You’ve probably heard the headline: Guns and cars are the leading causes of death among children. But to understand what policymakers can actually do to bring down rates of firearm and motor vehicle fatalities, researchers are going deeper into the intersection of age, sex, race, and ethnicity in mortality rates. On this episode of Policy Outsider, hear from two co-authors of a recently published article on firearm and motor vehicle pediatric deaths in the journal JAMA Pediatrics how prevention efforts need to be targeted across different high-risk subgroups to be most effective in bringing down the number of children killed by cars and guns.
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Joel Tirado 00:00
Welcome to policy outsider presented by the Rockefeller Institute of Government. I’m Joel tirado. You’ve probably heard the headline: guns and cars are the leading causes of death among children. But to understand what policymakers can actually do to bring down rates of firearm and motor vehicle fatalities. Researchers are going deeper into the intersection of age, sex, race and ethnicity and mortality rates. As we’ll hear from two co authors of a recently published article on firearm and motor vehicle pediatric deaths in the journal JAMA. Pediatrics prevention efforts need to be targeted across different high risk subgroups to be most effective in bringing down the number of children killed by cars and guns. On this episode of policy, outsider regional Gun Violence Research Consortium Executive Director Jaclyn Schildkraut speaks with Eric Fleegler, a pediatric emergency physician at Massachusetts General Hospital and an associate professor of pediatrics and emergency medicine at Harvard Medical School, and Lois K. Lee, Senior Associate in pediatrics at the Division of Emergency Medicine at Boston Children’s Hospital. That conversation is up next.
Jaclyn Schildkraut 01:35
Lois and Eric, thank you so much for joining us today to talk about your recent study. I want to kick off and ask you, what was the impetus for the study. That is, why is it so important to consider the comparability trends between pediatric deaths that are attributed to firearms and motor vehicles?
Lois K. Lee 01:53
Well, these are the two leading causes of death for children and youth in the United States, and actually, for decades, motor vehicles were the leading cause of death, and depending on the age range you look at but in pediatrics, we do care for college students. So if you look at young adults up until age 24 in 2017 that’s when the trend lines crossed, and firearms became the leading cause of death. This study, we did focus on children younger, zero to 19 years of age. We wanted to drill down in the intersection of race, ethnicity, sex and different age groups, because we know that there are different trends if you look at the intersectionality.
Eric Fleegler 02:32
Just to echo what Lois was saying, one of the challenges with kind of doing this type of research, especially around firearm injuries and fatalities is that there are some groups that are so dominant that they kind of like you can lose the signal about what’s going on with other groups. The most common example would be males versus females. Males die at much higher rates because of firearm injuries, whether it’s homicide or suicide or even unintentional. But if you drill down into this intersectionality, you start to really look at the nuance, then the trends and what has been happening over time becomes much more vivid and important to understand that it’s not just one group that’s being affected.
Jaclyn Schildkraut 03:08
You guys mentioned trends. Are there any specific trends you can point out that really capture your attention? And one more further investigation?
Lois K. Lee 03:17
Well, as Eric pointed out, really for decades, black teen males have had the highest rates of firearm deaths, primarily from firearm homicide. That continues to be true, but one of the things we found surprising was that for black females who die by homicide, there was a 40% annual percent change over time, which means, although their rates are lower that they’ve had a much higher increase, about double the increase of any of the other groups. And what was even more surprising was that there was an increase in firearm related suicide for black teen females as well, with an annual percent change of over 22% and so that just means we need to focus and do more research on this demographic group to figure out, what are the drivers of this, what are the risks, what are some protective factors? Potentially, because it’s fine to do this epidemiological research, but what’s really impactful is trying to figure out what are the interventions that can help address these important trends, and
Eric Fleegler 04:23
to put some fine details on it when you look at males versus females when it comes to firearm homicide, this has been well understood that the rates of firearm homicide are almost tenfold higher in general for males. We also know that there have always been significant disparities between the rates of whether you are white versus black or Hispanic or Asian, but when we drilled down into the teen females, so it used to be, historically, going back to 2011 that the rate difference between black females and white females was roughly five fold. But in 2019 this rapidly. Accelerated, and now Black women, black females, who are 15 to 19, are dying at rates 10 fold higher than the white females of the same age. We see similar trends with the black males. But you know, these this gets lost in the signal of all the data about the males that’s going on and really emphasizing the importance that we don’t just need to target the group such as males or black males, but we need to think about broadly about each group and think about the interventions that will be best for each group.
Jaclyn Schildkraut 05:27
Now, you guys looked at this sort of comparably to motor vehicle deaths to try and really set the scene. How did the findings in your study, sort of, you know, related to firearms, mirror some of this intersectionality as it related to motor vehicle deaths.
Lois K. Lee 05:43
I think one of the things I found surprising were that American Indian and Alaska Native, both females and males, have much higher rates, and that is an area I’m not sure there’s been particular attention to over time. One of the important things for next steps of research is really trying to determine why is this due to less drivers education? Is it due to increased alcohol and substance use Related driving? Is it due to just higher speeds because many of these youth live in more rural areas and so again, trying to figure out what are the interventions that will work for this population is important. Again, the absolute numbers are relatively small because it’s a smaller population, but that’s why it’s really remarkable that the rates are so much higher than for any of the other demographic groups when we
Eric Fleegler 06:37
when we drill down into the data, specifically looking at males and females who are teenagers, the ones who are going to be driving, we see that the rate among males has been kind of fairly steady over time for all of the racial groups. The one group that really stands out is it’s the females who have had the the Arab, American Indian and Alaska Native females that have had the greatest rate of rise and and that’s unfortunate given the fact that they have been trending down for the better part of from 2011 to 2018 but then they really kicked up in terms of their rates, and are now about the equivalent of where the males are close to approaching 30 per 100,000 fatalities, I think also, you know, as Lois was inferring, you know, we need to think about why this is happening. And there are many causes. But another thing is probably access to health care systems. We know that the rurality of the American Indian Alaska Natives, especially because of the reservation system, is really limits access to many health care systems that can take care of people who have had significant injuries from motor vehicle crashes. And that’s probably something that needs to be looked at closer. You know,
Jaclyn Schildkraut 07:40
it’s interesting that you mentioned that, given that you both have a health care background related to pediatrics, and I wonder, you know, thinking about, you know, these more rural communities, how do the limited resources and limited access to health care also impact, you know, the conversation we have about firearm violence, both preventing and responding to
Eric Fleegler 08:00
Lois K. Lee 08:49
And I also wonder about prevention. Are they wearing seat belts? Are they in areas where there’s perhaps, you know, if you know there’s law enforcement and you have a primary seat belt law, you’ll be more likely to, obviously, follow all laws, including wearing your seat belt. But we know this is a high risk group, also they might have less access to drivers education, and, you know, maybe in states that have less rigorous, Graduated Driver Licensing laws. But again, I think now that we know this, it’s important to kind of drill down and figure out, you know, why we’re seeing this. There was a 25% annual percent change in increased motor vehicle crash deaths for females, 15 to 19 years old, American Indian, Alaska Native. So again, a really a focused population where I think some good research could be done to develop some interventions.
Eric Fleegler 09:40
And of course, we’re seeing a lot of this increase that kind of took off during the time of the COVID pandemic. And so we know social norms were changing, people being in school versus being out of school. And so those probably had significant effects. What’s interesting to see is that the effects were not distributed equally among people of different races and ethnicities, or as our. Study shows even by sex and gender,
Jaclyn Schildkraut 10:03
well, and I also wonder, you know, thinking about the firearm violence aspect of it, you know, these are also communities where the culture around firearms is very different, right? You have a hunting culture. And, you know, safe storage practices might not be as prevalent because, you know, you take your firearm out, you know, to hunt animals for food or to protect your homestead in the absence of things like a large municipal police force. So I think that that’s fascinating. You know, were there any other findings in your study that really stood out to you, you know, especially thinking about firearms and the fact that they are the leading cause of death among juveniles or young adults. You know, anything that really stood out to you that you said, Hey, this is something we need to investigate further.
Lois K. Lee 10:46
I think another point again about the American Indian Alaska Native youth is that there was a 6% annual percent change over the entire study period, from 2011 to 2021 among males, 10 to 19 years old in this age group. So again, it’s not just about the motor vehicles. It’s also about firearm suicide. And our interventions for firearm suicide are going to be very different than firearm homicide. And I think there are some potentially good suicide prevention interventions that that could be focused on for this population. I
Eric Fleegler 11:19
think you also bring up kind of a very strongly related point, which is, what is happening to the change in kind of how guns are owned, how guns are stored, and what does this impact on the populations? You know, for many years, Lois and I have been involved in this research for over a dozen years now, for many years, the numbers were reasonably stable in terms of the fatality rates, and then it’s in the last four or five years that we’ve really seen a kick up in fatalities and injuries. And in part, this is probably a reflection of changes in gun ownership rates. We know that among white populations, it was very common that roughly 45 to 50% of households across the entire US owned guns. But very you know, for a long time, black and Hispanic households own them closer to 20% Well, data from national polls suggest those numbers have kicked up to 30 35% and one of the things we know when it comes to firearm fatalities, where there are more guns, there is going to be more deaths. Also, we know that the ownership of these guns is not equally distributed throughout the country. There are states such as Massachusetts where gun ownership rates are probably on the 10 to 15% range, and there are states out west, Wyoming and other and Montana and other states where it’s easily 60% or more, and in rural populations, as you alluded to, who have hunting cultures, it may even be above that. Unfortunately, the data that we know about this is really, really limited, because there have been no good national studies that have looked at the distribution of guns in our country since 2004 so that we are two decades behind in terms of truly knowing what the data is regarding gun ownership across our country.
Jaclyn Schildkraut 12:51
Eric, you mentioned, you know, some changes that potentially happened during COVID. And I wonder if you guys continue to grapple with this issue, both professionally and, you know, almost from an academic or research you know lens are you planning to continue to look into this, especially now that you know, as more and more data becomes available, obviously, we know that we do have a data lag in some respects. But you know, as data comes out, you know, for both the pandemic years and beyond the pandemic years, which of course, then allows for looking and isolating the effects of the pandemic. Do you think that you’ll continue to investigate this issue, and what questions do you have looking ahead?
Eric Fleegler 13:26
Yeah. I mean, there’s no question this problem is not going away. Lois and myself and one of our friends and colleagues, Rebecca Mannix, wrote an editorial right at the beginning of the pandemic saying we are seeing an increase in the rate of depression and mental health problems. We are seeing an increase in the rate of gun purchases during this time period. This can only lead to likely a bad connection with increased suicidality, not just in the immediate period, but over the long term. We’ve been seeing a positive thing in that probably in 2023 when the final data comes in, we are going to start to see a little bit of a downtrend in gun firearm fatalities, but still, we are at numbers that are extraordinarily high. So the need to understand who’s dying, why they’re dying, what are the mechanisms and what we can do to protect them is going to just continue to increase. Lois and I, for many years, have been really diving into the epidemiology and the disparities and trying to understand the etiology of these things, I think the next big phase of our careers is working, not just in those areas, but starting to work on the interventions themselves, to understand this better, you
Jaclyn Schildkraut 14:28
know. And that actually leads me to my next question, you know, we learned a lot from motor vehicle deaths, right? And we saw a lot of policy changes come about, both generally and also related to pediatric care and prevention of injury, things like, you know, seat belt and child safety laws. What can we learn? You know, as we think about our target audience of policy makers, you know, what might we learn from the changes that were made with the motor vehicle industry that can help us? You know, as we move forward thinking about how to prevent firearm violence, yeah.
Lois K. Lee 14:59
That’s an excellent question. And I think we need to start in the 1960s and realize back in the 1960s there were very high motor vehicle crash death rates, not just for kids, but also for adults. And honestly, the motor vehicle industry was really not interested in making safer cars. The thought was that, you know, crashes happen due to the fault of the driver. But there has been a sort of change in that thinking since the 70s, that there are it’s multifactorial, right, why crashes happen and why people might die or get injured from them. So we have to think about all the different layers of why that might happen. And so in the 70s, there was really a push to make cars and roads safer, and part of that was due to the establishment of the National Highway Transportation Safety Administration, which is a federal agency charged with making roads and cars safer right. And so we’ve seen huge changes the third brake light, seat better, seat belts, airbags, all those things, as well as improvements in the built environment, have led to decreases in dramatic decreases in motor vehicle crash deaths, you know, for all Americans. But part of that is also looking at the data. So it’s fine to, you know, put in interventions, but it’s also important to look at that. So part of what NHTSA does is they have a national database that includes both fatal and non fatal crash data, and that allows us to look at all sorts of risk factors. And they basically look at the crash and say, okay, was there alcohol involved? Were they wearing a seat belt? Were airbags deployed? What was the weather like? So we can look at, what are the risk factors, what are the protective factors, study them and ensure that we have, you know, sort of the best policies available. There’s also a lot of research funding to use those databases and to make improvements. And then again, having this multi pronged approach, we’ve developed lots of effective interventions, both active and passive, which have been very effective. So I think part of it, we need better data, as you mentioned yourself. Jacqueline, you know, there is a data lag. So although our paper was literally published three, three weeks ago, almost a month ago, now it’s, you know, 2021, data, right? We’re already four years behind. So, you know, yes, we see all these troubling trends, but this day, today, we don’t actually know what’s happening with firearm suicide rates for black females. And that is really something that needs to get fixed. You
Eric Fleegler 17:25
know, there, Dr Hayden is one of the leaders in thinking about, how do we prevent injuries from occurring? And he developed what’s known as the Hayden matrix, which looks at the before during the actual event and the after event, and then kind of divides it into various interventions that can be done to improve these and as Lois was saying, the amount of research and time and energy and regulations that have gone into improving motor vehicles is just dramatic, and we all benefit from it. None of this has occurred with firearms, if anything, obstacle after obstacle have been put in the way of trying to recognize something that kills over 38,000 people a year in our country and wounds another 200,000 and the fact that we just ignore this type of information is very sad, and it’s part because the funding has been was either completely cut off for almost 20 years, and now is kind of trickling in but but the keyword is trickle in terms of The quantity and then the data available and the regulations to make these differences, is just not really pushing to try to improve the health and life of Americans. This is not and this is an important thing. This is not to say, you know, we need to take all the guns away. Matter of fact, nobody looked at cars and said, there are a lot of people dying of cars. Let’s get rid of the cars. What they said was, let’s make this environment. Let’s make these cars safer. Let’s make the people are driving them safer. We should be able to do the same for firearms. And
Lois K. Lee 18:47
I want to add, you know, research funding is still a threat, right in 2020 for the first time, there was federal congressional funding appropriated for the NIH and CDC for Farm Research funding. And this was after, you know, the infamous Dickey Amendment was passed in 1996 which was interpreted to say that no federal funds could be used for research. And at that time, the Congress had actually tried to eliminate the National Center for Injury Prevention and Control at the CDC. They weren’t able to do that, but they were able to put in the Dickey Amendment, which really stymied federal research funding for farm related research. And then, you know, now we have research funding, so we just shouldn’t be complacent, however, because last year, the House Budget did propose to again eliminate funding for the National Center for Injury Prevention control at the CDC. So it thankfully that budget didn’t pass, but it is still, you know, an avenue that is being pursued in Congress.
Jaclyn Schildkraut 19:48
You know, one final question that I’m, you know, kind of thinking about is, you know, you guys are just starting to peel the layer back on this onion, so to speak, I think is, is the way you put it, and that you have more. Questions that you want to ask, but you found so many important insights in this article, and I’m wondering, as you think ahead, you know, especially as we know that firearm violence for pediatric you know, populations is still so prevalent, how might policy makers consider your findings as they’re thinking ahead? Obviously, we don’t have enough to think about every intervention, but what can they do with what you found today that can help prevent deaths tomorrow?
Lois K. Lee 20:28
I think there’s three areas that I would say, if you have to choose So number one, continuing to increase resources and funding for community violence interventions. And there’s some states like North Carolina doing very innovative work, using a Medicaid waiver to pay for hospital based and Community Based Violence Intervention Programs. Obviously, suicide prevention is very important, but I think looking at the demographics again within the state, trying to figure out which are the populations that could use more resources towards suicide prevention. But it’s also important to mention, right, that people with mental health disorders are not at increased risk for perpetrating violence, but actually at increased risk for being victims of violence. And then I think the third from the motor vehicle standpoint, is really focusing on our American Indian and Alaska Native youth. And say, you know, particularly the females, but males as well. You know, what are the risk factors and what are the interventions,
Eric Fleegler 21:24
you know, and as Lois alluded to, some of these types of interventions that are necessary are going to be very firearm specific, but some of them are actually going to be broader than that. Suicide is a perfect example of this. You know, one of the resources that is severely lacking our country are good mental health resources, especially for teens. Lois and I, you know, work in pediatric emergency departments. And you know, we the increase in the mental health crisis that patients are experienced coming in the emergency department has quite literally overwhelmed the system. And so if these patients can get access to the proper health and they have access to highly lethal means, like firearms, the results of these increased deaths are not surprising, so we need to think very broadly about this. And
Lois K. Lee 22:06
from a state policy standpoint, you know, in many states, trying to lead with sort of firearm injury prevention is going to be controversial, but everybody agrees that we need to improve resources around mental health for our children and youth. So I think starting with that, that is a foot in the door to then talk about lethal means prevention, as far as secure storage for firearms, but also other things like medications, etc, and then obviously resources to treat children with mental and behavioral to health disorders, although, again, suicides often impulsive, and you don’t always know when that’s going to happen. So again, that’s a multi pronged approach. Is necessary.
Eric Fleegler 22:48
As far as Lois point about the secure storage. Secure storage is, in theory, a method that could both decrease suicides, unintentional deaths and even homicides. You know, when you read about, you know, the shocking mass shootings that occurred that involved teenagers. They’re almost universally from their parents. And so if we actually develop the interventions to make sure that the guns cannot be used by the kids themselves, that are securely stored so they don’t have access to them, the positive potential out of that is enormous, but we’re not going to know what are the best ways to do this, unless we put the interventions in place, we study and see what happens.
Lois K. Lee 23:24
So in addition to policy, I think Eric was alluding to, you know, engineering designs. Why do we have handguns designed that a two year old can pull the trigger right when there are emerging technologies to have these personalized farms so only the authorized user can, you know, fire the firearm, and not a impulsive, you know, suicidal teenager or a curious toddler.
Jaclyn Schildkraut 23:48
Absolutely seems like there’s a lot of work to be done, and you guys are really, you know, in the trenches on it. Lois Eric, thank you so much for sharing your insights with us today.
Joel Tirado 24:02
You thanks again to Eric Fleegler and Lois Lee for joining us on the show to discuss what the data show about pediatric deaths from firearms and motor vehicles and how policymakers can target interventions to address this issue. Thanks also to regional Gun Violence Research Consortium Executive Director Jaclyn Schildkraut for leading this important conversation. If you liked this episode, please rate, subscribe and share it will help others find the podcast and help us deliver the latest in Public Policy Research. All of our episodes are available for free wherever you stream your podcasts and transcripts are available on our website. I’m Joel tirado until next time. Policy Outsider is presented by the Rockefeller Institute of Government, the public policy research arm of the State University of New York. The Institute conducts cutting edge nonpartisan public policy research and analysis to inform lasting solutions to the challenges facing New York state and the nation. Learn more at rockinst.org or by following RockefellerInst. That’s i n s t on social media. Have a question, comment, or idea? Email us at [email protected].
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