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    Transcript: At the Crossroads: Public Health and Gun Violence

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    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.

    [End of Audio]