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Probable Causation, Ep. 88: Sara Heller & Max Kapustin

EPISODE DETAILS:

In this episode, we discuss their work on how to reduce gun violence:

“Predicting and Preventing Gun Violence: An Experimental Evaluation of READI Chicago” by Monica P. Bhatt, Sara B. Heller, Max Kapustin, Marianne Bertrand, and Christopher Blattman.

OTHER RESEARCH WE DISCUSS IN THIS EPISODE:

Predicting and Preventing Gun Violence: An Experimental Evaluation of READI Chicago

Gun violence is the most pressing public safety problem in U.S. cities. We report results from a randomized controlled trial (N = 2,456) of a community-researcher partnership called the Rapid Employment and Development Initiative (READI) Chicago. The program offered an 18-month job alongside cognitive behavioral therapy and other social support. Both algorithmic and human referral methods identified men with strikingly high scope for gun violence reduction: for every 100 people in the control group, there were 11 shooting and homicide victimizations during the 20-month outcome period. Fifty-five percent of the treatment group started programming, comparable to take-up rates in programs for people facing far lower mortality risk. After 20 months, there is no statistically significant change in an index combining three measures of serious violence, the study’s primary outcome. Yet there are signs that this program model has promise. One of the three measures, shooting and homicide arrests, declined 65% (p = .13 after multiple-testing adjustment). Because shootings are so costly, READI generated estimated social savings between $182,000 and $916,000 per participant (p = .03), implying a benefit-cost ratio between 4:1 and 18:1. Moreover, participants referred by outreach workers—a prespecified subgroup—saw enormous declines in arrests and victimizations for shootings and homicides (79% and 43%, respectively) which remain statistically significant even after multiple-testing adjustments. These declines are concentrated among outreach referrals with higher predicted risk, suggesting that human and algorithmic targeting may work better together.

In Search of Common Ground: Expert Judgments on Gun Policy Effects

As our review of the existing literature demonstrated, there is very little scientific evidence available to support the decisions that policymakers and the public must make about whether to implement or change various gun policies. Without strong scientific evidence, policymakers and the public rely heavily on what advocates or social scientists believe the effects of policies are most likely to be. The opinions of these gun policy experts are an important influence on gun policy debates and decisions because people believe that the experts have an especially well-informed understanding of the gun polices under consideration, how similar laws have performed historically, and how specific policies would affect particular stakeholder groups.

Different communities of gun policy experts have sharply divided views on many gun policies, as often becomes clear in the debates that occur when states and the federal government consider new gun legislation. Less clear is whether there are laws or policies for which such differences are less stark, or whether there may be a combination of policies that experts of every stripe could regard as an improvement over existing policies. Finally, it has not been clear whether experts disagree about which objectives gun policies should be trying to achieve or whether experts agree on the objectives but disagree on which policies are most likely to achieve those objectives. If the experts chiefly disagree on the latter, this suggests a role for new and better scientific study of the true effects of gun policies.

To begin to answer these questions, RAND researchers surveyed 173 gun policy experts (across two fieldings in 2016 and 2020) on what they believed the effects of the following 19 gun policies would be on ten different outcomes.

The consequences of high-fatality school shootings for surviving students

This paper examines the impact of high-fatality school shootings on the subsequent outcomes of the survivors of those events. We focus specifically on the shootings at Columbine High School (Littleton, CO), Sandy Hook Elementary (Newtown, CT), and Marjorie Stoneman Douglas High School (Parkland, FL). We assess the subsequent educational record, including attendance and test scores, and the long-term health consequences of surviving students. In all analyses, we treat the timing and location of these events as random, enabling us to identify causal effects. Our results indicate that these high-fatality school shootings led to substantial reductions in attendance and test scores. These educational effects appear to be larger than the effects of shootings with fewer fatalities estimated by others. Children who survived the Columbine shooting were more likely to die by age 30, particularly among boys. They experienced higher levels of suicide and accidental poisonings (overdoses).

Handgun Waiting Periods Reduce Gun Deaths

Handgun waiting periods are laws that impose a delay between the initiation of a purchase and final acquisition of a firearm. We show that waiting periods, which create a “cooling off” period among buyers, significantly reduce the incidence of gun violence. We estimate the impact of waiting periods on gun deaths, exploiting all changes to state-level policies in the Unites States since 1970. We find that waiting periods reduce gun homicides by roughly 17%. We provide further support for the causal impact of waiting periods on homicides by exploiting a natural experiment resulting from a federal law in 1994 that imposed a temporary waiting period on a subset of states.

The impact of mass shootings on gun policy

There have been dozens of high-profile mass shootings in recent decades. This paper presents three main findings about the impact of mass shootings on gun policy. First, mass shootings evoke large policy responses. A single mass shooting leads to a 15% increase in the number of firearm bills introduced within a state in the year after a mass shooting. This effect increases with the extent of media coverage. Second, mass shootings account for a small portion of all gun deaths, but have an outsized influence relative to other homicides. Third, when looking at bills that were actually enacted into law, the impact of mass shootings depends on the party in power. The annual number of laws that loosen gun restrictions doubles in the year following a mass shooting in states with Republican-controlled legislatures. We find no significant effect of mass shootings on laws enacted when there is a Democrat-controlled legislature, nor do we find a significant effect of mass shootings on the enactment of laws that tighten gun restrictions.

Does the disclosure of gun ownership affect crime? Evidence from New York

While the social costs of gun violence are high, opponents of gun restrictions argue that gun ownership deters crime and creates a positive externality by increasing unobserved risk to criminals. This paper investigates the evidence for these two deterrence channels, exploiting the sudden disclosure of all handgun permit holders’ names and addresses in two New York counties. Permit holders have more crime incidents at their homes relative to non-permit holders in the baseline, which is not driven by selection into neighborhoods. I find little evidence in favor of direct deterrence, and little evidence of peer deterrence. Instead, I find that victimization is associated with a higher likelihood of future gun ownership.

Guns and violence: The enduring impact of crack cocaine markets on young black males

The violence associated with crack cocaine markets in the 1980s and 1990s has repercussions today. Using cross-city variation in when crack cocaine arrived and an older comparison group, we estimate that the US murder rate of black males aged 15–24 was still 70 percent higher 17 years after crack markets had emerged. Using the fraction of gun-related suicides as a proxy for gun availability, we find that increased access to guns led to persistently higher murder rates. Our estimates imply that more guns due to crack-related violence explains approximately one-tenth of the current life-expectancy gap between white and black males.

Smoking gun? Linking gun ownership to crime victimization

Using linked individual data on concealed handgun permits (CHP), reported crimes and arrests, I examine the dynamics of gun-ownership and criminal victimization. I initially show that being male, Republican, older, born in-state and a recent crime victim increases the probability that an adult obtains a CHP. Having a CHP increases property crime victimization by 46% with the largest impact on having a firearm stolen. Individual CHP holders see no change in violent crime victimization thus dispelling any benefits in terms of protection. Obtaining a CHP has a small (2%) increase in total crime and a larger increase on violent crime using a gun (8%) within the CHP holders neighborhood. Results suggest stolen guns spillover to neighborhood crime which is an important component of the larger social costs of gun ownership.

Healing the Healers – Supporting Physicians After Mass Public Shootings

As a disaster mental health (DMH) professional, I have responded to five mass public shootings since 2017 and have had the opportunity to provide support to hospitalized survivors as well as their loved ones. I’ve stood in emergency departments and intensive care units in Uvalde, Texas, Las Vegas, Nevada, and Lewiston, Maine. I have watched dedicated physicians work tirelessly to save the lives of fellow community members. I have heard stories of their heroism, and I have witnessed it with my own eyes. Yet, despite their significant role in the aftermath of these incidents, this group has been largely overlooked in academic literature, and their voices have often been excluded from discussions surrounding mass public shootings. In recent years, physicians have attempted to make their voices heard by tweeting photographs and stories about their experiences treating victims of gun violence using the hashtag “ThisIsOurLane,” a movement initiated by Brady Center to Prevent Gun Violence board chair and chief medical officer Dr. Joseph Sakran. Through these graphic images and narratives, it is clear that these healthcare professionals are profoundly impacted by what has been referred as a gun violence epidemic.

The Psychological Toll

Physicians are not immune to the physical and psychological effects of trauma. Due to the nature of their careers, these individuals often work long hours in high-pressure environments, frequently leading to exhaustion and burnout, particularly in emergency medicine (EM) settings. One recent study found that 15.8 percent of EM physicians and 29 percent of EM residents meet the criteria for posttraumatic stress disorder (PTSD). Additionally, up to 40 percent of trauma surgeons have posttraumatic stress symptoms (PTSS), with 15 percent meeting the full diagnostic criteria for PTSD. While these physicians frequently treat individuals affected by gun violence, when treating victims of mass public shootings, the prevalence of PTSS and PTSD among physicians may be even higher, as research suggests that exposure to human-made disasters can lead to increased levels of distress, especially considering the volume and severity of patient presentations. Furthermore, these physicians often live in the communities affected by these incidents, and some may even personally know the victims they are treating, especially in rural communities and smaller towns, potentially exacerbating their risk of experiencing both short- and long-term stress reactions. However, the needs of these medical professionals are frequently neglected during recovery efforts, and due to this, physicians have been considered unrecognized survivors of mass killings.

The needs of these medical professionals are frequently neglected during recovery efforts, and due to this, physicians have been considered unrecognized survivors of mass killings.

Recently, Dr. Craig Goolsby, Department Chair and Professor of Clinical Emergency Medicine at Harbor-UCLA, convened a group of emergency medical services (EMS) professionals, EM physicians, and surgeons who responded to six high-fatality mass shootings in the US. Their objective was to develop consensus recommendations for improving care and patient outcomes during these tragic incidents. Among their eight recommendations in the final report was the inclusion of tailored mental health services for all responders, whether present at the scene or the hospitals. While the experiences of other first responders, such as EMS, and other hospital personnel, like nurses, have been explored, less is known about physicians. Therefore, in collaboration with Dr. Goolsby, my research colleagues and I conducted a qualitative study using semi-structured individual interviews to explore the experiences and needs of physicians following mass public shootings. More specifically, our research centered on nine physicians in seven impacted communities. While a previous study examined the experiences and immediate needs of physicians working in hospitals located in communities impacted by mass public shootings, our study focused on the ongoing needs of these medical professionals across all disaster phases.

Our findings revealed that these incidents significantly affected most participants in the short term. Many shared how they initially compartmentalized their emotions and struggled to process what had happened. For instance, one participant shared, “it ended up being like, oh, wow, what was that about when I ‘woke up’ two days later…I remember getting home after another busy shift and just breaking down.” Participants also described how these incidents had lasting effects on their lives. One participant shared, “it’s life-changing…it will stay with me forever. It’s changed my career.” Some participants also experienced long-term impacts, including hypervigilance and avoidance of large crowds and gatherings. For instance, one participant stated, “I used to go to college football games all the time. I don’t think I’ve been to a college football game since.… I don’t want to be in crowds as much as I used to.” Another shared, “I had a very visceral reaction to discussions around it [the incident] for months, if not years. It has had huge effects.”

One participant shared, “it’s life-changing…it will stay with me forever. It’s changed my career.”

Stigma and Help-Seeking

Despite being profoundly impacted, most participants in our study did not seek formal mental health support. While many acknowledged that mental health support was made available to them following these incidents, these services were underutilized. Instead, many physicians preferred to engage in informal peer support, including peer mentorship and gatherings in relaxed settings, such as at the homes of fellow physicians.

Our interviews reflected that reluctance to seek formal mental health support might be due to the stigma physicians often face and the fear that licensing bodies may revoke or restrict their license to practice should a mental health issue be disclosed on a licensing application or renewal. For instance, one participant stated,

I strongly identify as an emergency physician….and that could be taken away from me if when I reapply for my medical licensure, they ask, ‘have you ever had any mental health disorders?’ If I get a diagnosis because I was having issues dealing with an event and I have to disclose that, I’m placing myself in jeopardy of losing my medical license.

Another shared, “if you go and seek help and receive that diagnosis, you will have to notify the [state] medical board. You could be in danger of losing your license, so there is not only a stigma, but there’s negative reinforcement.”

Stigma related to help-seeking is not unique to physicians who treat casualties of mass public shootings, as this issue has been discussed extensively for many years. However, the demand for mental health support and tailored services is likely even greater during and after human-made disasters, such as mass public shootings. Therefore, efforts should be made to alleviate barriers to accessing support to improve overall well-being, decrease burnout, and better equip physicians to respond during these and other trauma-related incidents. Creating a culture of care and taking proactive measures to promote wellness among physicians is imperative, as “an ounce of prevention is worth a pound of cure.”

Overcoming Barriers

Physicians face complex challenges and barriers when attempting to access mental health support. While the disclosure of mental health diagnoses to medical boards was initially intended to safeguard the public from physicians who may be impaired, the Federation of State Medical Boards (FSMB) contends that such disclosure does not reliably predict the risk of harm to patients. Instead, it prevents physicians from receiving necessary mental healthcare, potentially exacerbating impairment. To help mitigate these barriers, the FSMB offered several recommendations, including urging medical boards to “evaluate whether it is necessary to include probing questions about a physician applicant’s mental health, addiction, or substance use” on licensure applications or renewals. More specifically, the FSMB made the following recommendations to be compliant with the Americans with Disabilities Act (ADA): (1) limiting mental health questions to conditions that result in impairment; (2) limiting mental health questions to conditions within the past two years or less; (3) not requiring physicians to disclose their diagnosis or treatment to the board if they are enrolled in a Physician Health Program; and (4) using supportive language about seeking mental health care. However, a recent study found that only 5 percent of medical boards were in compliance with the FSMB’s recommendations.

Access to supportive services is vital, as burnout and poor mental health among physicians have been linked to increased rates of suicide, as well as medical errors and suboptimal patient care. Therefore, to eliminate barriers to help-seeking, state licensing boards might carefully consider revising their policies to align with the recommendations put forth by the FSMB. For example, in 2020, the Texas Medical Board (TMB) revised the language related to mental health in applications for initial medical licenses and renewals. Due to these changes, the TMB is now in full compliance with the FSMB’s guidelines, fostering a more supportive atmosphere and reducing obstacles to mental healthcare. Furthermore, because mental health support is underutilized by physicians, alternative forms of support should be made available to them following mass public shootings. Facilitating opportunities for peer support, for instance, can be a valuable resource, as this can help normalize emotions and reactions to difficult experiences and has been found to increase well-being and reduce mental health stigma among physicians. To enhance support, hospitals might consider organizing formal and informal gatherings for these individuals to come together and begin to process.

Additionally, physicians should be afforded ample space and time to decompress and grieve. In our study, five participants mentioned the challenges of dealing with the media coverage in the immediate aftermath of the incident and how they did not have an opportunity to reflect on or process their emotions before they were required to make a statement to the press, as has been seen in several post-incident news briefings in the past. Due to this, hospitals should allow physicians to decline requests for press interviews and consider designating a hospital spokesperson who is uninvolved in the medical treatment of casualties to handle any media requests.

Community support also plays a crucial role in the recovery process for physicians after mass public shootings. Hospital systems can partner with local and regional healthcare networks to facilitate shift coverage and adequate time off so that these individuals can participate in community memorials and vigils. Attending public rituals can promote community solidarity and cohesion, bolstering resilience in those affected by disasters. Additionally, hospitals should recognize the lasting effects mass public shooting incidents can have on physicians, providing tailored support and adopting a trauma-informed approach and policies across all stages of disaster recovery. Some participants, for example, expressed the desire to give back to their communities and the medical profession and found channeling their grief into action to be an important part of their recovery journey. One participant shared, “I had to figure out how I was going to make something better of this.” However, not all felt supported by their employers in pursuing these endeavors. Hospital systems should acknowledge the diverse ways in which meaning-making and healing occur and support physicians in these activities, as altruism has been found to foster post-traumatic growth.

Physicians are often overlooked following mass public shootings and may ultimately suffer in silence. These medical professionals should be offered equal opportunities to heal alongside others within their communities, as “no one who sees a disaster is untouched by it.” Ultimately, the mental health and well-being of physicians should be prioritized and help-seeking normalized after mass public shooting incidents. Additionally, while this piece highlights the needs of physicians, it is important to acknowledge that other members of the broader healthcare team, like respiratory therapists, hospital technicians, and social workers, are also often overlooked. Therefore, further studies are warranted to understand their experiences after mass public shootings. Ultimately, it is time to heed the call to care for those who selflessly care for us.

ABOUT THE AUTHOR

Rebecca Cowan is a faculty member in the College of Social and Behavioral Health at Walden University and an affiliate scholar with the Regional Gun Violence Research Consortium. As a disaster mental health supervisor with the American Red Cross, she has responded to several mass shootings, including the Route 91 Harvest Festival in Las Vegas, Nevada, Marjory Stoneman Douglas High School in Parkland, Florida, and Robb Elementary School in Uvalde, Texas. Cowan also served as a gubernatorial appointee on the Commission to Investigate the May 31, 2019, Virginia Beach Mass Shooting.