Gun Violence and Mass Shootings as a Public Health Priority in the United States: An Expert Panel Discussion

Introduction

The United States is unique among developed nations in its frequency of experiencing mass shooting incidents. In 2021, 691 mass shootings claimed the lives of 705 Americans. ¹ Media coverage during the spring and summer of 2022 leapt from a grocery store in Buffalo, New York, to an elementary school in Uvalde, Texas, to a hospital in Tulsa, Oklahoma, to a street fight in Philadelphia, to name a few—barely able to begin coverage of one event before the next shooting and subsequent loss of life and harm to communities occurred.

Easy access to weapons, shortage of mental health resources, and the prospect of new gun control legislation on Capitol Hill often take center stage in discussions surrounding mass shootings. In an interview with Becker’s Hospital Review, ² Ramin Davidoff, MD, co-CEO of The Permanente Federation, called attention to the need for all health care organizations to provide safe work environments for all clinical staff as an important component in providing high-quality health care. The Permanente Journal brought together this expert panel on July 12, 2022, to approach the conversation from a medical-psychological-social perspective to discuss gun violence and mass shootings as a public health priority within the United States.

Expert Panel Discussion

G Richard Holt

I want to thank each of you for participating in this roundtable discussion about gun violence and mass shootings as a public health priority in the United States. This is a very important topic, and each of our panelists brings a specific set of training, education, experiences, and knowledge to this conversation, which we’ll be exploring as we go through the questions. I’d like to ask each of our panelists to start by telling us a bit about themselves, their professional backgrounds, and the lens through which they are viewing our conversation topic.

Mary Ellen O’Toole

I’m the director of the forensic science program at George Mason University in Fairfax, Virginia. Prior to that, I was an FBI agent and FBI criminal investigative analyst (profiler) for 28 years. In that capacity, I worked in the FBI’s Behavioral Analysis Unit (BAU). In my experience with the BAU, we worked some of the most extreme violent crimes in the world and were tasked with developing analyses of these crimes as well as assessments of offenders and their motivations for committing their crimes. Part of my responsibilities in the BAU included serving as the principal investigator for a research project involving mass shootings. These unusual shootings were an emerging new crime trend that seemed to start in the mid-1980s with motivations and offender behaviors we had not seen before in the criminal justice system.

Initially, I was able to identify 18 cases from across the country. These shootings involved school-aged boys who walked into classrooms and cafeterias and killed and injured fellow students and teachers. Their motives were not consistent with other crimes of violence, wherein offenders were motivated by money, sex, drugs, jealousy, etc. In the midst of working on this research, the 1999 Columbine High School shooting occurred, shocking the world and becoming a true game changer.

Immediately after Columbine, the United States Attorney General, Janet Reno, asked the BAU to quickly organize a conference on all of the 18 cases we had identified, including Columbine, and to develop an understanding of the motivation of these shooters as well as the offenders’ behaviors both before and during the crimes. A select group of international subject matter experts, witnesses, victims, and law enforcement officers met to discuss these cases in an effort to better understand why they occurred, what the shooters’ motives were, and the commonalities that existed among the shooters. This effort resulted in the 2000 publication of The School Shooter: A Threat Assessment Perspective ³ in which we identified characteristics and traits that existed in the original 18 cases and therefore might exist in future cases. We provided a bio/psycho/social model by which teachers, parents, law enforcement, and others could assess those students who might pose a potential threat. Our goal was to help identify at-risk students, develop interventions, and prevent the next shooting. We knew in 1999 and 2000 there would be more school shootings, but no one realized the true impact of the Columbine shooting on our society, or all the shootings that would occur after Columbine. The difference between Columbine and other mass shootings are remarkable with features to them that suggest offender motivations, preparation, and planning that are frankly stunning. The behavioral features of this newer type of post-Columbine shooting was and continues to be truly unlike anything that we’ve seen elsewhere in US history or anywhere else in the world.

David C Grossman

I’m a pediatrician. I started my career working in a Level 1 trauma center at Harborview Medical Center in Seattle, Washington. At that time, I was focused on treating patients with trauma and burns as part of my teaching and clinical responsibilities. That’s where my interest in trauma, firearms, and trauma prevention started. Eventually I ran an academic research center at the University of Washington that was focused on the prevention of injuries, including firearm injuries. Much of my research has focused on that particular issue. I’m currently working for Kaiser Permanente as Vice President for Social Health and Health Equity. I work in key areas that address health equity, which includes matters such as violence. I’ve also been involved in Kaiser Permanente’s efforts to address gun violence.

Georges C Benjamin

I’m the executive director of the American Public Health Association. I originally trained in internal medicine, but self-identify as an emergency physician. I’ve been basically practicing emergency medicine most of my clinical career, and got involved in disaster medicine and terrorism response during my time in the United States Army. I have carried that interest throughout my career, particularly around weapons of mass destruction. When I left the army, I ran the Department of Community Medicine and Ambulatory Care at the City Hospital in Washington, DC, and later served as the Emergency Medical Services Director and City Health Commissioner. That was during the time when DC was known as the murder capital of America, with drive-by shootings occuring routinely throughout the city. It was also the peak of the crack cocaine epidemic, and a lot of those shootings were drug related or had some relationship to violence that was affiliated with drug trafficking. Throughout the rest of my career, I’ve become very involved in thinking about public health approaches to reducing firearm injury.

Joseph V Sakran

Thanks again for having me on this esteemed panel. Look, I come to this conversation as someone who is a survivor of gun violence. At the age of 17, I was nearly killed after being shot in the throat with a 38-caliber bullet. That moment inspired me to go into medicine to become a trauma surgeon, and really pushed me throughout the course of my professional career to work at the intersection of medicine, public health, and public policy.

I am currently at the Johns Hopkins Hospital, where I serve as the Vice Chair of Clinical Operations for Surgery. I’ve been working on this public health problem for over a decade. As a health care professional and someone who takes care of these patients day in and day out, I really have pushed myself to think beyond the operating room and trauma center. The concepts of how we approach gun violence in America, as Dr. Benjamin and others have suggested, is what led me to go to the Kennedy School and spend a year gaining a better understanding of the importance of public policy in tackling such a complex issue. I was then able to take that theoretical understanding and spend a year in the United States Senate as one of the National Academy of Medicine Robert Would Johnson Foundation health policy fellows. I was fortunate to land in the office of Senator Maggie Hassan, where I really started to understand the practical aspects of how we accomplish carrying out important pieces of legislation that can impact millions of people. It has been a real privilege and honor to work on gun violence in America and to really explore how to provide the best medical treatment, which is clearly prevention.

It may be no surprise by now that we often talk about this issue that’s centered around mass shootings, which is why I think it is critical to make sure that people understand the reality of everyday gun violence in cities like mine, here in Baltimore, where there are young Black men being slaughtered on our streets. Those stories are critical. We have both the opportunity and the responsibility to elevate and tell those stories and to figure out how we really empower the community to be part of the solution. And that’s what we try to do. I appreciate being part of this conversation and look forward to further discussion.

G Richard Holt

Thank you. Each of you brings that unique perspective that I mentioned. I’m an otolaryngologist, head, and neck surgeon, but my primary focus has been and head, neck, and facial trauma, care, and reconstruction. Like Dr. Benjamin, I also had long service in the military, including 2 combat deployments caring for patients with combat injuries. The topic for this conversation is one that is of great interest to each of us, as well as to our professions and society. The recent terrible tragedy in Uvalde, Texas, which is just west of San Antonio, has really brought gun violence home to a lot of us in Texas.

Etiology of Mass Shootings in the United States

G Richard Holt

Let’s move on now to discuss the background of mass shootings in the United States. What in your estimation are the major reasons driving the American epidemic of mass shootings and gun violence?

David C Grossman

I think that’s an important question, but not one that’s easily answered. Mass shootings are really just the very tip of the iceberg of the underlying problem of gun violence. Still, despite their horrific impressions and trauma that mass shootings create in our society, they’re still only a drop in the bucket relative to the overall magnitude of gun violence and suicide that we see in our society.

I think that mass shootings probably are correlated with the broader problem of gun violence and suicide, and when we see surges and overall gun violence, we also see surges and episodes of mass shootings as well.

Having said that, I don’t think we can say for sure what’s driving it, but it is my opinion and I strongly suspect that the social upheaval and the increased inequality that we’ve seen come to the fore during these past 3 very tumultuous years have exacerbated violence. I think it’s time for us to come to a resolution as to how we define a mass shooting. There is a lot of inconsistency in this country on how mass shootings are defined and who defines them, and that’s a prelude for us to be able to do a better job of tracking and analyzing these events.

Georges C Benjamin

I would agree that we don’t have a firm understanding of the etiology of mass shootings. The challenge we have, of course, is that everyone is looking for a single solution to mass violence and at the end of the day, violence is the one thing that we know is common to all of them.

I think that anytime you have a complex human problem, it requires a complex solution. So while we do need to better understand the exact etiology of mass shootings, and understand the minds of the people who perpetuate this violence, we also need to think about how we craft solutions.

The other thing is that we have to be careful that we don’t classify all mass shootings in the same manner. A shooting by a group of folks engaging in violence over drugs is a different kind of shooting than if someone goes into a school, such as what happened at Uvalde, Sandy Hook, or Columbine. The motives of the shooters are obviously very different for each of those events.

So, we have to make sure that we don’t continue to think of mass shootings as all being in the same category, but rather we must view them as a group of violent acts. From there, we need to figure out how to subcategorize them. I would anticipate that the solutions for each of the different classifications of mass shootings would simultaneously bear some common aspects as well as have some distinct solutions.

Joseph V Sakran

I agree in general with the other comments that have been made so far about the etiology of mass shootings in America. For me, when I think about this, we must first recognize that it is a multifaceted problem. One of the things that always remains at the core of this issue is the easy access to firearms. When you look at the evidence, it consistently shows that access to firearms increases the risk of suicide. Access to guns in the home increases the risk of homicide. This concept is abundantly clear time and time again. What we saw in Buffalo combined easy access to weapons with hatred. When you combine easy access with impulsivity, it is a similar result. You could think about a hub-and-spoke model where the central part of that figure would be the easy access to firearms. Without oversimplifying, I think that is one of the core problems that exist in America.

Of course, we cannot talk about this without factoring in the inequalities that exist. We have to understand and address the social and economic inequalities that are, I believe, the root cause of gun violence that often impacts communities of color, whether you’re looking at income inequality, poverty, public housing, underperforming schools – those factors create a disparity that are part of that root cause. Thinking about this in the spirit of a public health approach, it is critical to recognize that there is not going to be one single solution to the problem. We have to tailor the solutions to the specific gun-related injury we are attempting to impact. That being said, the easy access to weapons continues to fuel this public health crisis and is a central part of this problem.

Mary Ellen O’Toole

Each of the comments that have been made so far are excellent, and allow me to add to this.

Working in the BAU with the most violent of offenders, from serial rapists, serial sexual killers, and mass shooters, etc., doing research on these cases, and talking to offenders and reviewing their crimes, we know that violence really begins in the brain. Now, what does that mean? It can mean a number of things, but we know that some of these acts of mass violence are very well planned ahead of time. They are not impulsive. And the planning first includes developing a mindset by many of these offenders in which, from their perspective, people have become objects to them. In other words, when the shooter dehumanizes people, even strangers can become the target of their hatred. When you hate someone and dehumanize them, it’s easier to destroy them. Along with dehumanization, there is a profound loss of empathy and loss of compassion for others. The shooters develop a mindset based on this anger and hatred and perception of the world and blames others for their problems, situations in life, losses, and failures. They see the world as “me against them.” The development of this type of thinking in which people become objectified can take a long time to develop and it has to be reinforced by one’s environment, other similar-minded people, or online interactions. It can take weeks, months, or even years to happen. It does not just happen overnight. In the case of Charles Whitman at The University of Texas back in August of 1966, it took years for him to get to the point to form the belief that killing people was the answer to his hatred and his life’s problems.

It is important to understand that deciding to engage in these kinds of violent actions is a developmental process that takes time, and over time these shooters still live in homes and in neighborhoods and with people who care very much about them, and see them frequently, if not every day. During this time, these offenders begin to demonstrate behavior that we call “warning behaviors,” which are observable by the people around them. These warning behaviors can include a young man’s immersion in computer games (games, online conversations with strangers, etc.) that focus on murder and mass killings. He may become more isolated and withdrawn from the rest of the members of the household, preoccupied with other mass shootings, acquire firearms and ammunition, talk about prior mass shootings in ways that suggest his admiration for prior shooters, and leak behavior in which he forecasts his intentions by posting photos of his weapons online with threatening comments. He may also make comments or threats to other people, or act out violently toward others, for instance. At the same time, he can also seem depressed, appear to be very angry, and emote an overall nihilistic view of the world.

Recognizing these pre-incident behaviors is important in order to understand all the contributing factors to the shooter’s decisions to following through with a mass shooting. It is also critical that we understand how these decisions evolve and who is in a position to spot a shooter’s behavior as he moves forward with his plans.

For someone like me who wrote about warning behaviors over 20 years ago, it’s frustrating to know that we are still discussing the importance of educating people about warning behaviors. Why do the general public and other professionals not know about these behaviors or become trained to spot them so they can do something when they see them? For these more predatory, well-planned kinds of shootings like we saw in 2022 in Uvalde, Buffalo, and Illinois, these shooters took their time before reaching the point where they make the final decision to act out and strive for maximum lethality.

This period of planning and plotting, during which warning behaviors are visible to people around them, must become an important part of the conversation. Watching for these warning behaviors and then knowing what to do and who to contact is crucial. We can no longer default to saying these shooters just suddenly snapped.

Psycho-Social-Medical Aspects of Mass Shooters

G Richard Holt

Thank you, Dr. O’Toole. You’ve actually provided a very good lead-in to the next question, which will be directed to the 3 physicians in the discussion. Are there any kinds of early screenings that physicians and other health care practitioners, including those who care for children, could use in trying to identify tendencies that might indicate a cause for concern with respect to future violence?

Georges C Benjamin

I’d like to start by pointing out that people with mental illnesses are much more likely to be victims of violence than to perpetuate violence. Having said that, individuals who are bereaving, who have had an acute loss, or who have a mental illness with severe depression are at increased risk for suicide overall, and of course, the presence of a firearm makes that that act more likely to be successful.

Additionally, being in relationships in which violence is present and a firearm is available puts those individuals and the people around them at risk of death or injury by firearm. Furthermore, when alcohol or other substance use and a firearm coexist, firearm injury certainly becomes an issue.

Knowing that your patients have a firearm in the home and encouraging them routinely to store that firearm safely in the home is part of a routine review of systems. It’s something that was always done as part of routine screening as a physician based on age appropriateness or clinical condition. I am sure Dr. Grossman will have more to add regarding screening within the pediatric patient population.

David C Grossman

I think Dr. Benjamin covered it really well. Dr. Benjamin gave an example of screening for depression that could be followed by screening for firearm ownership in select cases as a pathway for firearm safety screening in mental health. Kaiser Permanente physicians and other clinicians are following this exact path in patients with severe depression. It is certainly very logical and plausible from the intervention standpoint. Screening for depression with a validated tool is already widely embraced as an important preventive service. At Kaiser Permanente, those patients who endorse suicidal ideation receive further screening to understand who is at high risk for suicide. Those who are at high risk for suicide can receive further screening about firearm access, and if they endorse suicidal ideation, care planning can ensue to decide how to keep that patient safe. That’s where red flag laws can also come into play.

Although your question is focused on screening for behaviors, I’d like to expand it to also address screening for gun ownership. We have to be knowledgeable about the interaction between behavior and the access to a gun, and ultimately we need to be looking at both. In the pediatric population, screening is usually just about the safety of the environment, as Dr. Benjamin was describing, and the presence of an unlocked gun constitutes an unsafe environment for the child or teen. Our Kaiser Permanente care delivery team and the Care Management Institute have done a lot of work to integrate firearm access screening into pediatric care and have piloted tools and resources with our physicians and members.

Coming back to mass shootings, we do not have strong evidence about screening in a clinical setting for future assaultive behavior. Maybe Dr. O’Toole can tell us more about that in terms of her experiences within the FBI, but certainly we don’t have good workflows or thoughts about doing that other than looking at victims of violence and addressing potential interventions for those that were injured.

I want to also mention that Kaiser Permanente is planning a new Center for Gun Violence Research and Education, where we hope to continue to stimulate the generation of new knowledge through research. We also plan to use the Center to educate the public, as well as health care and public health professionals, about the public health approach to addressing gun violence.

Joseph V Sakran

Drs. Benjamin and Grossman covered it really well, but I’ll just add just a couple things. The reality is that as health care professionals we often miss the screening piece. This is happening for a whole variety of reasons. I’ve spoken with a number of different physicians and health care systems and have found that depending upon the socio-geographic region or depending upon whether participants were raised with a firearm in the home or not, many of us involved in conversations with our patients may or may not be comfortable talking about this in a what we feel is an educated, objective, and nonjudgmental way. This has been some of the work that we’re trying to do. We are focused on how to empower clinicians across the entire health care spectrum to be able to have these conversations in a way that is thoughtful and helps us address some of these root issues so that we can identify those who may be a danger to themselves or others.

We also continue to work with responsible gun owners to ensure we have incorporated the voice of these important stakeholders and message concepts such as safe storage in the right way. We don’t do it nearly enough, and this is an area of opportunity that needs to be broadened. The American College of Surgeons committee on trauma Firearm Strategy team (FAST) has done a great job of doing this work. When you think about other public health efforts our nation has had to tackle—whether it’s obesity or smoking, for example—we have to get to that point where talking about gun safety with patients becomes second nature. I think this also goes back to what we were initially talking about, which could include screening for intimate partner violence, for instance. The presence of a firearm increases the risk of death for individuals involved in intimate partner violence by 500%. Therefore, thinking about how can be best working with these different demographics and groups is so critical.

G Richard Holt

I have noticed over the last 5 years or so that several of the electronic health records (EHR) that that I use have had questions for patients appear in new versions, including whether there are firearms in the home, and how are they are stored.

I also see questions in the EHR about whether the patient feels uncomfortable or unsafe in their home environment. Are they in a dangerous situation? Are they fearful in the home? I think that’s a good start because these are questions that have to be answered in the EHR, which means hopefully they’re being asked as well.

Joseph V Sakran

I think Dr. Holt’s point is absolutely critical regarding the questions around gun safety counseling that are now beginning to appear within the EHR. We’ve definitely made some headway that has allowed us to move the needle forward here and are beginning to train the next generation of health care leaders to discuss this with patients. What we found and heard, especially from gun owners, is that a health care professional may ask about guns in the home, however, they stop with that question. They are often unsure how to take the conversation to that next step, which is a really interesting perspective and insight.

One of our gun violence researchers, who happens to be a gun owner as well, had this experience with one of her child’s pediatricians where he has asked if she had a firearm in the home. The prompt was surprising and welcomed by this gun owner, but there was no follow-up to that question. So you’re absolutely correct that we have definitely made some headway, and we need to continue building out that infrastructure to take it to the next level. Health care organizations like Kaiser Permanente, Johns Hopkins, and the American Public Health Association have the ability to come together to really scale the existing progress and empower individuals and organizations to move it forward.

G Richard Holt

Thank you very much. The next question relates to the types of perpetrators of these acts of violence. What is the current state of knowledge surrounding the neurobiology of these individuals, and specifically in many cases, why do they happen to be White males?

Mary Ellen O’Toole

I’d like to answer this question from a behavioral perspective, which is my background and training. There are many contributors to what causes someone to move down the trajectory toward becoming violent. It’s remarkably unknown to so many people in our society what causes a person to become violent, and what violence actually looks like. Does it look like a depressed young man? Does it look like an angry young man? Is it a single hormone or a single personality trait? There are a lot of misconceptions about what causes someone to become violent. We know there is not a single cause. Having so many personal opinions out there among the general population about what does lead to violence is a problem and interferes with our developing a collective effort to teach people what to look for.

As I’m listening to Drs. Grossman, Benjamin, and Sakran talk about the value of intake with a young person and their family, this becomes so critical because violence frequently begins to manifest itself inside the family home. Family members may say things like, “Yes, our son does act differently at times, and he can be scary, but we just thought he was behaving like his grandfather did years ago and it probably does not mean anything. Anyway, he’ll grow out of it.” This type of interpretation serves only to normalize the behavior. When that happens, there is no follow-up and, more importantly, no help and/or intervention. Again, educating people pre-incident about warning behaviors is critical. Knowing what these behaviors are is no longer only important for law enforcement. Everyone has to be trained about what to look for.

There is a lot of debate about whether this is predominantly a White male crime. When the statistics get broken down, there are many experts who suggest that the numbers of White males involved in these crimes is proportionate to the overall number of White males in our society. I think it’s particularly important to look at the fact that this is predominantly a male crime and that in our society and in our culture, violence is projected differently depending on the gender of the perpetrator. Females can be violent, there’s no question about that, but it tends to be in a less predatory and overt manner than the way males act out violently. Also, I do think that when you look at some of the cultural contributors to mass shooting violence today, you see a number of contributors that can influence specifically young men.

We have subcultures today in which young men can feel aggrieved, angry, and want revenge for the problems in their lives and they sometimes look to groups, particularly online, that espouse similar feelings that they can identify with. Or, these young men can study other mass shooters, most of whom are also males, and follow their development and their crimes. We saw this following Columbine, and now we see how shooters today will study prior shooting cases and emulate aspects of past shooters and their crimes. Future mass shooters will likely go back and study how previous shooters committed their crimes, including locations where past mass shootings occurred, how they carried out their crimes, how they dressed, and the types of weapons that they used. Knowing about this type of copycat behavior is important because it can help us to better understanding how influential past mass shooting cases are to future shooters and why, in part, these crimes are predominantly perpetrated by males because males are modeling other males, as opposed to female mass shooters whose numbers are significantly smaller.

Mass Shootings and Medical Preparedness

G Richard Holt

Let’s transition now to the issue of preparedness in the medical setting to discuss violence in hospitals and clinic settings and preparing for prevention and response. Perhaps some of you have had some experience with that. What do you think is the general level of preparedness of hospitals and medical facilities to prevent violence in those settings, and are there any changes that might improve preparedness?

Joseph V Sakran

It’s absolutely tragic, and the impact of violence being experienced by both patients and health care workers is frankly terrifying. Recently I co-authored a piece in the Philadelphia Inquirer titled “When Gun Violence Comes Into the Hospital” ⁴ that highlights the impact in hospitals across America. We all want to feel safe when we come to hospitals, but the reality is the impact on hospitals is more mon than you might think. In 2010, at Johns Hopkins Hospital, a distraught family member shot a surgeon and then killed his mother and himself. ⁵ In fact, violence may be more common than you in think among health care workers. The United States Bureau of Labor Statistics reports that in 2018, 73% of all intentional workplace injuries were comprised of health care workers. ⁶

As we think about overall preparedness, it is important to recognize that there are some common themes that exist and, in fact, these themes may be very similar to the issues that we see around trauma systems. The 3 broad categories that can be problematic as it relates to being prepared to respond, whether it’s a mass shooting or some other disaster: communication failure, if there’s untested or unworkable plans, and if there’s lack of a coordinated response.

It’s those tenets that that often leave us rushing around trying to figure out how to respond during the immediate aftermath of an event. When we think about how this is structured within the overall public health system and how we interact in cities, some key pieces are missing. The first is that the public health efforts have not been really organized for success. What I mean by that is that when you think about it, the fact is that there are over 3,000 state, local, and tribal health departments, but there’s no actual single person or entity that’s coordinating those efforts and really helping organize this as a national public health effort, and that is problematic. I think there’s also been significant underinvestment and chronic underfunding, both in preparedness and in public health, and that has left behind a very weak infrastructure that, frankly, is antiquated and this just adds to the overworked and stressed workforces that all of us are seeing in hospitals all across the United States.

Also, from a health care system perspective, we’re missing the opportunity to figure out how to convert some of the collaborations that we have within cities with the public health agencies during emergencies and make this into something that is sustainable and really allows us to address some of the day-to-day challenges and scenarios that we experience. All of this is underscored by the fact that there is a significant amount of misinformation and frankly a lack of trust that we are facing across the country as it relates to the health care infrastructure. There are a variety of things we need to do to eliminate those gaps such as appointing a national coordinator to be in charge of operationalizing the numerous public health entities that exist. This was recently recommended in a report released by The Commonwealth Fund titled "Meeting America’s Public Health Challenge” ⁷ among other recommendations. Hospital preparedness also requires development of local, state, and regional systems by ensuring that 3 core systems are working together: the acute health care system, the public health system, and the emergency management system. ⁸ There are examples of this being done well, such as setting up of a regional medical operations center to help ensure a single point of shared situational awareness that can help effectively coordinate response to mass casualty incidents or other disasters.

Georges C Benjamin

The best way to ensure that you don’t have violence in your facility is to reduce violence broadly in your community. It is also important to ensure that people working in the health care setting are well prepared and understand de-escalation techniques. When I ran an emergency department, we always had protocols, and would practice those protocols we had prepared. We identified patients who might be at risk for violence either because they were impaired by substance use, mental illness, or dementia, for example.

We also worked very hard to make sure that we collaborated with one another because one of the things we are increasingly seeing, for example, is violence against nursing staff within hospital emergency departments. Many patients are treating the staff with disrespect. Obviously respecting one another is a two-way street, but it quite often starts with someone in the emergency department or the hospital who feels they’ve been aggrieved. There have been situations when a single staff person is around someone who, quite frankly, in retrospect, posed a risk that was not previously identified. Making sure that we’re collecting the data and identifying those risks early is important.

Staff who are under stress can behave just as badly and dangerously, just the same as staff anywhere else. Staff who come into hospitals and perpetuate violence within the work setting is another big issue. I recently saw a tragedy in Tulsa, Oklahoma where a patient went in and killed 4 people including 2 physicians, one of whom was his orthopedic surgeon. ⁹

I am only familiar with this particular story based on what I saw in the papers, but anytime a patient feels that they’ve been aggrieved, it poses a risky situation and people need to not just assume that it will go away and people need to begin to assess those situations in terms of their relative risks as part of that process and put in place a series of barriers so that staff feel protected within their work environments.

David C Grossman

I don’t have a lot to add other than to point out that according to Occupational Safety Health Administration statistics, hospital workers are at an elevated risk for violent injury relative to workers in other industries. So we do have a problem in our industry and we need to be thinking about it as Dr. Benjamin is describing, meaning the hospital as a microcosm of the broader community.

What happens around the hospital influences what happens within the hospital. Nonetheless, we still need to think about the solutions from a public health standpoint. There are gross deficiencies, some of which are related to the absence of consistent systematic data and absence of standards across jurisdictions and these sorts of things, as Dr. Benjamin pointed out. We also have to be prepared to address the psychological trauma that is experienced by victims, witnesses, and our staff. This type of trauma is long-lasting and requires our attention.

There are resources and out there and available for systems, but this area of focus clearly needs more attention.

Georges C Benjamin

In the 1980s, a gunshot wound to a patient who came into the emergency department was generally a single violent event. A knife fight was also generally a single violent event. But now what often happens is that individual gets patched up, they go out, they’ve been aggrieved, and then somebody else comes back in either more seriously injured or dead, or someone comes into the emergency department of the hospital to finish the job. So I think we have to recognize that those situations are very high risk. Just as the Police Department sees a domestic violence call as a high-risk situation, we need to plan for those as part of hospital policy and procedures.

Traumatic Aftermath of Mass Shootings

G Richard Holt

Thank you. Excellent thoughts and comments. I’d like to transition to addressing the aftermath of some of these tragedies, especially to consider how communities rebound. How do communities find their way back after experiencing a mass shooting event?

Mary Ellen O’Toole

This is a very important question and a very complicated one. Communities that experience these horrible crimes need so much support both immediately and years into the future. It’s not just about counselors coming in and talking to people or the provision of other critical support services. It’s not just about money or promises of fixes that may never happen. It’s about being heard and having people in power like legislators, politicians, and community leaders truly listen to the victims’ families and members of the affected communities, and following through with their suggestions and recommendations. The affected communities need to be heard and when they say “enough is enough, change is needed,” that message cannot be ignored. But, unfortunately, too often it is. Affected communities want action. They want to make sure that the shooting of their loved one that completely uprooted their community won’t be forgotten. When we look back at a number of these shootings, we hear passionate messaging from survivors and family members that unfortunately often fall on deaf ears, especially when it comes to the legislators, people who more than anyone can make the requisite changes. What has happened in past cases is that affected communities, after expressing their ideas and demands for change, feel marginalized. This is one of the worst things that can happen to a victim of violence. Demands for change by affected communities and victims cannot continue to be trumped by political agendas.

As I see it, it’s really important to have an understanding of the strong and life-changing generational damage these events have on the surviving family members and their communities. These tragedies are not something that will ever go away for them. It will always be there for them. We have to understand there is no such thing as closure in these cases. Sadly, the people that they’re counting on to hear them, to understand them—the people that they feel can fix things—oftentimes are falling short of their responsibilities to make the requisite changes, or to stay committed to the requests of the families.

Too often, we allow the cycle of violence to repeat itself without the change necessary to impede it, let alone reverse it. We basically and unfortunately move on too quickly from one tragedy in order to prepare for the next one.

There is someone right now, in their basement or in their bedroom, who is planning for the next mass shooting, and they are learning from what happened in Uvalde, Buffalo, Illinois, and from other mass shootings. And the voices of those forever impacted by those previous cases will become fainter and fainter over time. There are lessons learned from the past and we continue to ignore many of them and it’s just heartbreaking that we seem to be OK with that. People in grief can be remarkably astute in their solutions. They just have to be heard to be understood.

Georges C Benjamin

I think the first thing we ought to add to what Dr. O’Toole said is we also need to remember that everyone who is in the community where a mass shooting has occurred has been impacted. That includes the police and first responders, EMTs, and paramedics. They are placed in a unique situation because they have to show a “stiff upper lip,” so to speak.

I’ll share a few thoughts related to tragedies not related to a shooting. A hurricane went through southern Maryland when I was the health officer for Maryland. Every elected official that was in that community was severely impacted, but they could not show their grief, often because they needed to focus on the community’s needs over their own. Many of them lost their homes and all their worldly possessions.

We saw a similar scenario during Hurricane Katrina, when people came to work every day after they had lost everything.

We have to remember that the responders know the people that are experiencing these tragedies as fellow members of the communities they serve, particularly in smaller communities. They, too, require support. It may need to be more private, but they need to have that kind of support as well.

Part of this process of transitioning communities is to recognize that there s a range of folks needing support. These events have long tails.

I was recently troubled having seen interviews with some of the children who were directly impacted by the shooting in Uvalde. Whereas it’s important to understand their feelings, my concern is not only for how they are processing the shootings, but how others are processing it as well. We should remind ourselves that the children who are watching the news may very well be impacted by reports about those shootings too. Children can discern reality from fantasy.

We saw that in Illinois. It was reported that a 2-year-old child cried out for his parents who had been shot and killed. ¹⁰ Even our youngest children in today’s environment understand the impact of a violent act. It is going to take some work, realizing that that the whole nation was traumatized when we saw that.

G Richard Holt

Yes, and many physicians in those communities are spending a good deal of time supporting their patients and talking with them about how they’re dealing with the mental health strain these events are causing. These events impact everyone right down on the community physicians as well.

Joseph V Sakran

It’s important to recognize that as health care professionals where we also face the risk of traumatic events, we often don’t take the time to think about this. There is a term that we call the “second victim,” and this experience can be incredibly devastating. We at Hopkins have created a program called RISE (Resilience in Stressful Events) ¹¹ where essentially, it’s caring for the caregiver. This program allows the hospital to really set up a peer responder program that delivers what we call “psychological first aid and emotional support.”

It’s not just health care professionals, of course, but taking the time to realize that these events are so traumatic to so many of us in the communities that we’re living in and recognizing that, yes, we may have to be tough in the moment in order to do our jobs, but we also have to unpack the emotional and the mental trauma that exists from having to go through this time and time again. This is so important.

Historically we have brushed this off and chalked it up to it just being part of our jobs. However, just like everyone else, we are just as vulnerable and human. Everyone deals with grief in their own different ways. That’s the other piece: understand that not everyone is going to be able to deal with the stress caused by these events in the same way, and you may have to adapt and adjust. The first step is recognition.

David C Grossman

Dealing with the aftermath and trauma, including emotional trauma, from violence extends well beyond mass shooting events. Emotional trauma can also follow a single death, especially a violent one or a suicide. I conducted research in Alaska Native villages on suicide prevention and gun storage. My colleagues and I conducted a randomized controlled trial a decade ago, evaluating behavior change following the provision of a gun safe to improve storage of guns in those villages. ¹² I was deeply impressed by the collective trauma in the village that ensued, after even a single suicide in those villages, which ranged in size from somewhere between 50 and 500 people, for the most part.

Even a single firearm death actually can have fairly significant consequences to the overall community’s sense of grief and loss.

It’s certainly an important area and one where I think research really needs to be ramped up in terms of identifying the best and most effective types of intervention in those circumstances.

Policy Implications

G Richard Holt

Dr. O’Toole brought up the idea about policymakers needing to better listen to the communities. Where should our policies be directed and how should they change considering these tragic events?

Mary Ellen O’Toole

In my opinion, the policy response really needs to be reflective of the needs of the community and society at large. Victims and affected communities relay to our policymakers what their biggest concerns are, and it’s repeated time after time. Nonetheless, it is too often the same kind of commentary after every mass shooting event. Many policymakers tend to immediately opine on the mental health status of the shooter. Although mental health is a legitimate issue, it’s worth pointing out that often when these remarks are made, the policymaker or community leader does not know anything about the shooter, and certainly nothing about the shooter’s mental health. It’s a preemptive remark to shift the conversation to a solution that might not even be applicable, or worse, more comfortable for the speaker.

Quick opinions proffered by leaders in our communities following a mass shooting can be a problem that misleads the public, and ultimately even the investigation.

Frequently, policymakers and community leaders will immediately describe these crimes as being the crimes of an “evil” person or a “monster.” That kind of thinking catapults us back to the 14th century when people thought werewolves were responsible for violent crimes and evil was committed by a being with a spiritual defect.

This type of explanation for violence demonstrates a lack of understanding of what precipitates and causes and contributes to violence and it misleads the public by suggesting to them what to look for in their community regarding who this violent person is—an evil monster. Fantasy theories of crime have no solutions. These shooters are human beings who developed over time and made calculated decisions to engage in violent behavior, while manifesting observable behaviors along their trajectory.

Survivors and communities where these shootings occur want and need help from their leaders and policymakers. Communication between all facets is critical. But policymakers and community leaders have to listen before they reach and publish their opinions. These knee-jerk responses to explain how violence occurs often involves solutions that are, simply put, not only inadequate, but just wrong.

David C Grossman

When I learned about the tragic assassination of the Japanese former Prime Minister, I also learned that Japan experienced 9 gun deaths in 2018 and only 1 gun death in 2021. ¹³ This is such a telling contrast to what we have going on here in this country and it should give us great pause. The vast difference, no doubt, relates to the gun supply in Japan compared to that in the United States. Dr. Sakran began to address this by describing how the public health approach often starts with the environment. We know the environment is key as a key driver of the gun violence epidemic in the United States, and we must focus more carefully on access to highly lethal weapons, especially with certain populations.

Dr. Tom Frieden, the former CDC director, put forward the concept of the health impact pyramid (Figure 1) as a framework for public health action. We know that we will have more impact, and less expenditure of effort, if we can address the underlying social determinants of health, disparities in health, and the environmental context in which people live. There are policies targeting individuals, such as red flag laws, that are promising, but don’t address the social and physical environment in which people live. It’s not to say they’re ineffective, but we need to be thinking about policy that will have a broader impact and that addresses the much larger social context when it comes to violent gun deaths.

Figure 1:

Reproduced with permission from Frieden TF. A framework for public health action: The health impact pyramid. Am J Public Health. April 2010;100(4):590–595. DOI: https://doi.org/10.2105/AJPH.2009.185652

Joseph V Sakran

What a big question. Let me start in a positive way first. I know it may not seem this way, but I would say that the country has changed when you think about where we are now compared with where we were 10 years ago. There have been hundreds of pieces of common-sense legislation that have been passed in states all across America. Of course, we know that’s not enough because our state borders are open and people can go back and forth. That’s why we need federal legislation.

I think all of us were quite happy to finally see some action after nearly 30 years regarding the law that the President just finished celebrating on July 11, 2022. ¹⁴ That has to be recognized as a first step. As Dr. Benjamin said, there’s no single solution. A multifaceted approach is required in order for us to affect maximum change. We really have to be able to understand and engage with the depth and the breadth of the problem. We have to implement targeted policies to really address concentrated poverty, underfunded and underperforming schools, and an unfair criminal justice system.

This is critical because I think as all of us recognize, only policy can fix what policy has created in the first place. If we’re going to continue moving toward a public health approach, we have to focus our efforts to reduce violence in ways that really reflects the broad complexity of this problem in a multifactorial nature.

The last thing I’ll say is that policy, frankly, has been used as a tool of oppression. When we think about the public health problems we’re facing, we’re in a phase now where we’re equipped with the ability to eliminate the health inequities that continue to decimate a lot of the communities across the United States. I think honoring that indiscretion begins with implementing actionable solutions that chip away at the existing inequities so that we can finally realize how to function in a healthy, equitable, and inclusive society.

This issue is not a Democrat issue, it’s not a Republican issue. It’s a uniquely American issue and we need to leverage the commonality that exists among us as Americans to make communities safer.

Georges C Benjamin

Excess death, disability, and injury is preventable. We know that our policymakers should be problem solvers and not ideologues. I believe very clearly that the approach has to be to identify the problem you are trying to fix, to identify risks and protective factors, implement those protective factors, track the solutions, do the evaluation, and then do more.

It is a public health problem and in our lane, because it kills people, and hurts people, so therefore it’s a public health issue—policymakers need to park their ideologies at the door and solve this problem because this is out of control.

And I would argue that should they do that, it would be good policy, and good policy is good politics. And we can do that even though we have the 2nd Amendment. We can do that even without restricting (in most cases) responsible, law-abiding gun owners, from maintaining ownership of their firearms.

We have to do some things differently in our country, and unless we have the help of policymakers, this problem is not going to go away. This is clearly at their feet because they’ve crafted an environment wrought with problems that only they can solve because they put in place barriers for the regulators, for litigation lawyers, and they have handcuffed the police. Until they take those cuffs off of all of our arms and change those policies, we are going to continue experiencing mass shootings in our country.

Again, it must be understood that no single individual or single policy is going to immediately solve the problem, but it is a solvable problem because other nations have solved it.

G Richard Holt

Thank you, Dr. Benjamin, for the upbeat final comments there. I’d like to thank each of you for taking the time to join this panel discussion and to give your astute professional opinions on some of the most pressing issues with which the American public and health care professionals in the United States struggle. These are concerns for all of us.

It’s been a real honor to meet each of you on this panel, and we wish you the very best. And again, we’re very appreciative that you shared your expertise with The Permanente Journal and its readers on this timely and challenging public health issue.

Disclaimer

The thoughts, ideas, and positions expressed by the panelists in this discussion are their own, and do not necessarily reflect the positions of their respective organizations or employers, and do not reflect the position of The Permanente Journal or The Permanente Federation LLC.