Beyond the White Coat

At the Crossroads: Public Health and Gun Violence

Episode Summary

The most recent tragic murders throughout the United States at the hands of gun violence are heartbreaking. These assaults once again vividly illustrate the all-too-familiar consequences of how gun violence continues to plague our nation, and they are also a reminder of how homicides, suicides, and unintentional injuries with firearms take an overwhelming daily toll on our communities. These preventable tragedies will continue to be inevitable as long as lawmakers continue to choose inaction over reasonable protections to keep our children and our communities safe.

Episode Notes

In the latest episode of “Beyond the White Coat,” AAMC President and CEO David J. Skorton, MD, and Roger A. Mitchell Jr., MD, chair of the Department of Pathology at Howard University College of Medicine, have a compelling and informative discussion on gun violence as a public health crisis and how the academic medicine community can come together to address prevention.

Episode Transcription

David J. Skorton, MD:

Welcome to “Beyond the White Coat.” I'm David Skorton, president and CEO of the Association of American Medical Colleges. And today in “Beyond the White Coat,” we're incredibly honored to have as our guest, Roger A. Mitchell, MD, of the Howard University School of Medicine. Among Dr. Mitchell's many, many contributions to the local and national communities, he is a preacher. He is a former interim deputy mayor for public safety and justice in the District of Columbia. He's a distinguished physician. He's the current chair of pathology at Howard University and recently served as the national co-chair for the National Medical Association working group on gun violence and police use of force. Dr. Mitchell, thank you very much for joining us on “Beyond the White Coat.” It's a great honor to see you and a great honor to have you share your wisdom with us and our audience. Welcome.

 

Roger A. Mitchell Jr., MD:

Well, it's a pleasure, David. You know we've known each other for years, so it's a great opportunity to have a conversation with you and with your listeners.

 

David J. Skorton, MD:

Thanks very much. Dr. Mitchell, here we are again. Here we are again in our country, mourning the loss of innocence in many locations, for many reasons, at the hands of violence — and particularly gun violence. And please, Dr. Mitchell, help us understand this heart-wrenching issue as a public health crisis. Your thoughts on that please.

 

Roger A. Mitchell Jr., MD:

Well, I like how you ended that question — “as a public health crisis.” This country understands well what a public health crisis is. Being within a pandemic of COVID, watching this infectious disease move from person to person, and those that are more susceptible to the disease succumbing to the disease to the point of death. And now, we're talking about what post-COVID looks like, right? What the long-term effects of the COVID infection is — not just physically, but also emotional, socially, in people's finances, their life in general, what it means to have yourself suffer from COVID or have a family member who has suffered from COVID. And so, a lot of loss in that public health crisis.

 

And so, understanding violence, or gun violence, through the lens of a public health crisis is now not a far leap for many of us to think about it. And we think about it now differently — or should be — because when you have a public health crisis, that means that you can bring to bear the resources across multiple disciplines to try to solve the issue. So, we know that gun violence finds itself appearing differently in different communities, under different circumstances, but it is not a issue that can just be solved with the criminal justice system. It's an issue that must be solved by bringing together all of our systems — education, economics, housing, health care, environmental justice, and the criminal legal system — if we are going to affect change.

So, we are at a — and have been — at a crossroads surrounding gun violence in this country. And these last two events that have happened, literally only 10 days apart — one in Buffalo, an active shooter that killed 10, and one in Texas that killed 21 — we are in a crossroads that we really have to have a discussion about how medicine and the public health community shows up to solve this problem.

 

David J. Skorton, MD:

Dr. Mitchell, it's so interesting that you bring up COVID and the idea that we understand a public health crisis differently now than any of us understood it two years ago, even physicians. We've gone through a big, big learning curve — we're still learning, aren't we? Even about COVID. So, in that regard, one of the things that COVID did was uncover disparities in society. You mentioned different communities that of course were there for generations, hundreds of years, but are brought out in stark relief. Is that community-specific risk also true for gun violence?

 

Roger A. Mitchell Jr., MD:

Absolutely. Absolutely. We know that the social determinants of health — as we battle cancer; as we battle hypertensive and atherosclerotic cardiovascular disease, or heart disease; as we battle diabetes across this nation — we know where we live, love, work, play, and have our being affects our ultimate outcomes to this disease process. And that is no different in gun violence. Where we live, work, and play is going to affect how we want to resolve conflict and whether or not we believe that violence is the ultimate way that we need to resolve conflict.

In communities like mine, African American communities or Black communities, the social determinants — our access to education, economics, housing, health care and nondisparate criminal legal practices — has found its space and place in institutional and structural racism. In other communities that are not African American and Black, that might not be the case. It may be directly related to poverty. But at its core, gun violence, as it relates to smoldering homicidal gun violence that's happening day to day, those find themselves placed within social determinants.

Now, there's this big conversation, David, about mental health and the importance of diagnosing and treating mental health. And there is no doubt that we need to have that as part of our public health and medical response and prevention to gun violence, particularly surrounding suicides. Do you know that now 54% of all gun violence is suicide? So, the majority of gun violence that we see in our country — fatal gun violence — is suicide. And so, the disparity that was uncovered by COVID is the same disparity or very similar disparity that we see showing itself in gun violence.

 

David J. Skorton, MD:

I'm so glad, Dr. Mitchell, that you brought up the different ways in which gun violence can take lives, can steal lives. Suicide being a bit over half, as you mentioned. And you're one of the people who taught me that some years ago when I was first getting to know you. And then there are the interactions of person-on-person, domestic violence, other such things, such horrors. And then of course, the mass shootings. And getting back to your analogy with COVID: One of the things that we've learned, right from the beginning in COVID, even before we had vaccines and Paxlovid or any other things that we could do, was preventive practices. Things that we could do by staying a bit away from each other, by wearing masks, and so on and so forth. Are there important roles for prevention in this public health crisis? And if so, what are they, Dr. Mitchell?

 

Roger A. Mitchell Jr., MD:

Oh, there's no doubt, David, that there's prevention.How does your community view violence? Is violence acceptable in your community?

Now, we all live in a society and in a country where violence is acceptable. Let us not be confused that Americans love their violent movies. They love their violent heroes. They love their violent video games. They love their violent books. There's nothing about our culture in society that doesn't promote violence as a way to resolve conflict. And quite frankly, then we must guard individually in our families, much against what our culture and our society is saying about how we resolve conflict.

And so, prevention finds its way, also, David, in our access to jobs. We know that joblessness is a major motivator to what we're seeing in urban smoldering violence, which is the area of expertise that I find myself in on a regular basis. And so, making sure that individuals have access to good-paying jobs, not in a way that just meets their single-day needs, but a career trajectory that allows for them to build themselves into the middle class. Economic sustainability is going to be what truly, truly dismantles violence, particularly in the urban community.

 

David J. Skorton, MD:

One of the many terrible things that the violent culture in which we live and these shootings — one of the terrible things is they've stolen hope from many of our hearts. I know that I begin to lose hope sometimes for a way forward. But you're giving us a little bit of hope today by talking about specific things that can be done. And one of the things that's a more positive part of the American way, if you will, is the idea that we can each do our part to solve some big problem. So, help me understand, Dr. Mitchell, what can individuals do? What can communities do? What can society at large do? Give us that hope that we're needing so much as we see these things go on. There've been a couple of more mass shootings, even since the last one, and hope has been stolen from us. Tell us what each of us can do to regain that hope and to make a difference.

 

Roger A. Mitchell Jr., MD:

Well, David, I love the title of your podcast, “Beyond the White Coat.” I love that because it doesn't discount the importance of the white coat, but it suggests that there's work that physicians must do beyond treating the individual patient. And the AAMC has great power and influence over how physicians are educated and the culture of what medicine looks like. And I'll tell you that — speaking directly to the audience that may listen to this podcast and those of us that are listening to it now — that we must develop comprehensive curriculum within medical colleges that teach the next generation of physicians how to be violence preventionists, how to talk about violence.

Remember the Dickey Amendment — this Dickey Amendment is a provision that was inserted as a rider in the 1996 omnibus spending bill during the Clinton era that functionally prevented any funds used by the CDC to advocate or promote gun control. And that translated into no gun violence research being supported by the Centers for Disease Control. And so, there's opportunity now to do things different because we're no longer under that Dickey Amendment.It becomes real easy, David, because it's all — what it all comes out to is relationships. Who are you connected with? And if you're connected with people that you love, and when they're showing potential for violence, then you can talk to them about — and get them the help they need. So, most of these active shooters, they telegraph the fact that they're going to engage in violent behavior. And so, if you're around accountability and people and community — understand how important it is to engage and what those triggers are, both figuratively and literally — then they can impact that potential for this mass violence that we're seeing.

 

And that's happening with individuals that decide they want to take their own life. There are triggers and conversation that people need to be in in community to be able to prevent that. So, we have to be vigilant as community members.

 

David J. Skorton, MD:

And when you say engage, what I hear beyond that word is, listen. Listen. That's listen to the voices. Listen to the voices of the people in the community who are living this experience on all sides of it.

And that leads me to ask you, what can our hospitals do? Hospitals are major footprints in the community and definitely ought to be listening, learning from trusted voices within communities, because not only don't we have all the answers, but I believe, and I know you do, Dr. Mitchell, believe that the people most affected by any problem are also in a position to help figure out and communicate things that need to be taken into account to solve those same problems. So, tell me a little bit about your thinking on hospital-based and other community violence interventions. You've mentioned a little bit about this, but drill down a little bit deeper if you would, please.

 

Roger A. Mitchell Jr., MD:

One thing that I'll point out is that violence prevention takes time, David. Violence prevention is not something that is a pill that can be taken and it's gone. It takes work in community over years. The greatest violence prevention programs that we see, there was several that happened in Boston. Deborah Prothrow-Stith is one of the aunties of violence prevention. She's now dean at Charles Drew, and her program took a decade to take hold, and functionally decreased where — homicides in the double digits for those under 18 to the single digits, and still being sustained.

And so, when I say that, well, what did she do? It was an all-community approach. And that's what we're talking about public health. It was the faith-based community, it was the hospitals, it was government, it was the for-profits and the nonprofits, big business, hospital-based intervention programs where an individual comes in with an injury. That individual that comes in with an injury is vulnerable for healing throughout their whole family. They're vulnerable for healing of that gunshot wound or that stab wound, yes, but they're also vulnerable to talk about how they may want to change their lives and in their circumstances. It is also a window to get into the family to see what that family may need in the form of jobs and education and housing.

And so, we need to wrap around our community members so that when you gain entry into the health care delivery system, that your health care delivery doesn't end at the door of the hospital. It may begin at the door of the hospital, but it shouldn't end at the door of the hospital. That health care delivery should then follow you into your home to make sure that you have healthy living conditions environmentally, that you have what you need from a sustainability and a nutrition standpoint, that your prenatal care is taken care of, that all of the things that would lead to poor outcomes from a global health standpoint — those things that improve your health globally will change your philosophy on how you engage in violence to resolve conflict.

 

David J. Skorton, MD:

You know, all the 40 plus years that I've been in academic medicine, Dr. Mitchell, we've talked about the so-called tripartite mission of medical education, research, and patient care. But lately, we've added the fourth stool, which I think is exactly what you're talking about, and that is community. That it's not enough to educate and research and care for patients. And I think you said it so eloquently when you said, “Your job doesn't end at the door of the institution. It maybe starts at the door of the institution.” And so, I couldn't agree more. And I think that goes for all kinds of things that we deal with, and specifically, today for violence.

I want to change gears if we can and get back a little bit to your comparison of this public health crisis with COVID. And one of the things that a lot of us learned — a lot of Americans learned — during the early days of COVID, is the very important role of public health agencies. The National Institutes of Health — we wouldn't have the vaccines in 11 months if we didn't have well over a decade of basic research that led to mRNA vaccines — and the CDC and other health agencies. Give us your wisdom on that, Dr. Mitchell. What is the role of these public health agencies in dealing with this public health crisis?

 

Roger A. Mitchell Jr., MD:

Well, I think that the role of the public health agencies like the NIH and the CDC — those roles are the same in any other public health issue. It's the same role. They both — those two organizations — they have funding for violence prevention research, but they need to be providing more. There needs to be more. There needs to be a full-fledged deployment of public health resources for the epidemic of gun violence in our community, very similarly, to use another public health emergency — in the form of cancer and smoking.

You remember, David, when you and I would've been sitting having this conversation — you look like you probably would be a pipe guy. You probably would be sitting there smoking a pipe while I smoke on a cigar, while we're having a conversation about the health of community, right? And the lie would've been that that tobacco and that smoking does not cause cancer. That would've been the lie. There was a time where there was no connection being made with the physical instrument and the behavior. But now that's ludicrous. To this point, you can't get on a bus, you can't be in any public space, you barely have a carved-out area outside where you can smoke a cigarette or any other tobacco product. Because it is clear, not only that does it cause cancer in you, but people standing next to you can be triggered because of secondhand smoke, right? It's clear. Big Tobacco was taken to task. 

And so, that's the type of vigilance we need for gun violence. We need to be clear that gun violence is a public health issue. That there's a proximity between behavior and the instrument that can influence the morbidity and mortality of the disease and injury. And we're not willing yet, as a country, to have that real conversation about the public health approach to gun violence prevention, because we know once we start creating a causative — in fact, relation — causative relationship between the instrument and behavior, then there will be a decrease purchase of the instrument. And when the instrument decreases in purchase and those monies start decreasing in the corporations that support the instrument, then people start losing revenue. And when there's loss of revenue, there's loss of power. And so, we have to be honest about what we're against, just like physicians were willing to stand up against Big Tobacco. We need physicians, public health institutions, governmental public health institutions to call out the connection and be willing to research the connection between the gun and the instrument and the behavior that leads to death and illness.

 

David J. Skorton, MD:

Well there's certainly no doubt about the strength of the argument you're making now — the incredible correlation between the availability of guns, the number of guns, and the deaths at the hands of those with guns, whether it's self-inflicted or inflicted on someone else. And comparisons, as you so well know, Dr. Mitchell, of other countries shows how important that is. So, help me a little bit, now we've talked about public health agencies, we've talked about institutions, we've talked about those being educated and trained into the field of medicine. Most of us spend most of our careers in medicine after our formal training — college and medical school and a few years of residency or fellowship — and then the vast majority of our careers, most of us are not in academic medicine and most of us spend most of our careers in that practice realm that goes on for decades.

So, what can we tell our colleagues who are practicing physicians — not academics, practicing physicians — what is their role in this situation? If they're in an office, they're affiliated with a hospital, community health center. What are the roles of the very, very large number of practicing physicians in this public health crisis?

 

Roger A. Mitchell Jr., MD:

You know, David, I'm a big proponent of violence prevention in everything. I get excited when people ask that question, “Well, what can I do, I'm a physician, I'm a pediatrician, what can I do surrounding gun violence?” Well, ask the question about how your young person is resolving conflict, ask the parent if the child is not of age to answer that question, how conflicts are resolved in community and whether or not there's a weapon in the home, and whether or not there's safe storage in the home, and how they store their weapon in the home.

Although we're talking about gun violence now, gun violence — guns and the use of guns — is just a modality. Really, we're talking about a symptom of a system, right? Violence in and of itself is a symptom of a system that leads to violence, right? And so, yes, we want to focus on the symptom, but we need to dig deeper as physicians into what is the underlying cause. Now I certify death for a living. So, what is the underlying proximate cause for gun violence in your particular community, right? Because suicide may be the biggest leading gun violence symptom in your community. So why are young people or elderly white male in your community dying at the hands of gun violence? And doing the work to find out what are the structures that need to be broken down — the barriers that need to be broken down — and what are the positive structures that need to be built in your community to save the lives of that older white male who decides to point the gun to their own head and kill themselves, to be graphic, right?

In my community, it's understanding why that young Black male wants to point the gun at — outside of themselves and kill someone else. But at the end of the day — as physicians, public health officials, nurses, those of us in health care — we want to dig deeper into what is the underlying cause. And so, as a physician in your community, you can get involved in your local society, your local schools, your local places of worship to talk about gun violence and do work surrounding educating the community surrounding gun violence.

 

David J. Skorton, MD: 

That's terrific. Thank you for that. It's very, very helpful and words that we should all think about and follow. Dr. Mitchell, in any situation, let's talk about suicides just for a moment. There's all of the very important mental health — the stigma of getting counseling. I've had counseling at a time in my life that was incredibly helpful. I keep asking people who have achieved some success in their life and who've had counseling to talk about it, to be an example, to show that it's not a sign of weakness, that it's a sign of wisdom and strength. And all of these things that are preventive in nature are incredibly important. You've spoken about this today and for many years eloquently.

Then there's the other whole world of what has been called means restriction, where — separate of all of the things that we're talking about — we're just talking about removing the means. And tell me a little bit about your thoughts about what could be called means restriction. Because no discussion of gun violence in this country would be complete if we didn't touch a little bit on what sort of legislative things might happen to restrict access to guns, if we all agree that the ready availability of guns is a huge factor in these deaths. What are your thoughts there, Dr. Mitchell?

 

 

Roger A. Mitchell Jr., MD:

Yeah. I appreciate that. And I think that — and let me be clear, I'm a gun owner myself. And this is important to make that distinction, because there are some that believe that the millions of guns can somehow be collected from Americans. I'm not naïve to suggest that. So, I want to say that in the beginning. And then there are loopholes that are found with our gun shows where you can go with a driver's license and purchase guns and ammunition to your heart's content, without a background check. And as long as you have a license and live in that jurisdiction and you have the bank account to withstand it...

 

David J. Skorton, MD:

Excuse me, a driver's license.

 

Roger A. Mitchell Jr., MD:

A driver's license, an identification. And so, these gun show loopholes are allowing for thousands of guns to get into circulation and then they find themselves being used in the clandestine market. There's also — the ATF also knows where all of the guns that are collected are being bought and sold. And so, there are shops that — their weapons, when they're sold, are being used in crimes. And so, there's a need to ensure that these small businesses — and in some cases, large businesses — understand their role in vetting how that gun is being sold. One of the ways that we can do that is through universal background checks — ensuring that we have a universal background check, and that that universal background check, as well as licensing of the user of that weapon, happens on a regular basis. There's a renewal process.

 

And so, the Brady camp and several other advocacy groups talk about mirroring our renewing of our driver's license very similar to renewing of our gun ownership license, with the addition of more periodic background checks, as well as mental health screenings, as well as proof of safe storage and tactical. So, some of those policies are commonsense gun reform that all Americans — up to 80% of Americans — agree upon that we should be engaged in.

 

David J. Skorton, MD:

Do we understand everything we need to know or is there still a need for more research, and therefore, research funding? You've been studying this issue for many, many years. You're in a great position to answer this question. Do we need more research, and therefore, do we need more research funding on gun violence and violence in general?

 

Roger A. Mitchell Jr., MD:

Yeah, we absolutely need more research. We don't understand the effects of adverse childhood experiences on gun violence outcomes. There's a lot of anecdotal information that we're working upon. We need experts in the fields of neuroscience, fields of emergency medicine, and trauma, and behavior, social work. We need our legal minds, bioethics. We need our policymakers, political scientists to be researching this issue from every single angle. We don't have a body of work on violence — gun violence prevention in this country. There needs to be a body of work that is consistent with the burden of disease. And it's important for us to fund that body of work through philanthropy, through private donors, through university scholarship, as well as through the public health institutions like the NIH and CDC and the Department of Justice.

 

David J. Skorton, MD:

Well, last question for you, Dr. Mitchell. You know, I don't feel comfortable pontificating on what everybody else ought to do without you telling me what I should be doing and what the AAMC should be doing better. So, we'd love to hear your direct advice to us at the AAMC about how we could be more effective at making a change in this particular crisis.

 

Roger A. Mitchell Jr., MD:

Well David, it all starts with leadership. Bringing all the major organizations to the table to say, what and how are we educating the future surrounding gun violence prevention, the effects of social determinants into gun violence because of the disproportionate amount of Black men that are dying — Black and Latino men that are dying secondary to gun violence. And the presence of a diversity that ensures the health and safety of community.

Gun violence is the epicenter of how we can change the narrative within communities, particularly communities of color. We solve the epidemic of gun violence, David, in this country, then a whole generation of Black men and women — particularly Black men — are not going to jail and they're alive to raise families. And that changes the landscape of crime and violence. And then when we talk about what we need to do in policing reform, then policing reform and the capability of what happens in policing reform, it can be a reality because we've done the work of building out the health of a community through the lens of violence prevention. So be the voice and continue to echo it. But convene and hold people accountable, including your own organization, towards violence prevention in this country.

 

David J. Skorton, MD:

Dr. Mitchell, thank you for that guidance. Thank you for your wisdom and experience. Sharing the passion — not just passion, but the passion directed toward action with us. It's been a great pleasure and really an honor to have you on “Beyond the White Coat.” And I look forward to staying in touch with you. Thank you very much, Dr. Mitchell.

 

Roger A. Mitchell Jr., MD:

It's my pleasure. Thank you, David.