in advocating for more research.

You’ll hear perspectives on gun violence from the emergency room, with Megan Ranney, and from public health, with David Hemenway. Ranney is an associate professor in the Department of Emergency Medicine at Rhode Island Hospital/Alpert Medical School of Brown University and also chief research officer for the American Foundation for Firearm Injury Reduction in Medicine, a non-partisan philanthropy focused on filling the funding gap for high-quality, medically-focused, firearm injury research. Hemenway is a professor of health policy at Harvard T.H. Chan School of Public Health and director of the Harvard Injury Control Research Center. He has written widely on injury prevention, on topics including firearms, violence, suicide, child abuse, motor vehicle crashes, fires, falls, and fractures.

You can subscribe to Harvard Chan: This Week in Health by visiting iTunes or Google Play and you can listen to it by following us on Soundcloud, and stream it on the Stitcher app or on Spotify.

Learn more

Doctors affirm commitment to reducing gun violence (Harvard Chan School news)

New recommendations urge doctors to talk to patients about guns (Harvard Chan School news)

Uncommon Ground (Harvard Public Health magazine)

Full Transcript

NOAH LEAVITT: Coming up in a special collaborative episode of Harvard Chan, This Week in Health and Review of Systems, gun violence in the US, perspectives from the bedside in public health.

DAVID HEMENWAY: 100 people a day are dying, and 300 people are shot. And it’s not only the deaths. It’s the spinal cord injuries, to traumatic brain injuries. It’s the fact that communities are being destroyed.

AUDREY PROVENZANO: In this episode, the toll of gun violence in America. From the trauma bay of our nation’s ERs, to the frenzied coverage of mass shooting, to the iceberg of suicide deaths by gun that account for most gun deaths in the US, but are woefully under covered in the press, and sparked little public conversation.

NOAH LEAVITT: We’ll also explore why we still know so little about gun violence in America.

MEGAN RANNEY: Early on in my career as a violence prevention researcher, I was specifically told by multiple people to not talk about guns or firearms because there was no funding, but also, because there was a fear that it would end one’s career.

AUDREY PROVENZANO: Two experts on gun violence explain why firearms research is so rarely funded in the US, and how they are working to change that.

This week, another collaborative episode between Harvard Chan, This Week in Health, the podcast from the Harvard TH Chan School of Public Health, and review of systems the podcast from the HMS Center for primary care.

NOAH LEAVITT: Each year in the US, more than 30,000 people are killed by guns, with 2/3 of those deaths being suicides, and there are tens of thousands of nonfatal injuries. In this week’s episode, we’re taking an in-depth look at gun violence. Why we know so little about the toll of firearm injuries and deaths in the US, what researchers want to know and how they are engaging gun owners and enthusiasts as key stakeholders in advocating for more research.

AUDREY PROVENZANO: Professional organizations for clinicians such as the American College of Physicians are encouraging primary care physicians to talk to patients about guns in their homes. And with the surge in activism around firearms after last year’s Parkland shooting, the concept of gun violence as a public health issue has gained traction even outside of the public health community. So it’s a perfect topping for clinicians and public health professionals to think about together.

NOAH LEAVITT: I’m Noah Leavitt, host of Harvard Chan, This Week in Health.

AUDREY PROVENZANO: And I’m Audrey Provenzano, a PCP, and host of review systems.

NOAH LEAVITT: We have two guests joining us this week. David Hemenway is a professor of public health policy at the Harvard TH Chan School of Public Health, and director of the Harvard Injury Control Research Center, where he focuses his teaching and research on injury prevention.

AUDREY PROVENZANO: We’re also speaking via Skype with Megan Ranney, an associate professor in the Department of Emergency Medicine at the Rhode Island Hospital Alpert medical school of Brown University, a widely published researcher, and chief research officer of the firm, the American Foundation for firearm Injury Reduction in Medicine, focused on funding firearm injury research.

NOAH LEAVITT: You can find more information about both of our guests on our websites for review of systems, go to HMS.primarycare.edu, and just click on podcasts at the top of the page. And for This Week in Health, just go to HSPH.me/thisweekinhealth.
Now let’s dive into our conversation with Megan and David.

AUDREY PROVENZANO: So Megan, you’re a practicing emergency physician. I thought maybe we could start with you if you could tell us a story about a patient who was affected by gun violence, and how that experience drew you into becoming a gun violence researcher.

MEGAN RANNEY: So as an emergency physician, I, like all of my colleagues, have hundreds of stories of patients affected by gun violence. But one of the ones that has stayed with me, partly because of its uniqueness, but also because it highlights just that the tragedy and that prevented reality, is a story of a young man who took care of very early on in my career just after I became an attendee.

It was a July night, so I’ve been an attendant for all of a couple of weeks. And there was a call over EMS radio that there was a trauma code coming in. And what we always do for trauma, we prepared, got the trauma team down, and radiology techs. Gathered the med students and the whole team. And then EMS rolled in.

And what we had expected was not at all what rolled through the door. It was a young man who had been shot, but he had shot himself in the head. And was still alive, but barely, and as the story progressed, we learned that he’d actually shot himself with his father’s weapon.
And one of the reasons why that story stays with me is because I remember his dad and the utter tragedy for that father, and for that family, of knowing that this kid had died not just something preventable in general, a suicide attempt, but from something that was in their house. And that this young man didn’t necessarily have to have access to at that moment.
And that was the moment when kind of my approach to gun violence changed, because I started thinking about how many suicide attempts I see, and how many I can save, and how this young man was different. And how we very rarely see folks that hurt themselves with a gun, even to make it to doors of an ER. I think it’s really important for us to talk about all the types of gun violence, including community violence, and domestic violence, but those suicides really are the untold tragedy that affects all across the United States.

NOAH LEAVITT: I think it’s so powerful here we talk about suicides and gun violence because I think, David, you’ve talked a lot about the kind of role public health is in preventing not just gun violence in general, but firearm suicide. So can you talk a little bit about how you first came to looking at firearms as a public health issue? And I guess similar to Megan, was there a particular story or a moment when you realize that this is where you wanted to focus?

DAVID HEMENWAY: So, to step back, in 1975, I came to teach at the Harvard Chan School of Public Health. I’d been teaching undergraduates economics. And I just fell in love with the students. And they were my age, they really had a reason to be in school, I had something to teach them. And so I tried to figure out how to stay in public health. And first, they had me doing hospitals and doctors, and I wrote articles about how physicians respond to financial incentives. And I thought that was sort of silly, because everybody responds to financials– plumbers respond to financial incentives.
So I thought, is there something else I could do that would really make a difference. And I had worked for Ralph Nader in the ’06s and ’70s, so I thought I could really do something about injury and violence prevention. And two senior professors took me aside and said, A, this is not really public health, and B, there’s no money here so, you can’t really do this. But fortunately for me, in 1985, Injury in America came out. And basically, this was an IOM report saying that injury and violence are a huge public health problems, and we really should be studying and looking at them. And CDC got some money, and so we were able to start doing research.
In my career, I’ve always tried, I think, to focus on research areas which I thought were under researched, because I thought I could make a big difference there. I hadn’t quite recognized that the reason they’re under researched was because there often is no money and no good data. But injuries is still under research. But within injuries, firearms is probably the most under researched for the size of the problem.

And so in 1990, I started writing a little about firearms, and I was just flabbergasted how little literature there was. And then I would hear gun advocates say things, and I think, gee, that that can’t be right. And what does the science say, and I’d look and there was no science at all. So I thought, this is something that I could really try to improve our knowledge about, what’s happening in the world. So I’d say the majority of my injury work now is about firearms.

NOAH LEAVITT: And I know we’re going to talk about the lack of data in a few minutes, but just to also kind of establish a background, I mean, I know you talk a lot about this idea this public health approach to preventing greater violence. So what is that public health approach? So first, some people want to know why this is a public health problem. And the clear answer is 100 people a day are dying, and 300 people are shot. And it’s not only the deaths. It’s the spinal cord injuries, to traumatic brain injuries. It’s the fact that communities are being destroyed because if there’s a lot of street gun violence, people are afraid to go out at night. Tourists don’t come in, industry leaves.

And then the evidence is now overwhelming that exposure to violence really leads increases the risk of lifetime medical problems, both mental health problems and physical problems. So that’s a lifetime problem.
The public health approach, the reason I think it’s important, is because public health has been so successful in so many areas in the public health approach. A one sentence description is, try to make the world so that it’s really hard to get sick and injured, and really easy to be healthy. And so what that means is for obesity you try to make it so that it’s really easy to eat healthy foods and difficult to eat junk foods. And it makes it really easy to get good exercise and really hard to be a couch potato. In the United States, we do just the opposite, and why are we surprised that we have an obesity problem.

So the public health approach in part is stepping back, getting everyone to realize this is a big problem, and getting everybody to work together on that problem to try to prevent it. It’s really about prevention. Medicine talks about prevention, but 95% of the money is after the fact when something goes wrong. Same way criminal justice. Talks about deterrence, but all the money is really after something is a problem.

In public health, all the focus is on prevention. What we’ve found is that typically, instead of waiting to the last clear chance to do something, it’s so much more cost effective to go upstream and create an environment where it’s hard to make mistakes and hard to behave appropriately. And then if some people do, still nothing terrible happens.

It’s about populations, rather than individuals. So if I go and talk to a psychiatrist, I might say, why do you think there are so many more suicides in Arizona than there are in Massachusetts. They’re sort of the same size population. And if they’re honest, they’ll say, gee, that’s interesting, we didn’t know that. And the answer is, why should they, that’s not their interest. Their interest is on an individual’s. Jane feels depressed that how to reduce that depression, but public health is focused on the whole populations and trying to move the whole populations.

And then if I try to get them push them a little and say, well, what do you really think. They’ll say things like maybe it’s the sun, maybe it’s the immigrants, maybe it’s they don’t have enough psychiatrist, or whatever. And of course, the real answer is it turns out to be virtually nothing to do with mental health. It’s everything to do with firearms. And just the story that Megan told is just illustrative of that.

And again, so what you’re trying to do is create a good system so that it makes it easy for people to behave well. So the example which we always talk about is the motor vehicle example, where 60 years ago, the focus was always on the driver. Because if the driver has never made any mistakes, if they never behaved inappropriately, there would basically be no traffic problem. But people are people, and they get depressed, and they get angry, and they break the law, and they get distracted, and they’re tired, and they make mistakes.

And what public health understood is that the most cost effective way of reducing injuries and violence use of automobiles is to make the cars much safer, the roads much safer, the emergency medical system much safer. And so 60 years later, nobody thinks drivers are much better than when I was a little kid. But fatalities per mile driven have fallen by about 85%, one of the major success stories in public health. And there’s so many success stories.

AUDREY PROVENZANO: So both of you have written and spoken about the dearth of data on firearm injuries but we alluded to a little bit. And David also alluded to this issue of insufficient funding for this kind of research. There’s a really involved kind of back story about why this is in the United States involving the Dickey amendment. I wonder, David, if you can briefly tell us a little bit about what that amendment is and how it’s affected your ability to perform research.

DAVID HEMENWAY: Yes, so let me first talk about the data. Because in this area, not only are not a lot of data are deliberately not collected, but then a lot of data which are collected are deliberately withheld from researchers. So it’s really hard. So for example, we don’t really know how many people are shot every year in the United States. We don’t know if that’s been going up or going down, because we don’t have a good data system.
I cannot tell you how many people were shot unintentionally in the United States, or in Nevada, or anyplace. Because we don’t have good data systems. I can’t tell you what percent of households have guns in most states in my town. I don’t know. 12 years ago, the Centers for Disease Control used to collect that information. They used to have a very tiny module on the big behavioral Risk Factor Surveillance System, and that got eliminated. So we can’t find that we don’t know how people are storing their guns.
And then the data which are collected, there are data about gun tracing. We can’t get that data. So I can’t really tell you very much about the types of stores where criminals in Massachusetts are getting their guns. Even though that data are available, they’re just not available to researchers, and we can’t get that. Same way I can’t tell you very much about who has concealed carry permits and really, how are they doing and where those problems or not problems.

In terms of the research dollars, the Dickey amendment, people think it’s prevents the CDC from funding research, and it doesn’t. The Dickey amendment is just a symbol. All the Dickey amendment says is that no money that CDC or any other federal agency gives can be used to promote gun control. But every researcher understands that no money that the government gives can be used to lobby. That’s always the case. But what this amendment does, it says that it’s just the signal that says for every researcher, and particularly for the CDC, you give money on gun research, we are going to haul you in front of Congress. And we are going to not only write you, but we are going to cut your budget.

And they have done this in the past. And so like a battered woman who doesn’t have to be beaten every time, CDC understands that they should stay out of this area until they do. I go to meetings about gun violence and people in CDC don’t ever want to say the word firearms or guns in a public forum. If I talk to one of my friends at CDC, if we end up talking ever about guns, they will say, wait a second, let me call you back from my cell phone. And they will go out in the parking lot and talk to me about guns from the parking lot.

MEGAN RANNEY: And then just to add on to that, not only that, but then also, there’s been a generation of researchers who were very specifically told that this was a topic to not look into. And I was told so. Part of what I do is influenced very much by David and his work. But early on in my career as a violence prevention researcher, I was very specifically told by multiple people to not talk about guns or firearms, because there was no funding, but also, because there was a fear that it would end one’s career.

And you see the ripple effect of those little private conversations across the country when you look at the number of publications and the number of people who publish more than once or twice on firearm injury. Really, the number is staggeringly low. I mean, there’s a group has somewhere between five and 10 researchers across the country, of whom David is one, who has persistently been working in this area despite the lack of federal funding. And a number publications around firearm injury prevention dropped precipitously after that to Dickey amendment, which, as David, says, didn’t actually ban research, but essentially stopped the field cold. Really had a chilling effect.

And as a result, the state of the science on firearm injury prevention is largely where it was in 1996. And so although the vast majority of the public health approach and firearm injury prevention truly has nothing to do with quote, unquote, “gun control,” it’s about this larger public health approaches that David described. It’s about making people’s ships with guns safer, just as we’ve made cars and people’s relationships with cars in Canada driving safer.

We have been unable to meet that progress for firearms. There’s been no motivation in funding to do the really rigorous research that’s needed. Again, with a couple of very small exceptions, of whom David is one.

NOAH LEAVITT: Either Megan or David, how do you kind of operate in this funding environment? How do you manage to get around it? I guess, is there even a small change of things in the wake of Parkland, for example?

DAVID HEMENWAY: Yeah. In the last year since Parkland, there’s been some change. We’ve seen two states, New Jersey and California, who are funding some research, which was really good. We’re seeing a couple of more foundations. Also not funded in this area very much. They also have been really afraid because why take the hassle that they’re going to go to if they fund in this area. So there has been a little more funding. But it’s still very, very small. It’s like we have two epsilons as opposed to one epsilon. So it’s doubled, maybe, but it’s still very, very small.

And it’s been hard. We live hand-to-mouth. Our little group of four researchers, we have no basically, support. We get money from some foundations, a couple of brave foundations give us money. We’ve gotten money from– we do a lot of research about suicide. We’ve got money from, interestingly, from the state of Utah, to look at suicide, which is great.
The National Institute of Justice has a little bit of money. We got money to look at police killings. But it’s really year to year. We’re just hanging on. So hey, if anyone wants to send money, this is the place.

AUDREY PROVENZANO: So Megan, you actually started an organization called AFFIRM, which stands for the American Foundation for Firearm Injury Reduction and Medicine. You can find their website at affirmresearch.org So how did that come about, and why did you end up starting your organization?

MEGAN RANNEY: That came about because of very much what we’ve just been discussing. Really, after Sandy Hook, a number of us in medicine started to gather together and say, you know, this is crazy. We’ve been told for two decades that we can’t talk about guns. But we see every day in our practice that direct and the ripple effects of gun violence. So we see people who’ve been injured. We see people suffering from those long term effects of those injuries. And then we see the effects on communities. And all the way– the fear of gun violence affects the greater public, and what we see in our offices, and ERs and operating rooms. And it’s just crazy that we can’t apply this public health approach that we’ve used for every other epidemic.
And as we started to have this discussion, many of us thought, well, the answer is to testify before our congressional representatives, and they’ll see the light, and they’ll understand that doing research is not the same thing as advocacy. That it really is about applying public health approach. And you know what, we’ll get that federal funding for this research. And then year after year pass, and we said, actually, the funding is not coming. And meanwhile, we have approximately 100 people dying a day in approximately 200 to 300 being injured every day across the United States. And yes, those numbers are going up year after year.

And so we can keep waiting for someone else to do something or we can do something ourselves. And that was the really driving force behind founding AFFIRM with this knowledge that we had that truly, the collective wealth of medicine and health care, saying it’s time for us to do something. Something nonpartisan and nonpolitical, but it’s something to help our patients and to help us as clinicians to stop this epidemic.

And again, recognizing that it was time to start creating alternative funding sources. Our purposes are really twofold. One is to join health care professionals together– nurses, doctors, social workers– to provide them with the best possible tools based off of the limited existing evidence so that we in the health care space can have an effect on this epidemic for our high risk patients who are at high risk of suicide, or homicide, or domestic violence. That we can help them to avoid an injury.

And then to help further research. You know, David says that the funding rate right now is so low that anything makes a difference. And we’re proud to be working in partnership with the American Medical Association, American College of Physicians, ACEP– American College of Surgeons– AAP, and many other groups to be really starting this funding, both within specialties and also a larger national scale. It’s not enough, but we’re excited to have the public and health professionals working together to help change this conversation to bring into play many of the things that David is talking about and has worked so hard on for so many years. To help spread that to folks that may not have heard his message and utter reasonableness of it.

Approximately half of our advisory board are gun owners. We don’t see this as an us versus them issue. Most gun owners are safe. But the question is, how do you help the folks that maybe temporarily are not safe for themselves or others. And how do you help ensure that the chance of injury is lower.

NOAH LEAVITT: David, you spoke a few minutes ago about kind of all these kind of things you don’t know. Ultimately, what resources do you need in order to do the research that you think needs to be done? I guess, are there any policy changes that you’d hope to see at the CDC or elsewhere at the government level?

DAVID HEMENWAY: Yeah, so there’s so many things that government can do to try to reduce this problem. People focus on government as a legislative branch that passes laws. And there’s no question we should have universal background checks in the United States, and virtually everybody agrees. Every other developed country has them, and doesn’t have our problems. And we should probably ban certain assault weapons and so forth.
But there’s so many other things government can do. So presumably, government collects data, and it doesn’t collect nearly enough data in this area compared to other areas. Government provides money for research and does its own research, and it doesn’t do nearly enough in this area. Government rights standards.

The reason we have fire safe cigarettes in the United States– one of the big reasons is the government wrote a standard for fire safe cigarettes. And then states adopted that standard. Without that standard, states could not write the laws. Government is an enormous buyer. What government buys really matters. The reason we have airbags in cars, one of the big reasons is that the government bought thousands of cars with airbags. They were the first cars with airbags on the road, and they showed that airbags really worked. Government could be the first buyer of smart guns, for example.
Government is a big informer. Government provides information to people. So for example, what I would like to see, I would like to see a Surgeon General’s report about guns and suicide. The evidence is overwhelming about the relationship between guns and suicide. I’d like to have GIO have a report about guns. 25 years ago today, that a report about unintentional firearm deaths, and they haven’t done much since. I’d like to hear hearings, see hearings about firearms, which we haven’t seen at the federal level in many, many years.

There are just so many things that the government could do. And those, I guess, are policy changes or programmatic changes. But there is so much more. I mean, I think laws should be passed, but there’s so many more things the government negative.

AUDREY PROVENZANO: So one area of tension and conversations we’ve been having about gun violence over the last couple of years is the contrast in reaction that we sometimes see in shootings that affect predominantly Caucasian communities. For example, Sandy Hook or Parkland, although– For example, Sandy Hook or Parkland versus the gun violence that affects minority communities that may be affected more heavily and are less covered by the media.

So David, I know you’ve done some research specifically on the inequity a firearm related assault in various communities. Can you talk a little bit about what the data shows about how different communities are affected?

DAVID HEMENWAY: Yeah. In the United States, there’s no question that minority communities, particularly in urban areas, are incredibly disproportionately affected by gun violence, particularly street gun violence. And we as a society have not done very much about that, which is just terrible. You should recognize, though, that even sort of whites in the United States still have something like, four times the rate of homicide compared to anybody in any other developed country.

So yes, this is disproportionately an African-American problem in terms of assaults and homicides, but it’s also very much a white problem. It’s also true that suicide is not an African-American or Hispanic problem. It is a white problem. And most deaths– not shootings, but most deaths– are suicides. So we have a very disproportionately– it’s incredible. If you look across the United States in terms of deaths, it doesn’t vary that much between urban and rural areas, because in rural areas, you have you have suicides. In urban areas, you have homicides.

Now one of the things about the mass shootings is, yes, they just the tip of the iceberg. They are not the major problem in terms of firearms in the United States. But in all countries, the mass shootings are the ones that get publicity because, it’s so unusual or used to be so unusual. And so many people dying all at once.

So that is a time when people can consider and talk about the issue. And so in other countries, when there’s mass shootings, when there’s a mass shooting in Australia and Tasmania, they talked about it and they changed their laws to try to reduce the problem, and seemingly have been quite successful. In Scotland, when there’s the Dunblane killings, that was a time they immediately started talking about this issue, and then they made changes.

And so what the mass shootings in the United States do is they give us an opportunity to focus our attention on this problem and do something. Until really, the Parkland shootings, we haven’t done very much about that. And at the same time, we’re focusing on now– we should be focusing on the bottom of the iceberg, which is 90% of the problem, which is the suicide problem, the gun accident problem, the problems of gun assaults and homicides. And then even the intimate partner violence problems of guns being used to intimidate.

MEGAN RANNEY: Yeah, I think it’s a really important point to bring up and I very much appreciate that David highlighted what I often say when I give talks around this, which is that really the deaths are by and large a white problem that are also uncovered by the media. And I make the analogy often that the firearm suicide death patterns are in some ways similar to opioid deaths– that there’s something that affects rural lower middle class white men across the country and is unaddressed there are a lot of social determinants of health that go into all forms of firearm injury and death whether we’re talking about injuries and deaths in cities or in rural areas.
And I think attention to paid to both. And what I sometimes hear is that some folks dismiss the gun violence that happens in cities in cities as being purely criminal justice issue, when it absolutely does not. It has such a deep relationship, just as the suicide deaths do in rural areas, to a lot of the economic and mental health and again, social issues that lead people both to access firearms, and to use them. And when we talk about these disparities and these inequities, I think once again, it highlights the importance of taking this public health approach.

A criminal justice or a punitive approach will not work to stop suicide, and it will not work to stop community violence. There is again a portion of this, which is going to be based on policy. But very few public health problems have been solved exclusively through policy. I mean, look at the battle that we’re fighting right now around vaccines– changing public consciousness, and attitudes, and behavior is equally critical for firearm injury of all types. It’s important to understand that communities that are affected, and the underlying reasons why these injuries are occurring.

NOAH LEAVITT: And Megan do jump of that, I imagine like an important factor in this is, as you spoke about a minute ago, kind of engaging firearm owners and gun rights advocates as key stakeholders. I mean, you mentioned that the board of AFFIRM has got owners on it. I know you’ve looked at this, you did a study looking at online comments from gun rights advocates, kind of analyzing their reaction to having a doctor ask them about gun violence.

So from your perspective, as a physician, why is partnering with gun owners and advocates so crucial, as you said, kind of this idea of changing the conversation, changing kind of the public dialogue around firearms?

MEGAN RANNEY: So I think it’s absolutely critical for a number of reasons. So the first thing is we wouldn’t talk about bicycle safety or motorcycle safety without talking to people who ride bikes or motorcycles, right? It is essential to understand the reasons why people own guns, and how most gun owners are safe.

I also strongly believe that demonizing approximately 30% to 40% of the United States is the wrong way to go about solving a public health problem. We need all hands on deck to find solutions to this. And when we make this an us versus them debate, we essentially shut down the possibility for forward motion. There’s no way that we are going to solve this problem through one side shouting down the other. And I say that to both sides of the conversation. This has to be something where we come together.
And when you look at the physician community, the physician community like that of the United States in general, surveys again, are not great, but somewhere between 30% and 40% of docs own a gun. Many of them on it because they like to hunt or they engage in shooting sports. And some live in rural areas and own them because the police are two or three hours away, and for them, it’s a form of protection. Maybe they have a farm or know that they’re not going to have easy access to public safety.

We need to engage those folks because they are in some ways, the strongest messengers around the importance of talking to high risk patients, and helping us to start to make a dent in this epidemic. And I really can highlight the work that I do with some of my colleagues. And you mentioned the people that I worked on that was with Emmy Betz, who’s at the University of Colorado, who’s been a great partner in this work.

NOAH LEAVITT: What are some of those conversations like with gun owners, in your work through AFFIRM or even as your work in a position? I mean, how do you engage them in a way that’s productive?

MEGAN RANNEY: Right. And so I think it’s first of all, getting rid of that kind of us versus them– that we all have the same end goal, which is keeping people safe, and healthy, and uninjured. And so then starting to talk about the ways in which that can happen. We’re actually going to be leading a workshop at the Society for Academic Emergency Medicine in May in Las Vegas, talking about exactly this. Of how do you have these conversations in a way that’s nonjudgmental.

We spend a lot of time in Med school learning about how to ask people about drinking, and sexual orientation, and drug use in ways that permit patients to be honest with us, and that create the chance of a teachable moment, and of safe behavior. We’ve never taught physicians how to do that around firearms. It is truly essential. We need to create trust with our patients, that we’re asking them about firearm access. Not to take away firearms, not to condemn or lecture them, but to keep them in their family safe.

And recognizing that for many firearm owners, in fact, probably most, they are owning and storing them in ways that are safe. And so then it’s making sure that they are aware of ways in which there may be moments where they or their family are not safe. And again, I come back to that story I told at the beginning, where had that dad understood that his son being in the throes of depression was perhaps a time to temporarily store his firearm out of the house, perhaps that boy would still be alive today. And those are the types of conversations that we have to have. And that we can’t have, again, without engaging all physicians and honestly, all Americans.

NOAH LEAVITT: That segues well, David, because I wanted to ask– I know you and your team, Cathy barber particularly, have worked with gun owners extensively in the area of suicide prevention, particularly in New Hampshire and Utah. Can you explain the work you’ve been doing, and what’s the reaction from gun owners? What’s that been like?

DAVID HEMENWAY: Yeah, so again– and really Cathy Barber really has taken the lead on this, and she’s been great in New Hampshire. She and others in the public health community have worked with gun shops. And what they’ve done is they’ve gotten gun shops to be really interested in suicide prevention, because occasionally, not the biggest part of the suicide problem, but occasionally, people who are depressed go to a gun shop, buy a gun, and kill themselves. And gun shops can play a role and would like to play a role in trying to reduce this problem.

Nobody wants someone to come into their shop and buy a gun, and two hours later, they’ll be dead. And so in New Hampshire, over a half of the gun shops now have materials, and some training about how to prevent someone who’s clearly suicidal. How to get them help rather than give them a gun. And there are 20 states where gun shops are involved in this suicide prevention approach.

In Utah, Cathy went out and talked to the gun trainers there. Utah is really the gun training capital of the world. And she talked to the gun trainers who do concealed carry. And she’s asked them, she said, you’re doing such a good job trying to reduce gun accidents, but did you realize that in Utah, for every accidental gun death, there are 70 gun suicides. And they didn’t know that. And they know about guns, but we know about populations and data. And she said, raise your hand if you know someone who unintentionally killed themselves with a gun, and a few hands go up. And said, raise your hand if you know somebody personally who killed themselves with a firearm, and every hand goes up. Because these are all middle aged white guys who love guns.

And she said, well, could we work together to try to reduce this problem. Could we create a module for example, for your gun training class, where you talked about suicide, because none of them we’re talking about suicide at all. They’re talking about gun accidents. And they said, sure, let’s work together. And they created this module together, and they love it. It’s such a good module. And then she said, how do we get other trainers, how can we convince them that this is important to be discussing And they said, we don’t have to convince everybody, but we know all the legislators in Utah, we’ll make it mandatory.

So now it’s mandatory that in gun training classes in Utah, for concealed carry, there’s a module on suicide. And what’s a module basically said is that as friends don’t let friends drive drunk, you, as a good friend, should know that if your friend is going through a bad patch, he’s just getting divorced, then he’s drinking, and he’s talking crazy, that he should know and you should know that’s a social norm is that you babysit his gun for a while until he gets a new girlfriend and things are fine. And then he gets the gun back.

Because so many suicides are pretty transitory. I’ve decided that no matter what happens for the next 100 years, I’m going to kill myself, if I ever get the chance. It’s no, you get over these things if you can just get through this period.

And so the key thing is just to re-emphasize all the things that Megan was saying, is that the public health approach is about getting everybody together to work on this. That’s how you really get success. And the message matters, and to get the right message, you have to talk to the people who understand how to get the message. We’ve talked to them, and said, oh, maybe we should say this. And they say, no, no, you can’t say this. You have to say it this way. And isn’t that exactly what I just said? And they said, no, no, no, it’s not, it’s different.

And so OK. And then it’s not only the message, but the messenger is the most important, because everyone lives in their own tribes. And if somebody from the outside says you should do something, they’re not going to believe it. But if somebody who they trust says, boy, this is really important, we should be doing this, then of course, can have a real effect.

AUDREY PROVENZANO: So would you guys to find yourselves as researchers and advocates or just researchers? How do you manage that perception of maybe being biased, and just given how complex this issue is in the United States? Megan, do you want to start?

MEGAN RANNEY: Sure, so this is a great question. Just this morning, I was talking to someone who came into the meeting assuming that when I talk about gun violence, that what I am trying to say is gun control. And so I spent the first half of the meeting talking about how that is not true. I think that societal perception again, right now is that you are on one side or the other. And I think a lot of time that David and I both spend is talking about how the public health approach is really neither. It’s about finding truly care about finding best possible solutions. Just like Ralph Nader was not for or against cars, he was for car safety, right? And got car manufacturers to put seatbelts in place, and really helped transform what was then an epidemic of car crash deaths.

Similarly, same thing here. And I think one of our biggest tasks in the short term is making it very clear that we are researchers. Am I an advocate? I’m an advocate for our public health. I am an advocate for research. I’m an advocate for using evidence to make decisions. Unfortunately, we don’t have a lot of evidence right now, so I’m an advocate for gathering evidence first. And when folks accuse me you of being biased, I welcome them to sit down and talk with me.

And it is tremendously rare that after our conversation, folks who associate with either side of the political spectrum come away still thinking that I’m biased. Most folks kind of understand by the end of the conversation where I’m coming from, and really, the fact that this is a different path forward than the one that we’ve been stuck in for an awfully long time here in the United States.

DAVID HEMENWAY: I would agree with that, I think I’m a researcher of virtually 100%, because I don’t think I’d be a very good advocate. I haven’t been trained in advocacy, I’ve been trained a lot in research. I really believe in what the science says or doesn’t say. And I agree with Megan, there’s so much stuff we need to know that we don’t know. But there are some things we really do know. And one of the things is that having a gun in the home really increases the risk for suicide. I think we are at a point where we have better evidence now about guns and suicide than the Surgeon General had in the 1950s when these talked about cancer and cigarettes.

As an economist, I believe in specialization and the division of labor, and my specialization is research. That’s what I was trained to do, and so that’s what I try to do. And it’s whatever the science says, and it shouldn’t be what your predilections say, because what the goal is to try to make the world safer.

And if the evidence was there, that stand your ground laws really helped, so be it. Then we ought to have stand your ground laws if the evidence was that having easy access to assault weapons made people safer then I’d be for physicians advocating for people to get assault weapons. But that’s not currently what the limited evidence seems to indicate. The evidence seems quite the opposite. And it’s not like even close. Well, we’re not really sure. Well, the current evidence is very, very strongly that the more guns, the more gun problems and the more death.

NOAH LEAVITT: So we’re going to end with a little bit of a conversation about this kind of internet event that I think is actually what sparked this podcast idea Audrey reached out to me. This is towards the end of 2018, and the American College of Physicians had put out this guidance around gun violence and counseling patients. And the NRA tweeted that, quote, “self-important physicians should stay in their lane.” Just after that, there was another shooting in California. And this hashtag erupted on Twitter, #thisisourlane. And it was a lot of doctor sharing stories like Megan had about caring for patients who have been victims of gun violence.
So I know, Megan, you and some of your colleagues actually published a prospective piece about this whole phenomenon in the New England Journal of Medicine. So what did you find? And what do you think that kind of whole internet, Twitter viral conversation told us about the role of social media related to gun violence and public health in general?

MEGAN RANNEY: So I think that we are at a different moment in the United States and in the world, where folks traditionally were consumers of media, and now, they’re also creators of media. The response that we saw on Twitter to #thisisourlane really reflected the years of work that we’ve been doing to talk about gun violence as a public health problem. And the frustration of physicians that they haven’t been able to do that.

But that moment also reflected the fact that Twitter is there, and really is a form of– I’m going to use the word new power, which has been used by Henry Timms from the 92nd Street Y and Jeffrey Hyman from Australia. The idea that communities can come together and create a voice and a movement just like was done for Time’s Up or other kind of movements across the world. This is one of those.

This is a health professional saying again, regardless of our political affiliations, that this is an issue that we need to talk about. And the role of us on social media is spreading. This voice it’s not going to go away. I think that social media allows us to coalesce and amplify each of those individual voices in a really new and different way. And I’m honored to have been able to be a part of leading that.

We had a firm created a letter that was published in USA Today with over 40,000 physician signatures over a course of four or five days. That would not have been possible five years ago. And it’s really thanks to social media and that an online presence and community that exists.

The one thing that I was going to say– I actually did want to follow up on David’s comment, which is for better or for worse, we do have to recognize that there are 330 million guns in circulation in the United States. And we need to work with that. We can’t pretend that that’s going to go away. And so we need to create new solutions that keep people safe with those guns being present.

And sometimes, being present in hands that may not be safe. Again, most people that own guns are perfectly safe, but some aren’t. And I think that this social media conversation has engendered some really important conversations among people who again, you might think of as being on opposite sides of this political spectrum, who have come together to talk about ways that we can enhance the safety of our communities, of our patients, of our families, of our children. While also recognizing the unique political realities of the United States.

NOAH LEAVITT: And David, I’d be interested to you have your perspective on this, as we were talking before the interview began that you had a chance to meet for example, with the Parkland students, who have used social media so effectively. So what’s your view on the role of social media in moving this conversation forward?

DAVID HEMENWAY: Not that big of a big social media person, I think it’s incredible. I mean, I think this is so important. I do think that there’s no question that the Parkland kids have made a big difference and without social media, they would not have been able to do that. I love them saying that their parents are always saying, why are you on social media, and this is why. Because now, we know how to use this, which we weren’t going to be able to we learn in school from older folks.

One of the things I would emphasize from Megan’s discussions about now physicians organizing and making their presence felt is really so important. On the other hand, I would also say as an economist, I really do believing you can follow the money. And while these physicians en masse are doing I think, really important and useful things pushing the agenda, trying to create that this is a public health problem, and we, as a society can do something about it, as Mike Siegel at Boston University has been pointing out, the physicians organizations, where are their money going. And it’s typically going to support Congress people who are really anti the public health approach, and anti trying to increase the amount of research in this area.

And so you have to I think not only applaud physicians organizing together, but you have to also look at the positions, associations and who these physicians are giving money to that they are working at incredible cross purposes. And one I think, is trying to reduce the problem. The other unfortunately, is not.

And I wrote this book a number of years ago about success stories in injury and violence prevention. And there’s 64 documented successes I could’ve written about, another 64. But in all of them, it took a long time. People had to push and push, but there are always people in institutions against it. And it’s just incredible. How can you be against this. How could you be against preventing people, little kids from getting a hockey puck in their eye, but people are.

And even though it shouldn’t be us versus them, there is a struggle. And you want to get the overwhelming majority of people pushing. But to recognize that there will always be a force against progressive useful change to save lives.

MEGAN RANNEY: David, I hear you, and gosh, I’ve taught your book. I love it. I have it sitting on myself, and I’m looking across my office right at it as I do this podcast. But I am also an eternal optimist, and I think we’ve seen time and time again, across history, as illustrated in your book, that when you get the majority of the public and again, in the private sector– when you get the majority of the data on board, and when you mobilize public opinion, you can create change. And I am confident that we are at one of those moments where we are coming together increasingly as a nation in a way that I have not seen.

Again, David has been in this field longer than I, but it’s been over a decade that I’ve been working in violence prevention. And I have never had the kind of optimism and hope that I have right now I mean we are at the cusp of changing the way that we approach this problem, and really creating a way forward that is workable, and that is going to be effective.
And I think that podcast like this are part of that. I think kind of getting folks to sit down and talk to each other, again, across this partisan divide, is part of how we create that forward motion. And changing the way that physicians talk to patients is part of that conversation and changing the way that the public talks to other people in the public is also part of that conversation. And I think that the history of public health shows that those conversations all make a difference. And so I thank you guys for having this podcast, and allowing us to have this conversation, and to help move the field forward and help move public health forward.

NOAH LEAVITT: Great.

AUDREY PROVENZANO: Great.

NOAH LEAVITT: And we’ll Just do a little outro, I think.

AUDREY PROVENZANO: Great.

SPEAKER 1: OK.

AUDREY PROVENZANO: You’ve been listening to a very special episode of Review Systems, the podcast from the HMS Center for Primary Care. And This Week in Health, a podcast from the Harvard TH Chan School of Public Health. Once again, I’m Audrey Provenzano.

NOAH LEAVITT: And I’m Noah Leavitt. If you enjoy the show, please rate, review, and subscribe to both of our shows wherever you listen. It helps others find the show. And share us on social media with your friends and colleagues.

AUDREY PROVENZANO: We’d love to hear feedback and suggestions so you can tweet us @ROSpodcast or @HarvardChanSPH.
Thanks for listening.

NOAH LEAVITT: Did you want to throw in the HMS part?

AUDREY PROVENZANO: Yes, I will. I panicked for a minute. I was like, oh no, I don’t have the Harvard one. And then I skipped that one. OK, so I’ll just do the last bit again.

NOAH LEAVITT: OK, cool.

AUDREY PROVENZANO: We’d love to hear feedback and suggestions, so you can tweet us @ROSpodcast or @HMSprimarycare. Or @HarvardChanSPH. Thanks for listening.

NOAH LEAVITT: Awesome.