Gun violence expert says tackling underlying inequities key to prevention

Gun violence expert says tackling underlying inequities key to prevention

Through the news media, Americans are served an almost-daily dose of violence caused by guns. This year to date, more than 33,929 people in the United States have been killed and another 30,000+ have been injured by guns. The U.S. homicide rate for firearms is 22 times greater than that of the European Union, even though the European population is 35% larger.

But to Dr. Garen Wintemute, the statistics on injuries and deaths are only one part of the story. To reverse those appalling numbers, he says, the larger focus must be on changing the conditions that foster gun violence. These include the underlying inequities that are baked into the essence of American life.

“Violence has social determinants, such as disparities based on race/ethnicity, gender or sexual orientation, place of origin and other characteristics,” says Wintemute, director of the Violence Prevention Research Program at the University of California at Davis School of Medicine. He is an expert in the public health crisis of gun violence and a pioneer in injury epidemiology and prevention of firearm violence.

But to Dr. Garen Wintemute, the statistics on injuries and deaths are only one part of the story. To reverse those appalling numbers, he says, the larger focus must be on changing the conditions that foster gun violence. These include the underlying inequities that are baked into the essence of American life.

To really understand the root of gun violence, Wintemute says, you have to understand that the systemic forces that gave rise to it were intentional. “The structures that engender and perpetuate violence were built purposefully and must be taken down just as purposefully,” he says.

Wintemute has been leading by example. Since the 1980s, the emergency medicine doctor has been documenting and working to undo the grip that guns have on life and death in America, destroying lives and communities. Way ahead of the curve, Wintemute was among the first to call gun violence a public health crisis, in line with the former U.S. Surgeon General David Satcher, who wrote about it in 1995 while pushing for more funding to examine it.

Wintemute’s research, which includes undercover work at gun shows around the country, has helped to thwart the use of the widely popular handgun known as the Saturday Night Special. This cheap weapon, banned in West Hollywood, the city of Compton and 16 communities in the San Francisco Bay Area in the mid-1990s and other handguns have been linked to 90% of injuries and between 70 and 80% of murders over an 18-year period. His research and testimony also led to legislative debate attempting to restrict the sale of assault rifles, including the AK-47. And in 1997, Time magazine named Wintemute a Hero of Medicine for his gun violence prevention work.

Think you know something about historical trauma? PACEs Connection’s ‘Historical Trauma in America’ series promises to be an eye-opener

The murder of George Floyd in May 2020 unleashed hundreds of articles, books, podcasts, film and online documentaries. It’s not that the roots of racism and inequity in historical trauma hadn’t been known about or written about previous to his death (Frederick Douglas, James Baldwin, anyone?), but the pressures of hundreds of years of injustice began a near explosive untangling from the massive twisted and angry knot they’d formed over generations. It’s been like cutting through a gargantuan ball of rubber bands stretched to their limit: layers upon layers of hurt, unfairness, frustration, lives lost, lives constricted into rigid and narrow boundaries, all because of the human bent toward “othering”. (That’s something that PACEs science clearly demonstrates: There is no us and them. Just us.)

Despite all the stories that have been loosened from the grip of our remarkable ability to ignore what’s in front of us, White people are just beginning to learn—to our ongoing dismay, shame and horror—that racism and inequity are baked into everything we do, into all our systems, in every community in the U.S., even though most of us don’t know or want that. Fortunately, we are now in a time of reckoning, and have the potential to make real change. If you haven’t already put together your reading list to educate yourself, the 27 books here range from Ibram X. Kendi’s “How to Be an Antiracist”, to Cathy Park Hong’s “Minor Feelings”, to Toni Jensen’s “Carry: A Memoir of Survival on Stolen Land.”

Despite our individual ACEs, the White people among us have been incredibly fortunate to be born into a power structure from which most of us didn’t even realize we benefited. We’ve been swimming in a sea that we didn’t even know was wet. Thus I think it’s our obligation, from the moment we grok the enormity of how our history granted us immeasurable advantages, to spend the rest of our lives educating ourselves and educating as many people as we can to change our systems. That’s a major goal of our work at PACEs Connection, the social network that accompanies ACEs Too High.

Over the last two years, PACEs Connection team members Ingrid Cockhren and Donielle Prince have been leading efforts to educate our organization about racism, inequity, White privilege, and how PACEs science figures into that. Ingrid’s been leading a series of in-depth webinars for our team that have truly challenged our understanding of where we are and how we got here. It’s been sobering, but one thing that being in this PACEs community offers is that we help each other face not only our individual truths, but our society’s truths, because that’s one of our values. (If you aren’t a member of PACEs Connection, please join by going to PACEsConnection.com.)

“I came up with the idea for the series in response to the controversy concerning Critical Race Theory in schools,” says Cockhren, who is PACEs Connection’s director of communities, “or basically the reluctance to discuss America’s true history.” When she suggested that we host a series of webinars on historical trauma in six different regions of the country, the team jumped into action.

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Lesson learned integrating ACEs science into health clinics: Staff first, THEN patients

Dr Omotoso
Dr. Omoniyi Omotoso

About two years ago, a team from LifeLong Medical Clinics jumped at the opportunity to integrate practices based on adverse childhood experiences   when it joined a two-year learning collaborative known as the Resilient Beginnings Collaborative (RBC). RBC began in 2018 and includes seven safety-net organizations in the San Francisco Bay Area. (Here’s a link to a report about the RBC.)

To join the RBC, LifeLong Clinics — which has  14 primary care clinics in Alameda, Contra Costa and Marin Counties — and the other collaborative teams had to agree to introduce all staff members to the science of childhood adversity and trauma-informed practices. LifeLong went full steam ahead with a 2.5-hour introductory training for more than 100 employees who work at its clinics that serve pediatric patients. Trauma Transformed, a program of the East Bay Agency for Children in Oakland, CA, did the training in October and November 2018.

LifeLong Clinics’ decision to move forward on integrating ACEs science and trauma-informed practices into its clinics is important particularly in California where a state policy has made childhood adversity a front and center issue. On Jan. 1, 2020, as an incentive to doctors who serve Californians in the state’s Medicaid program, the state began offering supplemental payments of $29 to doctors for screening the estimated 12 million pediatric and adult patients for adverse childhood experiences (ACEs).

ACEs comes from the groundbreaking Adverse Childhood Experience Study (ACE Study), first published in 1998 and comprising more than 70 research papers published over the following 15 years. The research is based on a survey of more than 17,000 adults and was led by Drs. Robert Anda and Vincent Felitti. The study linked 10 types of childhood adversity — such as living with a parent who is mentally ill, has abused alcohol or is emotionally abusive — to the adult onset of chronic disease, mental illness, violence and being a victim of violence. Many other types of ACEs — including racism, bullying, a father being abused, and community violence — have been added to subsequent ACE surveys. (ACEs Science 101Got Your ACE/Resilience Score?)

The ACE surveys — the epidemiology of childhood adversity — is one of five parts of ACEs science, which also includes how toxic stress from ACEs affects children’s brains, the short- and long-term health effects of toxic stress, the epigenetics of toxic stress (how it’s passed on from generation to generation), and research on resilience, which includes how individuals, organizations, systems and communities can integrate ACEs science to solve our most intractable problems.

After it trained employees in 2018, brainstorming around workflow was provided for staff at the LifeLong Howard Daniel Health Center in Oakland, CA, in February 2019, where LifeLong plans to pilot ACEs screening in newborns to five-year-olds, said Dr. Omoniyi Omotoso, the pediatric lead at LifeLong Clinics, who led the brainstorming about workflow and additional training.

Four months into that training, in June, Omotoso showed staff the ACEs questionnaire and asked them how they thought patients would feel about it.

And that’s when Omotoso realized that they had to put on the brakes. “A lot of the staff were uncomfortable because they themselves had similar instances that they personally were triggered by as they read the [ACE] questions themselves,” said Omotoso, who splits his clinical time between LifeLong Howard Daniel Health Center and LifeLong William Jenkins Health Center. He said that LifeLong will be using the de-identified PEARLS ACE screener for its pediatric population, which asks those surveyed to write on the form the number of ACEs that apply to them. (Here’s a link to ACEs Aware, where you’ll find out more information about PEARLS, the only pediatric ACEs screener for which California providers can be reimbursed.)

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San Mateo (CA) launches county initiative to tackle ACEs and build resilience

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Group ice-breaker exercise

When you’re working with people who’ve had a lot of childhood and adult adversity, it’s hard for you to believe that anyone else can have a bad day, says Laura van Dernoot Lipsky. “Your neighbor or your best friend says: ‘I’ve had a bad day.’ And you think, ‘Oh, I’m sorry you had a bad day; were you sex trafficked today? No, you were not!’”

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Laura van Dernoot Lipsky

Van Dernoot Lipsky, the author of Trauma Stewardship: An Everyday Guide to Caring for Yourself While Caring for Others, was driving home one of several points of how working in a job that serves severely traumatized people can harm people who help them, too.

Screening for Childhood Trauma

Dr. Ken Epstein has been in the social services sector for nearly four decades and has witnessed firsthand the long-term effects of trauma. As both the son and father of fellow social workers, the work runs in his blood. He has been frontline staff at a residential facility for youth with severe mental and emotional challenges, a therapist, a family and couples therapy professor and director of the Child, Youth and Family System of Care for the City of San Francisco’s Department of Public Health. Now, he’s helping Bay Area health clinics screen for and address childhood trauma through the Resilient Beginnings Collaborative (RBC), led by Center for Care Innovations (CCI) and made possible by Genentech.

Trauma is pervasive. Studies show that one in seven children in California experience trauma by age five (Children Now, 2018), and research links adverse childhood experiences (ACEs) – incidences of abuse or neglect, household dysfunction, and community violence – to an increased likelihood of negative health outcomes. In youth, trauma can cause behavioral issues, asthma, and infections; as adults, those same individuals are at greater risk of heart, lung, and autoimmune disease, obesity, mood disorders, and substance use disorders. This is magnified when you include income disparities and the impact of systemic and structural inequities.

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Tributes honor the life of Rep. Elijah Cummings of Baltimore

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Image projected on a building of a younger Rep. Cummings taken on a street in his native Baltimore. From an unknown source, projected images and messages appear on the side of a building near my house in the Mt. Pleasant neighborhood of Washington, DC.

When the news alert came across my cell phone on Thursday morning that Elijah Cummings had died, I felt overwhelming sadness for the loss of a powerful, eloquent, and soulful human who understood trauma in his bones.  An immediate second thought was he died too soon as do many other African Americans whose lifespan is shorter by years than white people’s. Then I wondered how we can honor his legacy by building on what he started dramatically in the House Oversight and Reform Committee with the first hearing of its kind on July 11 this year (Click here for a story on the hearing in ACEs Connection).

Just the day before the news of Cummings’ death, I had read an email from Dan Press who leads the advocacy work for the Campaign for Trauma-Informed Policy and Practice (CTIPP) updating me and other members of the CTIPP Board about the latest thinking of Cummings and his staff about the advisability of moving ahead at this time with comprehensive legislation on trauma.  The strategy was fluid but it was clear that Cummings was engaged and focused on the what, when, and how of promising next steps with legislation.

Iowa ACEs360: Catalyzing a Movement

Iowa ACEs Policy Coalition joins Iowa Gov. Kim Reynolds as she signs a “Resilient Iowa” proclamation in 2018. Photo courtesy of Lisa Cushatt.

For years, advocates for a statewide children’s mental health system would stand before Iowa legislators and speak passionately about their own particular concerns.

Psychiatrists pointed to a need for more inpatient beds for youth with severe mental illness. Pediatricians said the answer was better screening to identify mental health issues in children from birth to age five. Educators wanted more school-based mental health services, and advocates from grassroots groups like the National Alliance on Mental Illness (NAMI) asked for increased crisis services.

“We were all saying, ‘Throw money at this issue,’” says Chaney Yeast, co-chair of the policy coalition of Central Iowa ACEs 360, a multi-sector network formed in 2012. “That confused legislators; they felt it was this black hole, and they didn’t act.”

This year—thanks in part to connections forged by Iowa ACEs 360—advocates for a comprehensive child behavioral health system told a single story: Children whose mental health needs are met will be more likely to graduate, be employed and become productive members of the community. Current mental health services for children are fragmented and inconsistent. We know what it would take to fix that.

Group after group that testified before Iowa legislative committee members—officials from the sheriff’s department, mental health providers, community advocates, child welfare workers—drummed home talking points that the ACEs policy coalition had developed with a public policy messaging and research firm.

“That common messaging hit home. We were all on the same page,” says Yeast. The bill—which requires Iowa counties to implement a coordinated array of preventive, diagnostic and treatment services for children, and calls for parents of children with mental health issues to have a voice in designing those services—passed the legislature in April and was signed by the state’s governor in May.

“That was a huge win in terms of collaboration,” says Yeast. It was also a clear example of the power that cross-sector networks can wield when members move beyond their own silos to support a shared goal. Such work is not easy—“It takes a lot of time and effort to continually nurture those relationships and connections,” says Yeast—but it is essential to making long-term, systemic change.

That’s been the ambition of Iowa ACEs 360 since its start, when a small group of stakeholders—in public health, mental health, family support and community advocacy—gathered, with the support of the Mid-Iowa Health Foundation (MIHF), to discuss the original CDC-Kaiser Permanente ACE Study and how their work needed to change in response.

That group decided on two priorities: collect Iowa ACE data and spread awareness of the ACE Study, so others could be galvanized by its findings on the lifelong, corrosive effects of early childhood adversity.

After Rob Anda, the co-investigator of the 1998 ACE Study, did a presentation about the ACE Study to a small group of key stakeholders, an early step was to include the ACE module in Iowa’s Behavioral Risk Factor Surveillance System (BRFSS). Following an invitation-only summit in 2011 that featured a follow-up with Anda, he and Laura Porter, a nationally known expert on ACEs and population health, spoke to 800 people at the 2012 Iowa ACE Summit.

Suzanne Mineck, president of MIHF and one of the original committee members who launched ACEs 360, says “water cooler conversations” in the weeks following Anda’s visits that gave the work momentum. “We all had the privilege of learning about compelling research, but it was the lingering impact, both on those in decision-making places and those on the front lines, that was as much of an ‘aha.’”

As the coalition grew, hosting quarterly learning circles, developing work groups and, in 2014, acquiring a part-time program manager, it became a place where people from various sectors—juvenile justice, child welfare, health care and education—could learn together.

“It created a culture where there wasn’t a singular response…a culture of transparency, humility, honoring and supporting risk-taking,” says Mineck. “Many felt they were learning things for the first time together.”

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CA announces robust perinatal depression prevention for Medi-Cal recipients

Melinda Coates experienced a tumultuous pregnancy. “I was really mentally upset literally from day one (of the pregnancy),” she says. (Melinda Coates is a pseudonym. To protect her and her children’s privacy and safety, we are not using her real name.)

Coates had hoped to get counseling last October, when she was seven months pregnant. That’s when she enrolled in the state’s Medi-Cal program, shortly after she and her abusive husband moved to California, “but nobody was able to get me in that quickly,” she says. “If I had gotten the help that I needed with my mental state, I may not have stayed in my abusive marriage as long,” she says.

Six weeks after her son’s birth she had one session with a counselor who prescribed an antidepressant. “I was supposed to go back, and I needed to reschedule, but I never heard from her again,” says Coates, who has been living in a domestic violence shelter since the end of June with her eight-month-old son and three-year-old daughter. She is currently separated and filing for a divorce from her husband.

A new policy in California that went into effect in July now makes it possible for pregnant women like Coates to get the counseling they need, according to a recently-released MediCal bulletin.

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The myth of motive in mass shootings

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Photo: Vernon Bryant, Dallas Morning News

Almost the first thing you hear out of the mouths of police after a mass shooting is: “We’re looking for a motive.”

In Gilroy, CA, the FBI is investigating the shooting at the Gilroy Garlic Festival as domestic terrorism. In El Paso, TX, police are describing the shooting as a possible hate crime and act of domestic terrorism, and focusing on the manifesto written by the shooter. Police in Dayton, OH, are still looking for a motive for why 24-year-old Connor Betts murdered nine people in 30 seconds.

But if we want to prevent shootings, asking about motive will just get you a useless answer to the wrong question. Police might feel as if they have an explanation for why 19-year-old Santino William Legan murdered three people, and why 21-year-old Patrick Crusius murdered 22 people. But motives don’t explain the roots of why those three young men, or any other mass shooters or bombers, foreign or domestic, start their journey as innocent babies and end up on a road to killing people. And in those roots, are our solutions.

If you use the lens of the science of adverse childhood experiences, the answer reveals itself, and usually pretty quickly.

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Personal stories from witnesses, U.S. representatives provided an emotional wallop to House Oversight and Reform Committee hearing on childhood trauma

William Kellibrew's grandmother receives standing ovation

Room erupts in applause for the grandmother of witness William Kellibrew during July 11 House Oversight and Reform Committee hearing.

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The power of personal stories from witnesses and committee members fueled the July 11 hearing on childhood trauma in the House Oversight and Reform Committee* throughout the nearly four hours of often emotional and searing testimony and member questions and statements (Click here for 3:47 hour video). The hearing was organized into a two panels—testimony from survivors followed by statements from experts—but personal experiences relayed by witnesses (including the experts) and the members of Congress blurred the lines of traditional roles.

Chairman Cummings
Chairman Elijah Cummings
Ranking Committee member Jim Jordan (R-OH)
Ranking member Jim Jordon (OH)

Chairman Elijah Cummings (D-MD) set the tone early in the hearing by recalling his childhood experience of being in special education from kindergarten to sixth grade, and being told he would “never be able to read or write.”  Still, he “ended up a Phi Beta Kappa and a lawyer.”

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