As new gun laws prove elusive, health officials take epidemic into their own hands

As COVID-19 slowly retreats, another kind of public health pandemic is re-emerging, healthcare experts say.

The murders of 19 children in Uvalde, Texas, last week and 10 elderly patrons of Tops Friendly Market in Buffalo, N.Y., two weeks ago once again has shone a grim spotlight on what medical professionals call the ongoing public health crisis of gun violence across the U.S.

As debate rises again about gun policies, hospitals and healthcare researchers are racing to understand and enact more effective programs and measures in hopes of stopping the bloodshed.

Those include identifying and addressing mental health warning signs as early as possible and teaching young people to recognize and regulate their emotions.

Deaths from gunshot wounds are up more than 20 percent in the past five years, and preliminary reports suggest homicides and suicides by guns rose 10 percent throughout 2020. More than 100 people died by firearms each day that year. And guns are now the leading cause of death for children in the United States.

"We have to be more intentional about recognizing firearm violence as a public health crisis," said Justin Heinze, an assistant professor of health behavior and health education at the University of Michigan and co-principal investigator at the National Center for School Safety. "We have to analyze the touch points for the youth who are engaging in this behavior, those who are 12 to 25, and find ways to treat the risk."

Heinze said firearm violence prevention measures exist, but they are not coordinated. A 1996 federal law known as the Dickey Amendment has banned the use of government funds for gun control advocacy, which made research grants on public health and firearms dry up, though $25 million for injury prevention was appropriated in 2020.

Intervention efforts include those that occur in the emergency department when a victim of gun violence is admitted or during depression screening at primary care physician offices.

"We start a lot of these conversations with physicians and parents, but there's not a lot of cross-coordination," Heinze said. "Wouldn't it be great if hospitals could interact and warn counselors? We think there is opportunity for information sharing to have these conversations at a more community-wide level."

There are effective gun violence prevention measures in place across the U.S, including the Advance Peace program in Stockton, Calif., and the national Lock2Live program.

Advance Peace uses outreach to educate and counsel individuals at high risk for gun violence in their neighborhood and mediate conflict. Lock2Live use emergency-room doctors to educate suicide patients on safe gun storage to mitigate suicide attempts.

However, broad connection of efforts between hospitals and the community is more difficult because of privacy concerns and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) law that prevents the sharing of medical information, including mental health status, without patient consent.

The potential for an overreaction or potential misidentifying of a threat also holds consequences.

"You have to work to avoid biases on which student may or may not be a threat and shape a conversation around it," Heinze said. "This shouldn't result in a sheriff's officer knocking on your door. Or that method (should be) used sparingly. This has to be done in a restorative way and paired with prevention. The bridge between schools, community organizations and hospitals, to avoid experiencing or perpetrating violence is a worthy cause to pursue."

Mitigating violence from those who end up in hospitals showing signs of being homicidal or suicidal is relatively common, but identifying potential perpetrators of mass violence isn't as easy, said Barbara Wolf, corporate director of behavioral health education and physician well-being at McLaren Health Care and an associate professor of psychiatry and family medicine at Michigan State University.

Doctors at McLaren Lapeer Region Community Medical Center and McLaren Oakland in Pontiac treated several victims of the mass shooting at Oxford High School on Nov. 30 last year that claimed the lives of four students.

"If someone with homicidal or suicidal thoughts presents themselves in the ER, we can resolve that by recommending inpatient psychiatric care," Wolf said. "But most active shooters are not identified as mentally ill, and mental illness doesn't equal violence. They are more likely to be attacked than be attackers. I think if somebody want to shoot up a school, they are not going to present themselves to an ER."

Researchers at Columbia University in New York created a database of 14,785 mass murders between 1900 and 2019 in an attempt to determine whether those shooters were mentally ill. Their study, released last year, revealed that 11 percent of all mass murderers and only 8 percent of mass murderers using a firearm suffered from a serious mental illness. Instead, most mass murderers in the U.S. were more likely to have dicey legal histories and drug abuse related to non-psychiatric symptoms, the study said.

However, those with suicidal thoughts do often see a primary care physician within 30 days of a suicide attempt, Wolf said, presenting opportunity for continued integration of primary care with behavioral health.

"We've been doing this for 20 years, but there's been an increased push for more integrated primary care where we have a behavioral health consultant in the primary care offices. If the primary care physician gets a sense that something is up, they can have a warm handoff with that behavioral health professional who has more of an expertise."

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But Michigan lacks enough mental health professionals to truly create a fully integrated primary care system, Wolf said.

A 2019 analysis of the state's mental health professionals found that 25 of Michigan's 83 counties have not a single psychiatrist and 10 counties with neither a psychiatrist or psychologist. In 2021, roughly 421,000 Michiganders did not receive needed mental healthcare, according to a study by the National Alliance on Mental Illness.

Wolf said if the caregiver shortage could be rectified, a focus on prevention at an early age is appropriate.

"I'd like to see school children learning about mental health from the first grade and they can self-regulate," Wolf said. "The right conversation is on prevention. Saying people are mentally ill because they shoot someone isn't accurate. They are disturbed and are upset and angry. We know all kind of mental exercises to decrease stress hormones that are elevated when someone is full of rage. If we can teach everyone to stop themselves, we can help them become less likely to act on that rage."

Wolf pointed to the work The Crim Foundation is performing in Flint and across Genesee County following the Flint water crisis that induced lead poisoning in residents, including school children.

Lead is a neurotoxin known to impact child development. Research shows increased lead in the body can cause behavioral problems in youth.

Research also suggests meditation and emotion regulation practices can improve the capacity to control behavior. So the nonprofit has worked with more than 10,000 school children in Flint and the surrounding area on meditation, yoga and other mindfulness work in hopes of curtailing any behavioral problems due to lead poisoning.

"That's proactive," Wolf said. "You can't start working with someone that's homicidal a week before they lose control. This sort of practice can bring long-term solutions to a crisis we're reacting to right now."

This story first appeared in our sister publication, Crain's Detroit Business.