6
Defining a Firearms Violence Prevention Road Map for Hospital and Health Systems
Before introducing the panelists for the workshop’s final session, Chethan Sathya of Northwell Health noted that the goal of the workshop was to focus on implementation and how to move from evidence-based strategies to actual implementation and practical solutions. Doing that, he said, is not possible without the community. The four panelists in this session were James Braxton of the National Institute for Criminal Justice Reform, Megan Ranney from Brown University, Tom Jackiewicz from the University of Chicago Medical Center (UChicago Medicine), and Rajeev Ramchand from the RAND Corporation. Rather than give formal presentations, panelists responded to questions posed by Sathya and commented on the workshop’s major lessons. Firearms violence prevention road map highlights can be found in Box 6-1.
HOW THE PANELISTS BECAME INVOLVED IN FIREARM INJURY PREVENTION
To start, Sathya asked the panelists to talk about their background, why firearm injury prevention is so important to them, and why they believe firearm violence is both a public health and health care issue. Braxton said that he grew up in the Hampton, Virginia, area, had trouble in school, was incarcerated, turned his life around, and ended up working in the neighborhood in which he grew up and serving as a symbol of transformation to the young men in that neighborhood. After working for the Boys and Girls Club, where he engaged with families in Newport News and Hampton who had been affected by violence and the Reinvest in Supportive Environments for
Young People organization, a statewide juvenile justice reform initiative, he turned to violence reduction work with the National Institute of Criminal Justice Reform. This work is important to him, he said, because he has lived experience with gun violence and still experiences loss from gun violence both through the people who are close to him and the young people he mentors.
He knows, too, that health care plays a significant role in addressing gun violence because he was also a case manager in a hospital violence intervention program in Virginia. “I saw the young people that came in, I met their families, and I provided intensive case management for a year after that,” said Braxton, continuing:
I know what they need, I know what complexities they face in their community, and it takes credible messengers and violence interrupters who have lived experience to be in these spaces and help create solutions. That is why I am here.
Sathya then asked Braxton how often he feels that he is truly included in conversations regarding hospital-based or community-based programs that collaborate with hospitals. Braxton replied that before his work in case management, he had never heard of hospital-based violence intervention, even
though he had been doing this work for more than a decade. He first encountered a program when he was working with two young people in the community who were shot and he was the first person at the hospital to help them. His thought at the time was that there should be a program to help these young people who come to the hospital and their families with resources. “It is typically not the guns, it is the circumstances around the guns and around these families and young people that lead to that,” said Braxton.
Next, Ranney explained that she is a practicing emergency physician who also trained as an injury prevention researcher and worked on violence prevention long before she went to medical school. She took on the issue of firearm injury prevention some 15 years ago after a number of disturbing cases she saw as a resident and then as junior attending physician in the emergency department, particularly a young man who killed himself with his father’s firearm. She noted that when she first started her injury prevention fellowship, multiple people, both within and outside of her institution, told her that although she could work on violence prevention, she had to be careful not to talk about firearms. After the case of the young man who killed himself, she decided she could not be silent and that is was essential to talk about firearms as a different source of violence, both self-directed and other directed, and something that could be prevented and treated the same way we prevent and treat other types of injury. “Making it a political third rail and not saying the word gun was not doing anyone any good,” said Ranney.
Since then, she has been working with many of the people who spoke during the workshop to try to change the conversation around firearm injury and move it away from it being an us-versus-them problem to being a public health issue. As a public health issue, she said, firearm injury can be addressed with good data on risk and protective factors, with theory-driven interventions that reduce those risk factors and increase protective factors, and then with dissemination of programs that make a difference. Achieving this goal involves creating partnerships with community members, parents, survivors, and family members left behind. It also involves a great deal of work with policy makers, the media, and people who may not typically consider themselves to be part of public health.
Ranney noted that she has been fortunate not only to conduct funded research on firearm injury prevention but also to work as a cofounder of a nonprofit and serve on the board of the local Nonviolence Institute in Providence, Rhode Island, all of which deeply informs her approaches to this issue. Concluding her introduction, Ranney said:
The biggest thing for me is that there is no reason not to talk about this disease in the same way we talk about any other disease as something that is both preventable, before it ever happens, using primary prevention, as something
that we can prevent after the first signs of disease using secondary prevention, and as something for which we have to take action after it has already happened using tertiary prevention.
Regarding interventions, Sathya commented that it is important to remember that despite there being a number of evidence-based solutions that work to reduce firearm injury, the health care industry has not been able to implement these strategies at large. “Of course the people who are listening today are passionate about this issue, but when you look at the health care industry overall, the implementation of these strategies is lacking in a majority of hospitals,” said Sathya.
Jackiewicz introduced himself by noting that he has been at UChicago Medicine for 20 months, following more than 8 years as chief executive officer of Keck Medicine at the University of Southern California in East Los Angeles, and before that serving as chief executive officer of the University of California, San Diego School of Medicine. One reason he joined UChicago Medicine was to tackle some of the health issues affecting the approximately 625,000 people who live in Chicago’s South Side community, 77 percent of whom are Black, 12 percent of whom are Latino/a, and 2 percent of whom are Asian. Greater than 50 percent of the community lives below the poverty line. Residents in the UChicago Medicine service area experience gun violence at a rate that is five times higher than the rest of Illinois. In the COVID-19 pandemic’s first year, gun-related violence in Chicago increased by greater than 60 percent. Jackiewicz said:
When I got here, I realized that if we were going to really make a difference in health equity on the South Side, we had to make the community safer, and with this level of gun violence, it was going to be impossible.
He noted that you cannot work at UChicago Medicine without seeing the impact of gun violence and what it has done to the community and to individuals living there, which makes it imperative to tackle gun violence and make a difference in the community. Making a difference requires focusing on economic issues, and for him that means hiring from the community through job training programs as part of the overall effort to address the root causes that others addressed at the workshop. He added that before going to Chicago, he read history books about the South Side and understood that many of the problems facing residents of the South Side are rooted in events that happened 100 years ago. “These are not new problems, so we are going to have to be really creative in terms of how we tackle this. Employment and creating opportunities is going to be absolutely critical,” he said.
The final panelist, Rajeev Ramchand, said that his passion for addressing suicide prevention started when he studied for his undergraduate degree at
the University of Chicago and volunteered to answer a suicide hotline. When he was in graduate school, the wars in Iraq and Afghanistan were raging, and because his brother was a Navy veteran, he could not turn his attention away from the emerging evidence about the effect of trauma on the men and women serving overseas. Wanting to understand the mental health sequelae of combat exposures led him to work on suicide prevention, particularly in the veteran community, and on evaluating suicide prevention programs, which to him, meant looking at firearms.
Ramchand said that as an epidemiologist, he comes to this issue with a passion for high-quality data. As a result, he is not only trying to understand the issues and the risk factors that others have spoken about but also working to improve the data infrastructure in the United States to provide more timely and accessible data on mortality, suicide risk factors, and firearm ownership in the general population. “If we can improve the data infrastructure, we can get to solutions, in my opinion as a scientist, much quicker and reduce the burden that firearms pose for suicides, unintentional injuries, and homicides,” said Ramchand.
SUCCESSES AND CHALLENGES
Responding to Sathya’s request to talk about some of the successes and challenges he has experienced, Braxton first explained that when he was the area director with the Boys and Girls Club and responsible for creating after-school and summer programs in the most deprived areas of Hampton and Newport News, gun violence was a regular occurrence right outside the club’s doors. To address this situation, he first had to understand who the community leaders were, because even though he is a credible messenger and could connect with people in certain neighborhoods, he could not go into every neighborhood because he was a stranger there. Once he identified the community leaders, he built relationships with them, helped them understand what his intentions were, and listened to learn what their needs were in their neighborhoods. “You have to identify those needs and engage organically,” said Braxton.
In his experience with hospital-based violence intervention engagement, he has seen programs that engaged well with the community and others that did not, and those that did not were largely stagnant and unsuccessful. Those hospitals that were successful went to community meetings and hired employees from the community. Taking that approach sends the message that the hospital is walking together with the community to create solutions and that it wants to combine the resources and assets it has with the creativity and authentic vision of those in the community.
Ranney, who has been working with the community-based violence intervention program in Providence, Rhode Island, for almost 20 years, has seen the
program’s funding increase and decrease and watched the number of firearm injuries in the community increase and decrease. One of the biggest lessons for her has been the importance of being relentless in advocating for the community and ensuring that her hospital’s residents, security guards, trauma surgeons, emergency medicine attendings, social workers, and nurses are aware of and comfortable with the violence intervention program. That is all the more important, she added, for community-based programs, as opposed to hospital-embedded programs, because those community-based programs are invited into the hospital setting with the permission of the patient, thanks to the provisions of the Health Insurance Portability and Accountability Act (HIPAA).
Ranney said she has seen plenty of programs on firearm suicide prevention and discussions of firearm access and lethal-means counseling fail. As with violence prevention programs, suicide prevention programs tend to come in waves, where a particularly high-profile case gets attention and people get involved, and then attention fades and so do the programs.
One of the biggest successes and challenges that Ranney noted was around tracking actual data on both firearm injuries and what she calls firearm injury adjacent patients. Getting those data requires collaboration between the hospital system, the state department of health, and community agencies. “When I think about our biggest areas of opportunity, they are around expanding awareness and availability of high-quality data,” said Ranney.
She noted that it is not the top priority of her violence interrupters to collect accurate data. Their top priority is stopping the cycle of retaliation and supporting both survivors and their families as well as the larger community in the days and weeks after an episode of violence. “We have to make it easy for them to have access to and track accurate data,” said Ranney, who would like to see the same for firearm suicide and active shooter threats. She noted that her hospital system has received threats that are not always reported by the media, and she is not sure how well those are tracked on a national level. The American Hospital Association, she said, has been active in talking about active shooter threats, but it is something that needs more attention going forward to help motivate change. She also called for more accurate and culturally competent screenings and day-to-day interventions.
Jackiewicz said that active shooter threats have not been a big problem in Chicago or where he was in Los Angeles. Having said that, he acknowledged that he worries constantly about the safety of his employees. Last summer, for example, an attempted shooting occurred right outside of the trauma center. In response to growing concerns among the employees about their safety and feeling personally threatened, the medical center is installing bulletproof glass around the trauma center and adding metal detection systems that are more subtle than those in airports but that can still detect weapons. He also noted that students have been shot and killed in the past 2 years, which is unusual
for the University of Chicago. In that vein, Sathya said that he has seen an uptick in momentum at Northwell Health to have active shooter training.
When asked about his successes or challenges with respect to implementation, Ramchand first noted that the National Action Alliance for Suicide Prevention has recommended that hospitals and health systems begin collecting postdischarge patient mortality and patient survival data as a patient-centered outcome. Researchers could use these data to test what is or is not working in terms of death prevention and firearm injury interventions. The alliance also called for standardization of external cause of injury codes and routine collection of them within the emergency department.
He then spoke about how he had certain conceptions about how to counsel lethal means safety for veterans and law enforcement personnel who are at risk for suicide until he spent some time at Camp Leatherneck in Afghanistan and realized those preconceived ideas were wrong. In an environment where it would be a signal that something was wrong if an individual did not have a firearm on them, it will take a different approach to help those individuals. Such an approach can only be developed by listening and learning from that community and having cultural humility, said Ramchand.
THINKING ABOUT EVALUATION
Sathya then asked Ranney to talk about how health systems and researchers can begin the journey of developing a framework to assist with evaluation in a collaborative manner that serves to support community organizations and produces the data needed to prove the effectiveness of these interventions. Ranney replied that building trust with the community and forming partnerships must be the first step. If community organizations do not trust that data are being collected for worthwhile reasons and not just to publish a paper, it will be impossible to collect the necessary data. It is also important to do the work, get funding, and help support people who are working on the frontlines of violence prevention, often at disturbingly low wages and with a lack of benefits.
Also needed, she said, are partnerships with organizations, such as the Centers for Disease Control and Prevention and philanthropic organizations, to provide funding to accurately collect and analyze the data. Partnerships with researchers and behavioral interventionists who can help community organizations move beyond constantly dealing with emergencies and lurching from one shooting or stabbing to another is also important. Ranney said:
It takes space, time, and money to be able to move beyond that, to incorporate best practices, and to be able to think about what does the data show actually works versus what are we doing just because it feels good. I think that is a
critical question for us to answer, for the sake of those who are on the ground doing the work, for the sake of the hospitals that are investing the money, but most of all for folks in the community who are affected by this cycle of violence and its emotional and mental aftereffects.
As far as what hospitals and health systems need to do to get started on adopting firearm injury prevention based on evidence-based strategies, Ranney said the first and biggest step is to see firearm injury as preventable, perhaps even more so than diabetes or heart disease. The second step is to engage the community and experts. One place she sees health systems go wrong, despite their best intentions, is not drawing on the well-developed, evidence-based firearm suicide prevention resources that are available. Another mistake if the goal is universal screening is to not think about the potential harms as well as the benefits of universal screening. Ranney said that while the biggest risk for a hospital or health system is to not do anything, the second biggest risk is engaging with the community without cultural humility and using polarizing language, destroying trust in that community in the process.
TRANSFORMING COMMUNITIES TO PREVENT FIREARM VIOLENCE
Sathya asked Braxton whether he could share his thoughts about the critical components that health systems need to consider when developing a road map to move forward with efforts to reduce firearm violence in the community. Braxton said that there is no one answer and that ultimately most of the responsibility falls to the community. He added, however, that he would focus on alignment with what is already happening in the community. Unfortunately, he said, there is too little collaboration and too many siloed efforts that never connect with other programs. That lack of connection, he said, is enough to stop good work from going forward. Communication is the key, he added.
Beyond that, Braxton said it is important to ensure that top-level leadership at the hospital is aligned with the top-level leadership in the community and the top level of physician leadership. Leadership culture is important, too, because it can send a message about how important this issue is to the health system or hospital. Putting the violence prevention program in the hospital basement next to the morgue, which one program he worked with did, sends the message that the program is not important. In the same vein, getting community input in exchange for a $25 gift card might seem to be a good enough message to send to the community, but a better message comes from getting community input and creating opportunities for employment. In
terms of addressing cultural biases that can exist, Braxton suggested establishing a diversity and equity board before doing anything else and ensuring that the board is involved in the entire program planning process.
Jackiewicz agreed with Braxton that alignment is critical. He recounted how when he first went to Chicago, he became involved in a 5-month long program that brings together city leaders to talk about what was occurring in the city that would make a difference. The main lesson he took back to UChicago Medicine was to improve his institution’s alignment and engagement with the community and with other programs in the city. “It is the synergy we can create with alignment that is so important,” said Jackiewicz.
He noted that his institution, with the help of community members, has assembled an extensive in-house team of violence recovery specialists who support trauma center patients. The specialists are integrated into the clinical care teams and work with community groups, like street outreach organizations, to provide wraparound support and connect gun violence victims with programs and resources that best meet their needs. The violence recovery initiative is also a workforce program. It is critical, he said, that UChicago Medicine hire members of the violence recovery team from the community. This allows the health system to provide individuals with a career track within the organization and a living wage and benefits, including a generous tuition benefit. Over one-third of the violence recovery specialists, many of them having personal experiences with violence, have returned to school for further education and training.
As a result of aligning the institution’s economic power—it is the largest employer on the city’s South Side, with 12,000 hospital employees and another 10,000 university employees—with its community-based programs, these programs are having a significant effect on reducing retaliatory violence. The UChicago Medicine trauma center’s violence recidivism rate is under 1 percent (UChicago Medicine, 2021). Jackiewicz added that 10 years ago, the UChicago Medicine had a much different attitude about working with surrounding neighborhoods and largely avoided community issues. That began to change in 2018 when the hospital opened its trauma center. In the ensuing years, the hospital started to work with South Side safety net hospitals and federally qualified health centers to further promote and support programs that provide more primary care, behavior health, and other much needed services, supported by $26 million in state funding for first-year initiatives and up to $146 million over 5 years. The transformation of the health systems relationship with the community, he added, has gained steam as a result of the pandemic, which he said strengthened UChicago Medicine’s mission to be an integral part of the community.
For Ramchand, another important first step is for a hospital or health system to understand the data about gun violence in their community and
where the gaps in those data exist. “It is only through baselining that you can understand how you are growing and improving,” said Ramchand. He added that not tracking a program and measuring improvement is a disservice to those working on the project, as well as a lost opportunity to build enthusiasm for a program that is working. It is also critical to understand the local culture regarding firearms as well as the laws that govern firearms in the community as a means of understanding the ecosystem in which the hospital operates.
He noted that he was part of an effort at RAND that reviewed state-level policies and their effects on a variety of outcomes. For example, child access prevention laws, which allow prosecutors to bring charges against adults who intentionally or carelessly allow children to have unsupervised access to firearms, were very effective at reducing suicide deaths among young people (Azad et al., 2020). States with stand-your-ground laws, on the other hand, had increased homicides (Degli Esposti et al., 2022). Ramchand said he hoped this type of research that evaluates the effects of laws will continue to produce insights into which types of laws can have the largest effect on the outcomes of concern. At the same time, it is important to understand how those laws affect people that worry about gun rights and about their effect on hunting, fishing, and other recreational activities.
Going forward, Braxton said he would like to see health systems engage in leadership advocacy training so that they can be effective advocates with state and local policy makers and help city leaders, for example, understand possible unintended consequences of policies they might enact. For example, a city might decide to demolish a decrepit apartment building, but that has the effect of displacing the people who were living in that building. Now, a teenager might have to go to a different school, one at which rivals predominate, and the teenager feels they have to bring a gun to school to protect themselves, an action that runs counter to an effective violence reduction strategy that was working in the community.
Jackiewicz recounted a story about someone he met who moved away from the South Side where she had been born and raised because she was scared of getting shot while walking to the grocery store. This common story highlights the need for violence prevention programs, health equity programs, investments in training community members, and other steps to be intertwined because unless people feel safe in their community, progress will be limited.
Ramchand’s final comment was to not forget about suicide prevention programs for veterans outside of the Veterans Administration (VA) given that two-thirds of veterans never step foot in a VA facility. A national effort to prevent veteran suicide would involve private and public hospitals in the community and working with veterans with cultural humility and the understanding that a veteran might need a different intervention than a nonveteran.
