Suicides top list of firearm-related deaths and injuries

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center.

I'm your host, Amber Smith.

One step toward reducing gun violence is to deal with it effectively. In public health and medical school programs, according to an Upstate researcher. My guest today is Margaret Formica. She's an associate professor of public health and preventive medicine at Upstate and one of 13 faculty on a national task force that drafted a report on gun violence and public health.

Welcome back to "The Informed Patient," Dr. Formica.

Margaret Formica, PhD: Thank you. It's great to be back.

Host Amber Smith: I'm curious about what we know and what we still need to know. Can you give us a short overview of the kinds of research that public health researchers have already done on gun violence?

Margaret Formica, PhD: Sure. Over the past decade, we've really seen an increase in gun violence research from public health (experts), and that's really continuing to grow. There's been research that's describing the problem, so who is affected by gun violence, where is gun violence occurring, how is it changing over time?

We've also seen research regarding the different types of gun violence, so if it's gun violence related to suicide or possibly homicide, mass shootings, accidental shootings, intimate partner violence.

There's also been some research on factors and policies that may prevent gun violence, so things like safe storage, community-based programs or hospital-based violence intervention programs.

And there's also been quite a bit of work around state gun laws and the impact that those laws have on gun violence.

Host Amber Smith: It sounds like we're reading and hearing about mass shootings every day in America. Is it true that there's a huge increase in the number?

Margaret Formica, PhD: Actually, that is one of the areas that I've been working in for quite a while now, for the last several years. But it's interesting because only about 1% to 2% of firearm-related deaths are due to mass shootings.

So it's really a very tiny proportion of the gun violence that occurs in this country, but it does get a lot of attention. But there has been an increase in mass shootings, and there's also been a 35% increase in gun violence in general, which is very alarming. We've definitely seen this across the board in a lot of the work that has been done recently around gun violence.

Host Amber Smith: So if the mass shootings that we hear so much about only account for a very small number of the gun violence in America, what is the rest of it?

Margaret Formica, PhD: So the majority of the gun violence that occurs is actually suicide, so more than half of deaths related to gun violence are suicide. We then see a very high proportion of assault-related gun violence or homicides due to gun violence.

And then there's also the accidental shootings, too, but those tend to be a pretty small proportion, also.

Host Amber Smith: What do we still need to learn about gun violence?

Margaret Formica, PhD: There's just so much that we really still do not know about gun violence. You know, we don't have a good sense of, for example, how guns move through the country.

We don't know which laws and policies are the most effective at preventing gun violence. We're really just beginning to learn about the long-term effects of children, or among children, of hearing and seeing gun violence. Things like, "How do we best communicate gun safety to the public?" Those are things that we don't know either.

We also know very little about the long-term outcomes for all of the people who are injured, but not killed, by gun violence. So there's really so much more that we need to learn.

Host Amber Smith: Do we have a good idea of what factors lead to gun violence?

Margaret Formica, PhD: I would say no. We really don't have a good sense of all the factors that lead to gun violence at this point.

There are a couple of factors that have been shown time and time again to be associated with gun violence.

Probably the factor with the most evidence is poverty. Now, does poverty actually cause gun violence? No, not in the traditional sense, but poverty is certainly associated with gun violence. So any efforts to address disparities in poverty levels will also likely have a positive impact on gun violence prevention as well.

Another factor that we do know is related to gun violence is previous exposure to gun violence, so either being a victim of gun violence or witnessing it, those are factors that we know lead to additional gun violence. It's really a vicious cycle. But that's why we really need to boost the research that's being done in this area, because there's definitely more that we don't know than what we do know at this point.

Host Amber Smith: Are you aware of any revolutionary research that's underway or that has wrapped up recently dealing with gun violence?

Margaret Formica, PhD: I've been fortunate in the last few years to have the opportunity to serve as a grant reviewer for gun violence research for the CDC (Centers for Disease Control and Prevention), so I've been able to see the direction that gun violence research is headed in.

And there's been significant work being done related to building the surveillance systems that we need in place to study gun violence and also gain a better understanding of how multiple factors work together that lead to gun violence.

But with respect to recent revolutionary findings, I really do think the most striking is simply that significant increase in firearm violence that we've seen since the beginning of the pandemic.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith.

I'm talking with Margaret Formica. She's an associate professor of public health and preventive medicine at Upstate, and she was part of a national task force that drafted a report on gun violence and public health.

Dr. Formica, the Association of Schools and Programs of Public Health published the report that you and your colleagues did, called "Gun Violence Prevention: an Academic Public Health Framework."

Can you tell us about the task force plan for academic public health to promote research, education and advocacy on this issue?

Margaret Formica, PhD: So the Association of Schools and Programs of Public Health, or ASPPH, is an organization that serves as really the voice of academic public health, and ending gun violence has long been a priority for ASPPH, but the mass shootings that occurred in Uvalde (Texas) and in Buffalo, really renewed the organization's commitment to the issue, which then led to the formation of the task force on gun violence prevention that I served on.

We were asked to develop a framework that could be used not only by schools and programs of public health, which was the primary intended audience, but really at any institution or organization interested in engaging in gun violence prevention efforts.

So we reviewed the (research) literature, we identified areas of need and gaps in resources, and then we developed the recommended strategies that formed the basis of the framework. And so what each institution can do might differ, depending on their mission, on their resources, but some examples would be adding gun violence prevention to curricula in their educational programs or advocating for donor support of gun violence prevention efforts, developing and supporting strong community relationships and partnerships.

These are all strategies that academic institutions can engage in.

Host Amber Smith: And so all of the task force members represent different academic public health departments across the country, right?

Margaret Formica, PhD: Yes. So we were a group of mostly schools of public health at different academic institutions across the country. There were a couple of smaller programs of public health, like what we have at Upstate, and so I was able to represent Upstate in that task force.

Host Amber Smith: What makes gun violence a public health issue?

Margaret Formica, PhD: Gun violence is a national public health crisis.

There are over 100 firearm-related deaths in this country every day, and there's an additional two to three times as many nonfatal firearm injuries. And so I think that's one of the statistics that people maybe aren't frequently aware of is the number of injuries related to firearm violence that occur.

It's also the leading cause of death among children and youth in the United States, that surpassed deaths related to motor vehicle accidents back in 2017. So gun violence is a public health issue because it's affecting the health of the public. It's also estimated to cost $280 billion a year, and not only does it impact the people who are injured and killed by gun violence, but it impacts their families, it impacts their loved ones, the community.

There's growing evidence of a long list of negative behavioral and health effects of exposure to gun violence, so those who aren't directly impacted, but they see and they hear gun violence regularly in their communities. There's also the fear and anxiety around frequent mass shootings that we face in this country, and I think "in this country" is a key point because we don't see this level of gun violence occurring in other countries. The United States has 26 times the number of deaths due to gun violence compared to other high-income countries.

Host Amber Smith: How does -- or does? -- gun violence impact someone who's not involved in any shooting?

Because a lot of people live in a community and are never a victim or witness. They're not involved in the shootings, but are they still affected by the fact that they're taking place?

Margaret Formica, PhD: That's an area that's really growing in terms of research right now, because we're just beginning to really understand that there are negative consequences to just living in an area where you hear the gun violence routinely, or you see the gun violence, you witness it.

We do know that being exposed to gun violence leads to more gun violence. But there's also other negative impacts, as well. So things like educational attainment is lower among children who live in neighborhoods where there's high levels of gun violence. We know that there's a lot of behavioral problems in teens and young adults in neighborhoods where they're exposed to gun violence. We know that there can definitely be negative health effects, even biological health effects, related to constant exposure to this gun violence, but we're really just beginning to understand that and learn more about that.

Host Amber Smith: Well, you mentioned that some of these gun violence numbers increased from before the pandemic until now. What role did the pandemic play in gun violence or did it?

Margaret Formica, PhD: We're trying to figure that out now, too. One of the areas that's really being pursued in research related to that increase is the fact that we saw a spike in gun sales at the very beginning of the pandemic, also.

So there's certainly a possibility that that's leading to some of the increase that we're seeing. We also in the past few years have seen a loosening of many state gun laws in other parts of the country, not necessarily New York -- we actually see the opposite in New York. But in some other states we've seen loosening of gun laws, and so there's definitely the potential that that is contributing to this increase that we're seeing.

But again, we're just really beginning to research that and have a better understanding of what happened.

Host Amber Smith: What has prevented research and education and advocacy about gun violence prevention from being implemented so far?

Margaret Formica, PhD: The public health approach that's been so effective at reducing other public health problems has really been hampered when it comes to gun violence.

So, to just give you a little background on the public health approach, the first thing is to define and monitor the problem.

Then we identify risk and protective factors.

Then we develop and evaluate prevention strategies.

And then we assure the widespread adoption of those strategies.

And the problem that we face with gun violence is that the infrastructure needed to monitor the problem, which is that very first step in the public health approach, just isn't there. We don't have the surveillance in place that we do for other public health problems, and that really hampers the remaining steps of the public health approach.

So, for example, much of the gun violence research to date has focused on firearm deaths because we know the data on deaths is accurate. But we're missing a huge piece of the puzzle because we aren't including those nonfatal firearm injuries. Currently we just don't have a mechanism to capture that data in an accurate and a timely way at the national level.

And part of the problem is there's been decades of restrictions in federal dollars being spent on gun violence research that really severely limited our understanding of the factors that lead to gun violence and what can be done to prevent it.

Host Amber Smith: Is there enough money going into research of gun violence?

Margaret Formica, PhD: Definitely not. When you compare the scope of the problem related to gun violence here in this country, the amount of research dollars going towards it is minuscule, compared to those other public health problems. So we definitely need more funding. We have seen an increase in the last few years at the federal level, some of the funding streams that were limited previously to the Centers for Disease Control and Prevention, or the CDC, or to NIH, which is the National Institutes of Health. We have seen some money opening up for gun violence research in the last few years, and so that's definitely helping, but there's still definitely not enough research money.

Host Amber Smith: The report on gun violence prevention indicates more than a hundred lives a day are lost to gun violence.

Half of those are to suicide. Four out of 10 are homicide, and one in a hundred are due to unintentional injuries or accidents.

How might the prevention strategies differ for suicide versus homicide versus accidents?

Margaret Formica, PhD: That's another great question because prevention strategies will be very different depending on the type of gun violence that we're dealing with.

For example, one of the newer policies that has a growing body of evidence supporting it as a prevention strategy for both suicide and intimate partner gun violence are extreme risk protection orders. They're also known as red flag laws. There's only a handful of states, including New York, that have these types of laws in place, but these laws essentially allow someone to petition the court to prevent a person from buying or possessing a firearm if they're at high risk of harming themselves or someone else. This is just a temporary order, so once the person is no longer considered a threat, the order is then lifted. But what we've seen is that states that have implemented these laws seem to have seen a reduction in firearm violence compared to the states that did not implement those laws.

On the other hand, if you were to look, let's say, at accidental shootings, the prevention strategies for that look quite different. So preventing the accidental shootings and deaths, or accidental injuries and deaths, the evidence really supports safe gun storage practices, firearm safety training.

So an example of that might be ensuring that firearms and ammunition are stored separately in locked cabinets so that children can't access them. So there are definitely differences depending on the intent and the circumstances around those types of gun violence.

Host Amber Smith: How would you go about setting up a study that would help determine a way to prevent gun violence?

Margaret Formica, PhD: I'm really personally quite interested in the community or the neighborhood level factors that influence gun violence. So we know that poverty is one of the leading factors associated with urban gun violence, but we also see that there are some neighborhoods that have very high levels of poverty that don't necessarily see those same high levels of gun violence.

That's definitely true here in the city of Syracuse, but it's true in other cities as well. So, with proper funding, what I would really like to be able to do is to take a deep dive into those neighborhoods to see what is it about those neighborhoods that actually protects them from the gun violence.

What's different about those highly impoverished neighborhoods that have low levels of gun violence compared to the highly impoverished neighborhoods that have high levels of gun violence? And so, really focusing in, again, on those root causes of poverty and those community level factors that could be playing a role, what can we do to prevent them?

And so studying those types of things is what's really my area of interest in gun violence research.

Host Amber Smith: In some of your research, you've already looked at injury epidemiology (injury's causes). What have you found regarding injury epidemiology?

Margaret Formica, PhD: Much of my research on injuries, including gun violence injuries, has focused on describing the problem, so again, the who, the what, the where, the when, so who is gun violence affecting, where is it occurring, how is it changing over time?

In the last few years, I've really looked quite a bit at the impact of the pandemic on injuries. So one of the projects I've been involved in is an international project that is actually combining injury hospitalization data from 40 pediatric hospitals.

And we're still analyzing that data, but preliminarily, we've seen some pretty interesting changes in the frequencies of different types of injuries from before the pandemic to during the pandemic. and that included an increase in firearm-related injuries. There's definitely more to come from that research.

We're really in those early stages, but I think there will be some really interesting findings from that.

I've also recently worked with a national data set on adult hospitalizations, and we found a spike in firearm-related hospitalizations in the first six to nine months of the pandemic, so very much in line with what other research has shown, related to firearm-related deaths.

And then just last month, a colleague at Syracuse University and I, Dr. Bryce Hruska, submitted a grant to look at the relationship of gun violence and neighborhood characteristics here in Syracuse. So, fingers crossed if the funding comes through, then we'll hopefully be able to gain a better understanding of those community factors that lead to firearm injuries here locally.

Host Amber Smith: Dr. Formica, thank you so much for making time for this interview.

Margaret Formica, PhD: Thank you. I really appreciate the opportunity to talk about this issue, so thank you for having me.

Host Amber Smith: My guest has been Dr. Margaret Formica, an associate professor of public health and preventive medicine at Upstate. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed.

This is your host, Amber Smith, thanking you for listening.