Everybody dies in the summer. Want to say your goodbyes, tell them while it’s spring. I heard everybody’s dying in the summer, so pray to God for a little more spring.
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ACEP Now: Vol 41 – No 07 – July 2022
These are the words of Chicago native Chancellor Bennet, also known as Chance the Rapper. He wrote these lyrics while he was just a high school student on the south side of Chicago.
In this hidden track on his adolescent mixtape, he depicts the realities faced by an inner-city child in low-income areas of many American cities. Summer is here and for many of us it’s our favorite season. Summer is a joyous time for the vast majority of our country: filled with beaches, sand, playing sports, and relaxing outdoors with friends and family. However, in some parts of America, summer is a season that is feared. It’s a time when violence rings out throughout the neighborhoods, when loved ones are lost and children are killed.
All throughout the United States we see the effects of gun-related injuries and deaths play out on the screens in our homes and on our personal devices. As a society we’ve become grossly desensitized and burned out by the habitual exposure to violence in media. Most of society has the privilege to remove the unwanted stimulus by changing the channel or scrolling past whatever harrowing event is in the headlines of the day, but this is not an option for us as emergency physicians. As emergency physicians, we will always be on the receiving end of tragedy.
Victim Demographics
When analyzing gun violence, the United States ranks number one in comparison to other high-income countries for the degree of gun-related deaths and injuries. Each year, over 40,000 Americans are killed due to gun-related injuries. About two thirds of these deaths are due to suicide and about one third are due to homicide. When we observe populations affected, what we find is that victims of suicide are mostly middle-aged white men, while victims of homicide are mostly young Black men.1,2 In fact, in Chicago where I work, 75 percent of the city’s gun-related deaths are in young Black males age 18–24 years old. This disparate distribution of injuries mirrors those seen in many urban environments in our country. Nationally, 60 percent of firearm homicide victims in the United States are Black Americans; however, Black Americans account for less than 15 percent of the population.3 In comparison with white men, Black men are 18 times more likely to suffer from gun-related assaults and 10 times more likely to die from gun-related homicide.2
There have been many resources created to help those in crisis who may cause harm. There is a large amount of public health messaging surrounding suicide and a plethora of suicide-specific resources that include easily accessible counseling, support services, and prevention hotlines. However, there have not been similar amounts of investment in homicide prevention resources. Most of our nation’s investment in homicide prevention resides in the form of safe gun usage and storage, stricter gun ownership laws, and heavy sentencing for those who commit interpersonal harm. Despite these efforts, gun-related shootings have spiked in the last two years with the U.S. seeing a 33 percent increase in gun violence between 2019 and 2020, and a further seven percent increase from 2020 to 2021.4 Harm reduction interventions are necessary, but the commonly used avenues miss the mark on addressing the root causes.
The root causes of gun-related homicide have been thoroughly investigated. Gun violence has been attributed to social inequity and intentional disinvestment of our marginalized communities. Specifically, the structural drivers are income inequality, poverty, underfunded public housing, underfunded public services, underperforming schools, easy gun access by high-risk individuals, and a sense of hopelessness.3 A lack of upward social mobility has also been found to have a strong relationship to interpersonal violence.
Gun-related homicide is a public-health epidemic that deserves a robust public health response. As emergency physicians, we are trained very well to treat the wounds of injured patients, but what can be done to prevent the injury? Active investment in the root causes of this epidemic are just as important as treating the downstream effects.
Tackling root causes can seem daunting, but there are some feasible ways that everyday emergency physicians can impact the upstream causes of gun-related injuries without overstretching. Emergency physicians can utilize a trauma-informed approach to patient care, actively work to mitigate bias toward those affected by gun violence, invest in violence-recovery support staff in our emergency departments (EDs), advocate for hospital partnerships with local community violence prevention programs and when able, increase physician support for community programming that addresses the root causes of interpersonal violence.
Trauma-Informed Care
It can be argued that every emergency physician should be trained in trauma-informed care and utilize this approach with every patient interaction. Taking a trauma-informed approach means to not only treat the patient’s chief complaint, but to acknowledge the adverse events that have occurred to our patients that led them to their behavior and health outcomes. As physicians, it’s important to realize how trauma affects our patient’s presentation. With trauma-informed care training, we are better equipped to recognize the signs of trauma and utilize tools to respondappropriately without re-traumatizing the patient. Taking this perspective and adding empathy to the visit has been found to improve patient engagement, adoption of treatment plans, and patient health outcomes. It can also boost staff wellness.
Mitigating Bias
At times we may have difficulty taking an empathetic approach to our patients’ experiences if we have already prejudged them. When treating gunshot victims, there can be automatic assumptions of wrongdoing of those injured. It’s important to recognize that our explicit and implicit biases play a major role in our interactions with our patients and the health care that we deliver. They have been found to be drivers of health inequities amongst marginalized populations and should be mitigated with proper training and continual self-improvement.
Violence-Recovery Support Staff
Emergency physicians should push to hire ED support personnel for patients who are victimized by gun-related violence and their families. A number of hospitals have incorporated the use of “violence recovery specialists” or “coaches” (social workers, mental health professionals, or peers with specialized training) to provide emotional and psychological first aid for victims and their loved ones at the time of the event. Awareness of how mental health is affected after having a loved one violently killed can promote active decisions in getting the necessary resources involved. After being traumatized by gun-related violence, patients may develop acute stress disorder or post-traumatic stress disorder followed by self-medication and further injury (victims of intentional violence have a high risk of being reinjured or injuring someone themselves). The violence recovery specialist works to decrease the risk of reinjury and recidivism by providing psychological first aid and organized access to social work, counseling services, spiritual services and social support programs. There are several different names and models of this support framework. Emergency physicians should research who provides this level of care in their area and advocate for their presence in their ED to assist with patients affected by gun violence.
Violence Intervention Programs
In addition to adding a violence recovery support staff in the ED, some hospital systems have created their own hospital-based violence intervention programs or partnered with community-based intervention programs. These programs to support victims and their families through their traumatization and simultaneously decrease recidivism. There are a myriad of violence intervention programs throughout the United States with various approaches to community health. Many focus on addressing the psychological impact and the cause behind the violence, dispatching peers to the scene to mitigate further violence. Several have joined forces to create the National Network of Hospital-Based Violence Intervention Programs spread throughout 25 cities. As emergency physicians we can advocate for our institutions to partner with these programs to be present in our ED, and if we are ambitious, we could follow a framework to create our own.5
Community Investment through Community Programming
There are several local community initiatives that address the social determinants of health. Emergency physicians can invest their time and energy into advocacy for these programs or thorough direct participation. Some examples include food pantry services in the ED to decrease food insecurity or mentoring with middle-school or high-school students. These interventions can decrease psychological stress and lead to less interpersonal violence. Investment in our youth can also boost self-perceived societal worth and can lead to fewer feelings of hopelessness. As physicians who work with our communities, we are well-positioned to advocate for initiatives that augment our patients’ health status.
With the summer here and the continued rise of gun-related injuries and deaths across the U.S. anticipated, there is a great disparity that is seen amongst those who suffer from gun-related homicide. As emergency physicians it is our responsibility to provide equitable care and resources to all of our patients regardless of their background or social circumstances. Many efforts have been put into addressing gun violence, but few address the root causes and attempt to provide equitable resources specific to those who are injured. At times, it can seem impossible to make an impact within our role of emergency physicians, however there are some tangible efforts that we can lead to make a difference. When we start focusing on these tools, we may finally start moving the needle in the right direction to address the needs of inner-city kids and adults disproportionately victimized by gun violence.
Dr. Haamid (@HaamidtheMD) is a practicing emergency physician at the University of Chicago.
References
- Gun violence in america. Everytown for Gun Safety Support Fund website. Published online 5/19/2020, updated 1/26/2022. Available at: https://everytownresearch.org/report/gun-violence-in-america/. Accessed June 12, 2022.
- Issue: impact of gun violence on Black Americans. Everytown for Gun Safety Support Fund website. Available at: https://everytownresearch.org/issue/gun-violence-black-americans/. Accessed June 12, 2022.
- The Root Causes of Gun Violence. The Educational Fund To Stop Gun Violence website. Published online March 2020. Available at: http://efsgv.org/wp-content/uploads/2020/03/EFSGV-The-Root-Causes-of-Gun-Violence-March-2020.pdf. Accessed June 12, 2022.
- Data tracker: City dashboard: murder and gun homicide. Everytown for Gun Safety Support Fund website. Published online December 16, 2021. Available at: https://everytownresearch.org/report/city-data/. Accessed June 12, 2022.
- Karraker N, Cunningham RM, Becker MG. Violence is preventable: a best practice guide for launching & sustaining a hospital-based program to break the cycle of violence. Oakland, Calif.: YouthAlive!; 2011. Available for download at the US Department of Justice website at: https://www.ojp.gov/ncjrs/virtual-library/abstracts/violence-preventable-best-practices-guide-launching-sustaining. Accessed June 12, 2022.
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