番茄社区

In this exclusive interview, Jeremy Faust, MD, editor-in-chief of 番茄社区, and LJ Punch, MD, trauma surgeon and director of the Bullet Related Injury Clinic (BRIC) in St. Louis, discuss a paradigm shift to look at bullet wounds in a more scientific way.

is a community-based clinic that helps people heal after they have been injured by a bullet.

The following is a transcript of their remarks:

Faust: Well, the first thing that I want everyone to be aware of is in the background preparing for this seminar or webinar about gun violence, Dr. Punch said something really, I thought, paradigm-shifting in my view, which is that this is not really a gun violence crisis.

I've been going around saying that it's a public health crisis with treatments and prevention, but you say something different. You say that the crisis is different.

Punch: Yeah. So when we think about public health, we're talking about structural realities in our day-to-day life, whether it's the water we drink, the food we eat, the air we breathe, the roads we walk on and drive on. There are structural realities that create the conditions for our health and well-being, and when something is structurally amiss, then we have a public health crisis.

But if you think about what the term 'gun violence' is, it's a very strange phrase. First of all, it's sort of two nouns or a noun and an action that don't really go together. But long story short, violence in this respect is talking about acts between people or the behavior of specific people.

Any time you decide that people themselves are a public health problem -- meaning someone's relationship or engagement or actions toward another human are a public health problem -- what you're saying is people are the problem. And if people are the problem, the solution is to 'un-people' the people, and that doesn't work. That doesn't work. Think about it: we don't get rid of cars because of the issues that people have when they're in motor vehicle collisions.

But also when we talk about gun violence, we take a highly polarized topic -- the issue of gun control and gun ownership -- and we inflict all sorts of value judgments without first understanding if we're gun-positive or gun-negative in our approach to what it is to own a gun.

I'm not here for that, as a physician. Here's the thing I know: It's the bullet that I find in the body. If we take a more scientific, accurate approach to what's happening in our country, bullets are endemic. They end up in people's bodies, and not just under the circumstances of what we would call 'violence.' Bullets are much more likely to end a life when they're self-inflicted.

So for these reasons, I have changed my narrative and embodied a much broader understanding of what's going on by using the term 'bullet-related injury' -- the physical, emotional, social, and spiritual impact that a bullet has in someone's life, not just when they're physically injured, but if someone they love has been injured or even lost.

Faust: And again, I found it to be a really interesting kind of paradigm shift. Hearing you say that, what that doesn't do is shift the problem to something that it isn't really. We hear a lot of talking points from people who don't want to do anything about this problem, and they say things like, 'The guns aren't the problem, it's the mental health [problem],' or 'It's the other problems,' or 'We need more guns, not less.'

And so when you say, 'The guns aren't the problem,' you're not replicating a talking point that's a nihilistic thing saying that it's just mental health or it's the that's the issue. Correct?

Punch: I'm actually doing the exact opposite. I am amplifying the responsibility that health and mental healthcare providers and systems of care, including trauma systems, have to addressing the impact of bullets. Because if we use that phrase right and we think about that terminology, there's a couple really, really important things we need to know.

First of all, bullets are the leading cause of death in children and black men. Children for the last year or two, and black men for decades. So this isn't theoretical. This is like the leading, show-stopping cause of death.

Two: 70% of people nationwide who have bullet injuries are managed in an ambulatory setting, meaning they're seen in the ER and they're sent home. There are very few dedicated aftercare spaces that can create a therapeutic home for what happens after a bullet has entered someone's life. There's a paucity of knowledge around what to do when someone has a bullet injury, especially if a bullet is retained.

And again, one of the most likely ways that a bullet ends up in someone's body is actually them putting it there themselves. And so the responsibility to understand what bullets do to people's hearts, minds, bodies, and souls is even more pressing when we frameshift away from an issue simply of human behavior or social structure and relationships, and instead we get curious about how bullets affect people's health and well-being. That is what the BRIC is about.

Faust: When you look at groups like the American Medical Association or -- I'm an ER doc, so the American College of Emergency Physicians, the American Public Health Association -- they've all come out and declared gun violence as a public health threat. I'm sure you talk to them. My question is, are these groups receptive to a paradigm shift? And also part B of this question is, what actions do you think change for them if they adopt that framework?

Punch: First of all, we have to re-think about the history and the way we got here.

If you look at the political environment in the '60s with several major assassinations, bullet injuries becoming a major threat, a great deal of civil unrest, and the launch of the by [President] Lyndon B. Johnson -- he spoke about, before he passed the in 1968, the violence of crime at gunpoint. That was the first time that we started equivocating guns, violence, and crime. They're not necessarily embedded in that way before then.

That language evolved over the years and through the '90s when the term 'gun violence' emerged -- it did not really exist in that way before then. That paradigm shift in that way of thinking of things, along with a serious cutoff of funding to understand the impact of bullets in people's lives due to the , made it so that there wasn't investment from the CDC and other funders to study this impact.

This narrative, which was deeply stigmatizing, was taking over.

Now, what does that sound like? There are plenty of other public health issues which have gone through a similar shift, for instance, HIV. HIV used to be [gay-related immune deficiency] and the " [homosexuals, hemophiliacs, heroin addicts, and Haitians]," a highly stigmatized way of talking about the disease process.

So we came to this honestly, and we didn't plan for it to get to this place. Nonetheless, this is the language as it exists now.

So to accept a narrative shift means we need to use even more of the tools of science. What is the actual final common factor that causes the impact in people's lives? How does it impact people, more than those who are just physically shot, but the ones who are around those people? And what are the long-term consequences when a bullet comes into someone's life?

This is perfect for scientific inquiry and scholarly approach, but we can't get there until we let go of the stigmatizing language. That's the challenge that I'm bringing to the health community and to the medical community right now.

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