September 8, 2023 • 31 mins
This episode is part 1 of a 3-part series and addresses gun-related violence as an epidemic in our country. Dr. Alisa Haushalter, former Director of the Shelby County Health Department in Memphis, Tennessee is my guest. Dr. Haushalter is currently an Associate Professor at the University of Tennessee Health Science Center in the College of Nursing. Join us as we discuss the trends and the attempts to mitigate gun violence.
Resources: https://www.pewresearch.org/short-reads/2023/04/26/what-the-data-says-about-gun-deaths-in-the-u-s/
https://www.apa.org/pubs/reports/gun-violence-prevention
https://www.cdc.gov/violenceprevention/firearms/fastfact.html
https://www.nursingworld.org/news/news-releases/2023/ana-2023-ma-gun-violence-recommendations/
https://www.aha.org/public-health-approach-addressing-gun-violence
https://www.commercialappeal.com/story/opinion/2020/11/12/shelby-countys-gun-violence-epidemic-public-health-concern/6265806002/
https://dailymemphian.com/article/17944/opinion-gun-violence-is-a-public-health-issue-memphis
https://www.tnpublichealth.org/assets/docs/Letter%20to%20address%20gun%20violence.pdf
https://en.wikipedia.org/wiki/Luby%27s_shooting
https://time.com/6309961/tennessee-cameron-sexton-shove-justin-peason-guns/
Resources: https://www.pewresearch.org/short-reads/2023/04/26/what-the-data-says-about-gun-deaths-in-the-u-s/
https://www.apa.org/pubs/reports/gun-violence-prevention
https://www.cdc.gov/violenceprevention/firearms/fastfact.html
https://www.nursingworld.org/news/news-releases/2023/ana-2023-ma-gun-violence-recommendations/
https://www.aha.org/public-health-approach-addressing-gun-violence
https://www.commercialappeal.com/story/opinion/2020/11/12/shelby-countys-gun-violence-epidemic-public-health-concern/6265806002/
https://dailymemphian.com/article/17944/opinion-gun-violence-is-a-public-health-issue-memphis
https://www.tnpublichealth.org/assets/docs/Letter%20to%20address%20gun%20violence.pdf
https://en.wikipedia.org/wiki/Luby%27s_shooting
https://time.com/6309961/tennessee-cameron-sexton-shove-justin-peason-guns/
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
This episode is part one of athree part series on gun related violence.
In this episode, I mentioned theshootings at post offices nationwide that began in
the nineteen seventies and the Luby's cafeteriashooting in nineteen ninety one. These were
horrific acts of violence. As allof these mass shootings have been I looked
(00:20):
up at these incidences and read thenames of the victims as a reminder to
me of all the lives that havebeen lost. The special legislative session in
Tennessee to address guns was mentioned,and this episode is being aired after that
session. I will provide a linkto some of the details in that session,
which has since ended. These episodesare dedicated to all of those who
(00:41):
have been victims of gun related violence. Welcome to That's Healthful, a podcast
about health and advocacy with a specialfocus on rural and vulnerable populations. Now
here's your host, family nurse practitionerand health advocate, doctor Lisa Beasley.
Today, I want to talk aboutan epidemic in our country, and that's
gun related violence. Gun violence isrelated to our physical health, our emotional
(01:06):
health, or mental health, whichis why this episode is important and today
My guest is doctor Elisa house Halter, and I would like to welcome you,
doctor house Halter. Thank you forhaving me. I'm glad to be
here and really glad to talk aboutthis very important public health topic. Can
you please let folks know a littlebit about you. Sure. So.
Currently I'm associate professor here at UTbut the majority of my career about forty
(01:30):
years, has been spent in publichealth practice, and most of that within
the Nashville area, but also herein Shelby County as director of the Health
Department, and I was there forabout five years. So I have a
lot of practice experience in public healthand injury prevention, including gun violence.
Prevention has been an area of interestto me really for probably thirty five of
(01:53):
those forty years. So what isgun violence or gun related violence? Gun
violence is any type of injury ordeath as a result of guns. But
the Center for Disease Control and Preventionidentify five different areas of gun violence,
and I think it's important to teasethose out because they are quite distinct and
(02:15):
do influence what interventions we might putin place to be able to reduce those
particular injuries. The first is intentionaland self inflicted, so that would be
suicides or attempted suicides using a gun. The second is intentional but inter personal,
intended to harm another person, andthat could be a homicide or attempted
(02:36):
homicide. The third is what's viewedis unintentional accidental, and that might be
someone who is injured or dies asa result of say cleaning their gun or
child finding a gun. There wasn'tany intent associated with that particular injury.
The fourth is legal intervention, andthat's a person who may experience an injury
(02:58):
or death during a police intervention orwhat's considered a line of duty injury,
and those are separated out because theinterventions obviously would be quite different. And
then the last is undetermined, whereit's really not clear what the mechanism or
intent was relative to that particular injury, and it can be anything from just
(03:20):
that an injury all the way upto death from that injury. How prevalent
is gun related violence in our countrytoday, so gun violence really is viewed
as an epidemic within the public healtharena because it has continued to grow as
an issue. The data that wehave most recently is the majority of national
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data is around twenty twenty one,and what we know in twenty twenty one,
almost forty nine thousand people died asa result of gun related injuries.
Within that forty nine forty eight,eight hundred and thirties, so almost forty
nine thousand, over half of thosewere self inflicted suicides, around forty three
percent were homicides, and three percentfell in those other categories or what we
(04:04):
would list as others. But whenyou think about that number of people,
that's a significant number of people,and it doesn't reflect those who were injured
but recovered from their injuries or sustainedlife altering injuries. And so the number
obviously is much greater than that fortyeight, eight hundred and thirty that I
(04:25):
mentioned. We do know that inTennessee, specifically, in twenty twenty,
we had fifty five children die asa result of gun injuries. And also
in twenty twenty we had thirty eightchildren die by suicide and fifty percent of
those or nineteen or a result offirearms. And if we bring it even
more closer to the Memphis community,because this is something that is in the
(04:47):
news quite a bit, is thatwe know that in twenty twenty two La
Mon treated over one hundred and fiftyfive children who suffered gunshot wounds, and
of those children, seven of thosecome to those injuries which were fatal injuries.
And in twenty twenty three already theBonners treated well over one hundred children
for a gun related injuries. Well, see, you've kind of talked about
(05:10):
this and have broken it down somewhat, but can we break down how gun
violence is related to our physical health, how it's related to our emotional health
and our mental health. And Iwould add to that also the financial impact
on our communities. So it isa problem that impacts us individually, it
impacts families, but it also impactslarger communities and societies. Physical injuries really
(05:33):
can range from minor injuries all theway up to severe, debilitating injuries.
I have treated many patients at homeas a public health nurse who had paralysis
as a result of gunshot ones,whether quadriplegia or paraplegia, and those are
obviously life altering injuries, or thosewho have suffered traumatic brain injuries as a
(05:56):
result of gunshot on as well.So that's physical, but when you begin
to take the emotional toll, thatcan range anywhere from PTSD to other types
of depression anxiety. Obviously, ifsomeone's not able to return to their activities
of daily living, they're not ableto perhaps work like they did before.
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They may develop a lot of subsequentillness as a relation to that. So
an example, if someone is paraplegia, if they're paralyzed, they may ultimately
suffer ulcers or skin wounds or otherthings that it's a lifelong focus on their
health as a result of the injuriesthat they that they've suffered. We look
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at a community level. If acommunity is labeled as a violent community,
people are less likely to visit there, less likely to live there, less
likely to want to buy a homethere, locate a business there, and
so they had significant financial impacts.And also at the community level, and
this is not common to hear,this is that people who live in communities
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where there's a lot of gun violenceare less likely to get out and be
social. And we know that socialinteraction really promotes our physical and mental well
being. And so if we isolateourselves to our houses or farmans or homes
because we're fearful, then we're notgetting the physical activity that we need.
We're not getting social interaction that weneed, so the impact grows exponentially beyond
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that number of people who are injuredor dies result of gun violence. I
think there are some people out therewho might agree that gun related violence is
a public health issue or community healthpublic health issue, but it is hard
to get many people to understand thedifference in how gun ownership and the violence
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associated with gun ownership affects community andpublic health, and why this is a
public health issue. Can you talkabout gun related violence as a public health
issue? That's a really great question, and I can say even within public
health there have been debates as towhether gun violence should be prioritized as a
(08:11):
public health issue. I think mostof us in public health now are on
the same page. We know it'sa public health issue, but historically there's
been some going back and forth aboutthat. And ultimately, when in public
health we ask a question of thisa public health issue, it is does
this impact the broader public's health?And the answer is yes. Gun violence
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is a very complex issue and itrequires multiple types and multiple facets of interventions
to be able to reduce those particularoutcomes. But we also know that it
is growing as a problem and that'sreally common. And when you look at
something from a public health perspective,is this spreading And the answer is yes,
it is spreading. We know it'simpacting more and more people. But
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also the question would be if takinga public health approach would improve outcomes or
not, and I would put forthyes, if we took a comprehensive public
health approach, then we are morelikely to see positive outcomes. And we
can compare gun violence to some otherareas that perhaps when they first were elevated
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as issues, may not have beenconsidered a public health issue, but now
it's very common to consider them publichealth issues. And I'll use motor vehicle
crash injuries. In the very beginning, that was really focused as more of
an engineering type problem and how doyou fix vehicles so that people are safer?
But the truth is it's a publichealth issue, and you have interventions
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that are engineering interventions, educational interventions, and enforcement or policy interventions. And
by focusing on that, over many, many decades, we've been able to
reduce one the number of crashes,but also the types of injuries that people
may suffer and then improve survivability becausewe've looked at it in a comprehensive way
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across multiple systems and look at thingsfrom primary prevention all the way up to
recovery. So what does it meanor what would it look like if we
were to take a public health approachto addressing gun violence. So any public
health issue we generally approach with astandard way of sort of what's the problem
and move forward. So the firstis really to define and monitor the problem.
(10:24):
It's to be able to assess whatis the problem, who's impacted by
the problem, When does the problemoccur, how often does it occur,
and so on. What's really criticalwith the data piece of that, So
it is gathering information to drive change. It has to be timely. I
mentioned earlier that some of the datathat I shared is from twenty twenty twenty
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twenty one. We need to belooking at data on a daily basis to
be able to determine in a givencommunity what the issues are and looking at
a national level. So I'll usemotor vehicle crashes again as an example.
If someone's involved in a motor vehiclecrash where there's a physical injury or the
damage to the cars above a certainamount, the same form is built out
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across the United States. All thatdata is fed up to the National Highway
Transportation and Safety Agency and they usethat data to drive change, but also
at a local level and a statelevel, public health officials as well as
partners look at that data to drivechange. Some examples of data collection already
or that the state of Tennessee participatesin what's called a child death review process.
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Any child eighteen or under who dies, their death is reviewed to look
at ways that it could have beenprevented. And obviously some of those deaths
are relayed to gun violence, andthat can help drive local interventions. The
other piece of data that's collected currentlyagain in Tennessee, but goes to the
CDC is via the National Violent DeathRegistry. This is relatively new, probably
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in the last five to six years, where states actually feed data to the
CDC so that we can have betterdata regarding gun violence. Historically that data
was not there. So this isa critical piece to the public health perspective
was really defining the problem and understandingthe scope of that problem. The second
is to identify those factors that areprotective and those that are risk factors,
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and using those protective and risk factorsto develop interventions. So an example,
a protective factor may have to makesure that we have universal background chains.
Another protective factor would be to haveboxes, you know, the safety boxes,
to be able to secure a gun. A risk factor would be someone
(12:39):
who has an intention of suicide.It may also be just easily accessible guns,
so that you look at those andthen you develop interventions from there.
That third piece is really what's critical. How do we innovate quickly to implement
interventions to reduce injuries? And Iwould like to compare that to COVID.
We were able to access data everyday, all day at the local level,
(13:03):
state level, and national level anduse that data to drive change.
For example, we have data inShelby County that people weren't wearing masks.
We were able to implement a policyto wear a mask and show quickly that
that policy worked and share that quickly. We need to do that with gun
violence as well. Is really implementthose interventions and determine what's working and not
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working, and then share that veryquickly so that others can use that as
well to reduce negative outcomes. Theother piece I want to mention about a
public health approach. As I saidearlier. It goes all the way from
prevention, how do we prevent someonefrom being injured with a gun all the
way up to recovery. So weneed to look at the systems and partner
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with those across the system. Sohow do we prevent injuries in the home
and the community. But once someone'sinjured, do we know if we have
enough ambulances, how quickly does theambulance get there. Do we have a
trauma center that's readily available with sufficientbids, do we have enough providers in
that trauma center? And then dowe have enough rehabilitation within the hospital setting.
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Then once a person goes home,what services are we providing to help
that person recover so that they're notlikely to be a victim again or potentially
a perpetrator. So we have tolook at it comprehensively across all of those
systems and partner with others to assessall of that and then implement measures at
all of those key levels. Thinkwhere and what that question is to recognize
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the complexity of it, that thisis not an issue that we will solve
overnight. We have to dedicate resourcesto have us sustain approach to reducing gun
violence in our country, and thatmeans we have to include enforcement, healthcare
providers, public health officials, thefaith community, the education community, individuals
who have been victims of violent crime, individuals who have perpetrated potentially gun violence,
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so that we can develop those interventionsand share those quickly with others.
We want to be able to getthat out and sort of get widespread adoption
very quickly. You mentioned it alittle earlier on about the financial cost,
So other than lives lost, whatis the cost to our healthcare system of
(15:15):
gun related violence? So I don'thave exact numbers in front of me,
and I apologize for that, butwe know that there's costs associated actually with
the treatment of the injury, andthat's cost to our healthcare system more broadly.
But it's also the toll that ittakes on the individuals, not only
who are injured, but those whocare for them, those who treat people
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in the trauma unit, people whotreat people in the intensive care units.
As a result, that takes atoll and can contribute to burnout and fatigue.
Moral distress is another term that getsused amongst healthcare providers, but there's
also the cost of that individual returningto their family and community, and if
they have permanent injuries, their abilityto earn a living or an income can
(15:58):
be enemize, which has further impacton that particular family and community. So
extensive costs really at the physical,mental, as well as financial levels.
Guns have always been a part ofthe American culture, and I'm going to
say always. I know there areno absolutes, but guns have been a
part of the American culture for avery, very long time. What's different
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about it now or why is itdifferent now? I think there's a variety
of things that are contributing to beingdifferent. One is there's an increased prevalence,
so we know that the numbers aregoing up, but also because of
the number of mass shootings, it'sa different tone and that has caused people
to be more attentive, particularly whenwe've had school shootings and children who have
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been shot in mass It makes thepublic pay attention. The other is because
of how we are able to accessinformation and news. Now we're able to
get real time information when there's anactive shooter, and so we become very
aware that this is a problem notlimited to a specific community or a neighborhood,
but that is actually a problem that'spervasive across our country, and that
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the risk is across our country.And the last piece that I think is
most important is public outcry, andparticularly when you have organization organizations like Moms
that demand action. People have hadenough and people are speaking up that it's
really time that we view this asa health issue, non enforcement issue.
It's about the health of our communitiesand our families, and that we need
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to do something different to reduce thenegative impact on our families and communities.
What are the American Nurses Associations recommendationson gun related violence? Us being nurses,
we should put that information out thereso it Starr was saying, there
are many organizations that have taken astand that historically may not have, but
(17:45):
have really said it's time that wedo something different, in part because of
the emotional toll. It's again notjust the physical toll, but the emotional
toll that it takes on all ofus as a larger society. And so
they put forth several statements, butAmerican Nurses Association does support a public health
approach towards reducing gun violence. Andthen in June of this year, they
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released a statement and they focused onthree key areas. One is advocacy and
legislation, so passing sensible laws andpolicy that could be at an organizational level,
but in this case mostly legislation ata state or federal level that we
know can reduce access to guns byindividuals who are more likely to perpetrate crimes.
The advocacy pieces all of us asnurses should be advocating for those things
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that are important to us. Weneed to stay informed, but we need
to be actively engaged with our professionalorganizations and as individuals again on those issues
that are important to us, andwe should expect our professional organizations to advocate
for those things that are critical.The other is policies and positions, and
some key things that they focused onis firearms safety and violence prevention, and
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then also incivility, bullying, andwork place violence. We really didn't talk
thus far about workplace related gun violence, but we also know that occurs,
and so trying to strive to createa culture of stability in workplaces can set
a foundation that reduces the likelihood ofviolence in that particular workplace. And that's
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things that the ANA has available theresources to us, and we should access
those and use those as we can. The third piece was education and engagement,
and those are everything from educating familieson gun storage, educating children and
young adults on how to use gunssafely. People do use guns for sport
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and so there's really not a pushto just eliminate the guns at all,
but assuring that people know how touse them safely and can access them in
a safe manner is critical. Anddoing that education really not just in little
groups, but bringing that to scaleas well. So I talked a lot
earlier about comparing the motor vehicle crashes. It's not usual for us to see
(20:00):
signage about seatbelts. We don't seesignage or any big push in a wide
scale way about gun safety and reducinggun So I think we can learn a
lot from our journey around motor vehiclecrashes, but also around our response to
the opioid epidemic. We quickly learnto get our locks on out and mass
to community members. We are gettingsome safety boxes out and storage boxes out
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to families, but are we gettingthat out sufficiently? And so that education
and engagement pieces the third component thatthe American Nurse Association has as pocused on
well, and if you do makethose available, there are going to be
people who don't want to use them. Again, education would be a key
component to the use of those safetyboxes. And I'm sure you remember back
(20:47):
in the eighties and nineties there wereyou had mentioned workplace violence and gun related
violence in the workplace. I'm sureyou remember in the eighties and nineties the
post Office, there seemed to beand there may be less than I think.
I haven't looked it up, butthere seemed to be quite a few
shootings at the post office at thattime by postal workers. I guess we
(21:08):
thought back then it was these werejust really isolated incidences. Somebody was just
upset at their boss or whatever itwere. And then another big one I
remember, I think was also inthe nineties, was a Lueby's, which
was a cafeteria that I don't thinkexists anymore, but Lueby's Cafeteria and somewhere
in Texas that someone came in andstarted shooting the patrons in that restaurant.
(21:36):
I think one of the things thatwe do know is that in some cases
people are under extreme stress, andI think that's part of what came out
of the Post office shootings. Wasa recognition that people were working in high
pressure environments, and so one ofthe interventions always is to make sure that
people who need assistance, particularly withmental behavioral health issues, that that's readily
(21:59):
excess to them and it's going tovary. I don't want to make the
direct link that if someone has ament or behavioral health diagnosis that they're obviously
more at risk of committing a violentact. That's not true. But you
know that people who may be experiencingthat crisis of some sort that then have
ready access to a gun or morelikely to be able to act because that
(22:22):
gun is readily available. And sohow do we make sure we're creating more
environments that are civil, That wehave employee assistance programs available to employees,
and that if we recognize that anemployee has some type of stressor or challenge,
what supports can we put in placeto make sure that they're receiving the
assistance that they need. And thatwe have had a safety sort of assessment
(22:45):
of our environment so that we keepit as safe as possible, and that
we also want to know what todo in the event of an active shooter
situation. I know you're going tobeing somebody else who's very experienced an active
shooter, making sure that businesses dothat training so that people have the chance
of surviving in the event of anincident. Well, you talked about the
(23:07):
American Nurses Associations recommendations. What aboutthe American Hospital Association Do they have any
recommendations? Are they in line withsome of the American Nurses Associations recommendations.
Yeah. I would say most organizationsthat you look at, particularly professional health
organizations, there's very close alignments.Some may have more detail than others.
(23:29):
The American Hospital Association also supports takinga public health approach and highlights specifically the
importance of doing research and being ableto implement innovations and take them to scale
really quickly. Historically, funding forresearch in the area of gun violence from
the federal government was very limited.That's a discussion for another day. But
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there's been much more focus on theneed to conduct research so that we can
better understand the scope of the problemand develop interventions, and so the AJA
has focused on we need to dothe research and be able to bring those
interventions to scale relatively quickly. Thethird organization now sort of moved to that
has to do with the American PublicHealth Association, and honestly, their very
(24:18):
first effort was to say this isa public health issue and kind of scream
from the rooftops that we need tobe looking at this differently than we have
historically, and to be able towork across the out and a bipartisan way
to develop interventions, knowing that someof them will work, some of them
may not work, but working togetherso that we can implement things again,
(24:41):
test them, and bring them toscale relatively quickly. And I want to
focus really locally on our Tennessee PublicHealth Association, and that's in part because
we do have a special session.It's scheduled soon, and the Tennessee Public
Health Association has elevated some key areasthat they think are important as we go
into the special session next week.One is universal background checks and assuring that
(25:06):
regardless of where a person purchases agun, that they undergo a universal background
check which includes also fingerprinting, andthat they're not able to purchase the gun
until the results of that background checkcomes back. The other is the need
for extreme protection orders, and thisis the temporary removal and I want to
underscore temporary removal of guns from somebodywho may be viewed and determined to be
(25:30):
at risk of harming themselves or others. An example I can use there is
I've known as someone that was asuicide risk, and it took a lot
of effort to have guns removed fromthat particular individual. But that would be
a good example where the family mightknow that person's at high risk because of
a crisis they're experiencing, and toremove that easily accessible gun from the environment
(25:53):
will reduce the likelihood that they willtake action. May not totally eliminate it,
but will reduce action. And thenthe other is to focus on child
access prevention and particularly safe storage ofguns within the home setting. And that's
the TPHA or Tennessee Public Health Associationpriorities for this particular upcoming session. You
(26:14):
have told me about a personal storythat you have. Would you like to
share it with the audience? Sure? And I actually want to share two
stories, one professional one one personal, because sometimes people think that someone just
all of a sudden becomes interested ingun violence. And this is something really
championed by my entire career, andit was because I was driven by the
patients that I saw at home whohad already recovered from the gunshot wound,
(26:40):
had gone through the trauma unit,had gone through all the other procedures that
they needed to then were sent home. And in some cases, I saw
those individuals for years for a varietyof things that were a result of their
gunshot wounds. And many of themwere very young people, and I remembered
struggling with how devastating those injuries were, but that one hundred percent of them
(27:00):
were preventable, and so it reallycompelled me to focus on injury prevention as
part of my career. One ofthe things I did in Nashville was we
started an injury prevention program. Wedid a lot of work around domestic violence,
gun related violence, sports injuries,and a variety of things, and
it really switched my thinking as anurse. Many people get excited about being
(27:22):
in an emergency room, excited aboutbeing in the trauma and those things are
needed, and we need nurses towork in those areas, but we also
need nurses to recognize a hundred percentof those are generally preventable and what can
we do to actually elevate the issueso that we focus on prevention as well
as treatment. And recovery, notjust a treatment, but prevention and recovery
(27:45):
as well. So that's really stoodwith me throughout my career and as really
critical to how I thought as anurse, particularly as a public health leader.
But I'll fast forward some years.I personally have a child that was
shot in a robbery attempt. Iwould have not viewed myself as at risk.
I would have not viewed my childas at risk. However, at
(28:07):
one thirty in the morning, Ihave police officers show up to my front
door to inform me that I havea child that experienced a trauma. I
thought my child experienced motor people crashtrauma. When I was told that he
suffered a gunshot wound, I couldnot really wrap my head around that.
And so it did allow me toactually experience firsthand what I know patients families
(28:30):
experience. But it also was areminder of how preventable that was. The
perpetrators of that crime were very youngpeople who had access to guns from their
home and access those guns to commita robbery. But also it's what happens
after the hospital. We were inthe court system for somewhere between six and
seven years to resolve all of thecases related to that. But then there
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was all the physical recovery that tookyears and the emotional recovery that took many,
many years. And I jokingly tellpeople I still wake up at one
twenty nine in the morning. That'sjust part of the outcome of that particular
event. So I can say frommy first person experience the traumatic impact it
has, again from a physical perspective, but the emotional toll, you really
(29:18):
can't calculate the toll of that becauseit's intermittent and it's lifelong. It's not
anything that really changes. It has, however, really pushed me to elevate
gun violence as a public health issueas a director of health. I have
said publicly, if we invested asmuch in gun violence as we did in
(29:40):
the COVID response, we could makea difference or the many people in our
community who suffer as a result ofgun violence. I totally agree with that.
Are there any last thoughts you'd liketo share with the audience today before
we in the program. I reallyencourage people to get engaged to truly understand
the problem. Any of us areat risk. It's not just some people
(30:03):
in some communities. We're all atrisk, but that there are sensible solutions.
We may not all agree on whatthe solutions are. There's no silver
bullet solution. It's going to takea lot of different approaches. So for
people to be engaged and to sharetheir perspective so that we as a society
can be as healthy as we can, but that we can all be equally
(30:25):
as healthy as we can. Today, my guest has been doctor Elisa Househalter,
and as you've heard, she hasquite a bit of knowledge and experience
with gunshot wounds, gun related violence, and hopefully we've been able to shed
a little bit of light on howthis is a community health or population health
or public health issue for the folksthat have listened today. I don't know
(30:48):
that we've changed anyone's mind about anything, but hopefully it'll give you some food
for thought. And doctor Househalter,thank you so much for joining me today
for this episode. So thank youfor having me and I really appreciate you
all inviting this particular public health issue. Thank you, You're welcome. You've
been listening to the That's Helpful Podcastwith your host, doctor Lisa Beasley,
(31:11):
a family nurse practitioner and healthcare advocate, views expressed on this podcast or the
views and opinions of the hosts andguests, and are not affiliated with any
facility or institution that may have beenmentioned in this episode. Dshelpful dot com.
For more information or to hear priorepisodes, follow at now Helpful on
(31:32):
Twitter, and That's Helpful on Facebookand Instagram. Like or comment on an
episode wherever you listen or stream yourfavorite podcasts music for this episode, it's
presided by local Memphis singer, musician, and songwriter Devon Yennick. For more
of Devon's music, visit Devin Musicdot weeble dot com
This episode is part one of athree part series on gun related violence.
In this episode, I mentioned theshootings at post offices nationwide that began in
the nineteen seventies and the Luby's cafeteriashooting in nineteen ninety one. These were
horrific acts of violence. As allof these mass shootings have been I looked
(00:20):
up at these incidences and read thenames of the victims as a reminder to
me of all the lives that havebeen lost. The special legislative session in
Tennessee to address guns was mentioned,and this episode is being aired after that
session. I will provide a linkto some of the details in that session,
which has since ended. These episodesare dedicated to all of those who
(00:41):
have been victims of gun related violence. Welcome to That's Healthful, a podcast
about health and advocacy with a specialfocus on rural and vulnerable populations. Now
here's your host, family nurse practitionerand health advocate, doctor Lisa Beasley.
Today, I want to talk aboutan epidemic in our country, and that's
gun related violence. Gun violence isrelated to our physical health, our emotional
(01:06):
health, or mental health, whichis why this episode is important and today
My guest is doctor Elisa house Halter, and I would like to welcome you,
doctor house Halter. Thank you forhaving me. I'm glad to be
here and really glad to talk aboutthis very important public health topic. Can
you please let folks know a littlebit about you. Sure. So.
Currently I'm associate professor here at UTbut the majority of my career about forty
(01:30):
years, has been spent in publichealth practice, and most of that within
the Nashville area, but also herein Shelby County as director of the Health
Department, and I was there forabout five years. So I have a
lot of practice experience in public healthand injury prevention, including gun violence.
Prevention has been an area of interestto me really for probably thirty five of
(01:53):
those forty years. So what isgun violence or gun related violence? Gun
violence is any type of injury ordeath as a result of guns. But
the Center for Disease Control and Preventionidentify five different areas of gun violence,
and I think it's important to teasethose out because they are quite distinct and
(02:15):
do influence what interventions we might putin place to be able to reduce those
particular injuries. The first is intentionaland self inflicted, so that would be
suicides or attempted suicides using a gun. The second is intentional but inter personal,
intended to harm another person, andthat could be a homicide or attempted
(02:36):
homicide. The third is what's viewedis unintentional accidental, and that might be
someone who is injured or dies asa result of say cleaning their gun or
child finding a gun. There wasn'tany intent associated with that particular injury.
The fourth is legal intervention, andthat's a person who may experience an injury
(02:58):
or death during a police intervention orwhat's considered a line of duty injury,
and those are separated out because theinterventions obviously would be quite different. And
then the last is undetermined, whereit's really not clear what the mechanism or
intent was relative to that particular injury, and it can be anything from just
(03:20):
that an injury all the way upto death from that injury. How prevalent
is gun related violence in our countrytoday, so gun violence really is viewed
as an epidemic within the public healtharena because it has continued to grow as
an issue. The data that wehave most recently is the majority of national
(03:40):
data is around twenty twenty one,and what we know in twenty twenty one,
almost forty nine thousand people died asa result of gun related injuries.
Within that forty nine forty eight,eight hundred and thirties, so almost forty
nine thousand, over half of thosewere self inflicted suicides, around forty three
percent were homicides, and three percentfell in those other categories or what we
(04:04):
would list as others. But whenyou think about that number of people,
that's a significant number of people,and it doesn't reflect those who were injured
but recovered from their injuries or sustainedlife altering injuries. And so the number
obviously is much greater than that fortyeight, eight hundred and thirty that I
(04:25):
mentioned. We do know that inTennessee, specifically, in twenty twenty,
we had fifty five children die asa result of gun injuries. And also
in twenty twenty we had thirty eightchildren die by suicide and fifty percent of
those or nineteen or a result offirearms. And if we bring it even
more closer to the Memphis community,because this is something that is in the
(04:47):
news quite a bit, is thatwe know that in twenty twenty two La
Mon treated over one hundred and fiftyfive children who suffered gunshot wounds, and
of those children, seven of thosecome to those injuries which were fatal injuries.
And in twenty twenty three already theBonners treated well over one hundred children
for a gun related injuries. Well, see, you've kind of talked about
(05:10):
this and have broken it down somewhat, but can we break down how gun
violence is related to our physical health, how it's related to our emotional health
and our mental health. And Iwould add to that also the financial impact
on our communities. So it isa problem that impacts us individually, it
impacts families, but it also impactslarger communities and societies. Physical injuries really
(05:33):
can range from minor injuries all theway up to severe, debilitating injuries.
I have treated many patients at homeas a public health nurse who had paralysis
as a result of gunshot ones,whether quadriplegia or paraplegia, and those are
obviously life altering injuries, or thosewho have suffered traumatic brain injuries as a
(05:56):
result of gunshot on as well.So that's physical, but when you begin
to take the emotional toll, thatcan range anywhere from PTSD to other types
of depression anxiety. Obviously, ifsomeone's not able to return to their activities
of daily living, they're not ableto perhaps work like they did before.
(06:19):
They may develop a lot of subsequentillness as a relation to that. So
an example, if someone is paraplegia, if they're paralyzed, they may ultimately
suffer ulcers or skin wounds or otherthings that it's a lifelong focus on their
health as a result of the injuriesthat they that they've suffered. We look
(06:40):
at a community level. If acommunity is labeled as a violent community,
people are less likely to visit there, less likely to live there, less
likely to want to buy a homethere, locate a business there, and
so they had significant financial impacts.And also at the community level, and
this is not common to hear,this is that people who live in communities
(07:02):
where there's a lot of gun violenceare less likely to get out and be
social. And we know that socialinteraction really promotes our physical and mental well
being. And so if we isolateourselves to our houses or farmans or homes
because we're fearful, then we're notgetting the physical activity that we need.
We're not getting social interaction that weneed, so the impact grows exponentially beyond
(07:27):
that number of people who are injuredor dies result of gun violence. I
think there are some people out therewho might agree that gun related violence is
a public health issue or community healthpublic health issue, but it is hard
to get many people to understand thedifference in how gun ownership and the violence
(07:50):
associated with gun ownership affects community andpublic health, and why this is a
public health issue. Can you talkabout gun related violence as a public health
issue? That's a really great question, and I can say even within public
health there have been debates as towhether gun violence should be prioritized as a
(08:11):
public health issue. I think mostof us in public health now are on
the same page. We know it'sa public health issue, but historically there's
been some going back and forth aboutthat. And ultimately, when in public
health we ask a question of thisa public health issue, it is does
this impact the broader public's health?And the answer is yes. Gun violence
(08:33):
is a very complex issue and itrequires multiple types and multiple facets of interventions
to be able to reduce those particularoutcomes. But we also know that it
is growing as a problem and that'sreally common. And when you look at
something from a public health perspective,is this spreading And the answer is yes,
it is spreading. We know it'simpacting more and more people. But
(08:58):
also the question would be if takinga public health approach would improve outcomes or
not, and I would put forthyes, if we took a comprehensive public
health approach, then we are morelikely to see positive outcomes. And we
can compare gun violence to some otherareas that perhaps when they first were elevated
(09:18):
as issues, may not have beenconsidered a public health issue, but now
it's very common to consider them publichealth issues. And I'll use motor vehicle
crash injuries. In the very beginning, that was really focused as more of
an engineering type problem and how doyou fix vehicles so that people are safer?
But the truth is it's a publichealth issue, and you have interventions
(09:39):
that are engineering interventions, educational interventions, and enforcement or policy interventions. And
by focusing on that, over many, many decades, we've been able to
reduce one the number of crashes,but also the types of injuries that people
may suffer and then improve survivability becausewe've looked at it in a comprehensive way
(10:00):
across multiple systems and look at thingsfrom primary prevention all the way up to
recovery. So what does it meanor what would it look like if we
were to take a public health approachto addressing gun violence. So any public
health issue we generally approach with astandard way of sort of what's the problem
and move forward. So the firstis really to define and monitor the problem.
(10:24):
It's to be able to assess whatis the problem, who's impacted by
the problem, When does the problemoccur, how often does it occur,
and so on. What's really criticalwith the data piece of that, So
it is gathering information to drive change. It has to be timely. I
mentioned earlier that some of the datathat I shared is from twenty twenty twenty
(10:45):
twenty one. We need to belooking at data on a daily basis to
be able to determine in a givencommunity what the issues are and looking at
a national level. So I'll usemotor vehicle crashes again as an example.
If someone's involved in a motor vehiclecrash where there's a physical injury or the
damage to the cars above a certainamount, the same form is built out
(11:07):
across the United States. All thatdata is fed up to the National Highway
Transportation and Safety Agency and they usethat data to drive change, but also
at a local level and a statelevel, public health officials as well as
partners look at that data to drivechange. Some examples of data collection already
or that the state of Tennessee participatesin what's called a child death review process.
(11:31):
Any child eighteen or under who dies, their death is reviewed to look
at ways that it could have beenprevented. And obviously some of those deaths
are relayed to gun violence, andthat can help drive local interventions. The
other piece of data that's collected currentlyagain in Tennessee, but goes to the
CDC is via the National Violent DeathRegistry. This is relatively new, probably
(11:54):
in the last five to six years, where states actually feed data to the
CDC so that we can have betterdata regarding gun violence. Historically that data
was not there. So this isa critical piece to the public health perspective
was really defining the problem and understandingthe scope of that problem. The second
is to identify those factors that areprotective and those that are risk factors,
(12:18):
and using those protective and risk factorsto develop interventions. So an example,
a protective factor may have to makesure that we have universal background chains.
Another protective factor would be to haveboxes, you know, the safety boxes,
to be able to secure a gun. A risk factor would be someone
(12:39):
who has an intention of suicide.It may also be just easily accessible guns,
so that you look at those andthen you develop interventions from there.
That third piece is really what's critical. How do we innovate quickly to implement
interventions to reduce injuries? And Iwould like to compare that to COVID.
We were able to access data everyday, all day at the local level,
(13:03):
state level, and national level anduse that data to drive change.
For example, we have data inShelby County that people weren't wearing masks.
We were able to implement a policyto wear a mask and show quickly that
that policy worked and share that quickly. We need to do that with gun
violence as well. Is really implementthose interventions and determine what's working and not
(13:24):
working, and then share that veryquickly so that others can use that as
well to reduce negative outcomes. Theother piece I want to mention about a
public health approach. As I saidearlier. It goes all the way from
prevention, how do we prevent someonefrom being injured with a gun all the
way up to recovery. So weneed to look at the systems and partner
(13:45):
with those across the system. Sohow do we prevent injuries in the home
and the community. But once someone'sinjured, do we know if we have
enough ambulances, how quickly does theambulance get there. Do we have a
trauma center that's readily available with sufficientbids, do we have enough providers in
that trauma center? And then dowe have enough rehabilitation within the hospital setting.
(14:07):
Then once a person goes home,what services are we providing to help
that person recover so that they're notlikely to be a victim again or potentially
a perpetrator. So we have tolook at it comprehensively across all of those
systems and partner with others to assessall of that and then implement measures at
all of those key levels. Thinkwhere and what that question is to recognize
(14:30):
the complexity of it, that thisis not an issue that we will solve
overnight. We have to dedicate resourcesto have us sustain approach to reducing gun
violence in our country, and thatmeans we have to include enforcement, healthcare
providers, public health officials, thefaith community, the education community, individuals
who have been victims of violent crime, individuals who have perpetrated potentially gun violence,
(14:54):
so that we can develop those interventionsand share those quickly with others.
We want to be able to getthat out and sort of get widespread adoption
very quickly. You mentioned it alittle earlier on about the financial cost,
So other than lives lost, whatis the cost to our healthcare system of
(15:15):
gun related violence? So I don'thave exact numbers in front of me,
and I apologize for that, butwe know that there's costs associated actually with
the treatment of the injury, andthat's cost to our healthcare system more broadly.
But it's also the toll that ittakes on the individuals, not only
who are injured, but those whocare for them, those who treat people
(15:35):
in the trauma unit, people whotreat people in the intensive care units.
As a result, that takes atoll and can contribute to burnout and fatigue.
Moral distress is another term that getsused amongst healthcare providers, but there's
also the cost of that individual returningto their family and community, and if
they have permanent injuries, their abilityto earn a living or an income can
(15:58):
be enemize, which has further impacton that particular family and community. So
extensive costs really at the physical,mental, as well as financial levels.
Guns have always been a part ofthe American culture, and I'm going to
say always. I know there areno absolutes, but guns have been a
part of the American culture for avery, very long time. What's different
(16:19):
about it now or why is itdifferent now? I think there's a variety
of things that are contributing to beingdifferent. One is there's an increased prevalence,
so we know that the numbers aregoing up, but also because of
the number of mass shootings, it'sa different tone and that has caused people
to be more attentive, particularly whenwe've had school shootings and children who have
(16:41):
been shot in mass It makes thepublic pay attention. The other is because
of how we are able to accessinformation and news. Now we're able to
get real time information when there's anactive shooter, and so we become very
aware that this is a problem notlimited to a specific community or a neighborhood,
but that is actually a problem that'spervasive across our country, and that
(17:03):
the risk is across our country.And the last piece that I think is
most important is public outcry, andparticularly when you have organization organizations like Moms
that demand action. People have hadenough and people are speaking up that it's
really time that we view this asa health issue, non enforcement issue.
It's about the health of our communitiesand our families, and that we need
(17:23):
to do something different to reduce thenegative impact on our families and communities.
What are the American Nurses Associations recommendationson gun related violence? Us being nurses,
we should put that information out thereso it Starr was saying, there
are many organizations that have taken astand that historically may not have, but
(17:45):
have really said it's time that wedo something different, in part because of
the emotional toll. It's again notjust the physical toll, but the emotional
toll that it takes on all ofus as a larger society. And so
they put forth several statements, butAmerican Nurses Association does support a public health
approach towards reducing gun violence. Andthen in June of this year, they
(18:07):
released a statement and they focused onthree key areas. One is advocacy and
legislation, so passing sensible laws andpolicy that could be at an organizational level,
but in this case mostly legislation ata state or federal level that we
know can reduce access to guns byindividuals who are more likely to perpetrate crimes.
The advocacy pieces all of us asnurses should be advocating for those things
(18:33):
that are important to us. Weneed to stay informed, but we need
to be actively engaged with our professionalorganizations and as individuals again on those issues
that are important to us, andwe should expect our professional organizations to advocate
for those things that are critical.The other is policies and positions, and
some key things that they focused onis firearms safety and violence prevention, and
(18:56):
then also incivility, bullying, andwork place violence. We really didn't talk
thus far about workplace related gun violence, but we also know that occurs,
and so trying to strive to createa culture of stability in workplaces can set
a foundation that reduces the likelihood ofviolence in that particular workplace. And that's
(19:18):
things that the ANA has available theresources to us, and we should access
those and use those as we can. The third piece was education and engagement,
and those are everything from educating familieson gun storage, educating children and
young adults on how to use gunssafely. People do use guns for sport
(19:38):
and so there's really not a pushto just eliminate the guns at all,
but assuring that people know how touse them safely and can access them in
a safe manner is critical. Anddoing that education really not just in little
groups, but bringing that to scaleas well. So I talked a lot
earlier about comparing the motor vehicle crashes. It's not usual for us to see
(20:00):
signage about seatbelts. We don't seesignage or any big push in a wide
scale way about gun safety and reducinggun So I think we can learn a
lot from our journey around motor vehiclecrashes, but also around our response to
the opioid epidemic. We quickly learnto get our locks on out and mass
to community members. We are gettingsome safety boxes out and storage boxes out
(20:25):
to families, but are we gettingthat out sufficiently? And so that education
and engagement pieces the third component thatthe American Nurse Association has as pocused on
well, and if you do makethose available, there are going to be
people who don't want to use them. Again, education would be a key
component to the use of those safetyboxes. And I'm sure you remember back
(20:47):
in the eighties and nineties there wereyou had mentioned workplace violence and gun related
violence in the workplace. I'm sureyou remember in the eighties and nineties the
post Office, there seemed to beand there may be less than I think.
I haven't looked it up, butthere seemed to be quite a few
shootings at the post office at thattime by postal workers. I guess we
(21:08):
thought back then it was these werejust really isolated incidences. Somebody was just
upset at their boss or whatever itwere. And then another big one I
remember, I think was also inthe nineties, was a Lueby's, which
was a cafeteria that I don't thinkexists anymore, but Lueby's Cafeteria and somewhere
in Texas that someone came in andstarted shooting the patrons in that restaurant.
(21:36):
I think one of the things thatwe do know is that in some cases
people are under extreme stress, andI think that's part of what came out
of the Post office shootings. Wasa recognition that people were working in high
pressure environments, and so one ofthe interventions always is to make sure that
people who need assistance, particularly withmental behavioral health issues, that that's readily
(21:59):
excess to them and it's going tovary. I don't want to make the
direct link that if someone has ament or behavioral health diagnosis that they're obviously
more at risk of committing a violentact. That's not true. But you
know that people who may be experiencingthat crisis of some sort that then have
ready access to a gun or morelikely to be able to act because that
(22:22):
gun is readily available. And sohow do we make sure we're creating more
environments that are civil, That wehave employee assistance programs available to employees,
and that if we recognize that anemployee has some type of stressor or challenge,
what supports can we put in placeto make sure that they're receiving the
assistance that they need. And thatwe have had a safety sort of assessment
(22:45):
of our environment so that we keepit as safe as possible, and that
we also want to know what todo in the event of an active shooter
situation. I know you're going tobeing somebody else who's very experienced an active
shooter, making sure that businesses dothat training so that people have the chance
of surviving in the event of anincident. Well, you talked about the
(23:07):
American Nurses Associations recommendations. What aboutthe American Hospital Association Do they have any
recommendations? Are they in line withsome of the American Nurses Associations recommendations.
Yeah. I would say most organizationsthat you look at, particularly professional health
organizations, there's very close alignments.Some may have more detail than others.
(23:29):
The American Hospital Association also supports takinga public health approach and highlights specifically the
importance of doing research and being ableto implement innovations and take them to scale
really quickly. Historically, funding forresearch in the area of gun violence from
the federal government was very limited.That's a discussion for another day. But
(23:52):
there's been much more focus on theneed to conduct research so that we can
better understand the scope of the problemand develop interventions, and so the AJA
has focused on we need to dothe research and be able to bring those
interventions to scale relatively quickly. Thethird organization now sort of moved to that
has to do with the American PublicHealth Association, and honestly, their very
(24:18):
first effort was to say this isa public health issue and kind of scream
from the rooftops that we need tobe looking at this differently than we have
historically, and to be able towork across the out and a bipartisan way
to develop interventions, knowing that someof them will work, some of them
may not work, but working togetherso that we can implement things again,
(24:41):
test them, and bring them toscale relatively quickly. And I want to
focus really locally on our Tennessee PublicHealth Association, and that's in part because
we do have a special session.It's scheduled soon, and the Tennessee Public
Health Association has elevated some key areasthat they think are important as we go
into the special session next week.One is universal background checks and assuring that
(25:06):
regardless of where a person purchases agun, that they undergo a universal background
check which includes also fingerprinting, andthat they're not able to purchase the gun
until the results of that background checkcomes back. The other is the need
for extreme protection orders, and thisis the temporary removal and I want to
underscore temporary removal of guns from somebodywho may be viewed and determined to be
(25:30):
at risk of harming themselves or others. An example I can use there is
I've known as someone that was asuicide risk, and it took a lot
of effort to have guns removed fromthat particular individual. But that would be
a good example where the family mightknow that person's at high risk because of
a crisis they're experiencing, and toremove that easily accessible gun from the environment
(25:53):
will reduce the likelihood that they willtake action. May not totally eliminate it,
but will reduce action. And thenthe other is to focus on child
access prevention and particularly safe storage ofguns within the home setting. And that's
the TPHA or Tennessee Public Health Associationpriorities for this particular upcoming session. You
(26:14):
have told me about a personal storythat you have. Would you like to
share it with the audience? Sure? And I actually want to share two
stories, one professional one one personal, because sometimes people think that someone just
all of a sudden becomes interested ingun violence. And this is something really
championed by my entire career, andit was because I was driven by the
patients that I saw at home whohad already recovered from the gunshot wound,
(26:40):
had gone through the trauma unit,had gone through all the other procedures that
they needed to then were sent home. And in some cases, I saw
those individuals for years for a varietyof things that were a result of their
gunshot wounds. And many of themwere very young people, and I remembered
struggling with how devastating those injuries were, but that one hundred percent of them
(27:00):
were preventable, and so it reallycompelled me to focus on injury prevention as
part of my career. One ofthe things I did in Nashville was we
started an injury prevention program. Wedid a lot of work around domestic violence,
gun related violence, sports injuries,and a variety of things, and
it really switched my thinking as anurse. Many people get excited about being
(27:22):
in an emergency room, excited aboutbeing in the trauma and those things are
needed, and we need nurses towork in those areas, but we also
need nurses to recognize a hundred percentof those are generally preventable and what can
we do to actually elevate the issueso that we focus on prevention as well
as treatment. And recovery, notjust a treatment, but prevention and recovery
(27:45):
as well. So that's really stoodwith me throughout my career and as really
critical to how I thought as anurse, particularly as a public health leader.
But I'll fast forward some years.I personally have a child that was
shot in a robbery attempt. Iwould have not viewed myself as at risk.
I would have not viewed my childas at risk. However, at
(28:07):
one thirty in the morning, Ihave police officers show up to my front
door to inform me that I havea child that experienced a trauma. I
thought my child experienced motor people crashtrauma. When I was told that he
suffered a gunshot wound, I couldnot really wrap my head around that.
And so it did allow me toactually experience firsthand what I know patients families
(28:30):
experience. But it also was areminder of how preventable that was. The
perpetrators of that crime were very youngpeople who had access to guns from their
home and access those guns to commita robbery. But also it's what happens
after the hospital. We were inthe court system for somewhere between six and
seven years to resolve all of thecases related to that. But then there
(28:55):
was all the physical recovery that tookyears and the emotional recovery that took many,
many years. And I jokingly tellpeople I still wake up at one
twenty nine in the morning. That'sjust part of the outcome of that particular
event. So I can say frommy first person experience the traumatic impact it
has, again from a physical perspective, but the emotional toll, you really
(29:18):
can't calculate the toll of that becauseit's intermittent and it's lifelong. It's not
anything that really changes. It has, however, really pushed me to elevate
gun violence as a public health issueas a director of health. I have
said publicly, if we invested asmuch in gun violence as we did in
(29:40):
the COVID response, we could makea difference or the many people in our
community who suffer as a result ofgun violence. I totally agree with that.
Are there any last thoughts you'd liketo share with the audience today before
we in the program. I reallyencourage people to get engaged to truly understand
the problem. Any of us areat risk. It's not just some people
(30:03):
in some communities. We're all atrisk, but that there are sensible solutions.
We may not all agree on whatthe solutions are. There's no silver
bullet solution. It's going to takea lot of different approaches. So for
people to be engaged and to sharetheir perspective so that we as a society
can be as healthy as we can, but that we can all be equally
(30:25):
as healthy as we can. Today, my guest has been doctor Elisa Househalter,
and as you've heard, she hasquite a bit of knowledge and experience
with gunshot wounds, gun related violence, and hopefully we've been able to shed
a little bit of light on howthis is a community health or population health
or public health issue for the folksthat have listened today. I don't know
(30:48):
that we've changed anyone's mind about anything, but hopefully it'll give you some food
for thought. And doctor Househalter,thank you so much for joining me today
for this episode. So thank youfor having me and I really appreciate you
all inviting this particular public health issue. Thank you, You're welcome. You've
been listening to the That's Helpful Podcastwith your host, doctor Lisa Beasley,
(31:11):
a family nurse practitioner and healthcare advocate, views expressed on this podcast or the
views and opinions of the hosts andguests, and are not affiliated with any
facility or institution that may have beenmentioned in this episode. Dshelpful dot com.
For more information or to hear priorepisodes, follow at now Helpful on
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