Articles, Blog

Firearm violence and its prevention

– Good morning, everybody. Welcome to MSU and Sparrow
Pediatric Grand Rounds. I would also like to extend a warm welcome to our colleagues in
Flint and Grand Rapids. Before we get started, I have
a couple of announcements. Today, at sub-specialty rounds, Drs. Kidwell and Burke will
do a PQ case presentation. Please join us next week
when Drs. Ann Liebert and Steve Mattin will present Pediatric Morbidity and Mortality. I’m now going to invite Dr. English up to introduce this morning’s speaker. – Thank you, good morning everyone. Welcome to Grand Rounds. My pleasure today to introduce my friend and colleague, Dr. Fred Rivara as our visiting Grand Rounds speaker. Dr. Rivara earned his undergraduate degree with highest honors at the
College of the Holy Cross, his medical degree at the
University of Pennsylvania, and then he trained in pediatrics at both the Children’s Hospital in Boston and the Seattle Children’s Hospital, where he was a Robert Wood Johnson Scholar and earned his master’s in Public Health. He sojourned for three years in the great state of Tennessee where I was later, but we missed each other by a few years. He was in Memphis at Le
Bonheur Children’s Hospital doing general pediatrics,
but then he was recruited back to Seattle where he has
spent the rest of his career. Fred has been really
a pioneer in the field of injury prevention and
injury prevention research. He’s got over 600 peer
reviewed publications, textbook chapters, and
books about this topic. Starting back early in his career, he’s had this focus for that time. He was the founding
director of the Harborview Injury Prevention Research Center, I think the leading such
center in the world in Seattle, and he’s been involved with all sorts of injury prevention
research over the years. He’s previously the editor
of General Pediatrics and now the editor of JAMA Open Network. As I mentioned, he was a founding director of the injury prevention
center in Seattle, and he’s won many awards, both in the injury prevention
field and in pediatrics. The Charles Shepard Awards from the CDC, the award from the American
Public Health Association, from the AAP, and from
University of Washington. And one of the awards
that I think he’s probably particularly happy about winning was the Stanley Stamm
Housestaff Role Model Award from the Pediatric Residency at the University of Washington. He was also the keynote speaker at my daughter’s White
Coat Ceremony in Memphis when she enrolled in medical school and so that was a very important
time for me personally. He was elected to the
Institute of Medicine in 2005, and today he’s gonna talk about a topic that unfortunately is sadly
relevant once again today in the United States and around the world and that’s firearm violence
and its prevention. Fred, thanks for coming. (audience applauding) – Thank you for admitting me. Thank you very much, Keith, for the chance to speak with you all here. This was the cover of
Time Magazine this week, many of you have probably seen it and it’s actually a pretty cool cover. If you go online, it’s
an interactive cover and you can see a lot of
different people here, here’s Kathy Gifford, here’s some people that are in a gun shooting club, here’s a trauma surgeon over here. And it really, I think,
depicts the broad spectrum of opinions about firearms. The shooting last night in California could have happened here in East Lansing. Bunch of college kids going
out and having a good time. Unfortunately, those episodes are really increasingly common incidents. What I want to try to do today
is to give you information. I think this is a topic that we all should be well-informed about. There are things that we can do, as physicians, as pediatricians, and as members of our community and I hope that you take away some ideas of how you can make a difference in your community. I think this encapsulates pretty well the magnitude of the
problem, that there are more people that died in the last 45 years on our nation’s homes and streets from firearms than died in
all of our wars combined, which is pretty remarkable. We talk a lot about terrorism, and you can see that the number of people who died from firearms in our country is far, far more than the number who died each year from terrorist attacks. Now, let’s pause for a
second before we talk more about firearm
injuries, and let’s talk about the success story
for motor vehicle crashes. This blue line shows the
number of miles driven in the United States
over the last century, and this is the death rate
per billion miles traveled. And you can see that
there’s been a remarkable 95% reduction in the number of fatalities per mile driven over the last 100 years. It’s a combination of a lot of factors, trauma care is certainly much better now than it was at the
turn of the century, but most part it’s really been motor vehicles, which have become safer. And the roads, which have become safer. And this is some of the background that was responsible for this remarkable decrease in motor vehicle deaths. Ralph Nader, before he screwed up the 2000 election, actually did some good. He wrote a book published in 1965 called Unsafe at Any Speed,
it’s about the Chevy Corvair, which was an incredibly dangerous car. And that really created some ground swell to try to make motor vehicles safer. President Johnson, the next year created the National Highway Traffic
Safety Administration, which is the organization
of the government that oversees motor vehicle safety, creates regulations about
motor vehicle safety, tracks motor vehicle crashes,
both fatal and non-fatal. Then you can see a series of regulations that they’ve published, front seat belts, collapsible steering wheels, 1979 they started doing
motor vehicle crash tests. 1978 was the first car seat
law in the United States, it was passed at the
advocacy of Bob Sanders, who was a pediatrician in
Murfreesboro, Tennessee. 1984, the first seat belt law in the United States, New York. Driver airbags weren’t
required until 1989, although the technology
existed from the ’60s. Here in Michigan, the
motor vehicle manufacturers strongly resisted putting in airbags, but then they realized that
they didn’t cost a whole lot and really could provide
a lot of protection. ’93, side impact regulation,
they had the crush standards. Event data recorders, just
like you probably don’t realize but your car has a black
box just like airplanes do. So if there’s a crash, that
information on the black box can be downloaded and provide information about how fast you were going, whether or not you were
wearing your seatbelt, whether or not you applied
the brakes before the crash. Now all states except New Hampshire, which has the motto live free
or die now have seatbelt laws. In contrast, there are many, many gaps in our policy around firearms. How’d that happen? Unlike motor vehicles, there
really is no licensing, for the most part, of gun owners, there’s no registration of firearms. In fact, because of an act in the 1980s, there’s specifically a federal law which prevented any kind
of database on guns. So we don’t really know
how many firearms there are in the United States,
there’s no national database. Unlike motor vehicles, where
there is a national database on motor vehicle fatalities,
there’s no national database of firearm injuries or fatalities. There’s very few
regulations on gun designs, few regulations on
required safety features. Spent a little time on the CDC website and put together this slide, you can see that around 2007, 2008, the lines cross. Now there are more firearm
fatalities in the state of Michigan than there are
motor vehicle fatalities, which is really pretty remarkable. You can see here there’s
actually been an uptick in both. I think this uptick in
motor vehicle fatalities, we all know is due to cellphones and distracted driving. For firearm fatalities, it’s
unclear why there has been this increase in fatalities
over the last few years, but certainly the important point to take away is that there are now more firearm fatalities than
motor vehicle fatalities. Now, when you talk about firearms, it’s really important to
disaggregate the problem. Now, with the news this morning, we think first about these, the homicides. Clearly an important problem. But you can see that what
really makes up the majority of firearm deaths are actually suicides. 59% nationally of firearm
deaths are suicides. In the state of Washington, it’s like 75% firearm deaths are suicides. As pediatricians, we think
a lot about this red slice, the unintentional injuries,
the eight year old boy who’s going over to a friend’s house, they find dad’s gun, play around with it, and it goes off and one of
them gets shot and killed. It’s actually quite a small number. We also hear a lot about this number here, the black slice, which are
the legal interventions, police killing citizens. This number from the CDC
is clearly a underestimate. The Washington Post and The Guardian both have maintained databases looking at these shootings,
and it’s estimated that it’s probably twice this number, probably more like about 1,000 a year. And then there are a few where the medical examiner
declares them undetermined. So let’s go through these individually and try to disaggregate the problem, better understand what’s going on. So thinking first about homicides, some important questions. Are we a more violent country than other countries around the world? And how does the homicide
rate vary with gun ownership? And, specifically, does
having access to a gun increase the risk of violent death? So, are we a more violent country than other countries of the world? You can see from this slide is not really. I don’t know what’s going on in Scotland but you can see that we’re
kind of in the middle there, we’re not a particularly violent country. What, Scott from APC? – [Scott] No. – Pry, that’s probably part of it. But, y’know, we’re not a
particularly violent country, and then I found this study here where it compared youth in
Osaka, Japan to Seattle, and you can see that, if anything, kids in Seattle are less
aggressive than kids in Japan. The point of it is is that we’re not necessarily a more violent country, there’s not a higher rate of assaults in the United States
compared to other countries. But where we do differ is
in the number of homicides, and specifically the red bar, the number of homicides
related to firearms. You can see that, compared to the other high income countries, we
are far, far higher for both. When you look at Japan here, and Japan essentially has
zero firearm homicides. But the United States, you can see our rate is really quite high. Michigan, it’s significantly
higher because of Detroit. And related to that is why we
have more firearm homicides? Well, we have more firearms. Again, these are estimates
’cause we don’t really know how many guns are in the United States. But you can see from any measure is that the United States
has far, far more firearms per citizen than the other
countries of the world. And here, you can see
in countries like Yemen, which is in the midst of a war, we have more than double
the number of firearms per citizen than they have in Yemen. And the other countries
which are fairly low. Yeah?
– [Man] We have more firearms than citizens? – Yes. It’s estimated probably
about the same number, it’s estimated there’s
like 300 million firearms in the United States,
and they’re aggregated into probably 20 to 30% of our homes. And so people that own guns usually own far more than one gun. So, putting those two
pieces of data together, firearm ownership and firearm deaths, you can see there’s a
pretty strong correlation, or appointee between the
two, and the United States leads the list here,
here’s Japan way down here. So there really is a strong association between firearm ownership
and risk of death. And then there’s a study from
the Global Burden Disease folks, the Institute for
Health Metrics and Evaluation, the University of Washington,
the published all these various papers on global
burden of illness. This was published just past
couple months ago in JAMA. But it looked at the global
burden of firearm injuries around the world, 1990 to 2016. You can see that in 2016, about 250,000 people died from firearms. Six countries, of which
the United States is one, accounted for 50% of the firearm deaths. In two countries, Brazil and the United States accounted for 1/3. And then this statistic,
just like the first one I showed you, that there are
more firearm deaths each year around the world than die in conflicts, except for Rwanda and the Rwanda genocide. I mean, it’s really pretty remarkable, here the number of people who died from firearms compared to conflicts. And the death rates range, remarkably, from 0.1 in Singapore
and countries like Japan, to 39 in El Salvador per 100,000 people. And again, pointing out the
importance of firearm suicide, which with the newspapers
today and the CNN today, they’ll never mention firearm suicides, you really focus on the homicides. But firearm suicides are
an important problem, and for us as physicians, that’s one of the things
we all need to think about. More than 1/3 of all firearm suicides in the world happen in the United States. Now, firearm deaths and gun ownership, as we all know, vary
widely across the country. And I’ve just put the arrow
here next to Michigan, but you can see that, y’know
when I was in Tennessee, we used to say thank God for Mississippi because they usually had
the worst health statistics. You can see states like
Massachusetts and Hawaii have both low rates of firearm ownership, and consequently low
rates of firearm deaths, but you can see there is a
pretty good straight line between the rates of firearm ownership and the rates of firearm
deaths in each state. And I think this also points out, which we’ll talk a little bit more later, about the importance of what
happens at the state level, the importance of what happens
in terms of state laws. Now why do Americans own guns? The most common reason,
by far, is 60% own them for protection and personal safety. And about 1/3 own them for hunting. And this is really a large change in the United States
over the last 50 years. 50 years ago, the NRA was
mostly made up of hunters and people owned guns for hunting. And then, in the ’60s,
really another group kind of took over the NRA
and they promoted the idea that you needed firearms
for self-protection. And as a result, we have self-protection as the most common reason that you should let people own guns. So why do people own guns then? They think that having a gun in the home is gonna protect their family, is going to decrease the risk
of death in their family. So what’s the data on that? So, this is a study done by my
colleague, Arthur Kellermann, who was also, like Keith and
I, in Seattle and Memphis, now he’s the Dean of the
Uniform Services Medical School. Arthur, when he was a clinical fellow, teamed up with Don Reay,
the medical examiner and they looked at firearm
ownership and gun deaths in the home in King County,
Washington where Seattle is. And they found out that there
were nine self-protection homicides, individuals killing an intruder that made their way into a home, but there were 12
unintentional injury deaths, kids playing with guns, 41
homicides, and 333 suicides. So that, for every
self-protection homicide, there were 43 people in the home who died, ratio of one to 43. To me, that’s pretty stark evidence that having a gun in the home
does not make your home safe. Ratio one to 43. 43 felt more likely somebody in your home was going to die, 37 more likely
it was going to be suicide than you were going to shoot an intruder. Remember what happened
on December 14th, 2012? Newtown, Newtown massacre. So, it was an assault
rifle that this individual used to kill 26 people,
20 of ’em were kids. The trauma centers were not
very busy, all the kids died. Next day, I saw this article
in the New York Times about an individual in China
who stabbed 23 children and a woman at a primary school,
none of the children died. Obvious reasons, firearms
are much more lethal than are knives in assaults. The dues received by
the NRA in the next year increased fairly dramatically, and the reason is pretty clear is that NRA members were
afraid that President Obama was going to pass laws
to take away their guns, so there’s a surge in membership in the NRA to protect gun rights. States did pass new gun
laws within the next year, Connecticut was really probably
the most stringent gun law, but in 24 of those states, the laws were less restrictive,
not more restrictive. And I think that, before we
leave the topic of homicides, it’s really important to
mention the racial disparities. Let’s look, for example, at young males, 10 to 24 years of age, you can
see the rates in black males are dramatically higher than they are in white males or Hispanic
males, dramatically higher. And it’s clearly a complex issue, it has to do with poverty, it has to do with the communities in
which individuals live, the absence of jobs and turning
to other sources of income, home substance abuse, it’s a complex issue but I think it really is important to realize that there is
this enormous disparity when you talk about firearm homicides. So, when you look at all this data and you put it together,
what can we conclude? Well, I think that we can conclude that there is a pretty close relationship between having guns in the community and then what people who are
going to commit crime use. Robbers and assailants are
more likely to use guns, and therefore there’s gonna
be more crime related to guns. And lethality of guns is much
more than are other weapons, and as a result we have more murders. And as I said, young
African American males are disproportionately affected. What we don’t know, more for
us as pediatricians, is this. How children who have been in schools with shootings will fare in the long term, kids that, when you see them walking out of their schools with
police with their hands above their heads, how
does that affect them? How about the kids who just
hear about school shootings in a state across the
country, how does that affect how they feel about going
to school the next day? How would children react to having their school teacher be armed? And what’s interesting there
is, in the CNN this morning, there’s a talking head police officer who said that police, when
they fire their weapon, hit their target only
one out of five times. That’s trained police officers, so you can imagine what would be the case for a school teacher who is less well-trained than a police officer. How are children affected
by active shooter drills? I remember growing up in elementary school and we had area drills for nuclear bombs. I mean they were stupid,
y’know hide under your desk, because the nuclear bomb
was gonna drop on you. But we have these active
shooter drills now for kids in elementary school,
how does that affect kids? We don’t know much about
this, but this is clearly an area, I don’t know if
there’s any child psychologists in the audience, but this is an area that we really need to think hard about, because our kids are
being affected by this. Alright, let’s change now
and talk about suicides. What proportion of suicides
are committed with guns? How does the risk of suicide vary when guns are available or less available? And the big question that people say, well if somebody is really
intent on killing themselves, just taking away a gun
won’t make a difference. This is looking at females, 2000 and 2016, the green bar being 2016. And you can see that the
rate of suicide among women has increased over this last 16 years. They increased pretty much
across the board in all ages, including among young adolescents as well as in young adults. Nationally, you can see
that the number of suicides from firearms is pretty much equal to the number of suicides
per non-firearms. And actually, the group at greatest risk of firearm suicides are
actually white males, older males, 65 and older. Wife dies, they’re left alone, they oftentimes own guns and they commit suicide very frequently. So, does having a gun in the home, how does that affect the risk of suicide? This is the result of a case control study that Arthur Kellermann
and I did back in the ’90s where we had interviewers go to homes where there had been a
firearm homicide or suicide, and this is the suicide data, and then they walked the neighborhood and found a control
household on the next block and asked the same sorts of questions. We had fantastic research
assistants who got 98% of people to talk to them, they
were just remarkable. But you can see here that
having a gun in the home increased the risk of suicide
tenfold for young adults, sevenfold for 25 to 40 year olds. And I think this is really
what’s really remarkable is that where there had not been a history of mental illness, the risk of suicide was increased 33 fold if
you had a gun in the home compared to not having a gun in the home. And it comes down to, I think
a lot of it is this slide. So this was an individual
who conducted a study where he interviewed people
who survived a suicide attempt and asked them how long was
it between when you decided to take your life and you
actually tried to do it. 24% of the attempts were
done within five minutes and 70% of the attempts
were done within one hour. So it’s an impulsive act. Yeah? – [Woman] Can I ask a question? Do you know like what triggered the episodes and what triggered the hour? – No, I don’t. The means used to try to commit
suicide, well it matters. So the data here on firearms are from King County, Washington, where you have probably one of the best emergency medical services
systems in the world, we have one of the leading
trauma systems in the world, and yet 93% of those who
try to commit suicide with a gun are going to die. We actually don’t see many of those at Harborview Trauma Center
because they die in the field. Compared to 2% of those who use pills. So the means used to
commit suicide matter, and that’s really what people talk a lot about now is means matter. And this may be one of the most important slides in the presentation today. So this is a survival curve,
you’re all familiar with these looking at, for example, cancer. And what’s the probability that, either at the index attempt or later, an individual is going
to die from suicide. And this is followed out to
20 years we’ve kept this. And you can see there
are females and males. Among males, 95% of those
who try to commit suicide and survive are gonna
be alive 20 years later. For females, it’s close to 100%. So, the really issue here
is what are the means that people use to try to commit suicide. If that means is not a firearm,
it’s a less lethal means, there’s great hope that this individual will get help and be alive full term. And I think that that falls on us as physicians to make
sure that that individual who is distraught doesn’t
have access to firearms. Now let’s talk a little bit
about some natural experiments which show that
restricting access to guns, restricting access to lethal means, may in fact result in reduction
of overall suicide rates. In the UK, in the ’50s and ’60s, the current method of
suicide was putting your head in the oven and turning on the gas. And the reason it was so successful is that you can see that
carbon monoxide poisoning, carbon monoxide percentage of content of domestic gas was very high. And the reason was it
was derived from coal, it was called coal gas, had
high carbon monoxide content. And then what’s happened in this late ’60s is that North Sea gas
and oil is discovered and it completely
substituted the coal gas. And so the North Sea gas did not have a high carbon monoxide content. And this is what happened
to suicide rates, male on the left, female on the right. You can see that the non-carbon monoxide suicide rate in males will stay the same, the carbon monoxide suicide rate decreased dramatically and as a result, there was an overall
reduction in the suicide rate. In females, there was
probably some subsitution with other lethal means, but nevertheless there was still a overall
reduction in suicide rates. So removing a lethal means, in this case, was successful in reducing
the overall rate of suicides. This is another example people bring up, well what about Israel
where everyone belongs to the Israel Defense
Force when they’re young and then they carry the guns
home with them on the weekends? Well, Israel sorta looked at that problem and said that that is a concern, and so in 2006, it required the soldiers to leave their weapons
on-base during the weekends. The overall suicide
rates decreased by 40%, the weekend suicide rates
dropped dramatically and the weekday suicide
rates didn’t increase. So again, restricting access
to guns, in this case, had a substantial effect
upon suicide rates in Israel. Somewhere here there’s an
analogy to college campuses. College campuses are
actually pretty safe places. And one of the reasons,
I don’t know what the law here is in Michigan, but in most states you’re not allowed to carry
guns on college campuses. One of the first mass
shootings in the United States was about 50 some odd years ago at the University of Texas in Austin, where some man went up
into the clock tower with a sharpshooter rifle and shot and killed about 35 people. Guns weren’t allowed on college campuses in Texas at that time, but
then 50 years to the day, 50 years to the day the governor of Texas signed into law allowing guns to be carried on college campuses. Another sort of national experiment, Switzerland had a pretty
large standing army and they decided back here in 2003 they didn’t need such a big army so they reduced the number
of soldiers that they had. And here’s what happened to their firearm suicide homicide rate,
and you can see here for suicide rates, here from firearms, they decreased dramatically. The non-firearm suicide
rate stays the same. So again, restricting
access to lethal means in this case had a fairly large effect. What’s the effect of gun laws on suicides? Various gun laws. Y’know, there is an
effect, it’s not dramatic, probably the best data
comes from South Dakota where they repealed the waiting period from purchasing a handgun, and you can see that after the repeal, the rate of suicides went up about 8.9%. So state laws do matter. So, putting together the data on suicides, there really is a pretty
strong association between access to guns, risk
of suicide, means matter. It means restriction
works because it’s not a complete substitution
with another lethal means. Currently, the other part of the problem is the unintentional firearm injuries. As pediatricians, wanna give you a little bit of data on kids. Experiment which some folks
did number of years ago where they took a group of
eight to 12 year old boys and put ’em in groups of two or three, and they had them go into
psych college laboratory, y’know room with the one way mirror where they interviewed the
investigators to watch the kids. In that room, they had a bunch of toys but there’s also a gun
hidden in a box of toys. So you can see that 3/4 of
the kids found the handgun, it’s like the story you can’t hide Christmas presents from your kids. 3/4 of those actually handled the gun, half of those pulled the trigger. So, kids are going to find a gun, they’re going to play with it, and they’re going to pull the trigger. And then there was another
study that we published last year in General Pediatrics from Brad Bushman, who’s at Ohio State. He did the same sort of a study, but first what he did is
he randomized the groups into watching a 20 minute video clip, it was from you guys probably remember a movie called The Rocket Man,
The Rocketeer I think it was. And half the clips,
there was gun violence, and the other half of the clips,
there was no gun violence. 20 minutes, and then he put the kids in the same sort of room, but
there was also a hidden gun. He found out that 83% of
the kids found the gun, and the kids who watched
the gun violence clip pulled the trigger 22 times more than the kids who didn’t
watch the gun part. And they played with the
gun three fold longer. 20 minute video that these kids watched. Alright, so given this problem,
what can we do about it? I think there are a lot of
things we can do about it. Let me talk about a few of these, safe storage of guns,
background check policies, they do work, preventing
individuals who are high risk of harming themselves or
others from owning guns, banning assault weapons and
large capacity magazines, increasing the arrest rates
for criminal shootings, promote the development
of personalized guns, and can we change the norms
around gun possession? This is work from Northeastern University, Matt Miller and his group there, they did a national survey
looking at gun ownership. And part of the survey here was looking at what proportion about guns in the home. So you can see that 1/3 of
households in the United States have guns in the homes
where there are kids. About the same number that have guns in the homes that don’t
have kids in the homes. Now, among homes with guns and kids, you can see only 21% were
stored locked and unloaded, 50% were stored either locked and loaded or unlocked and unloaded, and 29% were stored locked and unloaded. So, many of these homes are, kids are getting access to guns. Safe storage devices, there’s
lots of different kinds out there, there are cable locks, which are very cheap and don’t
really work all that well. There are trigger locks. Probably the best, though, is
gun lock box and gun safes. Does safe storage of firearms, does it decrease the
risk of injuries to kids? And the answer is yes. There’s a study done by
colleague David Grossman, case control study read through families where there had been a shooting, either accidental or suicide of a kid, and then households where there wasn’t. He showed that having
the gun safely stored decreased the risk of firearm suicide or accidental shooting by 78 to 80%. So safe storage really does matter. David did another study where he went into remote Alaskan
villages where guns are used all the time for subsistence hunting and protection against animals, and in half the villages
he actually gave away big gun safes that could store rifles and the other half none, and he went back to those villages a year later and he found out that the
intervention group here, the number of guns that were unlocked was much lower than the control group, ammunition unlocked, both unlocked. So even in this kind of a setting where guns are an important part of life, safe storage can make a difference. This is a study using the
National Comorbidity Survey, the study that tells us how many people have depression, psychosis, et cetera. Turns out, in this
substudy of adolescence, they also ask a question
about where there was a gun in the home, did you have access to it? And you can see that 30% of adolescents reported having a gun in the home, and almost half of those
reported easy access to it. And basically, what it found out is that, in kids with a history of mental illness, suicidally or substance abuse, they had as much access to guns as kids that didn’t have those problems. So this is really a failure on our part, a failure on us as physicians for not identifying
those kids and not making sure that they have,
don’t have access to guns. In Seattle, we had a school shooting up in Marysville, Washington
where a young man, high school kid, junior high school, got access to a firearm,
his dad’s firearm. He texted his friends the day before and said have lunch with me the next day. So, there were five of
them that were sitting around a table, he came
in and shot them all before killing himself,
four of the five died. One of the girls who died was the niece of one of our Senior Vice
Presidents at Children’s Hospital. And that led us to then develop a safe storage program where
it’s funded by the hospital, we have these events at
sporting goods stores like Cabela’s and we give away free lock boxes or free trigger locks. And we advertise these
things on social media and we find out people line up 6 a.m. to get their free
gun lock boxes at 10 a.m. And then what we did was we
called them up two weeks later to see did they actually use it, and you can see here the bottom line is that there was an
increase in the number of firearms that were
stored locked, unloaded, and ammunition stored separately. So something you could
do in your organization and you can do in your institutions, try to increase the likelihood
of guns being safely stored. We have heard about Florida
a number of years ago, the state passed a law
that basically forbid pediatricians and other physicians from asking patients about guns. The Florida Chapter of the
American Academy of Pediatrics sued and went back and
forth for a number of years, and finally last year,
the full appeals court, Eleventh Circuit threw it out and said that it violated the
First Amendment rights of the pediatricians,
that they have the right, we have the right to ask
families about gun ownership. Different organizations
look at the legislative strength of laws in each state. And simply show this that
there is a correlation between the strength of those laws and the risk of firearm deaths. As you would expect, Louisiana, Arkansas, Mississippi have very lax laws. Massachusetts has some
of the strictest laws. And there’s a pretty good relationship between the strictness of laws and the likelihood of firearm ownership. Here’s Michigan, kind
of in the middle there. This passed two days ago in Washington. Our state legislature,
like most legislatures, won’t do anything and
there’s a citizen’s group put together called the Coalition for Gun Owner’s Responsibility. This is the third
initiative that was passed, the first one was on
universal background checks, and the second was on
extremist protective orders where somebody can go to a judge and have a firearm removed from a home. And this one just passed,
as I said, two days ago. One of the impetuses for this was that there was another shooting in Washington, place called Mukilteo 30
miles north of Seattle where a 19 year old went to a
party of his high school mates and shot and killed like four people. Turns out that he went to
the gun store that week and was going to buy a handgun, but because he was 19,
he couldn’t buy a handgun because you have to be
21 to buy a handgun. But he could buy an AR-15
assault rifle at age 18. So, this law changed the age
at which you can buy that, also instituted a waiting period. And then it strengthened the
issue of that safe storage. And this passed 60 to 40
in the state of Washington. Gonna skip that. Most people in the United States
support stricter gun laws. You can just look at this yourself, very few support arming teachers, having metal detectors at school. But they support a
mandatory waiting period, they support assault weapons bans, they support universal background checks. We know that nothing’s gonna
happen at the federal level, at least for the period of time. But there should be
action at the state level, and that’s where I urge
you to get involved. Intimate partner violence, I know anyone over here has been very
involved with this. April Zeoli, who’s here in
the Department of Criminology, she’s been very involved with this. And these laws can make a difference in intimate partner-related homicides. Any state domestic
violence restraining order makes a difference, gun
confiscation is a reduction, violent misdemeanor
laws make a difference. So state laws for things
like domestic violence, protection laws, extremist protection laws do make a difference. Smart guns, can we make guns safer? Maybe. The technology right
now is pretty limited. There’s only one gun on the
market, it retails for $1,800. There are people on both sides of it which are not very enthusiastic about it, and it doesn’t really account for the fact that there are probably 300 million guns in the United States and
won’t really affect that. So I don’t hold up a lot of hope of that solving the problem. Want to end with the assault on science. Arthur Kellermann and
I wrote this editorial in JAMA the week after the
Newtown shootings back in 2012. You all know that Charlton Heston, who was the, Moses there
who was the President of the National Rifle Association. All of the work that Arthur and I did was published in New
England Journal of Medicine. After the suicide article, well this was after the
article that came out comparing Seattle to
Vancouver, British Columbia. The NRA called on their members to write the Assistant
Secretary for Health that using tax dollars to
conduct anti-gun pseudo-science. After the suicide paper came out, the NRA asked the PHS to conduct a Scientific Integrity
Review of Arthur and myself. Fortunately, the PHS declined. And that’s a big deal, as we all know. After the publication
of the homicide article in the New England
Journal, 10 Senators wrote the inspector to pass it
onto the certain general and the Assistant Secretary of Health expressing concerns about saying that the National Center for
Injury Prevention and Control of the CDC, their research was duplicative of that of the national
justice, which wasn’t true. And that they were
promoting a political agenda by funding firearm research,
and they threatened to eliminate funding
for the National Center for Injury Prevention
and Control entirely. They didn’t succeed in doing that, but they did pass something
called the Dickey Amendment, which you probably heard about in 1996. The Dickey Amendment, by Jay Dickey, didn’t actually forbid
the CDC from conducting firearm research, it just simply said that no federal money can be
used to lobby for gun control, which of course they
couldn’t keep the quota. But essentially what this
did, this was a threat to the CDC that they better not fund any more firearm research, this is 1996. The CDC has not funded
any more firearm research. Spoken to a couple of the directors of the National Center for
Injury Prevention there, they can’t even use the
word gun in the building. They can’t use that. So the CDC, our nation’s prevention agency for the last 22 years, has not
funded any firearm research. It turns out there’s even a clause in the like 900 page Accountable Care Act, protection of 2nd Amendment rights which forbids collection
of data about gun ownership as part of your right of protection. It was put in by Harry Reid in Nevada. As a researcher, I’m prevented from getting access to a lot of data. In 1986, this Firearm
Owners Protection Act, federal act banned any
federal registry of guns. The Dickey Amendment banned research. The Tiahrt Amendment banned the Bureau of Alcohol, Tobacco, and Firearms from releasing firearm
trace data to researchers. So there’s real restrictions
on what we can and can’t do. I wanna end with what can you do as a member of your community. I think first we need
to be asking patients and families about guns in the home. In polls about patients, the vast majority of patients think it’s fine
for you to ask about guns. The First Amendment gives you
the right to ask about guns. We need to promote safe
storage of firearms. We need to promote safe
storage of firearms. We need to counsel patients and families about domestic violence protection orders and extreme risk protection orders. With domestic violence protection orders, they’re probably the single best thing we had to prevent repeated
episodes of domestic violence. And, as part of that, I know in the state of Washington there’s a check box there about whether or not
the assailant has a gun. How many of us with domestic
violence are actually urging the woman to take
out a protection order? It’s not. In other words, this was passed
in the state of Washington, I think six states now have that. It’s basically where a
family can go to a judge and say my husband is mentally ill, he has a bunch of firearms, I think that it’s unsafe for him to have access to those guns while he’s mentally ill. The judge can then ask that those firearms be removed from the home, order them to be removed from the home. In the state of Washington,
the vast majority of these have been done at the
instigation of police, not the medical community, and I think that’s a failure on the part
of the medical community. Try not to base action on anecdote. The latest anecdote was
last night in California. You get all riled up about
these mass shootings. Obviously they’re tragedies. But don’t forget that 38,000 people a year die from firearms in the United States, and 60% of those were suicides. We need to be supporting
funding for firearm research, it is pretty darn hard
to find firearm research. NIH for a while had an RFA out there which funded firearm
research, that’s expired. And CDC, unless the House, when it turns, provides funding for
firearm research to the CDC, they still won’t fund that. There are a few foundations which support firearm research, but not a lot. The city of Seattle was
the first jurisdiction in the United States, actually, to support firearm research
with the Red Cross. I think we should be
informed, we need to know the data and be informed, and then finally I think we, as pediatricians, need to do what we’ve always done which
has been advocates for kids. And I’ll leave you with
this, thank you very much. (audience applauding)

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