Taking Back the ‘F Word’: Depoliticizing Firearms and Focusing on Safety to Protect Children and Teens

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00:00 Rebecca Cunningham: We have to, what I call, take back the F word. So we have to start talking about firearms again, not as a political thing. We talk about pools, we talk about cars. We have to start talking about guns and firearms again actively in conversation and not think of it as a third rail or too political. It's a safety issue. We have way too many people dying and we have to figure out how we can be safer with the guns that we have in this country.

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00:26 Speaker 2: Thousands of kids die each year because of guns, both from intentional and unintentional shootings. And tragically, the loss of these young lives is largely preventable. It's true that while school shootings get a lot of media attention, they make up a very small fraction of the children and teens who are killed by guns each year in the US. Today we'll talk to three researchers from the University of Michigan School of Public Health and Michigan Medicine to learn more about the public health work being done to increase firearm safety and reduce the number of gun-related injuries and deaths for American children and teens.

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01:04 S2: Hello and welcome to Population Healthy, a podcast from the University of Michigan School of Public Health. Join us as we dig into important public health topics; stuff that affects the health of all of us at a population level. From the microscopic to the macro-economic, the social to the environmental. From neighborhoods to cities, states to countries and around the world.

01:37 S2: First, let's examine the numbers to better understand the impact firearms have on children in the US. To learn more, we talked to Rebecca Cunningham, a physician and professor of emergency medicine at Michigan Medicine, and a professor of health behavior and health education at the University of Michigan, School of Public Health. Dr. Cunningham also co-leads the FACTS consortium, an interdisciplinary group of researchers, practitioners, and firearm owners from across the US who are dedicated to reducing child firearm injuries and deaths by engaging researchers and catalyzing the science of child firearm injury prevention.

02:14 RC: Firearm injury and death is the second leading cause of death among adolescents and children, and the leading cause of death among adolescents and teenagers in the country, killing almost 3500 youth every year between the ages of 1 and 19, that's about 60% homicide, and just under 40% suicide by gun, with about 2%-3% being related to accidental or unintentional injuries where a young child or a teenager finds a gun and accidentally shoots a friend or playmate. And then about 1% is more of this mass shooting and school shooting that we've been seeing a lot about in the news, that has been really high profile and been really important, especially in raising awareness for the country, but actually represents a pretty small portion of the number of kids that die actually by gun everyday in the country.

03:01 RC: So every week in the country about three children die by unintentional or accidental injury, and about eight die everyday by gun violence in the United States. We do know that in more urban areas it's more homicide and in more rural areas, it's more suicide by gun, typically teenagers. But that the rates are pretty much the same. So that's the rate pretty much in Ann Arbor as it is in rural Michigan, as it is in urban Michigan. The rates of firearm death have been pretty much stable in the country among kids for over 20 years. They were a little bit higher in the '90s, but since then, it's been very stable at about that four per 100,000. We see a disturbing trend since 2016, where we have gun homicide increasing by 32% among adolescents and children, gun suicide up 26%, where non-gun suicide is only up 15%. These are concerning increases and changes, and it's a trend that we saw again in the 2017 data. This is not a problem that's going away and we think it's a problem that's getting worse.

04:02 RC: The suicide by gun only recently has raised the awareness I think of a lot of the country, and that's partly 'cause suicide is so stigmatized and families don't tend to talk about those deaths in the same way. It's a little bit more hush hush in communities. But, the result of that has been that it hasn't really risen up to the fact that most of those suicides in more rural communities are by gun. It's young people being really depressed, having a particularly bad day or a bad week and have access to firearms in their homes, and are being impulsive with it. And we find the literature's pretty good to show that if we can eliminate that moment of impulsivity and they don't have access to a firearm during that time, they don't substitute, they don't go on and kill themself in some other way. So really, if we can eliminate that impulsive moment by better safe storage, by decreasing their access to firearms at a moment when they're really high risk, that we can save likely a lot of lives.

04:56 RC: This is a problem in all of our communities, so, since there's been almost no research for the past 20 years on this topic, really very silenced just in terms of research fields, our group has been working to jump-start and catalyze that research going forward.

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05:17 S2: The data tells us that this is a national problem because it affects virtually all of our communities. And tragically, due to the violence perpetrated by school shooters, some communities have been linked in our memories to gun violence. Let's learn more about school shootings and school safety from Justin Heinze, an Assistant Professor of Health Behavior and Health Education at the University of Michigan School of Public Health.

05:42 Justin Heinze: My interest is in the developmental transition from adolescence to emerging adulthood. So that's roughly ages 12 to ages maybe 25 or even 30. And I'm interested in all the different risks that tend to be associated with that period, so that includes things like substance use, mental health problems and also violence. And so, how can we look and identify risk and protective factors that will facilitate that transition to emerging adulthood, and hopefully help folks lead productive lives in the future.

06:12 JH: I get asked whether or not school shootings are becoming more common fairly frequently. I think that is a product to a certain extent of availability bias or media salience. I wanna stress that in general schools are very safe places to be, I just wanna put that out there right now. Extreme violence is very rare within schools fortunately, but it does happen and there is evidence to suggest that it can be prevented. Now having said that, there's data from the CDC that suggests firearm violence does seem to be increasing among adolescents in the past, maybe 15 or 20 years, and this is despite no obvious changes in monitoring or reporting. I don't think there's definitive evidence at this point that rampage shootings or multiple victim shootings are increasing, although I think the severity of shootings may be increasing. We've had some of the most high mortality rates within school shootings in the past maybe six years. We've also had some extremely violent events in Las Vegas and then also the Orlando nightclub shooting, so the number of casualties in some of these events does seem to be increasing and that could be the case, but the actual number of events doesn't seem to necessarily be increasing.

07:20 JH: I think one of the most vexing problems is whether we can predict violent events within schools which is also related to the causes of school shootings, and I really wish I could sit here and give you a profile of what to look for, when determining whether a violent event is going to happen. Unfortunately, it just doesn't exist and every situation is different. There is limited published work out there on the topic that can give us some hints as to where to look so shooters are overwhelmingly male, they're typically middle adolescence so roughly age 15, predominantly white, from smaller towns or cities so less than maybe 50,000 people. There's often some history of trouble with authority so maybe they've gotten in trouble at school or have gotten in trouble within their neighborhoods, history of trouble with their family which can include abuse, history of ostracism and victimization from bullying and at school and struggle with mental health issues and sometimes it's identified prior to a shooting but sometimes afterwards. I think even then how many students in the United States likely fit that profile? 

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08:23 JH: There's only a small number of students that move forward with plans to commit violence and an even smaller number of students that actually try to engage in these attacks, but I think one of the most difficult parts about this is we can look at just those highest risk groups but there are also examples of shooters who virtually check none of those boxes. Now, even though these common features might not help us identify specific school shooters, they're currently our best guidance for places for intervention. Much of my work is focused upstream, so we're looking at improving school climate for example in an effort to reduce some of these violent antecedents, particularly the bullying and victimization piece. These are universal strategies and that they're designed to affect all students not to specifically isolate those students that are most at risk. Ostracism does seem to be a pretty common precursor among active shooters as does previous victimization, so they've been victimized at school. And so I think building inclusivity into the school environment is really important.

09:25 JH: There's also pretty good evidence to suggest that the majority of active shooters share their plans with friends or other confidants, even through social media and in some cases through their schoolwork. And so you have teachers that in hindsight see some of these cry-for-helps or see some of this anger within their assignments, but it's difficult when you interact with students maybe once a day or for a limited amount of time to try to piece all of that information together and so oftentimes that goes overlooked. But then training educators and staff and parents to recognize signs that someone might be a danger to themselves or others is another universal approach that we use to help avoid some of these events. And in fact, we see things like tip lines in our home state of Michigan, Colorado, Florida being utilized by students and in more than a couple of cases they've identified students in crisis or in the planning stages for violence. But upstream interventions are not the only approaches that are used in schools, many of the existing policies are so ingrained within our school cultures now that you might not even recognize them.

10:28 JH: So since about the early '90s, districts have engaged in target hardening measures; these would be things like locking doors, using metal detectors, cameras to deter violence. It's actually pretty rare in 2019 to approach a school during class hours and not need to be buzzed or rung in. You'll find school resource officers or police officers in the hallways to try to encourage safety and potentially deal with disciplinary issues. Target hardening on the surface is a good thing, so locking doors and using security cameras but there were earlier surveys, I'm thinking kind of the middle 1990s that suggested students responded to these interventions in a negative way. So rather than making students feel safer, it actually made them feel less safe because there are all these reminders that school is not a safe place to be. And so there's conflicting attitudes and opinions about having a police officer in your school or having to go through metal detectors and they really were associated with less positive student outcomes.

11:33 JH: Now, what I think is really interesting in some of the more recent work that my colleagues and I have engaged in and we're seeing from colleagues in other places in the country suggests that those attitudes might be changing. We're finding that locked doors and cameras now are viewed as increasing safety and even school resource officers when paired with student engagement, so we're trying to facilitate the connections between students and those resource officers, are viewed more positively as well. So, safety does seem to be on the mind of students and these interventions that were introduced 25-30 years ago might be taking on a new meaning for students in this era.

12:08 JH: And then we have more recent developments like active shooter drills and even things like arming teachers with firearms. The former is implemented pretty widely and the latter is gaining traction in certain circles. Neither has any strong evidence to suggest their efficacy or their potential harm, and when I say that I'm thinking about specifically the active shooter drills. So my children participate in active shooter drills and knowing what to do in a crisis situation is important but these trainings probably come with a cost. I found my 6-year-old daughter in her bedroom playing active shooter drill with her little stuffed animals. It's hard to know how these drills affect our young learners' psyches, and whether these things create, again, a sense of safety or if they create a sense of concern or detract away from academics, and there's just not evidence out there to suggest one way or another, whether we should be doing these things.

13:02 JH: In a similar vein, I cannot say with any hard evidence whether arming teachers would reduce the injury burden related to firearms in schools. Trying to find that evidence of whether either of these initiatives could ultimately reduce the burden of injury is difficult because school violence is so rare. Can we really consider the lack of a shooting for example, as evidence that our intervention is effective? I will say that there's pretty strong data that suggests where there is more firearm availability, there's more injury burden. That's a pretty hard thing to dispute at this point, and I do have concerns about introducing more firearms to areas with vulnerable populations, so bringing guns into schools. But it's also possible to find incidents where a security guard or an armed citizen intervene in a crisis situation and save lives. But now we really are moving into the realm of anecdotal evidence for or against either of these policies and the bottom line is, I think we need more research.

14:00 JH: I think one of the consequences of the, again, media salience around these four or five very highly publicized shooting events, and this includes not just in the United States but elsewhere, is a renewed interest in policy or legislative solutions to rethink firearm laws and without commenting on specific legislation, I think having bills under consideration is going to help get both sides out to talk about potential solutions. I do think that that is a changing environment from where we were 15-20 years ago that might ultimately move that needle in one way or another. And for me and from the perspective of a researcher, I hope that we find solutions that are evidence-based, that are supported through rigorous research and that's the niche that we can try to address through our work at the School of Public Health.

14:58 S2: Further research can lead to new policies and new legislation, it can also lead to new strategies to keep the public safer through education and awareness, work that may just be the new frontier in gun safety. To learn more, we talk to Marc Zimmerman, who co-leads the FACTS Consortium along with Rebecca Cunningham.

15:17 Marc Zimmerman: I'm Marc Zimmerman, I'm a professor here in the Department of Health Behavior and Health Education at the School of Public Health at the University of Michigan. I've always been curious about kids who are exposed to risk factors that increase the probability that they might do something bad like drugs or delinquency or violent behavior, why some of those who have risk factors don't end up doing those bad behaviors, or doing what's called in literature problem behaviors. I've focused my entire career on trying to understand what's right in kids' lives rather than what's wrong in kids' lives. Firearm injury is estimated to cost $230 billion a year in the United States. That's a lot of money. If we could do something that reduces it by 10%, that's $23 billion with a B. That's a lot of money. So we try to think about what can be done and the work that we're doing around gun safety, we really wanna underline that's what it's about, it's about gun safety. It's not about taking away people's guns, it's not about gun rights, it's not about the Second Amendment or any of those political issues. It's about reducing injury and death from firearms.

16:34 MZ: Just like 30 years ago, we started with cars. How did we make cars safer? People thought about putting on seat belts, but today, there isn't a kid in America who doesn't get in that car and just automatically buckles up and we all do. I'm old enough to remember when people would figure out ways to buckle it and then sit in front of it or they didn't like the shoulder strap and now we do it. And it's the same thing with air bags, it's saving lives, no one's taken away the right to drive a car. In fact, the speed limits are even gone up but the cars have gotten safer, our roads are safer, there's more lighting, the cars themselves are safer, the number of safety features on a car... You almost can't buy a car now without some safety features, and it becomes a selling point now. Cars are bragging about the safety features they have. Why can't we do that with firearms in America today? The amount of money we put into let's say, diseases that are more rare, is something like 30-40 times what we do for the number of people who die by firearms.

17:41 MZ: As a public health professor and public researcher, we look at an epidemic and we think about, "Okay, what are the different ways to address this epidemic?" We talk about having to tailor them. It wouldn't be one size fits all. We haven't really even tested whether or not different training programs are more or less effective, what are the effective strategies. We haven't tested whether or not a physician asking families about gun storage is an effective strategy. Why not? We've done so little research on firearm safety that we don't really know what works, and we need to do that work.

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18:23 S2: It is challenging to discuss gun safety research without at least the backdrop of politics influencing the conversation. Let's return now to Rebecca Cunningham to see how researchers and physicians navigate this reality in their pursuit to save the lives of more young people.

18:39 RC: We're very apolitical, so we believe that there's a lot of work that we can do that will save kids' lives that will not necessarily change the number of guns or change any Second Amendment laws in this country. So we have more cars on the road now than we had in 1970, we've halved the death rate, we have more pools across the country than we had in 1970, and yet we have less kids drowning. So we think with good injury science we can make a big difference while fully understanding and respecting the country's Second Amendment rights. We're working with gun owners also and with a full cadre of stakeholders and gun rights and hunters and gun enthusiasts to have them help work with the academics so that we can understand best what it is that can be done. And everyone wants their kids to be safer in their homes and not have their depressed teen find their gun and shoot themself or have their toddler find their gun and shoot their brother.

19:31 RC: Car crash has been for the last 40 years plus the leading cause of death among children and teens, but we've seen a radical decline in that. So in the late 1990s when I first started practicing medicine that was at about 10 per 100,000 children were dying in a car every year, now it's about five; so we've halved the rate of death by kids in cars. And we were successful doing this by approaching every aspect of car crash, so we addressed individual behavior, we addressed drunk driving, we addressed who was too at risk to drive and we made really good licensing and policy choices. We introduced graduated driver licensing now where teens have to go through a whole series of stages before they're deemed safe and not impulsive and have enough experience to be safe on the road. We improved car safety seats, we developed crumple zones in cars. We mandated seatbelts across the country.

20:24 RC: We realized that a completely unacceptable amount of people were dying on the roads in the US and with that, we decided as a society that we wanted to see a change in that, and I think we can see a parallel, perhaps in that in the firearm area right now. We invested millions and millions and millions of dollars into research to figure out what were the best crumple zones, how should airbags work best, what should seatbelts be, what's the safest road? That's the kind of research that can be done where you approach injury science across all these different spectrums and then you come up with solutions and we can do the same thing for firearm research. We haven't really tried yet very much in the country, we have to decide that we wanna try and now we're working on... With our group that we indeed do wanna try, we need to rebuild the field to do that.

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21:11 RC: As a practicing physician both here and Ann Arbor as well as in Flint, Michigan I saw far too many young people shot and coming in with just devastating injuries. So here in Ann Arbor, we mostly would see patients who have been a victim to self-inflicted wounds or suicide attempts. I will say, actually, the vast majority of those patients don't make it to the ER, so physicians may see less of that in rural or even suburban areas because unfortunately, those children die on the field and don't make it to the ER at all.

21:41 RC: In Flint, we spent a lot of time and it was one of the reasons that I initially got into violence prevention is, we're standing in the trauma bay and the velocity and the magnitude of firearm injury to human tissue is such that by the time they're in the trauma bay, there's really only so much you can do. After spending a lot of time telling families really very bad news about injuries that never should have happened for children walking home from school or kids escalating an argument and having access to a gun was one of the reasons that I really focused on what we could be doing before kids got to the trauma bay.

22:15 RC: And then also the kids that did come in through the ER are adolescents maybe who are at risk for firearm violence or maybe had a lesser violent injury, but wasn't involved in firearms yet. What we can be doing with them from the hospital or from the ER to make sure that they don't come back with a firearm-related injury. And with that, we put into place a number of programs, one of them at Hurley Hospital in Flint called Safer Teens, where we started engaging kids who had had any fighting in the past year who came in through the ER for any reason, in a 30-minute counseling session that we found when rolled out with our team decreased their peer fighting and also their dating violence over the subsequent year, and so decreased their risk for that escalating to other violence. And those are the kinds of evidence-based programs that we need to be paying more attention to, to figure out how to engage youth that are at risk. And I think physicians need to know and families need to know, on the physician side, that if you take care of a kid in ER, especially an adolescent, the greatest risk they have for death is not what you're seeing them for that day, but it's by gun, and so what are we doing to address their potential for gun violence? 

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23:29 S2: Thank you for listening to this episode of Population Healthy from the University of Michigan School of Public Health. We're glad you decided to join us, and hope you learned something that will help you improve your own health or make the world a healthier place. If you enjoyed the show, please subscribe or follow this podcast on iTunes, Apple Podcast, Google Play, Stitcher, Spotify or wherever you listen to podcasts. Be sure to follow us @UMichSPH on Twitter, Instagram and Facebook so you can share your perspectives on the issues we discuss, learn more from Michigan Public Health experts and share episodes of the podcast with your friends on social media. You can also check out the show notes on our website, population-healthy.com for more resources on the topics discussed in this episode. We hope you join us for next week's episode where we'll dig further into public health topics that affect all of us at a population level.