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Guns were the weapons wielded in more than three-quarters of homicides in the U.S. during the first year of the Covid-19 pandemic, jumping 35% from 2019 to 2020 and marking the highest level since 1994, a new CDC analysis says. The suicide rate involving guns was stable at just over half of suicides, but there were increases in some groups of people.

The most striking disparity came among young people. Guns killed Black children and young adults from 10 to 24 years old at a rate 21 times as high as among their white peers. “We’re losing too many of our nation’s children and young people, specifically Black boys and young Black men,” Debra Houry, acting principal deputy director of the Centers for Disease Control and Prevention, said in an interview with STAT. “The difference between Blacks and whites in that age group for firearm homicide is just devastating.”

Firearm deaths overall widened disparities along racial, ethnic, and income divides. Counties with the lowest poverty levels had the lowest firearm homicide rates, and the rates of homicides with guns were higher and rose more in counties with higher poverty levels. While about 24% of Americans live in counties classified as the most impoverished, approximately 29% of the Hispanic population, 39% of the Black population, and 44% of the American Indian or Alaska Native population live in these counties.

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“The Covid-19 pandemic might have exacerbated existing social and economic stressors that increase risk for homicide and suicide, particularly among certain racial and ethnic communities,” the researchers write. “Longstanding systemic inequities and structural racism have resulted in limited economic, housing, and educational opportunities associated with inequities in risk for violence and other health conditions among various racial and ethnic groups.”

Houry is an emergency medicine physician who since 2014 was the director of the National Center for Injury Prevention and Control before assuming her current role 10 months ago. She talked to STAT about trends leading to the most recent data and what might work to stem the tide or turn it around. This interview has been lightly edited for length and clarity.

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Were you at all surprised at the numbers or at this gap?

I wasn’t surprised because we’ve seen this worsening. Certainly this rate was a significant increase from last year, but this was an issue pre-pandemic and it has worsened over the past year. And even in 2019, the difference was about 20-fold of a racial disparity. But to me, this just really speaks to the need to do something now. I’m an ER doc, I’m a mom, I’m a community member, and this just strikes home. We’ve got to address this issue.

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How much of a role do you think the pandemic played?

I think the pandemic likely contributed to some of this, when you look at communities that were already hard hit that then are facing economic losses, job issues, additional stressors. There’s an association with poverty. For homicide, the rates were 4.5 times as high in the counties of highest poverty levels and for suicide, you know, 1.3 times as high. So that just shows that the communities’ additional stressors can, certainly we can see some increased rates. But I also think it’s important to point out that we had issues with homicide and suicide pre-pandemic. Our numbers have been unacceptably high for years.

This has been something the CDC has been addressing for 30 years. And then two years ago, we got our first appropriation to do firearm violence research. So now we’re able to really innovate and work with the field on how do we prevent firearm violence and deaths and suicide deaths.

Can you tell me what works?

I like to think of it at three levels. We’ve seen that earned income tax credits can reduce violent crimes by about 10%. Again, that just shows the burden on communities and how you can alleviate some of these stressors. Similarly, affordable housing and child care subsidies can help with violence prevention. You take it a step up to the community level and you look at things like greening initiatives to take that vacant lot. You plant grass and trees and that helps build community connectedness and decreases violent firearm assaults we’ve seen in the most impoverished communities that can decrease firearms by about 29%. And then you take it up one more level, to individuals who are at risk and you look at things like hospital-based violence interventions.

In Michigan, they take someone who comes in after a violent injury, do motivational interviewing, and link them with resources. Also, street outreach workers can de-escalate conflicts. And finally, things like safe storage. If you’re in the hospital in the ER, if you have somebody who comes in after a suicide attempt who expresses feelings of depression, talk with them about it: do they have a firearm in their house and how to store it appropriately. Those are all things that can be done that work.

What about gun laws? Is there research you could tell me about?

That’s an area I’m not familiar with. We’re really focusing on the community-level interventions. And the people.

Tell me more about your experience as an ER doctor.

One of the reasons why I went into public health was really just what I saw in the field as a county ER doc for 15 years, just down the road from CDC. I would see that young Black male and I would resuscitate him and do my best to save his life. Often I would fail. My scrubs would have blood on them, and I would have to look for a clean white coat so that when I talked to his family, I was presentable and respectable. Breaking that news never got easier. It never got better.

And those that I was able to save, many of them had traumatic injuries, and disabilities afterwards. And I kept thinking if there was something I could do earlier to prevent these injuries, this violence, that would have such an impact on all of these young lives that were lost. And that was where I got involved at Grady, to see how we do a lot of violence interventions.

What are people trying?

There are hospital-based violence interventions, even models like Cardiff, that we’re piloting in Atlanta. It came from Cardiff, Wales, and it used law enforcement and hospital data to say, where are these violent injuries coming from? And they looked to see where in the city, what were the mechanisms, and then law enforcement, community leaders, and physicians worked together. We’re now funding a pilot project in Atlanta around that.

Thinking about where can intervention be done earlier, and particularly this age group, 10- to 24-year-olds, what about suicide?

I would start even earlier: things like adverse childhood experiences, so witnessing violence in the home or in the community, disruptions to daily life like in the pandemic, seeing some people use substances around you, or experiencing child abuse or other forms of violence. That can cause long-term health issues and increase likelihood of becoming a perpetrator or a victim of violence. So realizing that early on and putting programs in place, such as some of the social-emotional learning in schools that focuses on conflict resolution, coping skills — really important, and that can help with suicidality as well.

There’s a school-based program called The Good Behavior Game that is done in elementary schools, and it shows that it can prevent suicidality as well as other issues later in life by teaching a lot of those relationship skills, coping skills, conflict management, to build those blocks that are needed. Also after-school programs: Big Brothers, Big Sisters, so that you have that connection to a caring adult, whether it be a parent or somebody else that really sets up people for later in life.

What about mental health services in this age group?

Certainly, access to services is really important. I think that’s where we do see some of these disparities because where you live, work, worship, go to school impacts your access to health care, your access to good schools. And so I think that was another factor in the study.

Is this another example of structural racism?

When you look at where you live, work, and go to school, that can impact things. A lot of these inequities are not new and they have worsened. So addressing these social determinants and drivers of health are really important.

Are there any limitations to the study?

I think the limitations are that we can’t say causality, so we can’t say necessarily what caused these increases. We can hypothesize around some of the disparities in communities, looking at the racial and ethnic differences. To me, it’s really focusing on prevention.

There are strategies that work. We have funded youth violence prevention centers in many different cities. And we have found that when they have these comprehensive strategies that look at community-level interventions, they see reductions in youth violence. So we can do this. It just requires resources and focused attention on it.

Local public health departments are strapped these days. What would you say to a public health department that’s already facing so many issues competing for its limited resources?

Public health can’t do this alone. No one can do this alone. This certainly requires law enforcement, education system, parents, faith communities. And that’s what I think is the power of these comprehensive strategies, is that it requires all these strategies.

What are you seeing now?

We have 10 months of provisional data [for 2021], so it’s not complete yet. Unfortunately, the trends are continuing — we’re not seeing a decrease at this point and it will likely turn out to be higher than for 2020. That’s just how it’s tracking right now.


If you or someone you know is considering suicide, contact the National Suicide Prevention Lifeline at 1-800-273-8255 (Español: 1-888-628-9454; deaf and hard of hearing: 1-800-799-4889) or the Crisis Text Line by texting HOME to 741741.

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