Guns are Killing American Children: University of Michigan Researcher Rebecca Cunningham is Seeking To Find Out Why

Dr. Rebecca Cunningham - University of Michigan

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Marianne O ’ Hare : Welcome to Conversations on Health Care with Mark Masselli and
Margaret Flinter a show where we speak to the top thought leaders in
health innovation , health policy , care delivery and the great minds
who are shaping the health care of the f uture. This week Mark and
Margaret speak with Dr. Rebecca Cunningham, Interim Vice President
for Research at the University of Michigan's Office of Research and
Director of the CDC funded University of Michigan Injury Prevention
Center. She's leading a nat ional team that has just been awarded a
sizable grant to study the causes of the gun violence epidemic , now
the second leading cause of death for children overall.

Lori Robertson also checks in , the Managing Editor of FactCheck.org
she look s at misstatemen ts spoken about health policy in the public
domain , separating the fake from the facts . W e end with a bright idea
that’s improving health and well being in everyday lives. If you have
comments please e - mail us at chc [email protected] or find us on
Facebook or Twitter , or wherever you listen to p odcast . Yo u can also
hear us by asking Alexa to play the program Conversations on Health Care . Now stay tuned for our interview with gun violence and injury
prevention researcher , Dr. Rebecca Cunningham here on Conversations on Health Care .

Mark Masselli : W e're speaking today with Dr. Rebecca Cunningham, Professor of
Emergency Medicine at the University of Michigan Medical School .
She also is the Interim Vice President for Researc h at the University of
Michigan's Office of Research and Director of the CDC funded
University of Michigan Injury Prevention Center. She was recently
named to the National Academy of Medicine, Dr. Cunningham,
welcome to Conversations on Health Care .

Dr. Cu nningham : Thank you so much for having me today.

Mark Masselli : You know, I think guns are now the second leading cause of accidental
death for children in this country , and yet, gun violence affecting
American ’ s use gets 30 times less funding than any oth er cause of
harm in it. For those of our listeners who aren't familiar, there was a
Congressman Dickie who was from Alabama , who 20 years ago put a
prohibition on research funding coming out of the CDC or NIH . T his
really limited the research that could go on and be sponsored by the
government , but your team has just received a large grant from the
National Institute of Health to expand gun violence research, and I'm
wondering if you could help our listeners understand why this is such
an important turning point in research.

Dr. Cunningham: Yes, and it is a really exciting and important time. I think as our
country starts to realize the full impact and devastation that gun
violence and injury is having o n really our whole population. Our team

Dr. Rebecca Cunningham - University of Michigan

is really focus ed on children and teens. Our team identified that data
last year that this is going to be the second leading cause of death for
children that lived through infancy through the age of 18. In fact, it's
the number one guns are the number one cause of death for high
school age children in the country and really are affecting populations
across all communities that where we live. Children in rural
communities, children in suburban communities and children in urban
communities, all are dying at about the same r ate of about 4 per
1 00,000.

The grant that we were very fortunate to receive from the NIH was
really to start to get ahead of the problem you mentioned when you
first started, which is there was a real chilling effect on the research .
R esearch is kind of a wonky word , but what that really means is, what
kind of how we can f ind solutions to health problem, is how I think
about it. We have a big health problem on our hands , and we need to
find solutions that we can show work for taxpayers money and work
to he lp put in place in our communities to help stop this toll . B ut
unfortunately, there are almost no researchers le ft working on this
because in order to have researchers working on something you have
to have funding . That funding overwhelmingly , for health p roblems
comes from the government.

F rom about the late 1990s when you mentioned through 2017, there
was really very little , less than a million dollars a year for this giant
health problem across the country. My team recognize this , and we
pulled together about 20 of the experts around the countries who are
still working on this at all into a firearm safety for children and teens
consortium , which is really meant to jumpstart the field to start
getting the research done, again to start building the teams th at need
to happen, and getting data out there.

Margaret Flinter: Th e gra nt is really to study root causes of the firearm related violence
that's affecting our nation's youth. You talked a little bit briefly abo ut
these partners, but maybe tell our listener s a little bit more, who are
they? W hat are those root causes that you think you'll be focusing
on?

Dr. Cunningham: Sure, s o the consortium is centered here at the University of
Michigan, but it's with leading scientists who've been working on this
across the country. W e have partners in Seattle, we have partners at
UC Davis, in California , p artners at Brown , 12 different universities
engaged with us. There's a few very senior researchers who've been
working on this since the late 1990s , and other people th at we ’ re just
bringing on board young, energetic scientists who really want to help
solve this problem. R ight now we have about 25 scientists that are
working together on an assortment of teams as part of our
consortium .

Dr. Rebecca Cunningham - University of Michigan

W e are focused on the full problem of gun violence, some of the root
causes. We ’ re also focused on what some of the programs are that we
know work right now , and as well as figuring out other information
that is simply unknown, such as, what exactly are the consequences
of gun violence on m ental health and mental health on teams? We
saw last year devastating after Parkland . S ome of the survivors of
Parkland went on to commit suicide, some with a gun. We know that
these are not uncommon after witnessing really devastating violence
like this, and we need to understand what happens after so that we
can put better programs in place. This field of gun violence, there's
been so little data out there, that there's an awful lot to learn.

Mark Masselli : Well, there's so much to learn trying to create evidence based
research . S ome of the research already shows that the simple
presence of a gun in a home increases the likelihood of death by gun
by orders of magnitude . Wonder if you could talk about the research
you and others have done already on the fac tors that increase the
likelihood of gun violence, and its many contributors .

Dr. Cunningham: Sure, absolutely. So we really take an injury prevention approach to
this and really think of it in very much the same way we think about
cars and car safety. I t hink pools and pool safety is another good
concept for your listeners . H aving a car increases your risk of dying in
a car. Having a pool increases your risk of having your kids die in a
pool . H aving a gun increases the risk of having your child injured in
your home by a gun. Those facts are all true. There are a variety of
things that can be put in place that are safety measures for cars
without necessarily getting rid of cars a n d for pool s that will help keep
kids and teens a lot safer , and those are the t hings that we're
studying.

We know that people that are engaged in other kinds of domestic
violence or other kinds of violence in general are really high risk for
being perpetrators and/or victims of other gun violence . S ubstance
use, alcohol misuse and ot her drug use are really high risk factors.
Their engagement with a gun increases the likelihood many times fold
for having an injury with that gun or in your community.

W hen we think about gun violence in our facts consortium , we're
thinking about accident al or unintentional injury like you talked
about . W e're also talking about intentional injury, so getting shot by
your partner , getting shot on the street, including mass shootings, but
we're also talking about suicide by gun . I f you look at the entire
pop ulation , 60% of deaths in our country are related to suicide by gun
of the gun d e a th . F or kids , the numbers are a little bit reverse for
adolescents and teens and children . Oddly about 3000 children that
die and teens that die every year by gun, about 40% are suicide and
about 60% are homicide, with a few percent attributed to the sort of

Dr. Rebecca Cunningham - University of Michigan

really horrific mass shootings and public shootings that we're seeing.

Suicide , when you talk about risk factors is something that if you
decrease the impulse at the momen t, their access to lethal means,
like a gun, you can change the trajectory of that suicide attempt.
There's been good studies to show that, that people who are feeling
suicidal at a particular moment if they don't have access to that le thal
means , they won 't go on to complete by other means . I t's a way to
save a life by having guns either stored safely, or not having people
who are at super high risk, like people who are depressed or people
who are suicidal to separate them from their firearms during that
t ime that they're at really high risk.

Margaret Flinter: We know you've also been studying the effectiveness of some
prevention measures . The application of behavioral interventions in
the emergency setting , and also some success deploying tech enabled
solu tions. I wonder if you could elaborate on those a little bit more for
our listeners a nd how they're having an impact.

Dr. Cunningham: P revention is, is a key part of this , and we have an intervention that
we developed called the Safer Teens Intervention , w hich for 14 to 18
year olds who are coming into emergency departments, who live in
neighborhoods where there's been a lot of violence. T here are risks
simply by the neighborhood that they live in . I n fact, there are so
much risk that the number one thing - - and as an emergency physician
that they're likely to die from after I treat them. In the next year, their
number one cause of death in our urban communities would be by
gun violence .

W e started a program S afe r T eens in which we took kids and teens
who we re in the emergency department and we did a behavioral
intervention with them , a counseling session that was structured that
really gets them talking about what's going on in their life, what their
risks are and h elp them help us think about how they can b e safer,
what choices they can make that would make them lower risk . W e
found that that intervention with kids decrease their violence in our
experiences over the next year in multiple studies, and has been a real
success. T hat's the kind of intervention w hich we're looking at now,
how that could apply to gun violence specifically, and how we can also
stop the cycle of violence before it escalates to necessarily having a
gun involved.

Mark Masselli : We're speaking today with Dr. Rebecca Cunningham, Interim Vice
President for Research at the University of Michigan's Office of
Research and Director of the University of Michigan's Injury
Prevention Center. You know, Dr. Cunningham, we see this clash
happening between policymakers who were supported by the NRA
a nd policymakers who are in favor of limiting access to guns . B ut also
there's this groundswell of grassroots support in particularly moms

Dr. Rebecca Cunningham - University of Michigan

demand actions, calling for really sensible gun laws including universal
background checks . Wh at specific gun policies have been proven to
have an impact on reducing harm for gun violence? W hat laws would
you like to see promoted on both the state and federal level?

Dr. Cunningham: I think first of all, to speak to your two sides that are kind of
screaming at each other a nd over each other, the re are couple points
I get across to your audien ce that are really important. One , we can all
agree that we need to have less gun injury and less gun deaths , and as
we're having people screaming at each other, that's the common
groun d I think that we can find and that we can start from . O ur most
ardent NRA and gun rights folks as well as our most liberal citizens can
agree that , that is a good common goal. T hat is a place I encourage
your listeners to work from.

I also really like to get rid of the term gun control and move really to
the thought of gun safety. C ontrolling people is not really a good place
to start a conversation. Safety is really where our common ground is.
There's a lot of different views on how we get safer , but this is really
about gun safety and how we get to a safer place with the guns that
we own.

Mark Masselli : Great point.

Dr. Cunningham: O ur group has done some policy analysis, the first policy that I would
put forward overwhelmingly that is important is really about is really
about more research on this topic . W e saw recently in the past month
that Congress has passed the $25 million to really begin to jumpstart
research again . I can only say we spend about $300 million a year on
cancer research for kids , and i f we really want to make an impact on
this topic , the country is going to have to start funding the health
research that we need on it. We won't find solutions by our well
meaning elected representatives guessing . W e need evidence based
research and the wa y you get evidence based research is health
research , and the way you get health research is funding it.

W e don't ask elected officials to come up with cures for cancer. We
ask our scientists to do that. W e really have to fund this better . B ut
we d o know e ven without research, some things that are healthy.
First of all background checks are universally accepted by more than
85% of the country right now in some form or another , and getting to
the idea to an acceptable position on that for the country likely would
lead to less injury and less death . S ome of the other things that we
know that I've seen early success are something called ERPO Laws,
Extreme Risk Protection Orders , which are otherwise known as red
flag laws that are laws that have been put in plac e increasingly around
the country over the past years. That whereas if you know that the
person next to you is making threats, threatening their spouse with a
gun or threatening to shoot up a school, that there's a law and a

Dr. Rebecca Cunningham - University of Michigan

mechanism in place in many stat es now where the police can
investigate that, and those guns can be held from that person for a
period of time to protect public safety. We're actually doing some
analysis of those laws now that they're being rolled out. How do they
work? What happens ? Wha t happens when people get their guns
back? Those are questions that we can help answer but the early
analysis across multiple state show that those red flag laws had saved
lives, that are a good place for us to start thinking about those that
are most extr emely hurt.

Mark Masselli : Great.

Dr. Cunningham: The other work that our team has done are on CAP laws, which are
Child Access Prevention laws, which hold adults responsible. If they
either purposely or through negligence allow a child or a teenager
acces s to a gun and something bad happens with that gun , t here's
good evidence across states that some form of that law does indeed
help decrease child deaths in the places where it happened. T hose are
two beginning places . B ut then I'd also really put out ther e that
there's a lot that can be done t hat isn't policy and legally based either.

We know that if Americans start having safe storage in the same way
that in the 60s and 70s we learned to wear seatbelts and be safe in
our cars. That was a huge culture chan ge. You guys are both old
enough I know to remember too , i n the 60s and 70s and 80s. W e
learned, we thought it was radical, we were told we would all die in
our cars , in our seatbelts and we learned that this culture keeps us
safer . E ventually we can get t o a culture change place that doesn't
have to do with policy either where we would know that having a
handgun in our purse that's unsecured next to our toddler might be a
risk that we wouldn't take. T hose are culture change things that we
can pass that can have happened as well, but are going to take a lot of
thoughtful work.

Margaret Flinter: Well, I was thinking Dr. Cunningham , in appreciating your reference
s o the -- of factors some of them social factors that contribute to gun
violence . Y ou talked about , just to name a few , intimate partner
violence or domestic violence, substance abuse, and addiction, a
history of repeat offenses or violent offenses. We really live in the
primary care space and it seems like we're getting piecemeal at lots of
these . W e screen for substance abuse , we screen for intimate partner
violence, we screen for depression . I'm wondering if it's any element
of your study to look at how people on the front lines and health care
primary care providers can be very effective facilitator s for violence
prevention across the board , but how do we bring all this awareness
and screening of all these other factors together to really make a big
difference on gun violence?

Dr. Cunningham: Yeah, and recognizing, I think that physicians can't do ev erything in

Dr. Rebecca Cunningham - University of Michigan

the few minutes that they have with patients , but also as a leading
cause of death is one that needs to be high on our list of things to be
comfortable with working on prevention for. O ne thing I think primary
physicians and emergency need to b e way more comfortable than we
are now and talking about firearms. I think pediatricians have been
better at this than some of our other specialties , and the rest of us
who are catching up.

I talked a little bit about taking back to the F word. We have to be
comfortable asking our patients about firearms, and then more
importantly knowing what to do with the answer . M ost physicians
weren't trained on this topic necessarily at all . To that end on our
f act s website which we mentioned is childfirearmsafety.org . We have
resources for both pediatricians including training videos for them on
how you ask this and have this difficult conversation , and what you do
with the answer . S imple handouts on where to direct families to store
firearms more safely.

For emergenc y departments p hysician , it's about focusing on the
higher risk of folks who are coming in , who are clearly have had -- or
depressed or suicidal and really be clear about asking about lethal
means access, but offering resources and encouraging the family t o
be actively investigating that as well in terms of when it's safe . S ort of
the same way that culture messages is y ou look too drunk to drive
your car, can I hold your keys ? You and your wife have really been
fighting , why don't I just hold your guns for you for this time so that
everyone can be safer . There’s ways to approach that conversation
and we can get better at it , and there are some good training modules
within our site as well as popping up across health care sites across
the country on how to ha ve those conversations . W e just need to
start doing it , we need to start modeling it for our trainees so that
they're as comfortable with it as , as anything else.

Mark Masselli : We've been speaking today with Dr. Rebecca Cunningham, Director of
the Univers ity of Michigan's Injury Prevention Center. You can learn
more about her important work by going to injurycenter . umich.edu.
Dr. Cunningham, thank you so much for your dedication and your
focusing on this important public health issue , and for joining us as
well on Conversations on Health Care today .

Dr. Cunningham: Thank s.

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Mark Masselli : At Conversations o n Health Care we want our audience to be truly in
the know when it comes to the facts about health care reform and
policy . Lori Robertson is an aw ard winning journalist and Managing
Editor of FactCheck.org, a nonpartisan, nonprofit consumer advocate
for voters that aim to reduce the level of deception in US politics. Lori,

Dr. Rebecca Cunningham - University of Michigan

what have you got for us this week?

Lori Robertson: An outbreak of viral pneu monia that began in the central Chinese city
of Wuhan at the end of 2019 had sickened more than 20,000 and led
th
to more than 400 deaths as of February 4 . Scientists have made
rapid progress and understanding the culprit , a new virus in the
coronavirus fam ily, which temporarily goes by the name 2019 novel
coronavirus ( 2019 - nCoV ) . As the virus has spread however ,
misinformation has t o o . Multiple social media posts falsely claimed
that the virus has been patented and a vaccine is already available.
That's not true. The patents the posts referred to pertain to different
viruses . W ebsites and social media posts circulated the erroneous
claim that there are thousands or 10,000 dead as a result of the
W uhan corona virus.
th
When we published a story on that falsehood on January 27 , the
estimated death toll was 81 . As of February 4, it had risen to 427 with
all but two of those deaths in mainland China. A conspiracy theory
website distorted the facts about an emergency preparedness
exercise to falsely suggest that “ Ga tes Foundation and others
predicted up to 65 million deaths from the coronavirus now
spreading ” t he exercise dealt with a hypothetical scenario involving a
fictional virus. Numerous social media posts falsely suggested that
because Clorox and Lysol product s list human corona virus on their
bottles, the new coronavirus driving outbreak in China was already
known. It wasn't . There are many human corona viruses, and these
products were tested against the strain that causes the common cold.
For more on these vira l falsehoods and a Q & A on the new corona virus
s ee our website FactCheck.org . That's my fact check for this week. I'm
Lori Robertson, Managing Editor of FactCheck.org .

Margaret Flinter: FactCheck.org is committed to factual accuracy from the country's
major political players and i s a project of the Annenberg Public Policy
Center at the University of Pennsylvania . If you have a fact that you'd
like checked, email us at chcradio.com . We'll have FactCheck.org’s
Lori Robe rtson check it out for you here on Conversations on Health
Care.

Each week C onversations highlights a bright idea about how to make
wellness a part of our communities and everyday lives. Baltimore,
Maryland has one of the highest emergency medical call vol umes in the country , and it results in a significant number of patients being
taken to the ER for conditions that could have been treated outside of
the ER . The University of Maryland Medical Center and the Baltimore
City Fire Department teamed up in the h opes of reducing unnecessary
ambulance trips and hospitalizations. They created a new pilot program which pairs doctors and nurses at the hospital level with para medics in the field bringing medicine right into the patients ’

Dr. Rebecca Cunningham - University of Michigan

homes

Dr. David Marcozzi : 911 l ow acuity calls, we augment the Baltimore City EM S system, so
that we co - dispatch a paramedic and either a nurse practitioner or
doctor to the scene of low acuity calls, have them logged in at s c e nes
through E pic. Ask the patient what they would like to be treated at
s c e ne . We then enroll them into our program, register them there just
like a mobile urgent care center. We then treat them a t scene,
discharge them with the same exact paperwork we discharge them
from the hospital , with prescriptions as needed . T hen we follow up
with them within 24 hours to make sure they got what they need.

Margaret Flinter: Dr. David Marcozzi of the University of Maryland Medical Center says
that this community paramedicine program has a two prong goal .
One , reducing unnecessa ry trips to the ER by delivering right care at
the scene . T w o , bringing a coordinated paramedicine team including
doctors and nurses into the homes of patients being released from
the hospital to ensure that their recovery is supported for better
outcomes, with paramedics doin g frequent follow ups over a 30 - day
period, and thus greatly reducing the risk of re - hospitalization.

Dr. David Marcozz i: It's eye opening to , once you understand the challenges when we
discharge a patient or when patients are seen for low acuity issues,
people face just at home to navigate this short industry, the multiple
providers they're supposed to follow up with , then the follow up back
to their primary care . We are exploring, could we do this for longer or
is there a better way o nce we hopefully empower folks to transition
to maybe a lower resource intensive setting for THS , the Transitional
Health Support the 30 day follow program. Our data demonstrates
that the patients who are followed in our program are admitted to
the hospita l significantly less and utilize their health care primary care
services significantly more that translate into lower cost to the system
from a physician billing ’ s construct , from a hospital construct . Oh, by
the way , for many of us construct , because you know what happens?
Those patients typically call 911 t o get to the hospital .

Margaret Flinter: Dr. Marcozz i estimates that the two - year pilot will save the University
of Maryland Medical Center at least $4 million . B ut most importantly
he says the patient outcomes are markedly improved. The mobile
integrated health care community paramedicine program reducing
unnecessary emergency room trips. Now that's a bright idea.

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Mark Masselli : You've been listening to Conversations on Health Care . I’m Mark
Mas selli

Margaret Flinter: And I'm Margaret Flinter

Mark Masselli : P eace and health .

Dr. Rebecca Cunningham - University of Michigan

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