The Ripple Effects of Firearm Injuries in Children with Dr. Zirui Song

Teresa Huizar: Hi, I’m Teresa Huizar, your host of One in Ten.

In today’s episode, I speak with Dr. Zirui Song, Associate Professor of Healthcare Policy and Medicine at Harvard University Medical School, about the ripple effects of firearm injuries in children.

Now, any discussion of firearm injuries is fraught. Perhaps no issue is more polarized in the U.S. than discussions about firearm rights and responsibilities. But what all this discourse fails to capture, both on the right and the left, are the effects of firearm injuries on children and youth. Whether accidental or purposeful, whether a school shooting or a gun accidentally left where a toddler could pick it up, child abuse professionals and their multidisciplinary are left to deal with the terrible aftermath.

And as you will hear, while the physical wounds may heal, the trauma left behind, and the cost of addressing the medical and mental health needs, are long lasting. And these effects are felt in surprising ways, not only by the children and youth themselves, but also those who love the children most in the first place, their own families.

How can we prevent these injuries to begin with? How do we approach the topic of firearm injury prevention in with respect, empathy, and practical help. And how do we meet the needs of children and their caregivers after a tragic event has taken place? To learn more about how you can help, please take a listen.

Hi, Dr. Song. Welcome to One in Ten.

Zirui Song: Good morning, Teresa. Thank you so much for having me. It’s really nice to meet you.

Teresa Huizar: It may have been a little surprising to you when we first reached out because, you know, you’re talking to an audience of folks who work in child abuse and child abuse professionals. But let me tell you before we dive into our discussion, why we reached out to you and why we covered a piece of your research in a research to practice brief that we send out every Monday morning to our field.

And that’s really because Children’s Advocacy Centers, while they originated in dealing with different forms of child maltreatment, they now. I work with children who’ve experienced a variety of child trauma types and more recently have been involved in interviewing child witnesses in school shootings, in homicides, in cases where one child may have fired a gun and injured another accidentally or on purpose for that matter.

And so because of that, I think you’re going to find an eager audience who’s very interested in this. And then of course, Our multidisciplinary teams have those cases in which a child gets a holo loaded gun that’s kept in the home, shoots another child, and then you have a prosecutor who has to decide whether they intend to charge the parent or not with negligence or something else as a part of that, so.

That’s kind of our world. And I wanted to explain a little bit about that before we dived into this conversation. But what I would like to start with is what brought you to this work really looking at the intersection between firearm injuries and their cost emotionally and actual dollar sign cost to society.

What made you interested in that?

Zirui Song: Well, thank you for the question, Teresa, and thank you for all of the work you and your colleagues do in this space. It’s incredibly important. And as a parent, I’m very grateful for you and your colleagues and all of your efforts. My colleagues and I in the research world landed on this topic almost by accident because we were doing a lot of other research on healthcare spending and utilization in large claims databases.

That exists in our department of health care policy at Harvard Medical School in doing that work. We discovered that it was possible to link together family members, notably insurance plan holders and their dependents, parents who worked for large employers that offered health insurance to their workers and their dependents or children and spouses who are all part of that health insurance plan upon learning this fact and our other work.

We recognize that it was now possible to learn about the impact of various things that affect people as part of the family unit. When something affects one member of the family, it was now possible to study how ripples or develops ripple effects for other members of the family. And so this is the first topic outside of our traditional work in health insurance that we approached.

Largely because it was just important to us as regular human beings out in society when we watch news coverage of kids who are hurt by firearms. And when we watch news of mass shootings and school shootings. Those touch a deep nerve within all of us on our team, and we decided to first look at the impact of non fatal firearm injuries in our data because a cruel irony was that although so many of us in the public hear about the number of deaths due to firearms in this country, uh, what we often don’t hear about is The almost two to three times as many people in the U.S. every year who are shot but don’t die, who fortunately survive, and yet upon fortunately surviving, their stories and their battles to get back to productivity and back to a healthy life are often not covered, and we often don’t hear about them, and yet those members of our society are not covered.

Continuing on enrolling in health insurance and using health care services and being hospitalized and seeing doctors and getting rehab. So, we wanted to learn about the journey of the survivors and after that 1st step, we wanted to learn what it was like for families who endured a firearm injury. And so for kids who both survived firearm injuries and those who did not survive firearm injuries, we were interested in learning what the impact of those injuries were.

For the loved ones of the kids, notably for their siblings and parents. So, that’s how we got to this work.

Teresa Huizar: And, how common is it? You know, I think people may think it’s rarer than it is. How common are firearm injuries in youth?

Zirui Song: The best data that we have learned about recently suggests that for mortality, firearm injuries are now the leading cause of death for children in the United States, specifically for people ages 0 through 19.

Firearm injuries are now the leading cause of death surpassing motor vehicle accidents, just in the last few years. This evidence was published in the New England Journal of Medicine by other colleagues in the field and has been very influential in the last couple of years and  garnering awareness of this issue.

That is on mortality. On non fatal firearm injuries, to be honest, I think we still don’t really know. And the reason is that in the U. S., as many researchers have described in this field, data on non fatal firearm injuries are rather sparse. Data are not systematically collected at, say, a federal, state, or local level.

Data on non fatal firearm injuries typically do not have a infrastructure for data collection, and updating, and validating, or checking. So we have guesses, and we have estimates for non fatal firearm injuries in children in the U. S. as we do for adults, but we don’t have the exact numbers as we do for mortality.

Teresa Huizar: It’s interesting that you say that because I have to say that when we saw your article, A Non Fatal Injury, it was one of the first ones I can remember running across, which is not to say that you’re the only researcher, but it is to say that this is not some of the most common area of research that, that we, at least in our field, tend to encounter.

I’m wondering about this, you know, who are the kids who wind up getting injured? Let’s stay for a moment with the sort of non fatal injury of the paper that originated our discussions with you. And I thought it was so interesting how sort of age and gender specific it seems to be in some ways, at least in the findings of the study itself.

Zirui Song: Yeah, we should begin by just noting that the population in this particular study is employer-sponsored insurance enrolled members.

Teresa Huizar: So unique in that way, right?

Zirui Song: Yes, they are. They are families with employer sponsored health insurance, meaning that the parents, in most cases, the parents in these families are working for a large enough employer in the U.S. who offers health insurance.

Most of these employers offer self insured plans. So, these are large employers. What does that mean? Okay. It means that in this study, we do not have less socioeconomically advantaged families. Notably, we do not have families with Medicaid as their insurance or families who are uninsured. And the reason that’s important is that the employer sponsored insurance population is more advantaged in important socioeconomic ways.

So your question pertains to lots of children in the U.S. do not actually have the privilege of parents working for large employers who offer health insurance, about half the kids in the country, broadly speaking, it’s not exactly half, but about half of the children in our country are born with employer sponsored health insurance from their parents.

And another half or so are born with Medicaid coverage. And, it is our hypothesis that children with Medicaid, as they’re born and when they’re growing up, they endure a higher prevalence, a burden of injury from firearm incidents. And so, we are very interested in studying that more disadvantaged population at the moment, and we’re working fairly hard to begin answering that question.

But so far, all we have is evidence from the employer sponsored insurance population. And for this population, who are the kids? Well, they are, I think, more likely to be middle class, perhaps upper class families with stable jobs and large employers. But they’re also part of the 30 million children that we know of in the U.S. who currently live in households with firearms. And data suggests that about five million of that 30 million children live in homes where the firearms are kept loaded and unlocked. And so no matter what type of insurance they’re on, these are all kids who are part of that population at risk. The data for this study Range from, I think the late 2000s to the late 20-teens, just before the pandemic. But since the pandemic, we’ve also had another 5 million children in the U.S. who newly live in homes with firearms. Those are disproportionately in families with racial and ethnic minority parents or households. So, children at risk that are disproportionately disadvantaged to begin with, and that is further concerning.

So, we have a lot of work to do, and I would say this current evidence is one small step in learning about the total population of children at risk, and it may not be representative is probably not representative of children with Medicaid or children who are uninsured.

Teresa Huizar: So, weren’t the kids in this study, though, disproportionately male in terms of those who wound up injured, if I’m remembering right from your study?

Zirui Song: So, in the first appendix table to this study that I am now looking at, indeed, we had about 85 percent of the survivors, the child survivors of firearm injuries in the study being male, so about 15 percent female.

Teresa Huizar: Do we know anything about the ages of these kids? I mean, is it primarily little tiny children that are happening on to loaded firearms or for that matter, seeking them or older? Is it spread in an even distribution?

Zirui Song: Great question. The average age of the child survivors in this study was 16 years.

Teresa Huizar: Did that surprise you?

Zirui Song: No, it did not necessarily surprise us. The standard deviation around that average was 3.6 years. So, average age of 15.7 years old, standard deviation of 3.6 years old.

What that means is that the bulk of the population of children who survived a firearm injury in this study ranged probably somewhere between the early teenage years, maybe 12 or so, 11 or so, to the 18 or 19 range, and that’s the bulk of the children and that is not surprising in the sense that anecdotally and from much of the media coverage around child firearm injuries.

Children in their teenage years are more able physically or more curious to perhaps find firearms, use firearms. They’re obviously closer to being young adults than younger kids who may be less knowledgeable.

Teresa Huizar: I think the reason I ask you that maybe it’s because it surprised me a little bit and I’ll tell you why.

Because I think that, often, the general public does have some idea that somehow really small children are, I don’t know, crawling around or pilfering a closet and happen to just come up on a firearm that their parent thinks that they have very carefully put away or kept out of their reach. And then, they wind up in a sort of a tragic accident that couldn’t have been in their mind easily foreseen, you know.

Zirui Song: Yeah

Teresa Huizar: Now, we can debate to what degree any of that is actually based.

But, I think this has been a threat of a narrative. You know, the little kid who stands on a chair and gets up in mom’s closet and gets into something. But, if the average age is somewhere in that tween to 19 age, That’s not about little kids standing on chairs or any of the other things we’ve talked about.

They know their parent has a firearm and is very curious about it or seeking it out or something else and I think that, we’ll talk in a minute, but I think this also has some implications for prevention strategies because you’re not trying to prevent primarily a two year old from getting into something.

You’re trying to really talk to teens about these things as well as their parents and that’s a different endeavor altogether really.

Zirui Song: That’s a great point. Well, I think both things honestly can be true around every average is a distribution and even though the bulk of the kids who survived firearm injuries in our study were in the ages that you just described, there was certainly a range.

There certainly were children who were substantially younger than that. So, both situations do occur, even if the older kids getting injured Is more common. So, I think firearm safety in terms of gun locks or safes or other safety mechanisms at home to prevent little kids from accessing firearms inadvertently.

It has been increasingly a focus of our team and our colleagues efforts to bring this into clinical training for medical students and for residents just basic knowledge about how to engage with patients and families and parents about the safety of firearms in their houses. It’s about teaching a little bit of awareness about the availability and the fairly low cost of gun locks, about how to use locks and safes, or the options for avoiding accidental injury.

So that, I think, is focused on this younger age group. Even though it pertains as well to the older age group of kids, but for the older age group of teenagers, as you describe, yes, there are probably other strategies that go beyond what we’re talking about in the clinical visit just a moment ago.

Teresa Huizar: It’s interesting and encouraging to hear that, you know, up and coming physicians are being taught to ask questions about this, to talk with their patients about this. And, I also think there’s a role for child abuse professionals. I recently had a call from a prosecutor who had one of these tragic cases where a much younger child got a hold of a gun, shot another, they were deciding what to do.

And, what he did for Child Abuse Prevention Month in April was to decide to give out gun locks. And, he got a gun manufacturer and gun stores to actually donate the locks that were given out, which I thought was a really interesting partnership. And a really interesting way of approaching that because he’s going to have to deal with the legal implications of the case and what he decides to do in charging the parents, but he was very interested in how do you prevent these tragedies from happening in the first place and maybe it’s going to take looking outside of the normal kinds of things we do during the month of April when we’re talking about billboards and bus kiosk and spreading prevention messages in that way to doing some very practical things like handing out gun locks to people who might want them and a surprising number of people took them they had some sort of event caregivers took them back to your city.

Zirui Song: Well, just to add a quick note to what you just said recent numbers I saw, and I can’t recall exactly where I saw them, suggested that the price of a gun lock is as low as five dollars.

It could be quite affordable, obviously not perhaps for all families, but for many families could be quite affordable. And, back in May, we had an annual Society of General Internal Medicine meeting, which happened to be in Boston this time. Many colleagues locally here attended, as well as across the country.

And at this meeting, several of my colleagues from Massachusetts General Hospital put on a couple of really educational and insightful teaching sessions for internal medicine trainees and physicians across the country in which this issue of gun locks was discussed and taught. And there was practice using the gun locks.

There was awareness about Where one could obtain them and how much they cost. There was also discussion about how to make them available in primary care clinics so that any patient or family who wished to have one could have easier access. And, I thought speaking to your point that sort of a partnership or similar effort in making these more available because perhaps indeed more families would want to have one than we might realize if they were just made more available.

Teresa Huizar: I agree. And I just, I’m so encouraged by what you just described and I hope it goes on all over the country as well.

Zirui Song: Thanks.

So, I thought that your study was ingenious and first of all, approaching it from like, let’s look at the insurance records. Cause you’re going to tell us something different than what you might see if you were just trying to survey people or some other way of getting at that.

And did you find, before we get into sort of the financial cost, let’s talk a little bit about what you found in terms of the psychological impact to the kids who had been injured and to their caregivers. You know, what was the impact of that experience on them?

Zirui Song: Sure. Well, on average, after one year following the firearm injury, Kids who survived their injuries demonstrated or experienced a 117 percent increase in their physical pain disorders, which were diagnoses made by clinicians.

A 68 percent increase in psychiatric disorders. This included PTSD, anxiety, depression, psychosis, and a 144 percent increase in substance use disorders. These involved substances such as stimulants, opioids, even alcohol. And all of these increases, the 117 percent increase in pain, the 68 percent increase in mental health disorders, the 144 percent increase in substance use disorders, were all measured relative to a matched control group of kids who shared the same characteristics.

Age sex as the kids who were shot with the only exception that these control group children did not get shot. And so we compared these child survivors to a peer population of kids who looked alike in all the observable characteristics, but went on to live life without a firearm injury. And relative to that natural life without a firearm injury, these kids sustained these magnitudes of increases in mental health, substance use, and pain disorders. This was the main takeaway for survivors.

Teresa Huizar: Do you feel that, I mean, the pain one is not surprising to me, I can only imagine the sort of injuries that you’re seeing coming out of these. But do you think the rise in substance abuse disorders is tied to trying to self manage pain or self manage psychological injury essentially is associated with this or something else?

Zirui Song: Great question. So far, we don’t know yet. And the reason is that we have not yet dug into the substance use disorder category to break it down. We have started to do that. We have isolated and defined the types of substances that were used in the clinician’s diagnosis of the use disorder. But we haven’t gone back to rerun the analysis with each one of these subcategories to figure out what substances those were.

With that said, it is true that many survivors of firearm injuries, adults and children, are given strong pain medications, including opioids, obviously to treat the physical wound of the firearm injury. And we know from many, many years of clinical studies that go well beyond the firearms literature. that use of opioids to treat pain, real sources of physical pain can lead to addiction and opioid use disorders down the road.

That probably is a part of the picture. We just don’t know yet how big of part of a picture the opioids are.

Teresa Huizar: So, you also examined, which I thought was very interesting, sort of the family as well, not simply the person who had sustained the injury, but really looking at their caregivers. And so, can you talk a little bit about what you found there?

Zirui Song: Sure. Here, we looked at parents and siblings of Kids who survived their firearm injuries and then separately parents and siblings of kids who did not survive their firearm injuries So for the first group for kids who survived their firearm injuries their parents moms and dads on average Experienced a roughly 30 percent increase in their own psychiatric disorders again depression anxiety psychosis PTSD despite not being shot themselves.

The parents did not sustain their own firearm injuries, but the injuries of their children elicited a 30 percent increase in the parents mental health disorders. This led to, or was correlated with, a 75 percent increase in mental health visits. By moms, mostly by moms, we did not actually find a statistically significant increase in mental health visits by dads after their children were shot but survived a firearm injury.

Now, that result changes if the child died from a firearm injury, and we’ll get to that in a second. But moms demonstrated a 75 percent increase in mental health visits. The other finding here for survivors, which we did not expect, was a 5 to 14 percent reduction. So not enormous, but also not small, five to 14 percent reduction in routine medical care received by moms and siblings.

So brothers, sisters, and specifically moms had a decrease in their routine primary care, office visits, lab tests, imaging. And what that suggested to us was that the burden of caring for a child with a firearm injury in the family who survived it had a decrease. Negative spillover effect on the routine primary care of that child’s family members.

You can imagine parents and siblings who are distraught and busy with caring for their loved one that they are foregoing for the time being.

Teresa Huizar: Their own care.

Zirui Song: Yeah, they’re foregoing their own care in that first year after the firearm injury. So that was all for kids who survived their firearm injuries, for kids who died from their firearm injuries, as best as we can tell, death was not recorded as an objective data point of death in the claims data, but as far as we could tell, these deaths from firearm injuries occurred when children were shot by a firearm and then all of a sudden disappeared from the data, while their family members remained in that insurance plan going forward that for us was that criteria for defining a child who died from a firearm injury because a child is very unlikely to switch to their own insurance plan or move to a different part of the country or for adults in the adult case, get divorced and get their own insurance plan or a child.

Not likely to have those mechanisms at their disposal. So a child who suddenly gets shot and disappears from the insurance database in the enrollment while the rest of the family, or at least one family member, continues to enroll in that same exact insurance plan, suggests to us that the child probably died from their firearm injuries.

In those cases, family members of the deceased child experienced a much larger set of increases in their mental health disorders. So, if you put all family members together, it was a two to five fold increase, specifically 2.3 to 5.3 fold increases in their own psychiatric disorders defined the same way, psychosis, depression, anxiety, PTSD, and so forth.

So, roughly two to five fold increases as opposed to 30 percent increases. So, these are substantially larger. And then finally moms had a 15 fold increase in mental health visits and dads had an 87 fold increase in mental health visits after their kids died from firearm injuries. The reason that. is such a large number is that specifically dads more so than moms did not use much mental health care on average before their kids were shot by firearms.

Dads went from basically having close to zero mental health visits on average to many after. And so that change was an 87 fold increase after a child died. And we saw this as essentially a dose response relationship. The more intense the firearm injury, the more of an effect it had on the family’s mental health. Especially for parents.

Teresa Huizar: It’s just tragic, you know, just listening to you reel that out. I think that, but it’s, it’s just a catastrophic impact on the whole family when a child dies of a firearm injury. And certainly, even if they do survive, the numbers that you’re talking about are so significant. And I think.

Something that in our world, we have to think about within children’s advocacy centers. We provide a lot of mental health care to kids, but far less so for caregivers. Often, we’re referring those adults out for services if they need it and those kinds of things. But when we’re talking about the sort of scenarios, I sort of reeled out to you at the beginning that sort of brought us into this conversation.

I think it’s something for us to think about how let’s not assume that the child is the only one having survived that or having observed their sibling survive it or something like that. That’s going to need some intensive mental health support from that experience. That that’s really something that’s likely to be ongoing and for the whole family.

Zirui Song: You’re exactly right. We came to the same conclusions, Teresa that upon learning these ripple effects of firearm injuries throughout the family unit, clinically at least, it teaches us to better anticipate the needs of parents and siblings after a firearm injury. Not only in anticipating what they need in terms of mental health services and social supports, but also anticipating what they will probably miss out in terms of routine care that would be foregone.

And, those were important lessons to us. And just as you said, informs us about both prevention efforts and the response in the aftermath of firearm injuries.

Teresa Huizar: And also, thinking about our own victim advocates, I think it informs conversations that we might have with a parent about the importance of continuing their primary caregiver visits and reminders about that and reminders about the importance of taking care of oneself in order to be a good caregiver. So, I think all things for us to be thoughtful about moving forward. I want to transition for a moment to talking about the other aspect of this that you looked at, which was kind of the cost, you know, the actual burden financially that this imposed. And so, can you talk a little bit about your research there?

Because I think from a public policy perspective, there are some things for us to think about as well.

Zirui Song: Certainly. In this study, we found that after a child survives a firearm injury. That child’s healthcare spending increased, on average, by $35,000 in that first year following the injury. That, compared to before their injury, and relative to that matched control group, was a 17 fold increase in healthcare spending.

Because all of these kids had employer sponsored health insurance through their parents, and because most of these employers were self insured. What this meant was that this on average $35,000 per child per year increase in healthcare spending was borne by the revenues and wages and profits of their employers.

Effectively, their employers are paying for these preventable injuries, paying the direct medical costs stemming from these preventable injuries.

Teresa Huizar: Because they were self insured, they were large enough.

Zirui Song: That’s correct.

Teresa Huizar: Yeah.

Zirui Song: Correct. And if for a moment, We think about this kind of situation happening in Medicaid, or in Medicare for older adults, what this means is that taxpayers, at the end of the day, for public insurance programs, Medicare and Medicaid would be paying for the direct medical expenses of these firearm injuries.

So, that would be analogous. But here in this study, it’s a 17 fold increase, $35,000 per child per first year after injury, and 95 percent of that, so almost all of that $35,000 was paid by The employer sometimes through their insurer, who’s a third party administrator of the health insurance, but ultimately by the employer.

And, that has several implications. First, 5 percent of that $35,000. So even though it’s a small share, it’s still a large number. 5 percent of that 35, 000 is paid out of pocket by the child’s family, presumably not the child by the parents. And so what this means is that a non fatal firearm injury also hits the pocketbooks of families in a substantial way.

That other 95 percent paid by the employer, even though, and this is a general economics teaching that we in the health economics field often talk about, even though it looks like health insurance is paying for that 95%. At the end of the day, the costs of medical care, even after it goes through health insurance, ultimately are borne by workers themselves through slower wage growth.

And, that’s a well known finding in the health economics literature. Where a lot of research has shown that despite having third party insurance, despite carrying an insurance card in your pocket, which might say, any one of number of private health insurance companies names at the end of the day, employers, especially those who are self insured, are paying directly for the medical costs of their employees and their employees dependent from their revenues and their profits, and they ultimately need to take that out of wages.

So, we are subsidizing for the medical costs of, in this case, preventable injuries from the wages of the workforce. And, that’s an implication for employers that’s important, which we’ve also written about in other studies. And I’m happy to get into that if you would like, but I think there’s clearly a message here for American employers, large companies, that’s analogous to what would be for taxpayers and state and federal governments.

Teresa Huizar: Well, I mean, it’s a reason for all of us to want to pay attention to this, right? Because if employers are ultimately slowing wage growth to pay for that, they’re essentially passing the cost on in that way. Then I think it’s a both good news and bad news situation. I mean, yes, the bad news is we’re all paying for that.

The good news is it gives us all a stake in solving this problem, I think. Well, let’s talk about employers for a moment. In the discussion we’ve been having, when we get the impression that employers seeing this data should be passing out gun locks right and left. It’s just the numbers are so large. It’s like, well, here’s your insurance card and here’s your gun lock.

What has been the response of employers to your data?

Zirui Song: That’s a great question. The summer of 2022, so before the study came out, therefore, we can’t attribute that to this study, saw a public letter written by 550 CEOs and executives of U.S. companies, large and small, signed to U.S. senators, urging them to take meaningful action to reduce the burden of gun violence in the U.S. In that letter, these business leaders. talked about and really emphasized both the health and economic realities of firearm injuries. And in a separate paper that was entitled the business case for reducing firearm injuries, pulled a quote from this letter by the 550 CEOs across the country, which was that quote, the gun violence epidemic represents a public health crisis that continues to devastate communities.

Especially black and brown communities, and that quote, “on top of the human toll is a profound economic impact in a related study. We found that when adults survive a firearm injury, their health care spending was about $30,000 direct medical spending about $30,000 in the year after surviving a firearm injury.

So, not so different from the $35,000 we found for kids that suggested. That on average for a large employer, for a large business in America, they’re probably looking at somewhere around 30,000 to 35,000 of direct medical spending for a person that they’re covering from their revenues and profits in only that first year after the firearm injury and inevitably in year two and three and onward there are additional costs to that employer which we have not even studied. And so, what these business leaders were saying in our view at least was that they recognized the economic Implications of this public health issue and there was no longer only a health issue It’s no longer only a public health issue, but it was a business issue for them.

Now, one thing I’ve often asked among our research colleagues and in doing this work is are there this is a difficult question to ask and essentially a sad question to ask, but are there enough firearm injuries among employer-sponsored covered families and lives for businesses to take action. It is $30,000 to $35,000 per survivor in that first year, but for a large business with many, many millions or billions of dollars in revenue, $35,000 is not that much. So, it depends on how many injuries there are in an employed population. If there are relatively few injuries, then an employer might not have yet enough of an economic incentive or reason to climb this hill or fight this uphill battle to engage in a public health issue.

But if there is, then employers might. And to try to get at that question, this paper called the Business Case for Reducing Firearm Injuries, looked at the total rate of firearm injuries among self insured or large employers in these data, and it basically found a four to five fold increase in the rate in the last 12 to 15 years or so, the paper is a couple of years old now and covered about 13, 12 or 13 years of data. Essentially, it was an increase from about 2 to 3 survivors per 100,000 workers to now roughly 12 survivors per 100,000 workers. If you’re a large U.S. company with, let’s say, 100,000 workers that you insure and you pay their medical costs for. In the last 12 to 15 years, you may have, on average, seen the rate of firearm injuries grow from 2 to 12, or 3 to 12, let’s say.

Well, the question remains, is 12 enough for you to take action? 12 multiplied by $30,000 to $35,000 each still might be dwarfed by the overall revenue or costs of a large company. It still may not be large enough. So, I think that’s the reality we face. Although on a per person basis, it’s a large number in dollars spent, and it’s subsidized by workers wages or in the public program by taxpayers.

The sheer number of firearm injuries might still be small enough that the private sector as a whole may not yet have enough of an economic incentive to really engage in this issue with Policymakers and advocates and clinicians and broader society.

Teresa Huizar: Well, that’s depressing because we, you know, it really is because I think that’s true perhaps, but I also think that what is that number?

How many more children and youth have to be injured before it does rise to the level that it has enough economic impact to force action? So, what’s next for you research wise on this topic?

Zirui Song: Well, just to reflect on your question just now, I think we have, as a society or as parents, already surpassed what that number ought to be.

I think enough children have been hurt or killed by firearm injuries in the U.S. to already justify prevention and responses by large employers as well as by people in government or by policymakers. So, I don’t know what the number is. I don’t think any of us in the research community has written about what that number is.

I think we’re far past that number, but I guess reality suggests that the number is out there and we probably haven’t reached it yet, so that is a sad reality to consider. Some of my colleagues have had, and many Americans, as a U.S. Surgeon General recently reminded us, a large share of People in the U.S. have direct experience with firearm injuries, either through themselves or their family members or through close acquaintances or friends or loved ones. And so, this is an experience shared by many across the country, and similarly, how many more have to share in this experience before collective action?

Sitting here with you today, I don’t know, but I also think we’re far surpassed that number. So, what’s next for us in our research endeavor is to learn about the impact of firearm injuries in the Medicaid population and in the Medicare population. Medicaid, as I noted earlier, covers about something close to half, maybe 40 percent, something between 40 to 50 percent, I think, of births in the country.

And we simply don’t see a large share of kids in this study. And we would like to learn what the impact of firearm injuries are for kids who are born into socioeconomically more disadvantaged families and communities, where the burden and the rates of firearm injuries might well be larger to begin with.

We’re also interested in learning about the impact of firearm injuries in older populations in the U.S. And the most practical place to study that is the Medicare population for whom we have large claims data similar to what we’ve had here for employer sponsored families with employer-sponsored In Medicare, what is, um, additional challenge, but also an area of need to learn what the impact of firearm injuries are for older adults who begin to have cognitive challenges.

As you may well know, there is a increasing burden of cognitive impairment or dementia in the U.S. from the aging population, or as in the aging population. And clinically, we understand that in earlier phases of cognitive decline. It’s often not memory loss that appears first. But rather emotional instability or emotional lability, more labile emotions and less predictable behavior.

And so, we would like to both understand the risk factors for older adults using firearms and getting injured. As well as the impact of those injuries among our aging population. So those are two areas where we are currently expanding. And going back to one of your earlier questions, we are trying to figure out in more detail within these families with younger kids, what types of mental health implications and what types of substances are behind the substance use disorders and the psychiatric effects that we’ve already documented.

Teresa Huizar: When we think about the population that’s listening to this podcast, child abuse professionals who work with families all day every day, what’s your best advice about how to approach a conversation around firearm safety and protecting children from firearm injuries and also responding to those? What is your best advice for them?

Zirui Song: Coming at this from a clinician’s viewpoint, the best training I’ve received, and this is in large part thanks to my colleagues who teach a lot more in this space, is to listen first, to understand a patient or family’s reasons for having firearms available in the household. And, having practiced this clinically just a little bit, and I wouldn’t say I’m all that experienced at this, honestly, but I’ve learned that it is really instructive and really eye opening to hear the reasons people express for having firearms.

Right next to their pillow, in their living rooms, available on their counters or tables. Many people express a need for protection or self protection. Many people have questioned the ability to access a ready to use firearm if it were in a safe or locked, or if it were locked. Uh, and there’s teaching currently in the clinical community.

About just how quickly one is able to access a firearm, even if it is locked or in a safe to try to counterbalance that concern, but the concerns are real. And I think people’s genuine expressions of desire and need to have a firearm nearby are also real. And so listening to those stories has been important.

Very instructive. It’s helped shape conversations about how to approach the issue. I think just as a clinician, I’m a primary care physician. I practice two sessions a day, mostly with an adult population. But just like in other clinical scenarios, seeing the world at the same eye level as a patient is really important as a fellow with a fellow human being is really important.

Trying to walk or take a few steps or at least understand what it’s like to walk in their shoes. seeing the world from their eyes and then coming back to a clinical perspective. To think through how could we work together to both prevent disease or in this case prevent injury And how do we do so in a way that respects your autonomy?

Your beliefs your preferences and the way you live your life. I think that, although there is no formula or a magic way to to do this That human connection the bond the trust is almost always necessary Sometimes it’s not sufficient, but it seems to be almost always necessary You And sometimes we take what some call a long walk, where in that first conversation, the clinician and the patient don’t arrive at a Mutually agreed upon course of action, but in a follow up visit or in a year or two or three or many years after first meeting a patient, that longitudinal trust and the bond and what I like to call walking through the stages of life with someone creates enough of a fertile ground of trust that then your clinical recommendations or your advice or guidance can lead to a change in behavior at home.

It differs for everyone and sometimes it just doesn’t work. And that’s okay too. I think understanding that people have their freedoms and deserve their freedoms and autonomy at home and in this world is a way to, um, sort of a, it builds some necessary humility into clinical work. And it’s a way to recognize that as much as we can try, we won’t be able to reach everybody and that’s okay.

But to make a dent, even a small dent, On a big public health issue, like chronic diseases, or in this case, like firearm injuries, is still worth the time.

Teresa Huizar: Dr. Song, it’s been so helpful talking with you. Thank you so much for joining us. Is there anything else I should have asked you and didn’t, or is there anything else you wanted to make sure that we talked about today?

Zirui Song: Well, I would just emphasize first my gratitude to you and your colleagues for doing this work for families and kids everywhere. Again, as a parent, I’m, I’m very touched by your mission and the work that you do. I think about my kids a lot, not only in this context of firearm injuries when they go to school, but also more generally for their overall health.

So first, a thank you. And I would only just emphasize that although most of us in everyday life hear about deaths from firearms in the U. S., there is. Roughly two to three times as many people in the country who sustain firearm injuries, but are fortunate enough to survive and that we should try to remember them just as we remember those who die from firearm injuries and try to think about ways to.

Help them through the aftermath of an injury, which often requires not only lots of clinical care, hospitalizations or medical care, like we talked about, but also rehabilitation, um, physical therapy, occupational therapy, rehab, speech therapy, learning to walk again, learning to speak again, learning to work again, all of that comprises a huge societal uphill battle that has been fought largely in the shadows or in silence. So I think as members of society, if we can recognize that and help our fellow human beings get through that journey, that would be a good thing.

Teresa Huizar: Thank you so much. We so appreciate all this helpful information and look forward to when you complete your study on the Medicare and Medicaid population, please come back. We’d love to hear more about that as well.

Zirui Song: Got it. Thank you so much, Teresa. Really appreciate your time.

Teresa Huizar: Thank you for listening to One in Ten. If you liked this episode, please share it with a friend or colleague. And, for more information on this important topic, or any of our episodes, please visit our podcast website at oneintenpodcast.org.